title: Interventions to improve return to work in depressed people.
abstract: BACKGROUND
  Work disability such as sickness absence is common in people with depression.
  
  
  OBJECTIVE
  To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders.
  
  
  METHODS
  We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014.
  
  
  METHODS
  We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and clinical interventions for depressed people that included sickness absence as an outcome.
  
  
  METHODS
  Two authors independently extracted the data and assessed trial quality. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to pool study results in the studies we judged to be sufficiently similar. We used GRADE to rate the quality of the evidence.
  
  
  RESULTS
  We included 23 studies with 26 study arms, involving 5996 participants with either a major depressive disorder or a high level of depressive symptoms. We judged 14 studies to have a high risk of bias and nine to have a low risk of bias. Work-directed interventions We identified five work-directed interventions. There was moderate quality evidence that a work-directed intervention added to a clinical intervention reduced sickness absence (SMD -0.40; 95% CI -0.66 to -0.14; 3 studies) compared to a clinical intervention alone.There was moderate quality evidence based on a single study that enhancing the clinical care in addition to regular work-directed care was not more effective than work-directed care alone (SMD -0.14; 95% CI -0.49 to 0.21).There was very low quality evidence based on one study that regular care by occupational physicians that was enhanced with an exposure-based return to work program did not reduce sickness absence compared to regular care by occupational physicians (non-significant finding: SMD 0.45; 95% CI -0.00 to 0.91). Clinical interventions, antidepressant medication Three studies compared the effectiveness of selective serotonin reuptake inhibitor (SSRI) to selective norepinephrine reuptake inhibitor (SNRI) medication on reducing sickness absence and yielded highly inconsistent results. Clinical interventions, psychological We found moderate quality evidence based on three studies that telephone or online cognitive behavioural therapy was more effective in reducing sick leave than usual primary or occupational care (SMD -0.23; 95% CI -0.45 to -0.01). Clinical interventions, psychological combined with antidepressant medication We found low quality evidence based on two studies that enhanced primary care did not substantially decrease sickness absence in the medium term (4 to 12 months) (SMD -0.02; 95% CI -0.15 to 0.12). A third study found no substantial effect on sickness absence in favour of this intervention in the long term (24 months).We found high quality evidence, based on one study, that a structured telephone outreach and care management program was more effective in reducing sickness absence than usual care (SMD - 0.21; 95% CI -0.37 to -0.05). Clinical interventions, exercise We found low quality evidence based on one study that supervised strength exercise reduced sickness absence compared to relaxation (SMD -1.11; 95% CI -1.68 to -0.54). We found moderate quality evidence based on two studies that aerobic exercise was no more effective in reducing sickness absence than relaxation or stretching (SMD -0.06; 95% CI -0.36 to 0.24).
  
  
  CONCLUSIONS
  We found moderate quality evidence that adding a work-directed intervention to a clinical intervention reduced the number of days on sick leave compared to a clinical intervention alone. We also found moderate quality evidence that enhancing primary or occupational care with cognitive behavioural therapy reduced sick leave compared to the usual care. A structured telephone outreach and care management program that included medication reduced sickness absence compared to usual care. However, enhancing primary care with a quality improvement program did not have a considerable effect on sickness absence. There was no evidence of a difference in effect on sickness absence of one antidepressant medication compared to another. More studies are needed on work-directed interventions. Clinical intervention studies should also include work outcomes to increase our knowledge on reducing sickness absence in depressed workers.
authors.affiliation: Coronel Institute of Occupational Health/Dutch Research Center for Insurance Medicine, Academic Medical Center, University of Amsterdam, POBox 22700, Amsterdam, 1100 DE, Netherlands.K.Nieuwenhuijsen@amc.nl.
authors.forename: Karen
authors.initials: K
authors.lastname: Nieuwenhuijsen
authors.forename: Babs
authors.initials: B
authors.lastname: Faber
authors.forename: Jos H
authors.initials: JH
authors.lastname: Verbeek
authors.forename: Angela
authors.initials: A
authors.lastname: Neumeyer-Gromen
authors.forename: Hiske L
authors.initials: HL
authors.lastname: Hees
authors.forename: Arco C
authors.initials: AC
authors.lastname: Verhoeven
authors.forename: Christina M
authors.initials: CM
authors.lastname: van der Feltz-Cornelis
authors.forename: Ute
authors.initials: U
authors.lastname: Bültmann
mesh_terms: D000041:Absenteeism; D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use; D015928:Cognitive Behavioral Therapy; D003863:Depression / Q000628:therapy*; D003865:Major Depressive Disorder / Q000628:therapy*; D006801:Humans; D052580:Muscle Stretching Exercises; D016272:Occupational Health; D016032:Randomized Controlled Trials as Topic; D062707:Return to Work / Q000523:psychology*; D018582:Sick Leave
chemical_list: D000928:Antidepressive Agents