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## Complete Summary

#### GUIDELINE TITLE

Workplace interventions for people with common mental health problems:
evidence review and recommendations.

#### BIBLIOGRAPHIC SOURCE(S)

Seymour L, Grove B. Workplace interventions for people with common
mental health problems: evidence review and recommendations. London
(UK): British Occupational Health Research Foundation (BOHRF); 2005 Sep.
96 p. \[83 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Mental health problems in the work environment

**Note**: Severe mental illnesses, such as psychosis, schizophrenia or
bi-polar disorder were specifically excluded.

#### GUIDELINE CATEGORY

Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nursing\
Preventive Medicine\
Psychiatry\
Psychology

#### INTENDED USERS

Allied Health Personnel\
Health Care Providers\
Nurses\
Occupational Therapists\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

-   To provide evidence-based answers on key questions related to mental
    ill health in the workplace

-   To assist managers, occupational health professionals and other
    interested parties in making management decisions and offering
    advice in the confidence that they are based on the most robust
    evidence available

-   To provide employers and occupational health professionals with
    information to prevent or limit mental health in their workplace,
    minimise sickness absence and enable workers who experience mental
    ill health to remain in work, restored to full productivity

#### TARGET POPULATION

Adults in the workforce with common mental health problems

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Prevention**

Stress management interventions

**Retention and Rehabilitation Interventions**

1.  Cognitive behavioural therapy (CBT)

2.  Job reorganisation

3.  Other cognitive/educational interventions

4.  Multi-modal interventions

5.  Supervisory training

6.  Selective case management

7.  Computer-aided CBT

#### MAJOR OUTCOMES CONSIDERED

-   Incidence and prevalence of common mental health problems

-   Cost of mental health problems at work

-   Incidence of absenteeism due to mental health problems

-   Retention of employees with common mental health problems

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The literature was searched systematically to April 2004 using a variety
of standard methods. (See Appendix B: Inclusion and exclusion criteria
and Appendix C: Search history in the original guideline document for
details on search strategy.)

Databases searched were PsychInfo, NIOSHTIC, CISDOC, MEDLINE, CINAHL,
Sociofile, ASSIA, IBSS, Cochrane, Business Source Premier, Emerald,
PubMed and EMBASE.

The Research Working Group (RWG) did not limit our data pool to
experimental studies only; the RWG included a range of studies that were
relevant to the research questions (i.e. cohort studies, case studies,
participative action research and non-intervention studies).

The RWG also did not omit studies that described non-work based
interventions; our main criteria were that the study passed the critical
appraisal process and that employment was among the outcome measures. As
a consequence there are several studies where the intervention was
targeted at practitioners such as primary care physicians, but the
outcomes were focused on return to work or remaining in employment for
people with common mental health problems.

Electronic searches produced more than 15,000 references. Subsidiary
searches included the Chartered Management Institute library database
(200 references) and the Faculty of Occupational Medicine website (6
references).

The study selection is shown diagrammatically in Figure 1 on page 20 of
the original guideline document. The process used is summarised as
follows:

-   More than 200 titles and abstracts were considered. Abstracts were
    reviewed independently by the Senior Researcher and Scientific
    Secretary. Members of the Research Working Group (RWG) subsequently
    reviewed identified abstracts to select full papers for review.

-   144 of these papers were retrieved. 59 of these papers informed the
    context of the review and were read only by the Scientific Secretary
    and the Senior Researcher.

-   The remaining 85 papers were critically appraised by RWG members and
    assessed for methodological quality, using a pro-forma adapted from
    that used by CASP (Critical Appraisal Skills Programme) for this
    review. (see Appendix D of the original guideline document)

-   RWG members identified 68 follow-on references for consideration,
    drawn from the bibliographies of the first tranche of studies.
    References were reviewed by the Scientific Secretary and the Senior
    Researcher.

-   48 of these studies were not followed up for a variety of reasons
    (i.e. a focus on severe and enduring mental ill health, not relevant
    to workplace outcomes, not relevant to mental health, already
    reviewed in the first tranche and included in a meta-analysis that
    had already been reviewed).

-   RWG members reviewed and critically appraised a total of 20
    follow-on papers.

-   External peer reviewers also identified an additional six studies
    for consideration and these went through the critical appraisal
    process.

-   19 experimental studies were included dealing with various aspects
    of management relevant to occupational health guidelines and their
    main findings are listed in Table I of the original guideline
    document.

-   12 non-experimental and narrative studies were included and their
    main conclusions are listed in Table II of the original guideline
    document.

#### NUMBER OF SOURCE DOCUMENTS

19 experimental studies and 12 non-experimental and narrative studies

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Royal College of General Practitioners (RCGP) Three Star System**

\*\*\* [Strong evidence]{.underline} -- provided by generally consistent
findings in multiple, high quality scientific studies.

\*\* [Moderate evidence]{.underline} -- provided by generally consistent
findings in fewer, smaller or lower quality scientific studies.

\* [Limited or contradictory evidence]{.underline} -- provided by one
scientific study or inconsistent findings in multiple scientific or
narrative studies.

\- [No scientific evidence]{.underline} -- based on theoretical
considerations.

**Revised Scottish Intercollegiate Guidelines Network (SIGN) Grading
System: Levels of Evidence**

1++ High quality meta analyses, systematic reviews of randomised
controlled trials or randomised controlled trials with a very low risk
of bias

1+ Well conducted meta analyses, systematic reviews of randomised
controlled trials or randomised controlled trials with a low risk of
bias

1- Meta analyses, systematic reviews of randomised controlled trials or
randomised controlled trials with a high risk of bias

2++ High quality systematic reviews of case-control or cohort or
studies. High quality case-control or cohort studies with a very low
risk of confounding, bias, or chance and a high probability that the
relationship is causal

2+ Well conducted case control or cohort studies with a low risk of
confounding, bias, or chance and a moderate probability that the
relationship is causal

2- Case control or cohort studies with a high risk of confounding, bias,
or chance and a significant risk that the relationship is not causal

3 Non-analytic studies (e.g. case reports, case series)

4 Expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Studies were critically appraised by the Research Working Group members
and assessed for methodological quality, using a pro-forma adapted from
that used by CASP (Critical Appraisal Skills Programme) for this review.
(see Appendix D of the original guideline document).

The revised Scottish Intercollegiate Guidelines Network (SIGN) grading
system (2000) was used to grade each identified paper. The strength of
evidence for each statement was graded using the Royal College of
General Practitioners (RCGP) three star system (1995) as modified in the
Swedish Council on Technology Assessment in Health Care report for
scientific studies and the British Occupational Health Research
Foundation (BOHRF) Occupational Health Guidelines for the Management of
Low Back Pain at Work.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Definition of Common Mental Health Problems**

Common mental health problems as those that:

-   Occur most frequently and are more prevalent

-   Are mostly successfully treated in primary rather than secondary
    care settings

-   Are least disabling in terms of stigmatising attitudes and
    discriminatory behaviour

**Prevention of Common Mental Health Problems**

-   Amongst employees who have not manifested with common mental health
    problems or who are not at high risk, the evidence suggests that a
    range of stress management interventions can have a beneficial and
    practical impact.

-   These interventions also provide employees with a range of useful
    skills that can be exploited to their own and their organisation\'s
    wider benefit.

-   The extent to which any of these interventions prevent common mental
    health problems remains unclear.

**Retention at Work**

-   Amongst employees deemed to be at risk, either through their job
    role or who have been assessed as at risk, the evidence from the
    included studies demonstrates that individual rather than
    organisational approaches to managing common mental health problems
    are most likely to be effective.

-   However it is imperative that those populations are identified
    accurately so that interventions can be correctly targeted and
    applied and the anticipated benefits of retaining key skills in
    organisations can be realised.

**Rehabilitation**

-   For people already experiencing common mental health problems at
    work, the evidence from the included studies demonstrates that, the
    most effective approach is brief (up to 8 weeks) of individual
    therapy, especially cognitive behavioural in nature (CBT).

-   The research on CBT delivered via computer-aided software would
    ideally benefit from a corroborative study. This approach appears
    promising, although its effectiveness has currently only been
    demonstrated in the short term (i.e., at one month).

-   A stronger effect is associated with employees in high-control jobs.

**Recommendations for Practice**

The recommendations for practice have emerged from the data pool that
supports evidence of effective practice.

-   The evidence supports the use of CBT in brief therapy sessions of up
    to 8 weeks with people already presenting with common mental health
    problems.

-   CBT is most effective for jobs that already involve a high degree of
    decision latitude.

-   Jobs with low decision latitude should prioritise increasing control
    potential accompanied by CBT interventions.

-   Early psychological interventions are effective for common mental
    health problems, delivered in the workplace, comprising 4-5 sessions
    of CBT to increase activity and coping skills for those off sick for
    two weeks (van der Klink et al., 2003)

-   Interventions conducted by general practitioners (GPs) or
    occupational health (OH) Physicians or referred by them to
    psychologists or psychotherapists should be cognitive in nature.

-   Supervisors should keep in touch with employees on mental ill health
    sickness absence at least once every two weeks (Nieuwenhuijsen et
    al., 2004)

-   No intervention has effects that last forever; training programmes
    might be more effective at sustaining changes if they include
    booster and follow-up sessions (Reynolds et al., 1993)

**Interventions worth Consideration**

Although the evidence base did not strongly support these practices, the
guideline Working Group members think that any are worthy of
implementation and review if a workplace cannot implement the
recommendations for practice.

-   Other cognitive/educational approaches (sometimes described as
    directive or activating)

-   Multi-modal interventions (especially via the Internet or other
    forms of facilitated self help) for employees identified or deemed
    to be at high risk

-   Interventions to train and improve supervisory behaviour

-   Selective use of case management with those at risk of long term
    absence

-   Computer-aided CBT available in an amended 3-4 session format, to
    make it more acceptable to employees.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=10340)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The evidence included 19 experimental studies dealing with various
aspects of management relevant to occupational health guidelines (see
Table I in the original guideline document for details) and 12
non-experimental and narrative studies (see Table II in the original
guideline for details). The 19 experimental studies included randomized
controlled trials, quasi-randomized controlled studies, controlled
intervention studies, systematic literature reviews, and a
meta-analysis.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of workplace interventions for people with common mental
health problems to:

-   Prevent or limit mental ill health in the workplace

-   Minimise sickness absence and enable workers who experience mental
    ill health to remain in work, restored to full productivity

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The studies that have informed this review had various limitations
across a range of criteria. (See the section titled \"Limitations in the
Evidence\" in the original guideline document for details.)

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Seymour L, Grove B. Workplace interventions for people with common
mental health problems: evidence review and recommendations. London
(UK): British Occupational Health Research Foundation (BOHRF); 2005 Sep.
96 p. \[83 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Sep

#### GUIDELINE DEVELOPER(S)

British Occupational Health Research Foundation - Private Nonprofit
Organization

#### SOURCE(S) OF FUNDING

British Occupational Health Research Foundation

#### GUIDELINE COMMITTEE

The Research Working Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Group Members*: Dr Kit Harling (Chair) Consultant Occupational
Physician, Avon Partnership Occupational Health Service; Director, NHS
Plus; Dr Ira Madan (Vice Chair) Consultant Occupational Physician,
Guy\'s & St Thomas\'s NHS Foundation Trust; Dr Bob Grove (Senior
Researcher) Director Employment Programme, Sainsbury Centre for Mental
Health; Linda Seymour (Scientific Secretary) Research & Policy
Development Manager, mentality @ The Sainsbury Centre for Mental Health;
Dr Jed Boardman, Consultant/Senior Lecturer in Social Psychiatry, South
London and Maudsley NHS Trust and Health Services Research Dept,
Institute of Psychiatry King\'s College London; Dr Dennis Ferriday,
Director Health Services (Europe), Ford Motor Company; Dr Fiona Ford
(representing RCGP) Senior Lecturer in General Practice, University of
Central Lancashire; Ann Kelly, Representing Chartered Management
Institute; Dr Noel McElearney (BOHRF Trustee) Director Health Safety &
Environment, Scottish & Newcastle plc; Tom Mellish (resigned March 2005)
Health & Safety Officer, TUC; Hugh Robertson (from April 2005) Senior
Health & Safety Officer, TUC; Susan Scott-Parker, Chief Executive,
Employers Forum on Disability; Simon Pickvance, Senior Occupational
Health Adviser, Sheffield Occupational Health Advisory Service;
Professor Jenny Secker, Professor of Mental Health, Anglia Polytechnic
University & South Essex Partnership NHS Trust; Professor Justine
Schneider, Professor of Mental Health & Social Care, Nottingham
University; Grahame Whitfield, Department for Work and Pensions; Ben
Willmott, Employee Relations Adviser, CIPD; Brian Kazer, Chief
Executive, British Occupational Health Research Foundation

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Conflicts of interest were formally reviewed in respect of all members
of the research working group. No conflicts of interest were found.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[British Occupational Health Research Foundation Web
site](http://www.bohrf.org.uk/downloads/cmh_rev.pdf).

Print copies: Available from the British Occupational Health Research
Foundation, 6 St. Andrew\'s Place, Regent\'s Park, London NW1 4LB

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Systematic review of workplace interventions for people with common
    mental health problems: a summary for health professionals.
    Available from the [British Occupational Health Research Foundation
    Web site](http://www.bohrf.org.uk/downloads/cmh_hp.pdf).

-   Workplace interventions for people with common mental health
    problems: a summary for employers and employees. Available from the
    [British Occupational Health Research Foundation Web
    site](http://www.bohrf.org.uk/downloads/cmh_emp.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 7, 2007. The information
was verified by the guideline developer on May 23, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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Date Modified: 11/3/2008