CBT Versus a Return to Work Intervention for Patients With Common Mental Illness in Primary Care

Study Overview
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Brief Summary
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Background: Common mental illness, such as anxiety disorders and depression, is the main cause for sick leave in Sweden. Cognitive behavior therapy (CBT) has been shown to be effective in alleviating target symptoms of these disorders, but its effect on sick leave rates has not been sufficiently addressed. The investigators have developed an intervention called return to work (RTW), which is based in cognitive behavioral theory, that has a primary aim of helping sick-listed patients with common mental illness return to work. This new treatment has not been evaluated in a randomized controlled trial. Aims: The aim of this study is to investigate the effect of CBT and RTW for common mental illness in a randomized controlled trial conducted in primary care. Participants will be randomized to diagnosis specific CBT (n=70), RTW (n=70), or a combination of the two treatments (n=70). Main outcomes are days of sick leave and clinician severity rating of psychiatric symptoms. This study could contribute to new knowledge regarding how to best treat patients on sick leave with common mental illness.

Official Title
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Cognitive Behavior Therapy Versus a Return to Work Intervention for Sick-listed Patients With Common Mental Illness in Primary Care: a Randomized Clinical Trial

Conditions
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Anxiety Disorders, Major Depression, Stress Disorders, Primary Insomnia

Intervention / Treatment
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* Behavioral: Cognitive behavior therapy
* Behavioral: Return to work


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Have been on sick leave (at least 50%) for at least 1 month and not more than 6 months Have an anxiety disorder diagnosis (obsessive compulsive disorder, social phobia, panic disorder, generalized anxiety disorder, post-traumatic stress disorder, specific phobia), or/and major depression, or/and maladaptive stress reaction, or/and primary insomnia Exclusion Criteria: A lower score than 4 on the Clinician severity rating scale A higher score than 6 on the Clinician severity rating scale

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Cognitive Behavior Therapy<br>As the trial will include several different common mental disorders, the cognitive behavior therapy used in the study will be based on the protocols with best empirical support. Cognitive behavior therapy entails psychoeducational components, i.e. the patient is learns about the disorder and how to view it from a cognitive behavioral perspective. The most important part of the treatment is systematic behavior changes often targeted at exposure to feared stimuli. This is combined with cognitive interventions targeted at challenging negative automatic thoughts. All treatments will be delivered by licensed psychologists. | Behavioral: Cognitive behavior therapy<br>* Cognitive behavior therapy entails psychoeducational components, i.e. the patient is learns about the disorder and how to view it from a cognitive behavioral perspective. The most important part of the treatment is systematic behavior changes often targeted at exposure to feared stimuli. This is combined with cognitive interventions targeted at challenging negative automatic thoughts. All treatments will be delivered by licensed psychologists.<br>|
| Experimental: Return to work<br>Participants randomized to this arm will receive an experimental treatment, based in cognitive behavioral therapy, with primary aim to help patients return to work. Interventions are aimed at solving work-related problems and comprises problem-solving training and systematic employer-patient meetings aimed at facilitating a gradual return to the workplace. Licensed psychologists deliver all treatments. | Behavioral: Return to work<br>* Participants randomized to this arm will receive an experimental treatment, based in cognitive behavioral therapy, with primary aim to help patients return to work. Interventions are aimed at solving work-related problems and comprises problem-solving training and systematic employer-patient meetings aimed at facilitating a gradual return to the workplace. Licensed psychologists deliver all treatments.<br>|
| Experimental: CBT and Return to work<br>Participants randomized to this arm will receive a combination of cognitive behavior therapy and the return to work treatment. This arm is included in the study as the clinically most relevant therapy, would the return to work treatment be effective in reducing sick leave, is a treatment were patients are provided support to return to work but also is clinically effective in reducing psychiatric symptoms. | Behavioral: Cognitive behavior therapy<br>* Cognitive behavior therapy entails psychoeducational components, i.e. the patient is learns about the disorder and how to view it from a cognitive behavioral perspective. The most important part of the treatment is systematic behavior changes often targeted at exposure to feared stimuli. This is combined with cognitive interventions targeted at challenging negative automatic thoughts. All treatments will be delivered by licensed psychologists.<br>Behavioral: Return to work<br>* Participants randomized to this arm will receive an experimental treatment, based in cognitive behavioral therapy, with primary aim to help patients return to work. Interventions are aimed at solving work-related problems and comprises problem-solving training and systematic employer-patient meetings aimed at facilitating a gradual return to the workplace. Licensed psychologists deliver all treatments.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Sick leave | Number of days on sick leave | 1 year | 
| Clinician Severity Rating (CSR) | Change in CSR at post-treatment, 26 week follow-up, and 52 week follow-up compared to baseline. | Baseine, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Montgomery-Åsberg Depression Rating Scale-Self-report (MADRS-S) | Change in MADRS-S at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Work ability index (WAI) | Change in WAI at post-treatment, 26 week follow-up, 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Insomnia Severity Index (ISI) | Change in ISI at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder, 26 week follow-up, 52 week follow-up | 
| Health Anxiety Inventory (HAI) | Change in HAI at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Perceived Stress Scale (PSS) | Change in PSS at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Trimbos and Institute of Technology Cost Questionnaire for Psychiatry (TIC-P) | Change in TIC-P at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Quality of Life Inventory (QOLI) | Change in QOLI at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| EuroQol-5 dimension (EQ5D) | Change in EQ5D at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 feel follow-up, 52 week follow-up | 
| Sheehan Disability Scales (SDS) | Change in SDS at post-treatment, 26 week follow-up, and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Self-rated health 5 (SRH-5) | Change in SRH-5 at post-treatment, 26 week follow-up and 52 week follow-up | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Obsessive Compulsive Inventory-Revised (OCI-R) | Change in OCI-R at post-treatment, 26 week follow-up, and 52 week follow-up. Disorder specific. | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Liebowitz Social Anxiety Scale Self-report (LSAS-SR) | Change in LSAS-SR at post-treatment, 26 week follow-up, and 52 week follow-up. Disorder specific. | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Panic Disorder Severity Scale Self-rated (PDSS-SR) | Change in PDSS-SR at post-treatment, 26 week follow-up, and 52 week follow-up. Disorder specific. | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Penn-State Worry Questionnaire (PSWQ) | Change in PSWQ at post-treatment, 26 week follow-up, and 52 week follow-up. Disorder specific. | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up | 
| Post Traumatic Stress Disorder Symptom Scale-Self report (PTSDSS) | Change in PTSDSS at post-treatment, 26 week follow-up, and 52 week follow-up. Disorder specific. | Baseline, post-treatment (variable depending on disorder), 26 week follow-up, 52 week follow-up |