Use of a mental health guideline by occupational physicians and associations with return to work in workers sick-listed due to common mental disorders: a retrospective cohort study

Figures & data

Table 1. Summery of the Dutch occupational mental health guideline [8].

Part of the guideline		Content
1	Problem orientation and diagnosis	An early involvement of the occupational physician in the sick leave process of the worker is promoted (first consultation within 2 weeks after the worker reports sick). A simplified classification of mental health problems is introduced in four categories: (i) stress-related complaints, (ii) depression, (iii) anxiety disorder, and (iv) other psychiatric disorders. Furthermore, problem inventory should focus on factors related to the worker, his or her work environment, and the interaction between these two.
2	Intervention/Treatment	The occupational physician acts as a case manager by monitoring and evaluating the recovery process. If recovery stagnates the occupational physician should intervene by acting as care manager by using cognitive behavioral techniques to enhance the problem-solving capacity of the worker, providing the worker and the work environment with information and advice on the recovery and the return to work process, contact the general practitioner when problems remain the same or increase, and refer the worker to a specialized intervention if necessary. In addition, the occupational physician should advise the work environment (e.g. supervisors, managers, human resource managers) on how to support the worker and support the recovery and return to work process.
3	Relapse prevention	Integration of relapse prevention from the first contact with the worker by enhancing the problem-solving capacity of the worker. The newly acquired problem solving skills are explicitly addressed in at least one specific relapse prevention meeting after return to work.
4	Continuity of care/Evaluation	During all meetings, evaluation of the recovery process includes the perspectives of the worker, supervisor, and other involved professionals. Follow-up meetings with the worker should take place every 3 weeks during the first 3 months, and every 6 weeks thereafter. The supervisor or work environment should be contacted once a month. Follow-up contacts with the general practitioner or other professionals should take place when the recovery process stagnates or when there is doubt about the diagnosis or treatment.

Table 2. Description of 12 performance indicators for occupational physicians’ guideline adherence in workers’ medical records and criteria for their scoring [Joosen et al., submitted].

Performance Indicator		Criteria	Scoring*
1. Process diagnosis
1.1	Monitoring the recovery phase of the worker	The process of recovery (i.e. phase of the recovery process: crisis phase, problem solving phase, implementation phase) should be monitored throughout the sickness absence period	0 = Recovery phase not documented 1 = Recovery phase occasionally documented 2 = Recovery phase regularly documented
1.2	Assessment of the worker’s recovery tasks	The tasks needed to achieve recovery should be assessed throughout the sickness absence period (e.g. gaining insight into what happened, accepting the situation, regain day structure, problem identification and finding solutions, implement solutions, regain roles)	0 = Recovery tasks not documented 1 = Recovery tasks occasionally documented 2 = Recovery tasks regularly documented
1.3	Assessment of the employers’ perspective	The way the employer (e.g. supervisor, management, human resource management) copes with the sick-listed worker and their perspective on recovery should be assessed during the sickness absence period	0 = No information about the employers’ perspective 1 = Occasional information about the employers’ perspective 2 = Clear description of the employers’ perspective in relation to the worker’s situation
2. Problem orientation
2.1	Problem identification	The relation between factors that influence the mental health problems and performance at work and home should be identified (e.g. overburdened by high workload or work conflict or lack of social support)	0 = Problems not documented 1 = Problems documented, relation with performance not documented 2 = Problems and their relation with performance documented
2.2	Assessment of symptoms	Presence or absence of essential symptoms of mental health problems should be assessed (i.e. distress, depression, anxiety, and somatization)	0 = No symptoms documented 1 = Symptoms occasionally documented 2 = Presence or absence of the essential symptoms documented
2.3	Diagnosis	Diagnosis based on ICD-10 and supported with arguments	0 = No diagnosis documented 1 = Diagnosis documented without arguments 2 = Diagnosis documented, including arguments
3. Intervention/Treatment
3.1	Evaluation of the worker’s course of the recovery process	The course of the recovery process (stagnation or recovery process as expected) should be evaluated and supported with arguments.	0 = Course of recovery process not documented 1 = Course of recovery process documented without arguments 2 = Course of recovery process documented including arguments
3.2	Treatment in accordance with the worker’s recovery process	IF recovery process is 'as expected', the occupational physician acts as process manager by monitoring the process of recovery and using minimal interventions. IF recovery process stagnates, the occupational physician also acts as care manager by providing a more extensive guidance with treatment based on cognitive behavioral techniques, providing the employer with advice on recovery and the return to work process, contacting other health care professionals (e.g. general practitioner, psychologist), and if necessary referring the worker to specialized care.	0 = Treatment is not in accordance with the recovery process 1 = Treatment is in accordance with the recovery process without argumentation 2 = Treatment is in accordance with the recovery process including argumentation
4. Relapse prevention
4.1	Relapse prevention	Relapse prevention should be integrated during consultations AND the occupational physician has at least one consultation with the worker after full return to work	0 = No information on relapse prevention documented 1 = Information on relapse prevention during or after the sickness absence period documented 2 = Information on relapse prevention during the sickness absence period documented AND the occupational physician had at least one consultation with the worker after full return to work
5. Continuity of care/Evaluation
5.1	Rapid first consultation	First face-to-face consultation within 15 days from the first day of sickness absence.	0 = First consultation after 22 days 1 = First consultation between 15–22 days 2 = First consultation with 15 days
5.2	Regular contact with the worker	Consultations with the worker take place every 3 weeks during the first three months of sickness absence. Thereafter consultations take place every 6 weeks.	0 = Interval between consultations 6 weeks or more during first 3 months AND 9 weeks or more thereafter 1 = Interval between consultations 4–5 weeks during first 3 months AND 7–8 weeks thereafter 2 = Interval between consultations less than 4 weeks during first 3 months AND less than 7 weeks thereafter
5.3	Regular contact with the employer	Occupational physician contacts the employer (e.g. supervisor, manager, human resource manager) during the sickness absence period every 4 weeks.	0 = Contacts every 8 weeks or more 1 = Contacts every 5–8 weeks 2 = Contacts every 4 weeks or less

* Scoring: 0 = no adherence, 1 = minimal adherence, 2 = adequate adherence.

Table 3. Guideline adherence per performance indicator (percentages of workers, n = 114).

		No adherence = score 0		Low adherence = score 1		Adequate adherence = score 2
Performance Indicator		IG n = 55	CG n = 59	IG n = 55	CG n = 59	IG n = 55	CG n = 59
Process diagnosis		%	%	%	%	%	%
1.1	Monitoring the recovery phase of the worker	41.8	71.2	47.3	28.8	10.9	0.0
1.2	Assessment of the worker’s recovery tasks	29.1	61.0	65.5	39.0	5.5	0.0
1.3	Assessment of the employers’ perspective	32.7	33.9	49.1	52.5	18.2	13.6
Problem orientation
2.1	Problem identification	0.0	8.5	74.5	79.5	25.5	11.9
2.2	Assessment of symptoms	56.4	74.6	34.5	22.0	9.1	3.4
2.3	Diagnosis	10.9	20.3	78.2	76.3	10.9	3.4
Interventions/Treatment
3.1	Evaluation of the worker’s course of the recovery process	30.9	57.6	60.0	35.6	9.1	6.8
3.2	Treatment in accordance with the worker’s recovery process	40.0	57.6	45.5	32.2	14.5	10.2
Relapse prevention
4.1	Relapse prevention	72.7	86.4	25.5	11.9	1.8	1.7
Continuity of care/Evaluation
5.1	Rapid first consultation	34.5	28.8	12.7	18.6	52.7	52.5
5.2	Regular contact with the worker	36.4	35.6	36.4	39.0	27.3	25.4
5.3	Regular contact with the employer	78.2	79.7	9.1	8.5	12.7	11.9

IG: intervention group (n = 55);

CG: control group (n = 59).

Table 4. Baseline characteristics of the workers.

Characteristic		n	Mean	SD	%	% workers above cutoff value
Age		114	46.4	10.7	.	.
Gender, male		114	.	.	41.2	.
Return to work self-efficacy (range 1–6)^a		107	3.5	0.8	.	.
Workability (range 0–10)^a		103	5.4	2.5	.	.
4-DSQ (Four-Dimensional Symptom Questionnaire)
Distress (range 0–32, cutoff >10)^a		109	18.0	9.3	.	74.3
Depression (range 0–12, cutoff >2)^a		111	2.8	3.7	.	39.6
Anxiety (range 0–24, cutoff >3)^a		109	5.4	5.2	.	50.5
Somatization (range 0–32, cutoff >10)^a		107	9.3	6.6	.	35.5

^a Higher scores indicate a greater presence of the named factor.

Table 5. Effect of guideline adherence per performance indicator on time to first return to work, adjusted for significant confounders (n = 114).

Performance Indicator		HR	95% CI	p value	Confounder
Process diagnosis
1.1	Monitoring the recovery phase of the worker	0.68	0.44–1.06	0.088	Anxiety
1.2	Assessment of the worker’s recovery tasks	0.79	0.52–1.21	0.279
1.3	Assessment of the employers’ perspective	0.59	0.36–0.96	0.033*	Gender, anxiety, RTW-SE
Problem orientation
2.1	Problem identification	0.92	0.34–2.50	0.877
2.2	Assessment of symptoms	0.71	0.45–1.14	0.162
2.3	Diagnosis	0.75	0.43–1.30	0.302
Intervention/Treatment
3.1	Evaluation of the worker’s course of the recovery process	0.81	0.53–1.23	0.320
3.2	Treatment in accordance with the worker’s recovery process	1.05	0.69–1.59	0.829
Relapse prevention
4.1	Relapse prevention	1.47	0.87–2.48	0.150
Continuity of care/Evaluation
5.1	Rapid first consultation	1.32	0.84–2.09	0.231
5.2	Regular contact with the worker	1.26	0.81–1.98	0.304
5.3	Regular contact with the employer	1.36	0.82–2.26	0.228

RTW-SE: return to work self-efficacy;

HR: hazard ratio 95% CI: 95% confidence interval;

* Significant p < 0.05.

Table 6. Effect of guideline adherence per performance indicator on time to full return to work, adjusted for significant confounders (n = 114).

Performance indicator		HR	95% CI	p value	Confounder
Process diagnosis
1.1	Monitoring the recovery phase of the worker	0.62	0.39–0.97	0.035*	Anxiety
1.2	Assessment of the worker’s recovery tasks	0.92	0.60–1.38	0.667
1.3	Intervention group: assessment of the employers’ perspective	1.52	0.75–3.06	0.246	Anxiety, somatization, workability
	Control group: assessment of the employers’ perspective	0.37	0.18–0.77	0.008*	Anxiety, somatization, workability
Problem orientation
2.1	Problem identification	0.68	0.26–1.24	0.439
2.2	Assessment of symptoms	0.80	0.52–1.24	0.317
2.3	Diagnosis	0.87	0.50–1.54	0.642
Intervention/Treatment
3.1	Intervention group: evaluation of the worker’s course of the recovery process	1.72	0.68–4.38	0.254	Distress, anxiety, somatization, workability, RTW-SE
	Control group: evaluation of the worker’s course of the recovery process	0.63	0.29–1.39	0.254	Distress, anxiety, somatization, workability, RTW-SE
3.2	Treatment in accordance with the worker’s recovery process	1.16	0.77–1.75	0.487
Relapse prevention
4.1	Relapse prevention	1.21	0.74–2.00	0.443
Continuity of care/Evaluation
5.1	Rapid first consultation	1.29	0.81–2.03	0.281
5.2	Regular contact with the worker	1.66	0.98–2.81	0.058	Workability, RTW-SE
5.3	Regular contact with the employer	1.87	1.10–3.16	0.021*	Distress, depression, somatization, RTW-SE

RTW-SE: return to work self-efficacy; HR: hazard ratio 95% CI: 95% confidence interval;

* Significant p < 0.05.

Van der Klink JJL, Ausems CMM, Beijderwellen BD, et al. Richtlijn: Handelen van de bedrijfsarts bij werkenden met psychische problemen, herziene uitgave. [Guideline:The management of mental health problems of workers by occupational physicians; revised version]. Utrecht: NVAB [Netherlands Society of Occupational Medicine]; 2007.

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