Strategies for Implementing Occupational eMental Health Interventions: Scoping Review.

BACKGROUND: The implementation of eMental health interventions, especially in the workplace, is a complex process. Therefore, learning from existing implementation strategies is imperative to ensure improvements in the adoption, development, and scalability of occupational eMental health (OeMH) interventions. However, the implementation strategies used for these interventions are often undocumented or inadequately reported and have not been systematically gathered across implementations in a way that can serve as a much-needed guide for researchers. OBJECTIVE: The objective of this scoping review was to identify implementation strategies relevant to the uptake of OeMH interventions that target employees and detail the associated barriers and facilitation measures. METHODS: A scoping review was conducted. The descriptive synthesis was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and the Consolidated Framework for Implementation Research. RESULTS: A total of 31 of 32,916 (0.09%) publications reporting the use of the web-, smartphone-, telephone-, and email-based OeMH interventions were included. In all, 98 implementation strategies, 114 barriers, and 131 facilitators were identified. The synthesis of barriers and facilitators produced 19 facilitation measures that provide initial recommendations for improving the implementation of OeMH interventions. CONCLUSIONS: This scoping review represents one of the first steps in a research agenda aimed at improving the implementation of OeMH interventions by systematically selecting, shaping, evaluating, and reporting implementation strategies. There is a dire need for improved reporting of implementation strategies and combining common implementation frameworks with more technology-centric implementation frameworks to fully capture the complexities of eHealth implementation. Future research should investigate a wider range of common implementation outcomes for OeMH interventions that also focus on a wider set of common mental health problems in the workplace. This scoping review's findings can be critically leveraged by discerning decision-makers to improve the reach, effectiveness, adoption, implementation, and maintenance of OeMH interventions.

A regional systems intervention for suicide prevention in the Netherlands (SUPREMOCOL): study protocol with a stepped wedge trial design.

BACKGROUND: In the Netherlands, suicide rates showed a sharp incline and this pertains particularly to the province of Noord-Brabant, one of the southern provinces in the Netherlands. This calls for a regional suicide prevention effort. METHODS/DESIGN: Study protocol. A regional suicide prevention systems intervention is implemented and evaluated by a stepped wedge trial design in five specialist mental health institutions and their adherent chain partners. Our system intervention is called SUPREMOCOL, which stands for Suicide Prevention by Monitoring and Collaborative Care, and focuses on four pillars: 1) recognition of people at risk for suicide by the development and implementation of a monitoring system with decision aid, 2) swift access to specialist care of people at risk, 3) positioning nurse care managers for collaborative care case management, and 4) 12 months telephone follow up. Eligible patients are persons attempting suicide or expressing suicidal ideation. Primary outcome is number of completed suicides, as reported by Statistics Netherlands and regional Public Health Institutes. Secondary outcome is number of attempted suicides, as reported by the regional ambulance transport and police. Suicidal ideation of persons registered in the monitoring system will, be assessed by the PHQ-9 and SIDAS questionnaires at baseline and 3, 6, 9 and 12 months after registration, and used as exploratory process measure. The impact of the intervention will be evaluated by means of the RE-AIM dimensions reach, efficacy, adoption, implementation, and maintenance. Intervention integrity will be assessed and taken into account in the analysis. DISCUSSION: The present manuscript presents the design and development of the SUPREMOCOL study. The ultimate goal is to lower the completed suicides rate by 20%, compared to the control period and compared to other provinces in the Netherlands. Moreover, our goal is to provide specialist mental health institutions and chain partners with a sustainable and adoptable intervention for suicide prevention. TRIAL REGISTRATION: Netherlands Trial Register under registration number NL6935 (5 April 2018). This is the first version of the study protocol (September 2019).

Effectiveness of a self-management training for patients with chronic and treatment resistant anxiety or depressive disorders on quality of life, symptoms, and empowerment: results of a randomized controlled trial.

BACKGROUND: Anxiety and depressive disorders are common mental disorders. A substantial part of patients does not achieve symptomatic remission after treatment in specialized services. Current care as usual (CAU) for these patients consists of long-term supportive contacts. Termination of CAU is often not considered to be an option due to persistent symptoms, a low level of functioning, and the absence of further treatment options. A new intervention, ZemCAD, offers a program focused on rehabilitation and self-management, followed by referral back to primary care. METHODS: This multicenter randomized controlled trial was carried out in twelve specialized outpatient mental health care services in the Netherlands. Consenting and eligible patients were invited for the MINI interview and the baseline questionnaire. Assessments were done at 6 (T1), 12 (T2) and 18 (T3) months post baseline. We used linear mixed model analysis (LMM) to ascertain the effectiveness of the ZemCAD group relative to the CAU group on quality of life, symptom severity and empowerment. RESULTS: In total 141 patients were included. The results at 18-month follow-up regarding to quality of life and symptom severity, showed no significant differences between the ZemCAD group and the CAU group, except on the 'social relationships'-domain (d = 0.37). With regard to empowerment a significant difference between both groups was observed in the total empowerment score and one empowerment dimension (d = 0.45 and d = 0.39, respectively). After the ZemCAD intervention, more patients went from specialized outpatient mental health services back to a less specialized health care setting with less intensive treatment, such as primary care. CONCLUSION: The findings in this study suggest that patients with chronic and treatment-resistant anxiety and depression using the ZemCAD intervention improve on empowerment but not on symptom severity or quality of life. Since little is known about the effects of rehabilitation and self-management in patients with chronic and treatment resistant anxiety and depressive disorders, this is a first attempt to provide a proof-of-concept study in this under-researched but important field. TRIAL REGISTRATION: Netherlands Trial Register: NTR3335 , registered 7 March 2012.

Shared decision-making in mental health care using routine outcome monitoring: results of a cluster randomised-controlled trial.

PURPOSE: To investigate the effects of Shared Decision-Making (SDM) using Routine Outcome Monitoring (ROM) primary on patients' perception of Decisional Conflict (DC), which measures patients' engagement in and satisfaction with clinical decisions, and secondary on working alliance and treatment outcomes. METHOD: Multi-centre two-arm matched-paired cluster randomised-controlled trial in Dutch specialist mental health care. SDM using ROM (SDMR) was compared with Decision-Making As Usual (DMAU). Outcomes were measured at baseline (T0) and 6 months (T1). Multilevel regression and intention-to-treat analyses were used. Post hoc analyses were performed on influence of subgroups and application of SDMR on DC. RESULTS: Seven teams were randomised to each arm. T0 was completed by 186 patients (51% intervention; 49% control) and T1 by 158 patients (51% intervention, 49% control). DC, working alliance, and treatment outcomes reported by patients did not differ significantly between two arms. Post hoc analyses revealed that SDMR led to less DC among depressed patients (p = 0.047, d =- 0.69). If SDMR was applied well, patients reported less DC (SDM: p = 0.000, d = - 0.45; ROM: p = 0.021, d = - 0.32), which was associated with better treatment outcomes. CONCLUSION: Except for patients with mood disorders, we found no difference between the arms for patient-reported DC. This might be explained by the less than optimal uptake of this generic intervention, which did not support patients directly. Regarding the positive influence of a higher level of applying SDM and ROM on less DC and better treatment outcomes, the results are encouraging for further investments in patient-oriented development and implementation of SDMR.

Assessing Costs Using the Treatment Inventory Cost in Psychiatric Patients (TIC-P), TIC-P Mini and TIC-P Midi.

BACKGROUND: The Treatment Inventory Cost in Psychiatric patients (TIC-P) instrument is designed to measure societal costs in patients with psychiatric disorders and to be applied in economic evaluations. Efforts have been made to minimize respondents' burden by reducing the number of questions and meanwhile retaining the comprehensiveness of the instrument. Previously, a TIC-P Mini version and a TIC-P Midi version were developed and tested in a predominantly inpatient patient population. AIMS OF THE STUDY: The aims of this study are to examine the comprehensiveness of the abridged questionnaires in estimating the societal costs for patients with anxiety or depressive disorders and to assess the impact of productivity costs on the total costs. METHODS: The comprehensiveness of the abridged versions of the TIC-P was assessed in four populations: a group of primary care patients with anxiety disorders (n=175) and three groups of patients with major depressive disorders in various outpatient settings (n=140; n=125; and n=79). Comprehensiveness was measured using the proportion of total health care costs and productivity costs covered by the abridged versions compared to the full-length TIC-P. Costs were calculated according to the guidelines for costing studies using the Dutch costing manual. RESULTS: Our results showed that the TIC-P Mini covered 26%-64% of health care costs and the TIC-P Midi captured 54%-79% of health care costs. Health care costs in these populations were predominantly dispersed over primary care, outpatient hospital care, outpatient specialist care and inpatient hospital care. The TIC-P Midi and TIC-P Mini captured 22% and 0% of primary care costs respectively. In contrast, inpatient hospital care costs and outpatient specialist mental health care costs were almost fully included in the abridged versions. Costs due to lost productivity as measured by the full-length TIC-P were substantial, representing 38% to 92% of total costs. DISCUSSION: A reduction of the number of items resulted in a substantial loss in the ability to measure health care costs compared to the full-length TIC-P, because these outpatient populations consumed health care from a variety of health care providers. Two limitations of the study need to be stressed. Firstly, the number of patients in each of the four studies was relatively small. However, results were consistent over the four studies despite the small number of patients. Secondly, we did not take costs of medication into account. IMPLICATIONS FOR HEALTH POLICIES: In developing mental health policy, it is important to include considerations on cost-effectiveness. Increasing the evidence on instruments to measure costs from a societal perspective may support policymakers to adopt a broader perspective. IMPLICATIONS FOR FURTHER RESEARCH: The TIC-P Mini is not suitable to capture health care costs in outpatients with anxiety or depressive disorders. The comprehensiveness of TIC-P Midi compared to the full-length TIC-P varied. The TIC-P Midi should therefore be revised in order to better capture costs in all patient groups.

Neurocognitive dysfunctioning and the impact of comorbid depression and anxiety in patients with somatic symptom and related disorders: a cross-sectional clinical study.

BACKGROUND: The prevalence and severity of neurocognitive dysfunctioning of patients with somatic symptom and related disorders (SSRD) is unknown. Furthermore, the influence of comorbid depression and anxiety has not been evaluated. This study examines neurocognitive dysfunctioning of patients with SSRD and explores if comorbid depression and anxiety is associated with specific neurocognitive dysfunctioning. METHODS: Cross-sectional study with consecutive patients suffering from SSRD visiting an outpatient specialty mental health care Centre of Excellence for SSRD. Extensive neuropsychological assessment and assessment of depression and anxiety symptom levels using the Patient-Health-Questionnaire-9 and General Anxiety Disorder questionnaire-7 were performed at intake. Multivariate analysis was performed. RESULTS: The study sample consisted of 201 SSRD patients, with a mean age of 43 years (Standard deviation = 13) years; 37.8% were male. Neurocognitive dysfunction in the domains information processing speed, sustained and divided attention, working memory, verbal and visual memory were reported, compared with normative data. Comorbid depression and anxiety occurred frequently within the sample (75.1% and 65.7%, respectively). Neurocognitive dysfunctioning was worse in patients suffering from comorbid depression [multivariate F (7,161) = 2.839, p = 0.008] but not in patients with comorbid anxiety. CONCLUSIONS: Poor neurocognitive performance of patients with SSRD is common and worsens in case of comorbid depression. This may explain treatment dropout of patients with SSRD from neurocognitive behavioral therapy. Research on novel interventions is needed targeting neurocognitive functioning of patients with SSRD, particularly those with comorbid depression.

Decisional conflict in mental health care: a cross-sectional study.

PURPOSE: Decisional conflict refers to the degree to which patients are engaged in and feel comfortable about important clinical decisions. Until now, the concept has received little attention in mental health care. We investigate the level of decisional conflict in mental health care and whether this is influenced by socio-demographics, treatment setting, diagnoses, and locus of control. METHODS: Cross-sectional study among 186 patients in Dutch specialist mental health care using the Decisional Conflict Scale, which measures five dimensions of decisional conflict: information, support, clarification of values, certainty, and decisional quality. Descriptive statistics and forward stepwise linear regression analyses were used. RESULTS: Patients report relatively high levels of decisional conflict, especially those with more external locus of control. Having a personality disorder and higher education also increases decisional conflict on the dimensions support and clarification of values, respectively. Less decisional conflict was experienced by patients with psychotic disorders on the dimension certainty and by women on the information domain. CONCLUSIONS: Decisional conflict is common among patients in specialist mental health care and is very useful for assessing the quality of clinical decision making. Measuring decisional conflict and knowledge about influencing factors can be used to improve patients' participation in clinical decision making, adherence to treatment and clinical outcomes.

Schema therapy for personality disorders in older adults: a multiple-baseline study.

OBJECTIVE: No studies have been conducted yet into the effectiveness of treatment of personality disorders in later life. This study is a first test of the effectiveness of schema therapy for personality disorders in older adults. METHOD: Multiple-baseline design with eight cluster C personality disorder patients, with a mean age of   69. After a baseline phase with random length, schema therapy was given during the first year, followed by follow-up sessions during six months. Participants weekly rated the credibility of dysfunctional core beliefs. Symptomatic distress, early maladaptive schemas, quality of life and target complaints were assessed every six months and personality disorder diagnosis was assessed before baseline and after follow-up. Data were analyzed with mixed regression analyses. RESULTS: Results revealed significant linear trends during treatment phases, but not during baseline and follow-up. The scores during follow-up remained stable and were significantly lower compared to baseline, with high effect sizes. Seven participants remitted from their personality disorder diagnosis. CONCLUSION: Schema therapy appears an effective treatment for cluster C personality disorders in older adults. This finding is highly innovative as this is the first study exploring the effectiveness of psychotherapy, in this case schema therapy, for personality disorders in older adults.

Complexity Assessed by the INTERMED in Patients With Somatic Symptom Disorder Visiting a Specialized Outpatient Mental Health Care Setting: A Cross-sectional Study.

BACKGROUND: Somatic symptom disorders (SSD), a new classification in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition is associated with problematic diagnostic procedures and treatment that lead to complex care. In somatic health care, the INTERMED has been used to assess levels of complexity; however, in SSD this instrument has not yet been applied. OBJECTIVE: This study aims to explore complexity in patients with SSD using the INTERMED, hereby contributing to an increased comprehension of this new patient group. METHOD: In this cross-sectional study, the INTERMED was used to assess complexity in outpatients with SSD at the Clinical Centre of Excellence for Body, Mind, and Health (The Netherlands), along biologic, psychologic, social, and health care domains. This was done retrospectively with patient files from consecutive patients from 2011 until 2015. RESULTS: In the total SSD sample (N = 187), 63% was female, the mean age (standard deviation) was 42 (±12.4) years, with an average educational level. The mean INTERMED score was 23.5 indicating high overall complexity in this population. A high proportion of our sample (69%) scored as highly complex (>20). High complexity was associated with higher depression and anxiety scores, but not with a higher number of physical symptoms. CONCLUSIONS: This study demonstrates that patients with SSD form a high-complex group, with higher scores compared with literature about multiple sclerosis, rheumatoid arthritis, or patient waiting for a liver transplant. INTERMED outcomes indicate a need for extensive diagnostic procedures and integrated multidisciplinary care for patients with SSD. Attention should especially be paid to mental disorders (depression and anxiety), given their association with high complexity.

A digital intake approach in specialized mental health care: study protocol of a cluster randomised controlled trial.

BACKGROUND: Enhancing patient participation is becoming increasingly important in mental health care as patients use to have a dependent, inactive role and nonadherence to treatment is a regular problem. Research shows promising results of initiatives stimulating patient participation in partnership with their clinicians. However, few initiatives targeting both patients' and clinicians' behaviour have been evaluated in randomised trials (RCT). Therefore, in GGz Breburg, a specialized mental health institution, a digital intake approach was developed aimed at exploring treatment needs, expectations and preferences of patients intended to prepare patients for the intake consultations. Subsequently, patients and clinicians discuss this information during intake consultations and make shared decisions about options in treatment. The aim of this trial is to test the efficacy of this new digital intake approach facilitated by Routine Outcome Monitoring (ROM), peer support and training of clinicians as compared to the intake as usual. The primary outcome is decisional conflict about choices in treatment. Secondary outcomes focus on patient participation, shared decision making, working alliance, adherence to treatment and clinical outcomes. METHODS: This article presents the study protocol of a cluster-randomised controlled trial in four outpatient departments for adults with depression, anxiety and personality disorders, working in two different regions. Randomisation is done between two similar intake-teams within each department. In the four intervention teams the new intake approach is implemented. The four control teams apply the intake as usual and will implement the new approach after the completion of the study. In total 176 patients are projected to participate in the study. Data collection will be at baseline, and at two weeks and two months after the intake. DISCUSSION: This study will potentially demonstrate the efficacy of the new digital intake approach in mental health care in terms of the primary outcome the degree of decisional conflict about choices in treatment. The findings of this study may contribute to the roll out of such eHealth initiatives fostering patient involvement in decision making about their treatment. TRIAL REGISTRATION: Trial registration: Dutch Trial Register NTR5677 . Registered 17th January 2016.

Collaborative care for anxiety disorders in primary care: a systematic review and meta-analysis.

BACKGROUND: Studies evaluating collaborative care for anxiety disorders are recently emerging. A systematic review and meta-analysis to estimate the effect of collaborative care for adult patients with anxiety disorders in primary care is therefore warranted. METHODS: A literature search was performed. DATA SOURCES: PubMed, Psycinfo, Embase, Cinahl, and the Cochrane library. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials examining the effects of collaborative care for adult primary care patients with an anxiety disorder, compared to care as usual or another intervention. Synthesis methods: Standardized mean differences (SMD) on an anxiety scale closest to twelve months follow-up were calculated and pooled in a random effects meta-analysis. RESULTS: Of the 3073 studies found, seven studies were included with a total of 2105 participants. Included studies were of moderate to high quality. Collaborative care was superior to care as usual, with a small effect size (SMD = 0.35 95 % CI 0.14-0.56) for all anxiety disorders combined and a moderate effect size (SMD = 0.59, 95 % CI 0.41-0.78) in a subgroup analysis (five studies) on patients with panic disorder. CONCLUSIONS: Collaborative care seems to be a promising strategy for improving primary care for anxiety disorders, in particular panic disorder. However, the number of studies is still small and further research is needed to evaluate the effectiveness in other anxiety disorders.

Different Perspectives of Clinicians and Patients with Severe Mental Illness on Motivation for Treatment.

The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Clinicians show poor to moderate capability in estimating how patients perceive their motivation for engaging in treatment, especially so when the patient's motives revolve around feelings of shame and guilt. Clinicians generally give higher motivation ratings for patients where they experience a higher quality therapeutic relationships with, whereas-depending on the scale that is used to measure motivation-they give lower ratings to patients who respond in socially desirable ways and to ethnic minority patients. As patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment (regardless of the theoretical framework that is used to assess motivation), this implies that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions.

Shared Decision Making in mental health care using Routine Outcome Monitoring as a source of information: a cluster randomised controlled trial.

BACKGROUND: Shared Decision Making (SDM) is a way to empower patients when decisions are made about treatment. In order to be effective agents in this process, patients need access to information of good quality. Routine Outcome Monitoring (ROM) may provide such information and therefore may be a key element in SDM. This trial tests the effectiveness of SDM using ROM, primarily aiming to diminish decisional conflict of the patient while making decisions about treatment. The degree of decisional conflict, the primary outcome of this study, encompasses personal certainty about choosing an appropriate treatment, information about options, clarification of patient values, support from others and patients experience of an effective decision making process. Secondary outcomes of the study focus on the working alliance between patient and clinician, adherence to treatment, and clinical outcome and quality of life. METHODS/DESIGN: This article presents the study protocol of a multi-centre two-arm cluster randomised controlled trial (RCT). The research is conducted in Dutch specialised mental health care teams participating in the ROM Quality Improvement Collaborative (QIC), which aims to implement ROM in daily clinical practice. In the intervention teams, ROM is used as a source of information during the SDM process between the patient and clinician. Control teams receive no specific SDM or ROM instructions and apply decision making as usual. Randomisation is conducted at the level of the participating teams within the mental health organisations. A total of 12 teams from 4 organisations and 364 patients participate in the study. Prior to data collection, the intervention teams are trained to use ROM during the SDM process. Data collection will be at baseline, and at 3 and 6 months after inclusion of the patient. Control teams will implement the SDM and ROM model after completion of the study. DISCUSSION: This study will provide useful information about the effectiveness of ROM within a SDM framework. Furthermore, with practical guidelines this study may contribute to the implementation of SDM using ROM in mental health care. Reporting of the results is expected from December 2016 onwards. TRIAL REGISTRATION: Dutch trial register: TC5262. Trial registration date: 24th of June 2015.

Research priorities for public mental health in Europe: recommendations of the ROAMER project.

BACKGROUND: The ROAdmap for MEntal health Research in Europe project aimed to create an integrated European roadmap for mental health research. Leading mental health research experts across Europe have formulated consensus-based recommendations for future research within the public mental health field. METHODS: Experts were invited to compile and discuss research priorities in a series of topic-based scientific workshops. In addition, a Delphi process was carried out to reach consensus on the list of research priorities and their rank order. Three web-based surveys were conducted. Nearly 60 experts were involved in the priority setting process. RESULTS: Twenty priorities for public mental health research were identified through the consensus process. The research priorities were divided into summary principles-encompassing overall recommendations for future public mental health research in Europe-and thematic research priorities, including area-specific top priorities on research topics and methods. The priorities represent three overarching goals mirroring societal challenges, that is, to identify causes, risk and protective factors for mental health across the lifespan; to advance the implementation of effective public mental health interventions and to reduce disparities in mental health. CONCLUSIONS: The importance of strengthening research on the implementation and dissemination of promotion, prevention and service delivery interventions in the mental health field needs to be emphasized. The complexity of mental health and its broader conceptualisation requires complementary research approaches and interdisciplinary collaboration to better serve the needs of the European population.

Effectiveness of a blended web-based intervention on return to work for sick-listed employees with common mental disorders: results of a cluster randomized controlled trial.

BACKGROUND: Common mental disorders are strongly associated with long-term sickness absence, which has negative consequences for the individual employee's quality of life and leads to substantial costs for society. It is important to focus on return to work (RTW) during treatment of sick-listed employees with common mental disorders. Factors such as self-efficacy and the intention to resume work despite having symptoms are important in the RTW process. We developed "E-health module embedded in Collaborative Occupational health care" (ECO) as a blended Web-based intervention with 2 parts: an eHealth module (Return@Work) for the employee aimed at changing cognitions of the employee regarding RTW and a decision aid via email supporting the occupational physician with advice regarding treatment and referral options based on monitoring the employee's progress during treatment. OBJECTIVE: This study evaluated the effect of a blended eHealth intervention (ECO) versus care as usual on time to RTW of sick-listed employees with common mental disorders. METHODS: The study was a 2-armed cluster randomized controlled trial. Employees sick-listed between 4 and 26 weeks with common mental disorder symptoms were recruited by their occupational health service or employer. The employees were followed up to 12 months. The primary outcome measures were time to first RTW (partial or full) and time to full RTW. Secondary outcomes were response and remission of the common mental disorder symptoms (self-assessed). RESULTS: A total of 220 employees were included: 131 participants were randomized to the ECO intervention and 89 to care as usual (CAU). The duration until first RTW differed significantly between the groups. The median duration was 77.0 (IQR 29.0-152.3) days in the CAU group and 50.0 (IQR 20.8-99.0) days in the ECO group (hazard ratio [HR] 1.390, 95% CI 1.034-1.870, P=.03). No significant difference was found for duration until full RTW. Treatment response of common mental disorder symptoms did not differ significantly between the groups, but at 9 months after baseline significantly more participants in the ECO group achieved remission than in the CAU group (OR 2.228, 95% CI 1.115-4.453, P=.02). CONCLUSIONS: The results of this study showed that in a group of sick-listed employees with common mental disorders, applying the blended eHealth ECO intervention led to faster first RTW and more remission of common mental disorder symptoms than CAU. TRIAL REGISTRATION: Netherlands Trial Register NTR2108; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2108. (Archived by WebCite at http://www.webcitation.org/6YBSnNx3P).

Validation of the 4DSQ somatization subscale in the occupational health care setting as a screener.

PURPOSE: Somatoform disorders (physical symptoms without medical explanation that cause dysfunction) are prevalent in the occupational health (OH) care setting and are associated with functional impairment and absenteeism. Availability of psychometric instruments aimed at assessing somatoform disorders is limited. In the OH setting, so far only the Patient-Health-Questionnaire 15 has been validated as screener for somatoform disorder, and has been shown to have moderate validity. The Four-Dimensional Symptom Questionnaire (4DSQ) is frequently used in the OH setting but the Somatization subscale is not validated yet. The aim of this study is to validate the 4DSQ Somatization subscale as screener for DSM-IV somatoform disorder in the OH setting by using the MINI interview as gold standard. METHODS: Employees absent from work due to physical symptoms, for a period longer than 6 weeks and shorter than 2 years, were asked to participate in this study. They filled out the 4DSQ and underwent a MINI interview by telephone for DSM-IV classification. Specificity and sensitivity scores were calculated for all possible cut-off scores and a receiver operator curve was computed for the Somatization subscale. 95 % confidence intervals (95 % CIs) were calculated for sensitivity and specificity. RESULTS: The Somatization subscale of the 4DSQ has an optimal cut point of 9, with specificity and sensitivity equal to 64.3 % [95 % CI (53.6; 73.7 %)] and 60.9 % [95 % CI (40.8; 77.8 %)], respectively. Receiver operator curves showed an area under the curve equal to 0.61 [SE = 0.07; 95 % CI (0.48; 0.75)] for the Somatization subscale of the 4DSQ. CONCLUSION: The 4DSQ Somatization subscale is a questionnaire of moderate sensitivity and specificity.

Interventions to improve return to work in depressed people.

BACKGROUND: Work disability such as sickness absence is common in people with depression. OBJECTIVES: To evaluate the effectiveness of interventions aimed at reducing work disability in employees with depressive disorders. SEARCH METHODS: We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO until January 2014. SELECTION CRITERIA: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN 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). AUTHORS' 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.

Public mental health research in Europe: a systematic mapping for the ROAMER project.

BACKGROUND: As part of the ROAMER (ROAdmap for MEntal health Research in Europe) project, aiming to create an integrated European roadmap for mental health research, we set out to map the hitherto unmapped territory of public mental health research in Europe. METHODS: Five electronic databases (CINAHL, Health Management, Medline, PsycINFO, Social Services Abstracts) were used for identifying public mental health research articles published between January 2007 and April 2012. The number of publications for each European country in five research domains (i.e. mental health epidemiology, mental health promotion, mental disorder prevention, mental health policy and mental health services) was analysed by population size and gross domestic product (GDP), and mean impact factors were compared. RESULTS: In all, 8143 unique publications were identified. Epidemiology research dominates public mental health research, while promotion, prevention and policy research are scarce. Mental health promotion is the fastest growing research area. Research targeting older adults is under-represented. Publications per capita were highest in northwestern Europe, and similar trends were found also when adjusting the number of publications by GDP per capita. The most widely cited research origins from Italy, Switzerland, the UK, the Nordic countries, the Netherlands, Greece and France. CONCLUSION: In Europe, public mental health research is currently a matter of the affluent northern and western European countries, and major efforts will be needed to promote public mental health research in south and east Europe. In spite of a smaller public mental health research output, some Mediterranean countries produce highly cited public mental health research.

Implementing guidelines for depression on antidepressant prescribing in general practice: a quasi-experimental evaluation.

BACKGROUND: Internationally, guidelines for depression recommend a stepped care approach, implying that antidepressant medication should not be offered as a first step treatment to patients with sub-threshold or mild depression. In the Netherlands, antidepressant prescribing rates in general practice as a first treatment step are considered to be high. The aim of this study was to evaluate the implementation of guideline recommendations on antidepressant prescribing. METHODS: A quasi-experimental study with a non-equivalent naturalistic control group and three years follow-up was performed in the general practice setting in the Netherlands. General Practitioners (GPs) participated in a national Quality Improvement Collaborative (QIC), focusing on the implementation of a guideline based model for a stepped care approach to depression. The model consisted of self-help and psychological treatment options for patients with milder symptoms as an alternative to antidepressants in general practice. Changes in antidepressant prescription rates of GPs were documented for a three-year period and compared to those in a control group of GPs, selected from an ongoing national registration network. RESULTS: A decrease of 23.3% (49.4%-26.1%) in antidepressant prescription rates for newly diagnosed patients with depressive symptoms was found within the intervention group, whereas no difference occurred in the reference group (50.3%-52.6%). The decrease over time was significant, compared to the usual care group (OR 0.44, 95% CI: 0.21-0.92). CONCLUSIONS: An implementation program using stepped care principles for the allocation of depression interventions resulted in reduced antidepressant prescription rates in general practice. GPs can change prescribing behaviour within the context of a QIC.

Cost-utility analysis of a collaborative care intervention for major depressive disorder in an occupational healthcare setting.

PURPOSE: Major depression is associated with high levels of absence and reduced productivity. Therefore the costs to society are high. The aim of this study was to evaluate the cost-utility of collaborative care for major depressive disorder (MDD) compared to care as usual in an occupational healthcare setting. A societal perspective was taken. METHODS: In this randomised controlled trial, 126 sick-listed workers with MDD were included (65 collaborative care, 61 care as usual). Baseline measurements and follow up measures (3, 6, 9 and 12 months) were assessed by questionnaire. We applied the Trimbos/iMTA questionnaire for costs associated with psychiatric illness, the SF-HQL and the EQ-5D respectively measuring the health care utilization, production losses and general health related quality of life. RESULTS: The average annual healthcare costs in the collaborative care group were €3,874 (95 % CI €2,778-€ 5,718) compared to €4,583 (95 % CI €3,108-€6,794) in the care as usual group. The average quality of life years (QALY's) gained were lower in the collaborative care group, 0.05 QALY. The majority of the ICERS (69 %) indicate that collaborative care is less costly but also less effective than care as usual. Including the productivity costs did not change this result. CONCLUSIONS: The cost-utility analysis showed that collaborative care generated reduced costs and a reduction in effects compared to care as usual and was therefore not a cost-effective intervention.