A meta-regression of the impact of policy on the efficacy of individual placement and support.

OBJECTIVE: Individual placement and support (IPS) has shown consistently better outcomes on competitive employment for patients with severe mental illness than traditional vocational rehabilitation. The evidence for efficacy originates from few countries, and generalization to different countries has been questioned. This has delayed implementation of IPS and led to requests for country-specific RCTs. This meta-analysis examines if evidence for IPS efficacy can be generalized between rather different countries. METHODS: A systematic search was conducted according to PRISMA guidelines to identify RCTs. Overall efficacy was established by meta-analysis. The generalizability of IPS efficacy between countries was analysed by random-effects meta-regression, employing country- and date-specific contextual data obtained from the OECD and the World Bank. RESULTS: The systematic review identified 27 RCTs. Employment rates are more than doubled in IPS compared with standard vocational rehabilitation (RR 2.07 95% CI 1.82-2.35). The efficacy of IPS was marginally moderated by strong legal protection against dismissals. It was not moderated by regulation of temporary employment, generosity of disability benefits, type of integration policies, GDP, unemployment rate or employment rate for those with low education. CONCLUSIONS: The evidence for efficacy of IPS is very strong. The efficacy of IPS can be generalized between countries.

A smartphone application for treating depressive symptoms: study protocol for a randomised controlled trial.

BACKGROUND: Depression is a commonly occurring disorder linked to diminished role functioning and quality of life. The development of treatments that overcome barriers to accessing treatment remains an important area of clinical research as most people delay or do not receive treatment at an appropriate time. The workplace is an ideal setting to roll-out an intervention, particularly given the substantial psychological benefits associated with remaining in the workforce. Mobile health (mhealth) interventions utilising smartphone applications (apps) offer novel solutions to disseminating evidence based programs, however few apps have undergone rigorous testing. The present study aims to evaluate the effectiveness of a smartphone app designed to treat depressive symptoms in workers. METHODS: The present study is a multicentre randomised controlled trial (RCT), comparing the effectiveness of the intervention to that of an attention control. The primary outcome measured will be reduced depressive symptoms at 3 months. Secondary outcomes such as wellbeing and work performance will also be measured. Employees from a range of industries will be recruited via a mixture of targeted social media advertising and Industry partners. Participants will be included if they present with likely current depression at baseline. Following baseline assessment (administered within the app), participants will be randomised to receive one of two versions of the Headgear application: 1) Intervention (a 30-day mental health intervention focusing on behavioural activation and mindfulness), or 2) attention control app (mood monitoring for 30 days). Participants will be blinded to their allocation. Analyses will be conducted within an intention to treat framework using mixed modelling. DISCUSSION: The results of this trial will provide valuable information about the effectiveness of mhealth interventions in the treatment of depressive symptoms in a workplace context. TRIAL REGISTRATION: The current trial is registered with the Australian and New Zealand Clinical Trials Registry ( ACTRN12617000547347 , Registration date: 19/04/2017).

Personality and long-term health-related benefits.

BACKGROUND: Although it is well documented that non-medical factors, like educational level, are associated with sick leave and disability pensioning, the role of personality has only been studied to a limited degree. AIMS: To examine how normal personality traits (as measured by 'The Big Five') are associated with long-term sick leave and disability pensioning. METHODS: In 2008, a sample of Norwegian women participating in the population-based Tracking Opportunities and Problems (TOPP) study were assessed for personality traits. Three years later the women reported on their job status and any episodes of sick leave and disability pensioning over the previous 6 months. Using logistic regression analyses, we examined the association between standardized measures of personality traits and any episodes of long-term sick leave and disability pensioning. RESULTS: Three hundred and sixty-four women were included in the analyses (40% of those invited). One standard level increase in neuroticism was significantly associated with disability pensioning with an odds ratio (OR) of 2.07 (95% confidence interval [CI]: 1.38-3.10). In contrast, an increase in extroversion and conscientiousness was negatively associated with disability pensioning with ORs of 0.59 (0.39-0.90) and 0.65 (0.43-0.99), respectively. For long-term sick leave, there were no significant associations, although the trends in the estimates were similar. CONCLUSIONS: Personality is strongly associated with disability pensioning, but not with long-term sick leave. In particular, high neuroticism, low extroversion and low conscientiousness seem to increase the risk for disability pensioning. Initiatives aimed to reduce the prevalence of disability pensioning should take personality traits into account.

Explaining the gender gap in sickness absence.

Background: In many western countries, women have a much higher rate of sickness absence than men. To what degree the gender differences in sickness absence are caused by gender differences in health is largely unknown. Aims: To assess to what degree the gender gap in sickness absence can be explained by health factors and work- and family-related stressors. Methods: Norwegian parents participating in the Tracking Opportunities and Problems (TOPP) study were asked about sickness absence and a range of factors possibly contributing to gender differences in sickness absence, including somatic and mental health, sleep problems, job control/demands, work-home conflicts, parent-child conflicts and stressful life events. Using a cross-sectional design, we did linear regression analyses, to assess the relative contribution from health and stressors. Results: There were 557 study participants. Adjusting for health factors reduced the gender difference in sickness absence by 24%, while adjusting for stressors in the family and at work reduced the difference by 22%. A simultaneous adjustment for health factors and stressors reduced the difference in sickness absence by about 28%. Conclusions: Despite adjusting for a large number of factors, including both previously well-studied factors (e.g. health, job control/demands) and lesser-studied factors (parent-child conflict and sexual assault), this study found that most of the gender gap in sickness absence remains unexplained. Gender differences in health and stressors account for only part of the differences in sickness absence. Other factors must, therefore, exist outside the domains of health, work and family stressors.

Case-specific colleague guidance for general practitioners' management of sickness absence.

BACKGROUND: General practitioners (GPs) report sickness absence certification as challenging. They express need for support with functional assessment beyond guidelines and reforms. Case-specific collegial one-to-one guidance for other clinical topics has proved popular with GPs and may be an acceptable and effective way to improve GPs skills and competence in sickness absence certification. AIMS: To present a new model of case-specific colleague guidance focusing on the management of long-term sickness absence and to describe its feasibility in terms of application and reception among GPs, and also GPs' self-reports of effects on their practice. METHODS: Randomly selected GPs received case-specific collegial guidance over a 12-month period, in two Norwegian trials, delivered by former GPs employed by the social security administration. We measured reception and perceived effects by GPs' self-report and registered participation and withdrawal rates. RESULTS: The participation rate (n = 165) was 94%, and no GPs withdrew during training. Among the 116 GPs responding to the survey (70%), 112 (97%; 95% CI 92-99) stated they would recommend it to their colleagues. Considerable benefit from the guidance was reported by 68 (59%; 95% CI 50-68). The GPs self-reported other effects on their sickness absence certification, specifically an increased use of part-time sickness absence (Fit-Note equivalent). CONCLUSIONS: This model of case-specific colleague guidance to aid GPs' management of long-term sickness absence is feasible and was popular. This type of guidance was perceived by GPs to be somewhat beneficial and to alter their sickness absence certification behaviour, though the true impact requires further testing in controlled trials.

Workplace interventions for common mental disorders: a systematic meta-review.

Depression and anxiety disorders are the leading cause of sickness absence and long-term work incapacity in most developed countries. The present study aimed to carry out a systematic meta-review examining the effectiveness of workplace mental health interventions, defined as any intervention that a workplace may either initiate or facilitate that aims to prevent, treat or rehabilitate a worker with a diagnosis of depression, anxiety or both. Relevant reviews were identified via a detailed systematic search of academic and grey literature databases. All articles were subjected to a rigorous quality appraisal using the AMSTAR assessment. Of the 5179 articles identified, 140 studies met the inclusion criteria, of which 20 were deemed to be of moderate or high quality. Together, these reviews analysed 481 primary research studies. Moderate evidence was identified for two primary prevention interventions; enhancing employee control and promoting physical activity. Stronger evidence was found for CBT-based stress management although less evidence was found for other secondary prevention interventions, such as counselling. Strong evidence was also found against the routine use of debriefing following trauma. Tertiary interventions with a specific focus on work, such as exposure therapy and CBT-based and problem-focused return-to-work programmes, had a strong evidence base for improving symptomology and a moderate evidence base for improving occupational outcomes. Overall, these findings demonstrate there are empirically supported interventions that workplaces can utilize to aid in the prevention of common mental illness as well as facilitating the recovery of employees diagnosed with depression and/or anxiety.

Common mental disorders and long-term sickness absence in a general working population. The Hordaland Health Study.

OBJECTIVE: To examine and compare the prospective effect of the common mental disorders (CMD) anxiety and depression on duration and recurrence of sickness absence (SA), and to investigate whether the effect of CMD on SA is detectable over time. METHOD: Information from a large epidemiological health study (N = 13 436) was linked with official records of SA episodes lasting ≥16 days up to 6 years after participation. Common mental disorders were assessed with the Hospital Anxiety and Depression Scale (HADS). Associations were analysed with Cox regression and multinomial logistic regression models controlling for potential covariates. RESULTS: Comorbid anxiety and depression, and anxiety only were significant risk factors for SA after adjusting for covariates, whilst depression only was not. Anxiety and depression were stronger predictors for longer duration of SA episodes compared with shorter duration and associated with more frequent recurrence of SA. There was a general trend toward the effect of CMD on SA becoming weaker over time; however, the effect of anxiety only on SA remained stable throughout the follow-up. CONCLUSION: Common mental disorders are long-lasting predictors of onset, duration and recurrence of SA. Anxiety appears to be a more important contributor to long-term SA than previously described in the literature.

Mental and personality disorders and abstinence from alcohol: results from a national household survey.

BACKGROUND: The beneficial outcomes associated with moderate compared with low alcohol intake or abstinence may be due to the inclusion of people as 'low consumers', who have stopped consumption because of poor health. We investigated the association between alcohol abstinence and symptoms of common mental disorder and personality disorder, distinguishing between lifelong abstinence and abstinence following previous consumption. METHOD: Analyses were based on the British National Survey of Psychiatric Morbidity 2000, which sampled 8580 residents aged 16-74 years. Hazardous drinking (Alcohol Use Disorders Identification Test) was excluded. Symptoms of common mental disorder (depression/anxiety) were identified by the Clinical Interview Schedule. The screening questionnaire of the Structured Clinical Interview for Axis II Personality Disorders was used to identify potential personality disorder. Self-reported alcohol abstinence was divided into lifelong abstinence and previous consumption. Previous consumers were asked why they had stopped. Covariates included socio-economic status, social activity and general health status. RESULTS: After adjustment, alcohol abstinence was associated with both common mental disorder symptoms and any personality disorder, but only for previous consumers, in whom odds ratios were 1.69 (95% CI 1.23-2.32) and 1.45 (95% CI 1.09-1.94). Associations were non-specific, being apparent for most individual mental disorder symptoms and personality disorder categories. More detailed analysis indicated that associations were again limited to previous consumers who reported ceasing alcohol consumption for health reasons. CONCLUSIONS: Worse mental health in low alcohol consumers, particularly those who have previously ceased for health reasons, should be taken into account when interpreting associations between moderate (compared with low) alcohol consumption and beneficial health outcomes.

Somatization: the under-recognized factor in nonspecific eczema. The Hordaland Health Study (HUSK).

BACKGROUND: Psychodermatology has focused primarily on depression and anxiety in eczema. Skin symptoms are listed among many others for the ICD-10 diagnosis of somatization disorder. Somatization (unexplained somatic symptoms) is highly prevalent in the general population, but its association with eczema is yet to be empirically investigated. OBJECTIVES: We therefore explored the association between somatization and eczema by examining the extent of somatization in eczema compared with allergic rhinitis, and by examining if eczema was more strongly associated with somatization than with anxiety and depression. Finally, we aimed to examine the relationship between the site of eczema and somatization for individual somatic symptoms and for somatic symptoms as a whole. METHODS: For this population-based cross-sectional study we employed data from the Hordaland Health Study (HUSK) with 15,225 participants aged 41-48 years. Information on nonspecific eczema, allergic rhinitis, somatization, anxiety, depression and other covariates was obtained by self-report. RESULTS: The association between nonspecific eczema and somatization was strong and followed a dose-response pattern, as did all somatic symptoms in our index of somatization when analysed separately. The association between nonspecific eczema and somatization was stronger than that between rhinitis and somatization, and also the association between nonspecific eczema and anxiety and depression. In multivariate models, somatization accounted for most of the association between nonspecific eczema and anxiety/depression. In contrast, the association between nonspecific eczema and somatization was robust for adjustment for anxiety/depression. CONCLUSIONS: Somatization was strongly associated with nonspecific eczema. This applies to a whole range of somatic symptoms constituting the construct of somatization. There is hardly any mention of somatization in leading dermatological journals, in contrast to anxiety and depression which are frequently reported in eczema. We speculate that this under-recognition of somatization in the dermatological literature may correspond to under-recognition of this factor also in clinical practice.

Obesity and sickness absence: results from the CHAP study.

BACKGROUND: Obesity is an increasing public health problem. A small number of studies have examined the relationship between obesity and sickness absence, with mixed results, particularly regarding short-term sickness absence. AIMS: To determine if obesity is associated with short- and long-term sickness absence and to investigate the mechanisms that may underlie any association. METHODS: Cross-sectional (n = 1489) and prospective (n = 625) analyses were conducted on staff from London Underground Ltd. All participants underwent regular clinical examinations that involved their height and weight being measured, obesity-related medical problems being diagnosed and psychiatric disorders being identified. The number of days taken for short- (<10 days in an episode) and long-term sickness absence were recorded by managers on an electronic database. RESULTS: There was a positive linear association between employees' body mass index (BMI) and the number of days' work missed due to sickness absence on both cross-sectional and prospective analyses (P < 0.001). Obesity was a risk factor for both short- and long-term sickness absence. Obese individuals typically took an extra 4 days sick leave every year. The majority of the increased risk for long-term sickness absence appeared to be mediated via co-morbid chronic medical conditions. The excess short-term sickness absence was not explained by obesity-related medical problems, psychiatric disorders or workplace factors. CONCLUSIONS: Obese employees take significantly more short- and long-term sickness absence than workers of a healthy weight. There is growing evidence to support employers becoming more involved in tackling obesity.

Metabolic syndrome and risk of mortality in middle-aged versus elderly individuals: the Nord-Trøndelag Health Study (HUNT).

AIMS/HYPOTHESIS: Recent reviews indicate that the metabolic syndrome is a risk factor for cardiovascular disease and mortality, but evidence is scarce in elderly individuals. We therefore examined the relationship between the metabolic syndrome and mortality rates among individuals aged 40-59, 60-74 and 75-89 years. We also examined whether the syndrome was associated with mortality rates over and above the Framingham risk score. METHODS: We studied prospectively 6,748 men and women who participated in the Nord-Trøndelag Health Study, Norway, from 1995 to 1997 (HUNT 2) and defined the metabolic syndrome by the International Diabetes Federation criteria. RESULTS: During 53,617 person-years of follow-up (mean per person, 7.9 years), 955 individuals died, of whom 585 died from cardiovascular disease. Among individuals who were 40-59 years of age at baseline, the presence of the metabolic syndrome was associated with increased relative risk of cardiovascular and total mortality (age- and sex-adjusted hazard ratios 3.97 [95% CI: 2.00-7.88] and 2.06 [1.35-3.13], respectively, equivalent to population-attributable risks of 20.7 and 14.2%, respectively). The Framingham risk score accounted for less than one-third of the effect of metabolic syndrome on mortality rates. After the age of 60 years, the metabolic syndrome was not associated with increased mortality rates. We found a significant interaction between the metabolic syndrome and age on the relative risk of mortality. Results were confirmed in a sub-sample without cardiovascular disease at baseline. CONCLUSIONS/INTERPRETATION: The metabolic syndrome is a risk factor for mortality, over and above the Framingham risk score, in middle-aged, but not in elderly individuals.

No association of depression and anxiety with the metabolic syndrome: the Norwegian HUNT study.

OBJECTIVE: To examine the associations of depression and anxiety with the metabolic syndrome. METHOD: Cross-sectional study of 9571 participants aged 20-89 years in the Nord-Trøndelag Health Study (HUNT 2). We assessed anxiety and depression with the Hospital Anxiety and Depression Scale and the metabolic syndrome with the International Diabetes Federation criteria. RESULTS: Despite generous statistical power and use of both continuous and categorical approaches, we found no association between anxiety or depression and the metabolic syndrome in models adjusted for age, gender, educational level, smoking, physical activity and pulse rate. When adjusted for age and gender only, we found a weak positive association for depression when a continuous measure was used, but not at the case level. The findings were similar across sexes, and robust for exclusion of cardiovascular disease and antidepressants. CONCLUSION: In this largest study to date we found no association of anxiety and depression with the metabolic syndrome.

The effect of OSAS on sick leave and work disability.

The objective of the present study was to examine the independent contribution of symptoms of obstructive sleep apnoea syndrome (OSAS) to long-term sick leave and permanent work disability. Using a historical cohort design with 4 yrs of follow-up, information on sick leave and disability benefit recipiency were merged with health information from the Hordaland Health Study, carried out in western Norway during 1997-1999. Persons aged 40-45 yrs (n = 7,028) were assessed for self-reported symptoms of OSAS (snoring, breathing cessations and daytime sleepiness), body mass index, somatic conditions and other potential confounders. The outcomes, cumulative sick leave of > or =8 weeks and permanent work disability, were identified in records from the National Insurance Administration. After excluding participants with work disability at baseline, symptoms of OSAS were found to be a significant predictor of both subsequent long-term sick leave and permanent work disability. These effects remained significant after adjustment for a range of possible confounding factors. Daytime sleepiness showed the greatest explanatory power, followed by breathing cessations and snoring. It is concluded that self-reported symptoms of obstructive sleep apnoea syndrome are an independent risk factor for subsequent long-term sick leave and permanent work disability. These findings need to be replicated using objective measures of obstructive sleep apnoea syndrome.

Health status before, during and after disability pension award: the Hordaland Health Study (HUSK).

OBJECTIVES: Up to one in eight of the working age population receives permanent disability benefits. As little is known about the consequences of this major event, analysis aimed to compare health status before and after disability pension award. METHODS: Data from the population based Hordaland Health Study (HUSK) in Norway 1997-99 (n = 18 581) were linked to official disability benefits registries. The study identified 1087 participants who were awarded a disability pension before, during and after the health survey. These were grouped into different strata defined by temporal proximity between disability pension award and health survey participation. The study then compared health status across these strata covering the 7 years before to the 7 years after the award. RESULTS: The study found an inverse U-shaped trend with an increase in reported symptoms (anxiety, depression, pain distribution, sleep problems and somatic symptoms) approaching the award, and a reversing of this trajectory afterwards (p<0.05 for the non-linear trend for all symptoms). We found no similar trend for the more objective health measures blood pressure, physical diagnoses and prescribed medication. For most measures, similar levels of health problems were found 3-7 years before compared to 3-7 years after the award. CONCLUSION: When comparing the strata defined by time to the event of disability pension award, there was an increase in symptoms around the time of the disability pension award, with a subsequent return towards pre-award levels. The design precludes any firm conclusions as to what causes the observed results, but possible explanations include temporary adverse health effects from the process itself, the beneficial effects of being removed from harmful work conditions, and recovery after increasing health problems leading up to disability pension award.

Depression and anxiety through the climacteric period: an epidemiological study (HUNT-II).

AIM: The aim of this study was to examine the prevalence of anxious and depressive symptoms related to menstruational status in a large community sample. METHOD: In the HUNT-II study all adults in Nord-Trøndelag County of Norway were asked about demographic factors, lifestyle, physical symptoms and somatic diseases, a total of 94,197 persons. Anxious and depressive symptoms were recorded by the Hospital Anxiety and Depression Scale (HADS). Of female persons invited aged 35-60 years (N = 19,677), 16,080 (82%) took part. The menstruation status were defined as pre-, peri- and postmenopausal periods, calculated as the time period from last menstruation to examination date. RESULTS: There was a significantly higher score on depression and anxiety in the peri- and the postmenopausal period compared to the premenopausal period. Comparing the postmenopausal period with the perimenopausal period, the score for depressive symptoms was somewhat higher while the score for anxious symptoms was somewhat lower. These differences did not reach significance. CONCLUSION: There was a general effect of age on the scores on HADS-D. For scores on HADS-A there was a peak in the score in the perimenopausal period, indicating a high degree of anxiety symptoms in this time period which is especially connected to fluctuations in the serum level of gonadal hormones.

Seizure-related factors and non-verbal intelligence in children with epilepsy. A population-based study from Western Norway.

PURPOSE: To study the relationship between seizure-related factors, non-verbal intelligence, and socio-economic status (SES) in a population-based sample of children with epilepsy. METHODS: The latest ILAE International classifications of epileptic seizures and syndromes were used to classify seizure types and epileptic syndromes in all 6-12 year old children (N=198) with epilepsy in Hordaland County, Norway. The children had neuropediatric and EEG examinations. Of the 198 patients, demographic characteristics were collected on 183 who participated in psychological studies including Raven matrices. 126 healthy controls underwent the same testing. Severe non-verbal problems (SNVP) were defined as a Raven score at or <10th percentile. RESULTS: Children with epilepsy were highly over-represented in the lowest Raven percentile group, whereas controls were highly over-represented in the higher percentile groups. SNVP were present in 43% of children with epilepsy and 3% of controls. These problems were especially common in children with remote symptomatic epilepsy aetiology, undetermined epilepsy syndromes, myoclonic seizures, early seizure debut, high seizure frequency and in children with polytherapy. Seizure-related characteristics that were not usually associated with SNVP were idiopathic epilepsies, localization related (LR) cryptogenic epilepsies, absence and simple partial seizures, and a late debut of epilepsy. Adjusting for socio-economic status factors did not significantly change results. CONCLUSIONS: In childhood epilepsy various seizure-related factors, but not SES factors, were associated with the presence or absence of SNVP. Such deficits may be especially common in children with remote symptomatic epilepsy aetiology and in complex and therapy resistant epilepsies. Low frequencies of SNVP may be found in children with idiopathic and LR cryptogenic epilepsy syndromes, simple partial or absence seizures and a late epilepsy debut. Our study contributes to an overall picture of cognitive function and its relation to central seizure characteristics in a childhood epilepsy population and can be useful for the follow-up team in developing therapy strategies that meet the individual needs of the child with epilepsy.

Screening for postnatal depression. Validation of the Norwegian version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression.

OBJECTIVE: The Edinburgh Postnatal Depression Scale (EPDS) is a self-rating scale developed to screen for postnatal depression. The aim of this study was to validate a Norwegian translation of the EPDS, study its psychometric properties, and identify risk factors for postnatal depression. METHOD: EPDS was filled in by 411 women at 6-12 weeks postpartum. Of these, 100 were interviewed using the Mini International Neuropsychiatric Interview for DSM-IV major and minor depressive disorders. RESULTS: When using a cut-off of 11 on the EPDS, 26 of 27 women with major depression were identified (sensitivity 96%, specificity 78%). An aggregate point prevalence of 10.0% of major and minor depression was found. A one-factor model accounted for 46.6% of the variance. Strongest risk factors for postpartum depression were previous depression, depression in current pregnancy, and current somatic illness. LIMITATIONS: Women screened using the EPDS who had a score above threshold, yet did not attend the diagnostic interview could cause the point prevalence of depression to be higher than indicated here. CONCLUSION: The Norwegian translation of EPDS functions equally well as other translations as a screening tool for postnatal depression. The risk factors that were found are compatible with other studies.

Widespread pain and medically certified disability pension in the Hordaland Health Study.

Widespread pain (WSP) is common in the general population and is associated with poor outcomes. The aim of this study was to quantify the risk for medically certified disability pension from WSP. We further studied how other common physical symptoms, common mental disorders and functional limitations influenced this risk. A prospective cohort design was established by linking the large population based Hordaland Health Study (n > 18000 individuals aged 40-46) with an administrative registry on disability pension awards. We modelled hazard ratios for later all-cause and diagnosis specific disability pensioning from WSP, adjusted for potential confounders and examined the impact of other co-occurring health problems and functional limitations. WSP was common (12.4%) and associated with a range of mental health, and non-specific and non-musculoskeletal symptoms. As expected, WSP was a strong predictor for disability pension award. Hazard ratios (HR) adjusted for socio-economic status, health behaviours and comorbid medical diagnoses indicated WSP was strongest in predicting pensioning for musculoskeletal diagnoses (HR = 5.91, 95% CI 4.64-7.54), but also predicted pensioning for mental disorder (HR = 3.13, 95% CI 2.20-4.46) and other diagnoses (HR = 1.81, 95% CI 1.30-2.51). Further adjustments for other common symptoms, including mental illness, reduced, but did not abolish these risks. WSP is a major risk factor for disability pensions, and not only pensions for musculoskeletal disorders. The global impact of WSP, and its close association to other symptoms, suggests prevention of the severe occupational outcomes for this group must have a broad focus and move beyond symptom directed approaches.

Comparison of chronic fatigue syndrome/myalgic encephalopathy with other disorders: an observational study.

OBJECTIVES: To examine the level of activity in online discussion forums for chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) compared to other disorders. We hypothesized the level of activity to be higher in CFS/ME online discussion forums. DESIGN: Observational study SETTING: Norway, which has more than 80% household coverage in internet access, September 2009 PARTICIPANTS: Twelve Norwegian disorder-related online discussion forums MAIN OUTCOME MEASURES: Number of registered users and number of posted messages on each discussion forum RESULTS: Two forums were targeted towards individuals with CFS/ME. These forums had the highest number of registered users per estimated 1,000 cases in the population (50.5 per 1,000 and 29.7 per 1,000), followed by a site for drug dependency (5.4 per 1,000). Counting the number of posted messages per 1,000 cases gave similar indications of high online activity in the CFS/ME discussion forums. CONCLUSIONS: CFS/ME online forums had more than ten times the relative activity of any other disorder or condition related forum. This high level of activity may have multiple explanations. Individuals suffering from a stigmatized condition of unknown aetiology may use the internet to look for explanations of symptoms or to seek out alternative treatments. Internet forum activity may also be reinforced by the creation of in-group identity and pre-morbid personality traits. More knowledge on the type and quality of information provided in online forums is urgently needed.

Work and common psychiatric disorders.

Psychiatric disorders are now the most common reason for long-term sickness absence. The associated loss in productivity and the payment of disability benefits places a substantial burden on the economies of many developed countries. The occupational dysfunction associated with psychiatric disorders can also lead to poverty and social isolation. As a result the area of work and psychiatric disorders is a high priority for policymakers. There are two main agendas: for many researchers and clinicians the focus is on the need to overcome stigma and ensure people with severe psychiatric disorders have meaningful work; however the public health agenda predominantly relates to the more common disorders such as depression and anxiety, which contribute a greater burden of disability benefits and pensions. In this review we attempt to address this second agenda. The relatively sparse evidence available reveals a complex field with significant interplay between medical, psychological social and cultural factors. Sick leave can be a 'process' as well as an 'event'. In this review we propose a staged model where different risk and protective factors contribute to the onset of psychiatric disorders in the working population, the onset of short-term sickness absence, and the transition from short- to long-term absence. We also examine strategies to manage psychiatric disorder in the workforce with a view towards returning the employee to work. Our aim in this review is to highlight the complexity of the area, to stimulate debate and to identify important gaps in knowledge where further research might benefit both patients and wider society.