The effects of different types of organisational workplace mental health interventions on mental health and wellbeing in healthcare workers: a systematic review.

OBJECTIVE: To determine if and which types of organisational interventions conducted in small and medium size enterprises (SMEs) in healthcare are effective on mental health and wellbeing. METHODS: Following PRISMA guidelines, we searched six scientific databases, assessed the methodological quality of eligible studies using QATQS and grouped them into six organisational intervention types for narrative synthesis. Only controlled studies with at least one follow-up were eligible. RESULTS: We identified 22 studies (23 articles) mainly conducted in hospitals with 16 studies rated of strong or moderate methodological quality. More than two thirds (68%) of the studies reported improvements in at least one primary outcome (mental wellbeing, burnout, stress, symptoms of depression or anxiety), most consistently in burnout with eleven out of thirteen studies. We found a strong level of evidence for the intervention type "Job and task modifications" and a moderate level of evidence for the types "Flexible work and scheduling" and "Changes in the physical work environment". For all other types, the level of evidence was insufficient. We found no studies conducted with an independent SME, however five studies with SMEs attached to a larger organisational structure. The effectiveness of workplace mental health interventions in these SMEs was mixed. CONCLUSION: Organisational interventions in healthcare workers can be effective in improving mental health, especially in reducing burnout. Intervention types where the change in the work environment constitutes the intervention had the highest level of evidence. More research is needed for SMEs and for healthcare workers other than hospital-based physicians and nurses.

Implementation and evaluation of a multi-level mental health promotion intervention for the workplace (MENTUPP): study protocol for a cluster randomised controlled trial.

BACKGROUND: Well-organised and managed workplaces can be a source of wellbeing. The construction, healthcare and information and communication technology sectors are characterised by work-related stressors (e.g. high workloads, tight deadlines) which are associated with poorer mental health and wellbeing. The MENTUPP intervention is a flexibly delivered, multi-level approach to supporting small- and medium-sized enterprises (SMEs) in creating mentally healthy workplaces. The online intervention is tailored to each sector and designed to support employees and leaders dealing with mental health difficulties (e.g. stress), clinical level anxiety and depression, and combatting mental health-related stigma. This paper presents the protocol for the cluster randomised controlled trial (cRCT) of the MENTUPP intervention in eight European countries and Australia. METHODS: Each intervention country will aim to recruit at least two SMEs in each of the three sectors. The design of the cRCT is based on the experiences of a pilot study and guided by a Theory of Change process that describes how the intervention is assumed to work. SMEs will be randomly assigned to the intervention or control conditions. The aim of the cRCT is to assess whether the MENTUPP intervention is effective in improving mental health and wellbeing (primary outcome) and reducing stigma, depression and suicidal behaviour (secondary outcome) in employees. The study will also involve a process and economic evaluation. CONCLUSIONS: At present, there is no known multi-level, tailored, flexible and accessible workplace-based intervention for the prevention of non-clinical and clinical symptoms of depression, anxiety and burnout, and the promotion of mental wellbeing. The results of this study will provide a comprehensive overview of the implementation and effectiveness of such an intervention in a variety of contexts, languages and cultures leading to the overall goal of delivering an evidence-based intervention for mental health in the workplace. TRIAL REGISTRATION: Please refer to Item 2a and registration ISRCTN14104664. Registered on 12th July 2022.

Outcome assessment of a complex mental health intervention in the workplace. Results from the MENTUPP pilot study.

OBJECTIVE: Multicomponent interventions are recommendable to achieve the greatest mental health benefits, but are difficult to evaluate due to their complexity. Defining long-term outcomes, arising from a Theory of Change (ToC) and testing them in a pilot phase, is a useful approach to plan a comprehensive and meaningful evaluation later on. This article reports on the pilot results of an outcome evaluation of a complex mental health intervention and examines whether appropriate evaluation measures and indicators have been selected ahead of a clustered randomised control trial (cRCT). METHODS: The MENTUPP pilot is an evidence-based intervention for Small and Medium Enterprises (SMEs) active in three work sectors and nine countries. Based on our ToC, we selected the MENTUPP long-term outcomes, which are reported in this article, are measured with seven validated scales assessing mental wellbeing, burnout, depression, anxiety, stigma towards depression and anxiety, absenteeism and presenteeism. The pilot MENTUPP intervention assessment took place at baseline and at 6 months follow-up. RESULTS: In total, 25 SMEs were recruited in the MENTUPP pilot and 346 participants completed the validated scales at baseline and 96 at follow-up. Three long-term outcomes significantly improved at follow-up (p < 0.05): mental wellbeing, symptoms of anxiety, and personal stigmatising attitudes towards depression and anxiety. CONCLUSIONS: The results of this outcome evaluation suggest that MENTUPP has the potential to strengthen employees' wellbeing and decrease anxiety symptoms and stigmatising attitudes. Additionally, this study demonstrates the utility of conducting pilot workplace interventions to assess whether appropriate measures and indicators have been selected. Based on the results, the intervention and the evaluation strategy have been optimised.

Evidence for the effectiveness of interventions to reduce mental health related stigma in the workplace: a systematic review.

OBJECTIVES: Increasing access to mental health support is a key factor for treating mental disorders, however, important barriers complicate help-seeking, among them, mental health related stigma being most prominent. We aimed to systematically review the current evidence for interventions focusing on reducing stigma related to mental health problems in small and medium enterprises (SMEs). DESIGN: Systematic review with a focus on interventions targeting mental health related stigma in the workplace in accordance with PRISMA guidelines. The methodological quality of included articles was assessed using the Quality Assessment Tool for Quantitative Studies Scale. DATA SOURCES: PubMed, Ovid Medline, PsycINFO, Scopus, and Cochrane databases and Google Scholar were searched from January 2010 until November 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included experimental or quasi-experimental studies about workplace interventions aiming to reduce stigma, where the outcomes were measured in terms of stigmatisation against depression, anxiety and/or other mental health problems. DATA EXTRACTION AND SYNTHESIS: Records were screened by two independent reviewers after inspecting titles and abstracts and a full-text read of the articles to assess whether they meet inclusion criteria. The results were synthesised narratively. RESULTS: We identified 22 intervention studies, 3 with high quality, 13 with moderate quality and 6 with weak quality. Only 2 studies included SMEs, but no study focused on SMEs exclusively . The mode of delivery of the intervention was face to face in 15 studies, online in 4 studies and mixed in 3 studies. We found a significant reduction in stigmatising attitudes in almost all studies (20/22), using 10 different instruments/scales. Effects seemed to be independent of company size. Online interventions were found to be shorter, but seemed to be as effective as face-to-face interventions. CONCLUSIONS: Although we did not find interventions focusing exclusively on SMEs, it is likely that antistigma interventions also will work in smaller workplaces. TRIAL REGISTRATION: PROSPERO: ID: CRD42020191307.

Supporting employees with mental illness and reducing mental illness-related stigma in the workplace: an expert survey.

An expert survey was designed to support the development of a workplace-based multi-country intervention tackling depression, anxiety, and mental illness-related stigma in small- and medium-sized enterprises (SMEs). Academic experts and representatives of SME organisations, specific sector organisations, labour or advocacy groups, and occupational health organisations, were contacted across eight European countries and Australia. The survey comprised closed and open text questions to assess expert opinion about interventions for employees with mental health difficulties, interventions supporting their managers, and anti-stigma interventions. The survey was available in six languages. The online platform Qualtrics was used for data collection. Quantitative data was analysed through descriptive statistics and qualitative data was analysed through thematic analysis. Sixty-five of 146 experts responded, representing a 42% response rate. Results showed only 26.2% of experts agreed that employees could speak openly about mental health issues, and 81.5% of experts indicated a large or medium unmet need for support for employees with mental health issues. Psychoeducational materials, face-to-face workshops and interventions based on cognitive behavioural therapy were ranked most likely to be taken up by employees. Experts rated as most useful for managers' guidelines on how to act if an employee has mental health issues (67.7%). The greatest number of experts indicated workshops of people with lived experience of mental illness (80.0%) and awareness campaigns (78.5%) were most required to tackle stigma. Responses were consistent between experts from different countries and areas of expertise. Experts in this multinational survey assessed that interventions supporting mental health in the workplace and tackling stigma are greatly needed. A multicomponent intervention with a wide range of materials and tools is supported.

Effectiveness of iFightDepression® online guided self-help tool in depression - A pilot study.

BACKGROUND: Depression is one of the leading causes of human misery and disability worldwide. For those fortunate enough to have access to the rapidly expanding World Wide Web, online self-help tools can guide those suffering from depression, with or without professional intervention, to better manage their symptoms and maintain some measure of self-actualization. This study assesses the efficacy of the widely used, online self-help tool, iFightDepression®. METHODS: A six-week, observational study was conducted with 143 participants (29.4% men, mean age: 37.8; standard deviation [SD] = 12.05, range = 18-70, years) in three intervention groups, as follows: 1) Treatment As Usual (TAU), 2) TAU combined with access to the iFightDepression® tool (TAU + iFD®), 3) TAU combined with iFightDepression® and weekly phone support (TAU + iFD® + phone). Depression symptoms were measured pre- and post- by Patient Health Questionnaire-9. RESULTS: There was a significantly greater decrease of depressive symptoms in both iFD® groups compared to the TAU group (time × group interaction: F(2) = 34.657, p < 0.001, partial η2 = 0.331). The reliable change index calculation identified one participant (0.7%) as having experienced a statistically reliable deterioration in depression. A total of 102 participants (71.3%) showed no reliable change, while 40 participants (28.0%) showed a statistically reliable improvement. Multiple binary logistic regression analysis found odds of reliable improvement to be significantly higher in both iFD® groups compared to the TAU group (TAU + iFD®: OR = 18.52, p = 0.015, TAU + iFD® + Phone: OR = 126.72, p < 0.001). Participants living in Budapest were found to have significantly higher odds for a reliable improvement compared to those living in the countryside (odds ratio [OR] = 4.04, p = 0.023). Finally, higher levels of depressive symptoms at baseline (pretest) were also associated with increased odds for post-intervention improvement (OR = 1.58, p < 0.001). The variance explained by the model is 62.0%. With regards to the iFD® self-help program, the mean of completed modules was 4.8 (SD = 1.73, range = 1-6). Participants in the group supported by weekly phone calls completed significantly more modules (n = 50, M = 5.7, SD = 0.76) than participants without weekly telephone support (n = 52, M = 3.9, SD = 1.94, Z = 5.253, p < 0.001). However, there was no significant difference in the number of completed modules between respondents with a reliable improvement in depression (n = 39, M = 4.9, SD = 1.57) and those without a reliable change (n = 63, M = 4.7, SD = 1.83, Z = 0.343, p = 0.731). CONCLUSION: Our results confirm previous findings regarding the efficacy of web-based interventions with the low-intensity guidance of mental health professional. Findings suggest that a relatively short additional weekly call may result in a significant decrease in depressive symptoms and higher number of completed iFD® modules. The study confirms that the IFD® tool, both alone and with additional phone support, is a possible and effective way to help patients with mild to moderate and, in some cases, even severe depression. Providing mental and primary health care systems with the availability of online self-help tools may contribute to the efficacious treatment of depression and prevention of the increase in depressive symptoms.

Workplace interventions to reduce depression and anxiety in small and medium-sized enterprises: A systematic review.

BACKGROUND: Depression and anxiety are the most prevalent mental health difficulties in the workplace, costing the global economy $1 trillion each year. Evidence indicates that symptoms may be reduced by interventions in the workplace. This paper is the first to systematically review psychosocial interventions for depression, anxiety, and suicidal ideation and behaviours in small-to medium-size enterprises (SMEs). METHODS: A systematic search following PRISMA guidelines, registered in PROSPERO (CRD42020156275), was conducted for psychosocial interventions targeting depression, anxiety, and suicidal ideation/behaviour in SMEs. The PubMed, PsycINFO, Scopus, and two specific occupational health databases were searched, as well as four databases for grey literature, without time limit until 2nd December 2019. RESULTS: In total, 1283 records were identified, 70 were retained for full-text screening, and seven met the inclusion criteria: three randomised controlled trials (RCTs), three before and after designs and one non-randomised trial, comprising 5111 participants. Study quality was low to moderate according to the Quality Assessment Tool for Quantitative Studies. Five studies showed a reduction in depression and anxiety symptoms using techniques based on cognitive behavioural therapy (CBT), two reported no significant change. LIMITATIONS: Low number and high heterogeneity of interventions and outcomes, high attrition and lack of rigorous RCTs. CONCLUSIONS: Preliminary evidence indicates CBT-based interventions can be effective in targeting symptoms of depression and anxiety in SME employees. There may be unique challenges to implementing programmes in SMEs. Further research is needed in this important area.

Factors associated with serious intent to die among suicide attempters in Hungary.

As suicide attempts pose major risk for future suicide death, understanding the underlying factors of suicide attempts and suicidal behaviour is an important mental health imperative. The aim of this study was to examine suicide attempts with a special focus on the intention. A total of 2540 discharge summaries were collected between 2009 and 2011 in Miskolc, Hungary, and a content analysis was conducted. Data regarding the method, the reason for suicide attempts, the amount, the source, and the type of the medication taken were examined. Deliberate self-poisoning was the most frequent method (73.8%) committed with more than 200 different types of drugs. 40.5% of the patients attempted suicide with an intent to die, whilst 35.6% of the patients wanted to escape from an unbearable situation. Older age groups, greater amount of taken pills, and affective disorders were associated with self-reported serious intention to die. Our findings should be taken into consideration when monitoring drugs for older patients with depressive disorders.

Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries.

The 'European Alliance Against Depression' community-based intervention approach simultaneously targets depression and suicidal behaviour by a multifaceted community based intervention and has been implemented in more than 115 regions worldwide. The two main aims of the European Union funded project "Optimizing Suicide Prevention Programmes and Their Implementation in Europe" were to optimise this approach and to evaluate its implementation and impact. This paper reports on the primary outcome of the intervention (the number of completed and attempted suicides combined as 'suicidal acts') and on results concerning process evaluation analysis. Interventions were implemented in four European cities in Germany, Hungary, Portugal and Ireland, with matched control sites. The intervention comprised activities with predefined minimal intensity at four levels: training of primary care providers, a public awareness campaign, training of community facilitators, support for patients and their relatives. Changes in frequency of suicidal acts with respect to a one-year baseline in the four intervention regions were compared to those in the four control regions (chi-square tests). The decrease in suicidal acts compared to baseline in the intervention regions (-58 cases, -3.26%) did not differ significantly (χ2 = 0.13; p = 0.72) from the decrease in the control regions (-18 cases, -1.40%). However, intervention effects differed between countries (χ2 = 8.59; p = 0.04), with significant effects on suicidal acts in Portugal (χ2 = 4.82; p = 0.03). The interviews and observations explored local circumstances in each site throughout the study. Hypothesised mechanisms of action for successful implementation were observed and drivers for 'added-value' were identified: local partnership working and 'in-kind' contributions; an approach which valued existing partnership strengths; and synergies operating across intervention levels. It can be assumed that significant events during the implementation phase had a certain impact on the observed outcomes. However, this impact was, of course, not proven.

Risk factors for multiple suicide attempts among Roma in Hungary.

In recent years, suicide rates in Hungary have been among the highest in the European Union. Attempted suicide rates in the Roma population are 2-3 times higher than in the non-Roma population. Since individuals making multiple attempts have a higher pro-bability of eventual death by suicide, and there are limited data on suicidal behaviour of the Roma population, the aim of this study was to explore the sociodemographic and psychological background factors of multiple suicide attempts in the Hungarian Roma population. Semistructured interviews were conducted with 150 individuals admitted to hospital toxicology departments, who made suicide attempts by deliberate self-poisoning, 65 of whom were multiple attempters. Detailed information regarding the current attempt and previous suicidal acts was recorded. Patients also completed the Shortened Beck Depression, the Beck Hopelessness Questionnaire, and the Social Support Questionnaire. Independent samples t-tests were used to evaluate differences in psychological variables between the Roma ( N = 90) and non-Roma ( N = 60) groups. Stepwise linear regression and odds ratios analyses were performed to identify potential background factors of multiple suicide attempts. There was a significantly higher level of previous suicidal events among the Roma in the sample population (3.53 vs. 0.84, p < .001). Roma ethnicity was found to be a strong predictor of multiple suicide attempts. Current major depression, hopelessness, and diagnosed mood disorder were identified as significant risk factors of repeated attempts. Smoking (OR = 5.4), family history of suicide (OR = 4.9), and long-term unemployment (OR = 4.6) were additional risk factors among Roma patients. A thorough understanding of the ethnicity-specific risk factors for multiple suicide attempts could facilitate the development of effective intervention and postvention programmes.

Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach.

BACKGROUND: Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals. OBJECTIVE: This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases. METHODS: The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program. RESULTS: Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals. CONCLUSIONS: It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries.

BACKGROUND: In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts. METHODS AND FINDINGS: Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male). Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded "OSPI-Europe"-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ2-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts. FINDINGS MAIN RESULTS: Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35-44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ2 = 35.74; p < 0.000001). MAIN LIMITATIONS OF THE STUDY: Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths. CONCLUSIONS: Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.

Effects of Parliamentary Elections on Suicide Rates in Hungary.

Background: Phillips and Feldman reported a decline in suicides leading up to the American presidential elections, but Wasserman argued that elections had no impact on suicide. Aims: The present study explored the impact of elections on suicides in Hungary. Method: The study examined changes in the number of suicides in Hungary during the period 1990-2010 on the days of parliamentary elections, and in the weeks and months surrounding the elections. Results: There was no significant impact from the elections on the number of suicides. Conclusion: The data from Hungary replicated the results of Wasserman rather than those of Phillips and Feldman.

Gender differences in deliberate self-poisoning in Hungary: analyzing the effect of precipitating factors and their relation to depression.

BACKGROUND: The suicide rate in Hungary is one of the highest in the European Union, with a male-female ratio of 3.55:1. Suicide rates correlate positively with suicide attempts, for which depression is the most frequent underlying disorder. AIMS: The aim of this qualitative study was to examine gender differences in suicide attempts, with a focus on the effect of precipitating factors on depression. METHOD: Semistructured interviews were conducted among 150 suicide attempters. Data on circumstances, reason, and method of attempt were recorded. Patients completed the Shortened Beck Depression Inventory, the Beck Hopelessness Scale, the Sense of Coherence Scale, and the Social Support Questionnaire. RESULTS: Interpersonal conflict was found to be the most frequent precipitating factor. There were significant gender differences in depressive symptoms among patients with interpersonal conflicts. We found differences in depressive symptoms according to presence or absence of interpersonal conflicts among men, but not among women. Male suicide attempters who indicated interpersonal conflicts had lower levels of depression. CONCLUSION: Depressive symptoms are frequent among suicide attempters. However, a subgroup of male attempters reporting interpersonal conflicts are characterized by a lower level of depression. This subgroup of attempters would probably not be detected with depression screening programs and may have an unmet need for other forms of screening and prevention.