Rehabilitation cooperation and person-centred dialogue meeting for patients sick-listed for common mental disorders: 12 months follow-up of sick leave days, symptoms of depression, anxiety, stress and work ability - a pragmatic cluster randomised controlled trial from the CO-WORK-CARE project.

OBJECTIVES: To study whether early and enhanced cooperation within the primary care centres (PCC) combined with workplace cooperation via a person-centred employer dialogue meeting can reduce days on sick leave compared with usual care manager contact for patients on sick leave because of common mental disorders (CMD). Secondary aim: to study lapse of CMD symptoms, perceived Work Ability Index (WAI) and quality of life (QoL) during 12 months. DESIGN: Pragmatic cluster randomised controlled trial, randomisation at PCC level. SETTING: 28 PCCs in Region Västra Götaland, Sweden, with care manager organisation. PARTICIPANTS: 30 PCCs were invited, 28 (93%) accepted invitation (14 intervention, 14 control) and recruited 341 patients newly sick-listed because of CMD (n=185 at intervention, n=156 at control PCCs). INTERVENTION: Complex intervention consisting of (1) early cooperation among general practitioner (GP), care manager and a rehabilitation coordinator, plus (2) a person-centred dialogue meeting between patient and employer within 3 months. CONTROL GROUP: regular contact with care manager. MAIN OUTCOME MEASURES: 12 months net and gross number of sick leave days at group level. SECONDARY OUTCOMES: 12 months depression, anxiety, stress symptoms, perceived WAI and QoL (EuroQoL-5 Dimensional, EQ-5D). RESULTS: No significant differences were found between intervention and control groups concerning days of sick leave (intervention net days of sick leave mean 102.48 (SE 13.76) vs control 96.29 (SE 12.38) p=0.73), return to work (HR 0.881, 95% CI 0.688 to 1.128), or CMD symptoms, WAI or EQ-5D after 12 months. CONCLUSIONS: It is not possible to speed up CMD patients' return to work or to reduce sick leave time by early and enhanced coordination among GP, care manager and a rehabilitation coordinator, combined with early workplace contact over and above what 'usual' care manager contact during 3 months provides. TRIAL REGISTRATION NUMBER: NCT03250026.

Effects of Additional Individually Tailored Interventions on Sick-Leave and Symptoms in Patients with Exhaustion Disorder: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of adding individually tailored interventions to a standard treatment in patients with stress-related exhaustion disorder, with regard to sick-leave days and symptoms of burnout. The study design was a 2-armed randomized controlled intervention, with follow-up after 15 months. Data were obtained from patients referred to the Institute of Stress Medicine, and were collected between 2011 and 2014 in western Sweden. METHODS: Inclusion criteria were scoring above cut-off in at least 1 of 4 dimensions; mental and physical exhaustion, disturbed sleep, reduced cognitive function and perceived poor self-esteem. The total study population comprised 142 patients (112 females, 30 males) allocated through block randomization to either the intervention group (n = 71) or the control group (n = 71). The intervention group received 1-4 individually tailored interventions (physical activity, cognitive behaviour therapy for insomnia, computerized memory training, cognitive behavioural therapy for self-esteem), based on the results of screening assessments. The interventions were additional to a standard treatment. The control group received solely the standard treatment. The primary outcome measure was the proportion of participants not sicklisted at the 15-month follow-up. RESULTS: At the 15-month follow-up, 30% of subjects in the intervention group and 34% in the control group had 0% sick-listed (p = 0.58). No change between baseline and follow-up was seen in 42% of the intervention group and 39% of the control group, while an increased sick-leave rate was seen in 1% of the intervention group and 4% of the control group. However, no statistically significant difference was seen between groups. CONCLUSION: Adding individually tailored interventions to a standard treatment in patients with stress-related exhaustion did not reduce sick-leave days or burnout symptoms.

Symptom patterns in patients newly sick listed for common mental disorders and associations with work-related and socioeconomic factors: a cross-sectional study in Swedish primary care.

OBJECTIVE: The aim was to determine symptom patterns of depression, anxiety and stress-related mental disorders in newly sick listed due to common mental disorders in Swedish primary care patients and to examine associations with sick leave diagnosis, also in relation to socioeconomic, work-related and demographic factors. DESIGN: Cross-sectional study. SETTING: Primary care in western Sweden. PARTICIPANTS: From a randomised controlled trial, patients aged 18-67, seeking primary care and on sick leave due to depression, anxiety and/or mental stress, in total 341 individuals, during 2018-2020. PRIMARY OUTCOME MEASURES: Patterns of depressive, anxiety and stress symptoms measured via self-assessment questionnaires (Montgomery Asberg Depression Rating Scale-Self (MADRS-S), General Anxiety Disorder Scale-7 (GAD-7), Karolinska Exhaustion Disorder Scale (KEDS)), sick leave diagnosis, perception of Work Ability Index and job strain via the job strain model. RESULTS: A combination of high levels of depressive and stress-related symptoms was more frequent than single symptom clusters among persons with common mental disorders (CMD) on sick leave: 7% of the patients had scores above cut-off for one of the instruments MADRS-S, GAD-7 and KEDS, 12% above cut-off for two and 80% had above cut-off for all three instruments. There was no significant association between low socioeconomic status, high-job strain or working in healthcare/education and having scores above cut-off level for two or more of the instruments. Only perception of own poor work ability showed association with having scores above cut-off level for all three of the assessment instruments of CMD (OR 9.45, 95% CI 2.41 to 37.04). CONCLUSION: The diagnosis on the sick certificate is not always congruent with the dominating symptom score level. In patients sick-leaved for CMDs, possible negative factors such as low socioeconomic status, low social support, high-work strain or working in healthcare/education sector did not show significant associations with self-assessment instruments of anxiety, depression and stress. Only patient's perception of own poor work ability was associated with high scores on all three domains. TRIAL REGISTRATION NUMBER: NCT03250026.

Long-term follow-up of residual symptoms in patients treated for stress-related exhaustion.

BACKGROUND: Many patients with stress-related exhaustion seem to struggle with long-term recovery. The primary aim of this study was to explore residual symptoms and perceived recovery in patients previously treated for stress-related exhaustion, 7 years after seeking care. METHODS: A total of 217 former patients (74% women) previously treated for exhaustion disorder were asked to participate in follow-ups 2, 3, 5, and 7 years post treatment. Symptoms of depression, and anxiety were measured with questionnaires. Remaining symptoms of extreme fatigue, sleep disturbances, problems with concentration, problems with memory and reduced stress tolerance, were rated with single item questions. A subgroup of patients (n = 163) participated in a clinical assessment to confirm residual stress-related exhaustion not caused by other diseases. RESULTS: Almost half of the patients previously treated for stress-related exhaustion perceive fatigue 7 years after initially seeking care, and as many as 73% reported decreased stress tolerance. The clinical assessment confirmed that a third of the patients were clinically judged as still suffering from stress-related exhaustion. Male and female patients showed similar patterns regarding residual symptoms. CONCLUSIONS: One third of patients with exhaustion disorder are clinically judged to have exhaustion, 7 years after seeking care. Further studies are needed to elucidate the reason for such a long-term recovery and ultimately to identify methods for prevention.

Newly educated care managers' experiences of providing care for persons with stress-related mental disorders in the clinical primary care context.

OBJECTIVE: Our aim was to explore how the care managers put the complex care manager task into practice and how they perceived their task, which was to facilitate effective, person-centred treatment for stress-related disorder concordant with evidence-based guidelines in primary care. DESIGN: This was a qualitative study using examination reports from the course for care managers. Systematic text condensation according to Malterud was used for the analysis. SETTING: Primary health care centres. SUBJECT: Twenty-eight newly educated care managers in primary health care participated in the study. The median age was 50 (31-68) years. Twenty-seven were women and one was a man. Twenty-one were employed as nurses and seven as counsellors. RESULTS: The informants perceived the role as care manager as meaningful but at times complicated. To participate in teams and to work closely with the general practitioner was experienced as important. The co-ordinating function was emphasised as especially important, as well as the increased continuity in care. The dual role as care manager and counsellor was sometimes experienced as problematic. CONCLUSION: The informants took advantage of the knowledge they had attained during the course. They perceived themselves as being a bridge between patients and other professionals. The result of having dual roles at the primary health care centre unexpectedly revealed difficulties for some professionals. The nurses seemed more familiar with the new way of working.

Prevalence of perceived stress and associations to symptoms of exhaustion, depression and anxiety in a working age population seeking primary care--an observational study.

BACKGROUND: Prolonged stress may lead to mental illness, but the prevalence of stress in a working age population seeking primary health care for whatever reason, is unknown. This paper seeks to examine to what extent this group perceives stress, as well as symptoms of burnout/exhaustion, depression and anxiety. METHODS: In 2009, 587 primary health care patients aged 18-65 years (377 women, 210 men), with an appointment with a primary health care physician, participated in the study. A screening questionnaire with questions about age, gender, marital status, employment, reason for medical consultation, and the QPS Nordic screening question about stress was distributed:" Stress is defined as a condition where you feel tense, restless, anxious or worried or cannot sleep at night because you think of problems all the time. Do you feel that kind of stress these days? There were five possible answers; "not at all" and "only a little" (level 1),"to some extent" (level 2),"rather much" and "very much" (level 3). In a second step, symptoms of burnout/exhaustion (Shirom-Melamed Burnout Questionnaire and the Self-rated Exhaustion Disorder instrument) and anxiety/depression (Hospital Depression and Anxiety scale) were assessed among those with higher levels of perceived stress. RESULTS: 345 (59%) of the study patients indicated stress levels 2 or 3 (237 women and 108 men). Women more often indicated increased levels of stress than men. Two thirds of the participants expressing stress levels 2-3 indicated a high degree of burnout, and approximately half of them indicated Exhaustion Disorder (ED). Among highly stressed patients (level 3), 33% reported symptoms indicating possible depression and 64% possible anxiety. CONCLUSION: More than half of this working age population perceived more than a little stress, as defined, women to a greater extent than men. Symptoms of burnout and exhaustion were common. A high level of perceived stress was often accompanied by symptoms of depression and/or anxiety.