Preventing depression and promoting resilience: feasibility study of a school-based cognitive-behavioural intervention.

BACKGROUND: The limited reach and effectiveness of psychological treatments for adolescent depression have fuelled interest in alternative approaches designed to promote resilience. Schools offer a convenient location for the widespread delivery of depression prevention programmes, although little research has evaluated the feasibility of delivering interventions in this setting. AIMS: To investigate the feasibility of delivering and evaluating a universal school-based depression prevention programme for children aged 12-16 years. METHOD: A three-arm pilot study was conducted in one UK secondary school (n = 834). RESULTS: Interventions had good reach (96%), with high rates of consent (89%) and reasonable retention (78%). The majority of intervention sessions were delivered as intended, with 85% of students attending seven or more sessions. The programme was acceptable to students and teachers, with the specific content of the active intervention being rated differently from the control programmes. CONCLUSIONS: Delivering and undertaking methodologically robust evaluations of universal school-based depression programmes is feasible.

School connectedness, peer attachment, and self-esteem as predictors of adolescent depression.

Recent literature suggests that school connectedness (SC) may be a key determinant of adolescent mental health. Specifically, SC has been found to have a negative relationship with adolescent depression. In the current, cross sectional study, we examine whether the relationship between SC and symptoms of low mood is dampened or moderated by self-esteem (SE) and peer attachment style. Participants were 5022 adolescents (aged 11-16) who completed a battery of questionnaires in school, including measures of low mood, SC, SE, and peer attachment style. The relationship between SC and low mood was reduced by the inclusion of SE and peer attachment style. Peer attachment style was the largest predictor of low mood. The relationship between SC and low mood was not moderated by SE or peer attachment style. Interventions for adolescent depression may be most effective by focussing on increasing SE and fostering secure attachments, rather than solely focussing on increasing SC.

The cost effectiveness of NHS physiotherapy support for occupational health (OH) services.

BACKGROUND: Musculoskeletal pain is detrimental to quality of life (QOL) and disruptive to activities of daily living. It also places a major economic burden on healthcare systems and wider society. In 2006, the Welsh Assembly Government (WAG) established a three tiered self-referral Occupational Health Physiotherapy Pilot Project (OHPPP) comprising: 1.) telephone advice and triage, 2.) face-to-face physiotherapy assessment and treatment if required, and 3.) workplace assessment and a return-to-work facilitation package as appropriate. This study aimed to evaluate the feasibility and cost-effectiveness of the pilot service. METHODS: A pragmatic cohort study was undertaken, with all OHPPP service users between September 2008 and February 2009 being invited to participate. Participants were assessed on clinical status, yellow flags, sickness absence and work performance at baseline, after treatment and at 3 month follow up. Cost-effectiveness was evaluated from both top-down and bottom-up perspectives and cost per Quality Adjusted Life Year (cost/QALY) was calculated. The cost-effectiveness analysis assessed the increase in service cost that would be necessary before the cost-effectiveness of the service was compromised. RESULTS: A total of 515 patients completed questionnaires at baseline. Of these, 486 were referred for face to face assessment with a physiotherapist and were included in the analysis for the current study. 264 (54.3%) and 199 (40.9%) were retained at end of treatment and 3 month follow up respectively. An improvement was observed at follow up in all the clinical outcomes assessed, as well as a reduction in healthcare resource usage and sickness absence, and improvement in self-reported work performance. Multivariate regression indicated that baseline and current physical health were associated with work-related outcomes at follow up. The costs of the service were £194-£360 per service user depending on the method used, and the health gains contributed to a cost/QALY of £1386-£7760, which would represent value for money according to current UK thresholds. Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user. CONCLUSIONS: This pragmatic evaluation of the OHPPP indicated that it was likely to be feasible in terms of service usage and could potentially be cost effective in terms of QALYs. Further, the study confirmed that improving physical health status for musculoskeletal pain patients is important in reducing problems with work capacity and related costs. This study suggests that this type of service could be potentially be useful in reducing the burden of pain and should be further investigated, ideally via randomised controlled trials assessing effectiveness and cost-effectiveness.

Challenges to remaining at work with common health problems: what helps and what influence do organisational policies have?

INTRODUCTION: Common health problems have a significant impact on work productivity (presenteeism), and sickness absence. The aim of this study was to examine the attitudes and beliefs of employees in the public sector about common health problems and work using the Flags system as a conceptual framework to identify problems and potential solutions. METHOD: 63 employees took part in 14 focus groups in two public sector organisations. Discussions were audio-recorded, transcribed, and analysed thematically using NVivo. RESULTS: The study confirmed the importance of heath-focused clinical factors (Yellow flags), perceptions of work (Blue flags), and more objective characteristics of work and organisational policies (Black flags), which emerged as major themes. The social and moral norms surrounding sickness absence and presenteeism were frequently discussed, including the impact of absence on colleagues, guilt, legitimising illness, and trust. There were interactions between the different Flags, often mediated by managers via their relationships with employees and their role in implementing organisational policy. CONCLUSIONS: The Flags system was useful as a conceptual framework in this context for identifying a number of obstacles to working with health problems, many of which were potentially modifiable on worker, workplace, or wider systems levels.

What happens to work if you're unwell? Beliefs and attitudes of managers and employees with musculoskeletal pain in a public sector setting.

INTRODUCTION: Musculoskeletal complaints can impact on work in terms of productivity, sickness absence and long term incapacity for work. While employee attitudes and knowledge can drive absenteeism and presenteeism behaviour, managers also play an important role in influencing this via the quality of their relationships with employees and their role in implementing organisational policies and procedures. The aims of this study were to investigate the beliefs and attitudes of managers and employees with musculoskeletal pain about sickness absence, presenteeism, and return to work and to identify areas of consensus and conflict. METHODS: 18 employees with musculoskeletal pain and 20 managers from two large public sector organisations in South Wales, UK, took part in individual face-to-face interviews. Data were analysed thematically using NVivo. RESULTS: Employees' and managers' reports indicated that there was a strong culture of presenteeism in these organisations. Establishing the legitimacy of complaints was a salient theme for both managers and employees, although their views were in conflict. Employees reported feeling that contact with employers was intrusive when sickness absence was legitimate. Managers were supportive of those who they felt were 'genuinely' unwell, but also cited examples of people 'working the system' and not reporting absences appropriately. CONCLUSIONS: These issues require careful consideration of the rights and responsibilities of both employees and employers, where strategies for improving communication, trust, and creating an environment conducive to successful return to work need to be investigated.

Protocol for a randomised controlled trial of a school based cognitive behaviour therapy (CBT) intervention to prevent depression in high risk adolescents (PROMISE).

BACKGROUND: Depression in adolescents is a significant problem that impairs everyday functioning and increases the risk of severe mental health disorders in adulthood. Relatively few adolescents with depression are identified and referred for treatment indicating the need to investigate alternative preventive approaches. STUDY DESIGN: A pragmatic cluster randomised controlled trial evaluating the effectiveness of a school based prevention programme on symptoms of depression in "high risk" adolescents (aged 12-16). The unit of allocation is year groups (n = 28) which are assigned to one of three conditions: an active intervention based upon cognitive behaviour therapy, attention control or treatment as usual. Assessments will be undertaken at screening, baseline, 6 months and 12 months. The primary outcome measure is change on the Short Mood and Feeling Questionnaire at 12 months. Secondary outcome measures will assess changes in negative thoughts, self esteem, anxiety, school connectedness, peer attachment, alcohol and substance misuse, bullying and self harm. DISCUSSION: As of August 2010, all 28 year groups (n = 5023) had been recruited and the assigned interventions delivered. Final 12 month assessments are scheduled to be completed by March 2011. TRIAL REGISTRATION: ISRCTN19083628.

Common health problems, yellow flags and functioning in a community setting.

INTRODUCTION: Common health problems such as pain, depression and fatigue have a high impact on daily life, work and healthcare utilization. This study aimed to investigate the prevalence of these complaints in a UK community setting and to establish whether psychosocial risk factors, or 'yellow flags', moderate their impact on daily life and work. METHODS: 580 women and 420 men participated in a cross-sectional survey in the UK in 2007. 467 (57.2%) of the 816 working age adults in this sample reported complaints over the last month and were included in the moderator multivariate analysis. RESULTS: Women and the not employed group reported a higher number and greater extent (frequency x severity) of complaints. Statistically significant models emerged for interference with daily life (F (9,457) = 36.54, P < 0.001, adjusted R (2) = 0.407) and time off work (F (4,462) = 31.22, P < 0.001, adjusted R (2) = 0.213). Age (beta = .238) and socio-economic status (beta = -.216) were associated with time off work. Extent of complaints and number of yellow flags were independently associated with interference with daily life (extent beta = .25, yellow flags beta = .15) and time off work (extent beta = .154, yellow flags beta = .201). No moderating effect of yellow flags was found. CONCLUSIONS: Common health problems and yellow flags can be briefly and simply assessed. A broader approach is needed in managing these complaints in community and work contexts, moving beyond reducing complaint severity. Interventions need to acknowledge and address people's beliefs and affective responses to complaints, as well as wider socio-economic issues.

Impacts on work absence and performance: what really matters?

BACKGROUND: A number of factors influence an individual's decision to take sickness absence or to remain at work while ill. The relationship between health, work characteristics, individual perceptions of work and sickness absence and performance is complex and further clarification of the interactions between these factors is necessary. AIMS: To assess the relative impact of health, work characteristics and perceptions of work on absence and performance. METHODS: Cross-sectional survey of two public sector organizations (n = 505). Data were analysed using multivariate linear regression to assess the individual and combined influence of each class of independent variables on the following: days sickness absence, spells of sickness absence, VAS performance and presenteeism. RESULTS: Characteristics of work were weakly associated with days absence and performance. Perceptions of work were more strongly associated with performance than absence. Measures of mental health, rather than physical health, had the greatest influence on ability to work. Poor health had a greater impact on work performance than work absence. When considered together, health variables accounted for the largest proportion of explained variance in both absence and performance when compared with characteristics of work and work perceptions. CONCLUSIONS: Using absence as a marker of health-associated compromise at work may lead to an underestimation of the impact of health on work. This study demonstrates the need to manage the impact of health problems on the workforce not only from a bio-medical perspective but also in terms of the psychological pressures and the social context in which employees work.

Examination of the Work Organization Assessment Questionnaire in public sector workers.

OBJECTIVE: To investigate the utility of the Work and Organization Assessment Questionnaire (WOAQ) for public sector data. METHODS: A cross-sectional survey was performed in public sector organizations measuring demographics, work characteristics, work perceptions (WOAQ), sickness absence, and work performance. RESULTS: Confirmatory factor analysis of the WOAQ showed that factor structure derived for the manufacturing sector, for which the questionnaire was developed, could be replicated moderately well with public sector data. The study then considered whether a better more specific fit for public sector data was possible. Principal components analysis of the public sector data identified a two-factor structure linked to four of the five scales of the WOAQ assessing Management and Work Design, and Work Culture. These two factors may offer a context-sensitive scoring method for the WOAQ in public sector populations. These two factors were found to have good internal consistency, and correlated with the full WOAQ scales and the measures of performance and absence. CONCLUSIONS: The WOAQ is a useful and potentially transferable tool. The modified scoring may be used to assess work and organizational factors in the public sector.

Working with Musculoskeletal Pain.

Pain has a significant impact on work in terms of presenteeism, sickness absence, and long-term incapacity for workA bio-psychosocial approach is required in understanding pain-related disability and incapacity for workLong-term absence from work is associated with a number of negative outcomes including; poverty, social exclusion and poorer physical and psychosocial well-beingReturn to work can improve recovery for people with musculoskeletal complaints and painInterventions to reduce the impact of pain on work can operate at clinical, worker, workplace, and wider systems levelsA broader whole systems approach to pain management needs to be adopted, with a greater focus on work retention as well as rehabilitation.

Beliefs about common health problems and work: a qualitative study.

Common health problems (CHPs) such as pain, depressed mood and fatigue are often cited as causes of disability and incapacity for work. The aim of this qualitative study was to investigate beliefs about CHPs in relation to work. Focus groups (n=16) were undertaken with 79 people aged 17-83 in South Wales, UK, where there is a high prevalence of limiting long-term illnesses in a number of areas. The findings indicated that depression and stress were consistently reported to have a high impact on life and work relative to other CHPs, with work being perceived as a primary cause of these complaints. The social, moral and economic pressures involved in work and sickness absence emerged as a major theme. Differences were identified in beliefs about CHPs and work according to gender, age and socio-economic status. Beliefs were relatively consistent across geographical locations, although changes in forms of work and social structure of communities were more salient issues within the ex-coalfield areas. Care needs to be taken that initiatives aimed at reducing incapacity for work due to CHPs do not simply add to the pressure to 'be well'.

Prioritising pain in policy making: the need for a whole systems perspective.

This review aims to bring together current evidence on the impact of chronic pain in terms of its economic costs, cost to healthcare services and benefit agencies, and quality of life, and to discuss the implications of this for government policies. Quantifying the burden and cost of pain is challenging due to its multi-factorial nature and wide reaching effects. Nonetheless, there is a consensus that chronic pain has a significant impact on levels of resources across society and on quality of life. Pain is a complex bio-psychosocial experience and chronic pain is a consequence, in part, of adopting a narrow biomedical treatment approach to a problem which requires a multi-disciplinary approach to address the psychosocial, behavioural and biomedical aspects of pain. Although effective pain management interventions and programmes exist, provision of these services is inconsistent, and chronic pain is not given the priority it requires in view of the extent of its burden on individuals and society. Current relevant government policies in U.K. are discussed to highlight the need to prioritise pain and adopt a whole-systems approach to its management if governments are to successfully reduce its cost and burden.

A daily process design study of attentional pain control strategies in the self-management of cancer pain.

This study investigated the use of attentional control strategies in the self-management of pain using daily process design methodology. Twenty six cancer patients with pain completed diaries 3 times daily for 10 days. Diaries incorporated measures of pain intensity, affect, coping, coping efficacy, and the novelty and predictability of pain, and participants completed a cross-sectional measure of catastrophizing. At the across-person level, focusing on pain was associated with increased negative affect, and the use of pain focusing strategies was positively correlated with experiencing pain that was novel in its location or quality. Distractions that were interesting, important and pleasant were positively correlated with positive affect, perceptions of control over pain and ability to decrease pain. Over-prediction of pain was positively correlated with catastrophizing, and negatively correlated with perceptions of control over and ability to decrease pain. The within-person analysis (ARIMA modelling) showed that catastrophizing moderated the effects of pain focusing strategies, novel pain and over-predictions of pain. Meta-analysis of the ARIMA models revealed that the within-person effects of using attentional strategies did not generalize across the sample. These findings indicated that the effects of distraction strategies are influenced by their motivational-affective significance rather than the frequency with which they are used, and provided further evidence that the threat value of pain influences the way in which people cope with their pain. Theoretical and clinical implications are discussed.