Summary of evidence
Summary of evidence
Common mental health conditions such as stress, anxiety and depression affect one in six workers in the UK (Mind, 2017). Mental ill-health is one of the most prevalent causes of short and long term sickness absence in the UK (CIPD, 2015) with 1 in 3 Fit Notes issued by General Practitioners citing mental ill-health as the reason (NHS Digital, 2017). Irrespective of whether mental health issues are work-related or not, having a common mental disorder (CMD) can have a negative influence on an individual’s ability to work.
The cost of mental ill-health sickness absence can be significant for both the individual, impacting an their work ability, productivity and well-being and the organisation. Research demonstrates that the longer employees are off work, the less likely they are to return. Early intervention to support an employee back to work is vital and can bring benefits to the employee and organisation. Introducing interventions early and ensuring on-going communication with their organisation, specifically their manager, is imperative to support an employee RTW (Pomaki, Franche, Murray, Khushrushahi & Lampinen, 2012).
There is a growing body of practitioner and academic research that aims to identify the best ways to support employees return to work following mental ill-health related sickness absence. These approaches are introduced in this summary. To explore these studies in further detail please click on Explore the evidence.
What is Return to work?
Employment has been found to be beneficial for our health and well-being. However, there will always be times where employees will become unwell and unable to work. Return to work (RTW) is a term for the process an employee takes when returning to work after sickness absence. This can be due to various reasons, (e.g. pain related, common ill health, musculoskeletal disorders etc.) but for the purpose of this summary there will be a focus on RTW following sickness absence due to common mental disorders (such as stress, anxiety and depression).
Where absences are more than a couple of days, it is commonly accepted that the returning employee and the manager, or HR/ OH professional, hold a return to work interview to identify how the absence, any ongoing illness or treatment plan, may affect their ability to do their job. A phased return to work following sickness absence is preferred and provides the employee with the best chance to return to work successfully. A phased return to work refers to an arrangement whereby the employee gradually resumes their full duties over a pre-agreed time period, and may include adaptations to their working hours or duties.
Prevalence and trends of RTW following mental health sickness absence
There are some staggering figures and statistics surrounding mental health in the workplace. Mental ill health is the cause of about 40% of all days lost through sickness absence (Sainsbury Centre for Mental Health, 2007) and is the reason cited for 1 in 3 Fit Notes issued by General Practitioners (NHS Digital, 2017). We also know that only 50% of individuals who are off for 6 months or more actually return to work (Blank, Peters, Pickvance, Wilford & MacDonald, 2008). These figures emphasise how important it is for key stakeholders to have the tools and know-how to support employees returning to work and then support them to stay in work.
The long term impact of mental ill-health sickness absence is highlighted in a five-year long study by Norder et al. (2017). The employment status of 4,612 male Dutch production workers, of which 552 had sickness absence due to mental health reasons, was tracked over time. By following up on the employees over a five year period, the authors were able to compare workers without mental sickness absence and workers with sickness absence due to mental health. 18% of workers who had returned to work after mental health sickness absence left their employment, compared to 9% of employees without mental health sickness absence. Those returning after mental health sickness absence were also found to voluntarily resign in the first year following their RTW, whilst in later years they were dismissed due to poor work functioning. As the authors found clear differences in employment status amongst the two groups, they argue that these findings highlight the importance of continual after care following an employee’s return to work in order for workers to remain employed and healthy.
Barriers and facilitators to RTW
A large body of literature has now been dedicated to understanding the predictors of returning to work. Researchers have considered various aspects that influence a successful RTW and reduce sickness absence length, these include: early intervention (Alonso, Marco & Andani, 2017), workplace-based interventions (Pomaki, Franche, Murray, Khushrushahi & Lampinen, 2012), the risk factors affecting RTW (Blank, Peters, Pickvance, Wilford & MacDonald, 2008), the importance of continual care following RTW (Norder, van der Ben, Roelen, Heymans, van der Klink & Bültmann, 2017), communication with supervisors (Nieuwenhuijsen et al., 2004) and a lack of coordination between healthcare professionals (Andersen, Nielsen & Brinkmann, 2012) to mention just a few.
In their review focusing specifically on employees with mental ill-health, Andersen, Nielsen, & Brinkmann (2012) found that the challenges and facilitators of the return to work process related to the employee's support network within their workplace, their personality, and the social and rehabilitation systems in place. Importantly, the study demonstrated that employees found it difficult to know when they were ready to return to work and experienced difficulty when trying to incorporate RTW solutions once they were back at work. The authors also suggest that the RTW process should be viewed as a continuous and coherent process whereby an employee’s previous experiences and future expectations can influence their perception of their RTW process.
A recent IOSH report conducted by Joosen et al. (2017), explored the barriers and facilitators of returning to work following sickness leave in workers with CMD. By gathering a multi-stakeholder perspective of the RTW process, the authors identified several themes of facilitators and barriers which were key in the RTW process. Key stakeholders including health care professionals and employers identified features of personalised RTW support, type of work the individual returns to, coming back to a stigma-free work environment, collaboration between treatment professionals, workers’ motivations to return versus their emotions, cognition and coping styles. In contrast, workers in the RTW process identified that the features they felt could foster or hinder the RTW process included: having a supportive/understanding manager, doing work which they value, taking control through recovery-engaging behaviour and gaining self-awareness and understanding their limits. This study highlights the need to take a multi-perspective approach to return to work.
Reviews of RTW interventions
Many of the reviews that examine return to work include compare illnesses or conditions, other than mental health (such as musculoskeletal disorders). Only reviews relating to mental health are included in the evidence section in this hub topic.
Blank, Peters, Pickvance, Wilford, & MacDonald (2008) highlighted several risk factors which are said to prevent those suffering with mental ill health from returning to work. For example, one of the studies reviewed considered supervisor’s behaviours and found that better communication between the employees and their supervisor was related to the time taken to fully return to work, although, interestingly, this was not found in employees with depressive symptoms (Nieuwenhuijsen et al., 2004). Additionally, another study included within this review found that the best predictor of RTW in individuals with work-related stress was whether they had attempted to return within 505 days from their initial absence (Russell, Young & Hart, 1995).
After reviewing the research on common mental health disorders and workplace disability prevention, Pomaki, Franche, Murray, Khushrushahi, & Lampinen (2012) identified three key components which were found to be effective in improving absence duration, work functioning, quality of life and economic outcomes. These were 1) facilitation of access to treatment 2) provision of workplace-based high intensity psychological intervention and 3) facilitation of navigation through the disability management system. Based on the evidence, the authors also make several recommendations for the use of workplace-based interventions which focused on communication, early intervention, access to quality care, creating clear mental health policies and procedures and having workplace-based components within interventions.
Reavley, Ross, Killackey & Jorm (2012) conducted a review of literature on guidance and best practice to support employees RTW after an episode of anxiety, depression or related disorder. Following this, a panel of experts were consulted to produce guidelines and strategies, using the existing literature, in order to inform organisations how best to support an employee through the RTW process.
To explore these studies in further detail please click on Explore the evidence.
Most of the RTW research is focused on various individual interventions which aim to support the employee successfully RTW quickly and reduce sickness absence duration. In this summary, several papers are dedicated to investigating and evaluating various individual interventions for the RTW process.
The majority of papers included within this review focus on evaluating the effectiveness of various tailored RTW interventions. For example, Dalgaard et al. (2017), considered a stress management intervention (based on cognitive behavioural therapy) amongst Danish participants on sick leave due to work-related stress. As a result, the intervention group was found to return to work four weeks sooner than the control group (who only received a clinical assessment and no treatment). On the other hand, Arends, van der Klink, van Rhenen, de Boer & Bültmann (2014) focused their study on recurrent sickness absence in those with CMDs. The authors based their ‘Stimulating Healthy participation And Relapse Prevention’ (SHARP) intervention on empowerment theories to support employees through the RTW process and reduce recurrent sickness absence. At follow up, the SHARP group of participants had a lower incidence of recurrent sickness absence and increased time until recurrent sickness in comparison with the care as usual group.
Other types of individual interventions that were investigated within this section include: whether time until the start of therapy can affect RTW (Alonso, Marco, & Andani, 2017), a web based RTW intervention (Volker, Zijlstra-Vlasveld, Anema, Beekman, Brouwers, Emons, & van der Feltz-Cornelis, 2015), whether psychoeducation can influence RTW (Pedersen, Søgaard, Labriola, Nohr, & Jensen, 2015), predictors of RTW using psychotherapy treatment (Victor, Lau, & Ruud, 2017) and the development of a self-efficacy questionnaire in relation to RTW (Lagerveld, Blonk, Brenninkmeijer, & Schaufeli, 2010).
The role of the line manager in supporting an effective return to work has been recognised. In a study conducted by Munir, Yarker, Hicks, & Donaldson-Feilder, (2012), the behaviours required by line managers to support an employee through absence and on return were identified using a mixed methods approach. The study led to the development of a set of behaviours that can be used as a quick-view checklist for managers to identify their strengths and development needs, or as a measurement of supervisory support.
Training line managers to identify signs and signals of mental ill-health and how to manage those who present with them have been found to be beneficial. Milligan-Saville, et al. (2017) investigated the effect of mental health training for managers on employees who were on sick leave. Managers were given a four-hour mental health training programme and subsequently followed up after six months to evaluate whether sickness absence had been affected. They found that employee work-related sickness leave decreased for the managers who undertook the mental health training. Training not only offered benefits for the returning employee, but also potential financial gains. Findings indicated that the return on investment of the training programme was £9.98 per £1 spent on the mental health training.
The majority of research in this area has focused on interventions focused at the individual and less is known about the wider organisational factors that influence successful returns. Rather, research at the organisational level is wrapped up in wider studies of barriers and facilitators of return to work – where organisational factors such as support from HR or management, clear information on policy and practice, and an open culture to discuss and support mental ill-health are noted.
Alonso, S., Marco, J. H., & Andani, J. (2017). Reducing the time until psychotherapy initiation reduces sick leave duration in participants diagnosed with anxiety and mood disorders. Clinical Psychology & Psychotherapy, 1-6.
Andersen, M. F., Nielsen, K. M., & Brinkmann, S. (2012). Meta-synthesis of qualitative research on return to work among employees with common mental disorders. Scandinavian journal of work, environment & health, 93-104.
Arends, I., van der Klink, J. J., van Rhenen, W., de Boer, M. R., & Bültmann, U. (2014). Prevention of recurrent sickness absence in workers with common mental disorders: results of a cluster-randomised controlled trial. Occup Environ Med, 71(1), 21-29.
Blank, L., Peters, J., Pickvance, S., Wilford, J., & MacDonald, E. (2008). A systematic review of the factors which predict return to work for people suffering episodes of poor mental health. Journal of occupational rehabilitation, 18(1), 27-34.
Joosen, M., Arends, I., Lugtenberg, M., van Gestel, H., Schaapveld, B., van der Klink, J., van Weeghel, J., Terluin, B., & Brouwers, E. (2017). Barriers to and facilitators of return to work after sick leave in workers with common mental disorders: Perspectives of workers, mental health professionals, occupational health professionals, general physicians and managers. IOSH Report.
Lagerveld, S., Blonk, R., Brenninkmeijer, V., Meij, L., Schaufeli, W., & Hurrell, Joseph J. (2012). Work-Focused Treatment of Common Mental Disorders and Return to Work: A Comparative Outcome Study. Journal of Occupational Health Psychology, 17(2), 220-234.
Lagerveld, S. E., Blonk, R. W., Brenninkmeijer, V., & Schaufeli, W. B. (2010). Return to work among employees with mental health problems: development and validation of a self-efficacy questionnaire. Work & Stress, 24(4), 359-375.
Martin, M. H., Nielsen, M. B. D., Madsen, I. E., Petersen, S. M., Lange, T., & Rugulies, R. (2013). Effectiveness of a coordinated and tailored return-to-work intervention for sickness absence beneficiaries with mental health problems. Journal of occupational rehabilitation, 23(4), 621-630.
Milligan-Saville, J. S. et al. (2017). Workplace mental health training for managers and its effect on sick leave in employees: a cluster randomised controlled trial. The Lancet Psychiatry, Volume 4, Issue 11 , 850 – 858.
Munir, F., Yarker, J., Hicks, B., & Donaldson-Feilder, E. (2012). Returning employees back to work: developing a measure for supervisors to support return to work (SSRW). Journal of occupational rehabilitation, 22(2), 196-208.
Nieuwenhuijsen, K., Verbeek, J. H. A. M., De Boer, A. G. E. M., Blonk, R. W. B., & Van Dijk, F. J. H. (2004). Supervisory behaviour as a predictor of return to work in employees absent from work due to mental health problems. Occupational and Environmental Medicine, 61(10), 817-823.
Norder, G., van der Ben, C. A., Roelen, C. A., Heymans, M. W., van der Klink, J. J., & Bültmann, U. (2017). Beyond return to work from sickness absence due to mental disorders: 5-year longitudinal study of employment status among production workers. European journal of public health, 27(1), 79-83.
Pedersen, P., Søgaard, H. J., Labriola, M., Nohr, E. A., & Jensen, C. (2015). Effectiveness of psychoeducation in reducing sickness absence and improving mental health in individuals at risk of having a mental disorder: a randomised controlled trial. BMC public health, 15(1), 763..
Pomaki, G., Franche, R. L., Murray, E., Khushrushahi, N., & Lampinen, T. M. (2012). Workplace-based work disability prevention interventions for workers with common mental health conditions: a review of the literature. Journal of occupational rehabilitation, 22(2), 182-195.
Reavley, N. J., Ross, A., Killackey, E. J., & Jorm, A. F. (2012). Development of guidelines to assist organisations to support employees returning to work after an episode of anxiety, depression or a related disorder: a Delphi consensus study with Australian professionals and consumers. BMC psychiatry, 12(1), 135.
van Beurden, K. M., van der Klink, J. J., Brouwers, E. P., Joosen, M. C., Mathijssen, J. J., Terluin, B., & van Weeghel, J. (2015). Effect of an intervention to enhance guideline adherence of occupational physicians on return-to-work self-efficacy in workers sick-listed with common mental disorders. BMC public health, 15(1), 796.
Victor, M., Lau, B., & Ruud, T. (2017). Predictors of return to work among patients in treatment for common mental disorders: a pre-post study. BMC public health, 18(1), 27.
Volker, D., Zijlstra-Vlasveld, M. C., Anema, J. R., Beekman, A. T., Brouwers, E. P., Emons, W. H., ... & van der Feltz-Cornelis, C. M. (2015). Effectiveness of a blended web-based intervention on return to work for sick-listed employees with common mental disorders: results of a cluster randomized controlled trial. Journal of medical Internet research, 17(5).