Sick leave assessments of workers with subjective health complaints: a cross-sectional study on differences among physicians working in occupational health care.

Aims: To obtain more insight into differences in sick leave assessments of workers with subjective health complaints, we studied sick leave assessments among Dutch occupational and insurance physicians, and explored possible determinants for these differences.Methods: A cross-sectional study was conducted among 50 occupational and 43 insurance physicians in the Netherlands. They all assessed sick leave (complete, partial or no) of nine video case vignettes of workers with subjective health complaints and gave their opinion on the complaints, sick leave and health status. Data were analyzed via a multinomial regression approach, using generalized estimating equations in SPSS.Results: Compared to occupational physicians, complete sick leave was less likely to be assessed by insurance physicians (odds ratio 0.74, 95% confidence interval 0.56-0.97). For occupational physicians, psychological diagnoses, private issues and reduced work ability had more influence on the outcome of the sick leave assessment than for insurance physicians.Conclusion: There are differences in sick leave assessments for workers with subjective health complaints between physicians working in the same occupational health system; insurance physicians are stricter in assessing complete sick leave than occupational physicians. These differences may be explained by differences in roles, tasks and perspectives of the physician in occupational health care.Implications for Rehabilitation  Sick leave assessments of workers with subjective health complaints. • The current study showed that there are differences between occupational physicians and insurance physicians in sick leave assessments for workers with subjective health complaints. • These differences may be based on different perspectives, roles and tasks of physicians. • Physicians working in the rehabilitation and occupational health system should be more aware of the impact of these differences on their assessments and advices. • Better communication and collaboration between physicians, and more insight into and clarification of the perspectives may result in more agreement between physicians' sick leave assessment and advice towards workers.

Are there patient-related factors that influence sickness certification in patients with severe subjective health complaints? A cross-sectional exploratory study from different European countries.

OBJECTIVES: To develop hypotheses about whether there are patient-related factors that influence physicians' decision-making that can explain why some patients with severe subjective health complaints (SHCs) are more likely to be granted sick leave than others. DESIGN: Exploratory cross-sectional. SETTING: Assessments of patient-related factors after watching nine authentic video recordings of patients with severe SHC from a Norwegian general practice. Our previous study showed that three of these nine patients were less likely than the remaining six patients to be granted sick leave by physicians from five European countries. PARTICIPANTS: In total, 10 assessors from Norway, the Netherlands and France. OUTCOMES: The direction in which the assessments may contribute towards the decision to grant a sickness certificate (increasing or decreasing the likelihood of granting sick leave). RESULTS: Physicians consider a wide variety of patient-related factors when assessing sickness certification. The overall assessment of these factors may provide an indication of whether a patient is more likely or less likely to be granted sick leave. Additionally, some single questions (notable functional limitations in the consultation, visible suffering, a clear purpose for sick leave and psychiatric comorbidity) may indicate differences between the two patient groups. CONCLUSIONS: Next to the overall assessment, no notable effect of the complaints on functioning and suffering, a lack of a clear purpose for sick leave and the absence of psychiatric comorbidity may be factors that could help guide the decision to grant sick leave. These hypotheses should be tested and validated in representative samples of professionals involved in sickness certification. This may help to understand the tacit knowledge we believe physicians have when assessing work capacity of patients with severe SHC.

Recovery and recurrence of mental sickness absence among production and office workers in the industrial sector.

BACKGROUND: Manual workers in the public sector have previously been found to be at risk of mental sickness absence (SA). As the impact of mental illness differs across economic sectors, this study investigated mental SA in the industrial sector, differentiating between office and production workers. METHODS: Ten-year observational cohort study including 14 369 (8164 production and 6205 office) workers with a total of 101 118 person years. SA data were retrieved from an occupational health register. Mental SA episodes were medically certified as emotional disturbances [10th version of the International Classification of Diseases (ICD-10 R45)] or mental and behavioural disorders (ICD-10 F00-F99). The first mental SA episode since baseline was called index mental SA. Recurrences were defined as any mental SA episode occurring >28 days after recovery from index mental SA. RESULTS: The incidence of mental SA was higher in production workers than in office workers, but office workers needed longer time to recover from mental SA. Mental SA recurred as frequently in production workers as in office workers. The median time to recurrence was 15.9 months and tangibly shorter in office workers (14.9 months) than in production workers (16.7 months). Production and office workers aged >55 years were at increased risk of recurrent mental SA within 12 months of recovery from index mental SA. CONCLUSIONS: The incidence of mental SA was higher in production workers than in office workers, whereas recurrence rates did not differ between them. Occupational health providers should pay special attention to older workers as they are at increased risk of recurrent mental SA.

Validation of the 4DSQ somatization subscale in the occupational health care setting as a screener.

PURPOSE: Somatoform disorders (physical symptoms without medical explanation that cause dysfunction) are prevalent in the occupational health (OH) care setting and are associated with functional impairment and absenteeism. Availability of psychometric instruments aimed at assessing somatoform disorders is limited. In the OH setting, so far only the Patient-Health-Questionnaire 15 has been validated as screener for somatoform disorder, and has been shown to have moderate validity. The Four-Dimensional Symptom Questionnaire (4DSQ) is frequently used in the OH setting but the Somatization subscale is not validated yet. The aim of this study is to validate the 4DSQ Somatization subscale as screener for DSM-IV somatoform disorder in the OH setting by using the MINI interview as gold standard. METHODS: Employees absent from work due to physical symptoms, for a period longer than 6 weeks and shorter than 2 years, were asked to participate in this study. They filled out the 4DSQ and underwent a MINI interview by telephone for DSM-IV classification. Specificity and sensitivity scores were calculated for all possible cut-off scores and a receiver operator curve was computed for the Somatization subscale. 95 % confidence intervals (95 % CIs) were calculated for sensitivity and specificity. RESULTS: The Somatization subscale of the 4DSQ has an optimal cut point of 9, with specificity and sensitivity equal to 64.3 % [95 % CI (53.6; 73.7 %)] and 60.9 % [95 % CI (40.8; 77.8 %)], respectively. Receiver operator curves showed an area under the curve equal to 0.61 [SE = 0.07; 95 % CI (0.48; 0.75)] for the Somatization subscale of the 4DSQ. CONCLUSION: The 4DSQ Somatization subscale is a questionnaire of moderate sensitivity and specificity.

Cost-utility analysis of a collaborative care intervention for major depressive disorder in an occupational healthcare setting.

PURPOSE: Major depression is associated with high levels of absence and reduced productivity. Therefore the costs to society are high. The aim of this study was to evaluate the cost-utility of collaborative care for major depressive disorder (MDD) compared to care as usual in an occupational healthcare setting. A societal perspective was taken. METHODS: In this randomised controlled trial, 126 sick-listed workers with MDD were included (65 collaborative care, 61 care as usual). Baseline measurements and follow up measures (3, 6, 9 and 12 months) were assessed by questionnaire. We applied the Trimbos/iMTA questionnaire for costs associated with psychiatric illness, the SF-HQL and the EQ-5D respectively measuring the health care utilization, production losses and general health related quality of life. RESULTS: The average annual healthcare costs in the collaborative care group were €3,874 (95 % CI €2,778-€ 5,718) compared to €4,583 (95 % CI €3,108-€6,794) in the care as usual group. The average quality of life years (QALY's) gained were lower in the collaborative care group, 0.05 QALY. The majority of the ICERS (69 %) indicate that collaborative care is less costly but also less effective than care as usual. Including the productivity costs did not change this result. CONCLUSIONS: The cost-utility analysis showed that collaborative care generated reduced costs and a reduction in effects compared to care as usual and was therefore not a cost-effective intervention.

Mental health symptoms as prognostic risk markers of all-cause and psychiatric sickness absence in office workers.

BACKGROUND: To investigate mental health symptoms as prognostic risk markers of all-cause and psychiatric sickness absence (SA). METHODS: Mental health symptoms were measured in 1137 office workers with the Four-Dimensional Symptom Questionnaire (4DSQ), including scales for distress, depression, anxiety and somatization. The total number of SA days was accumulated prospectively on the individual level and high SA was defined as ≥30 SA days during 1-year follow-up. Psychiatric SA was also tallied on the individual level during 1-year follow-up. Baseline 4DSQ scores were associated with high all-cause SA and psychiatric SA by logistic regression analysis. The Hosmer-Lemeshow test and calibration slope were used to assess the accuracy of predictions by 4DSQ scores. The ability of 4DSQ scores to discriminate high-risk from low-risk employees was estimated by the area under the receiver operating characteristic curve. RESULTS: Six hundred thirty-three office workers (56%) participated in the study. All 4DSQ scales were prospectively associated with high all-cause SA and with psychiatric SA. Distress and somatization scores showed acceptable calibration, but failed to discriminate between office workers with and without high all-cause SA. The distress scale did show adequate calibration (calibration slope = 0.95) and discrimination (area under the receiver operating characteristic curve = 0.71) for psychiatric SA. CONCLUSION: Distress was a valid prognostic risk marker for identifying office workers at work, but at risk of future psychiatric SA. Further research is necessary to investigate the prognostic performance of distress as risk marker of psychiatric SA in other working populations and to determine cut-off points for distress.

Collaborative care for sick-listed workers with major depressive disorder: a randomised controlled trial from the Netherlands Depression Initiative aimed at return to work and depressive symptoms.

OBJECTIVES: Major depressive disorder (MDD) is associated with absenteeism. In this study, the effectiveness of collaborative care, with a focus on return to work (RTW), was evaluated in its effect on depressive symptoms and the duration until RTW in sick-listed workers with MDD in the occupational health setting. METHODS: In this randomised controlled trial, 126 sick-listed workers with MDD were randomised to usual care (N=61) or collaborative care (N=65). Collaborative care was applied by the occupational physician care manager, supported by a web-based tracking system and a consultant psychiatrist. Primary outcome measure was time to response. Secondary outcome measures were time to remission, depressive symptoms as continuous measure and the duration until full RTW. RESULTS: Collaborative care participants had a shorter time to response, with a difference of 2.8 months. However, no difference was found on time to remission or depressive symptoms as continuous measure. With a mean of 190 days in the collaborative care group, and 210 days in the usual care group, the groups did not differ significantly from each other in the duration until full RTW. Adherence to the collaborative care intervention was low. CONCLUSIONS: These results do not justify a widespread implementation of collaborative care in occupational healthcare, as it was operationalised in this study. However, since the study might have been underpowered for RTW and because treatment integrity was low, further research, with larger sample sizes, is needed to develop the best fitting (collaborative care) model for addressing RTW in depressed sick-listed workers. TRIAL REGISTRATION: : ISRCTN78462860.

Presentation of the Multidisciplinary Guideline Medically Unexplained Physical Symptoms (MUPS) and Somatoform Disorder in the Netherlands: disease management according to risk profiles.

OBJECTIVE: January 2011, the Dutch Multidisciplinary Guideline for Medically Unexplained Symptoms (MUPS) and Somatoform Disorder (SD) was published. The aim was to set a standard for multidisciplinary prevention, diagnosis and treatment of MUPS and SD. METHODS: First, the Multidisciplinary Guideline group defined a conceptual approach for the guideline. After this, a systematic literature review, followed by consensus meetings in the Multidisciplinary working group, aimed to answer the following questions: 1) What evidence exists for preventive interventions, including the patient-doctor communication in MUPS and SD? 2) How can the diagnosis of MUPS be established? 3) What effective treatments of MUPS are available? 4) Which types of treatment are most effective for which patients? RESULTS: As conceptual approach for the guideline, based on existing literature, in this guideline MUPS are considered a category of symptoms that have many common aspects and are best approached by one, generic approach. 1) Research for preventive interventions and the patient-doctor relationship in MUPS and SD is scanty. 2) To establish the diagnosis of MUPS or SD, the GP should follow a parallel somatic-psychosocial diagnostic step plan. 3) A Systematic Review identified Cognitive Behavioral Treatment (CBT), treatment of comorbid depressive and anxiety disorder, psychiatric consultation with a Consultation Letter to General Practitioners (GPs) and stepped care as evidence based interventions for MUPS and SD. 4) In order to apply the best fitting treatment to patients, patient risk profiles were formulated to guide stepped-care treatment that should start at an appropriate level and treatment setting. Three levels are discerned: Low risk patients need reassurement by the GP. Moderate risk patients suffer from comorbidity. They need case-management and generally can be treated by the GP as well, who can be supported by psychiatric consultation. High risk patients often have long term SD and a perturbed patient-doctor relationship with their GP. For this group, specialist mental health treatment is needed. CONCLUSION: Disease-managament based on risk profiles, providing stepped care and case management by the GP, supported by psychiatric consultation with a consultation letter, and mental health in-patient multidisciplinary treatment for severe cases, is the recommended strategy of the Dutch Multidisciplinary Guideline for MUPS and SD.

Validation of the PHQ-15 for somatoform disorder in the occupational health care setting.

INTRODUCTION: Within the occupational health setting, somatoform disorders are a frequent cause of sick leave. Few validated screening questionnaires for these disorders are available. The aim of this study is to validate the PHQ-15 in this setting. METHODS: In a cross-sectional study of 236 sicklisted employees, we studied the performance of the PHQ-15 in comparison with the Mini International Neuropsychiatric Interview (MINI) as golden reference standard. We approached employees who were sick listed for a period longer than 6 weeks and shorter than 2 years for participation. This study was conducted on one location of a large occupation health service in the Netherlands, serving companies with more than 500 employees. All employees who returned the PHQ-15 were invited for the MINI interview. Specificity and sensitivity were calculated for optimal cut point and a receiver operating characteristic (ROC) was constructed. RESULTS: A total of 107 participants consented to participate in the MINI interview. A non-response analysis showed no significant differences between groups. According to the MINI, the prevalence of somatoform disorders was 21.5%, and the most frequent found disorder was a pain disorder. The PHQ-15 had an optimal cut point of 9 (patients scoring 9 or higher (≥9) were most likely to suffer from a somatoform disorder), with specificity and sensitivity equal to 61.9 and 56.5%, respectively. ROCs showed an area under the curve (AUC) of 0.63. CONCLUSION: The PHQ-15 shows moderate sensitivity but limited efficiency with a cut point of 9 and can be a useful questionnaire in the occupational health setting.

[The Dutch multidisciplinary guideline entitled 'Medically unexplained physical symptoms and somatoform disorder']. / De Nederlandse multidisciplinaire richtlijn 'Somatisch onvoldoende verklaarde lichamelijke klachten en somatoforme stoornissen'

The Dutch multidisciplinary guideline called 'Medically unexplained physical symptoms (MUPS) and somatoform disorder' presents a disease-management approach based on three pillars: (a) maintaining patient profiles estimating the risk of iatrogenic harm as well as chronicity, (b) stepped-care treatment starting at a level appropriate for the patient's profile, and (c) the introduction of the family physician as case manager (in serious cases: the medical specialist or psychiatrist) whose task is to channel use of the health care system. Patients with a 'minor risk' profile require psycho-education and two-track treatment by the family physician. The 'moderate risk' profile is complicated by co-morbid depression, anxiety disorder or a somatic disorder; the prognosis is favourable when this co-morbidity is treated. The 'serious risk' profile is assigned to patients with long-term somatoform disorders and a history of surgery for MUPS in addition to disturbed patient-doctor relationships. Limiting iatrogenic harm is of highest priority in these patients. Implementation should focus on providing access to care as described in the guideline.

Recurrence of sickness absence due to common mental disorders.

PURPOSE: Common mental disorders (CMDs) are an important cause of work disability. Although CMDs are known to have high recurrence rates, little is known about the recurrence of sickness absence due to CMDs. This study examines the recurrence risk of sickness absence due to CMDs. METHODS: A cohort of 9,904 employees with a sickness absence due to CMDs, working in the Dutch Post or Telecommunication company, was studied over a 7-year period. Recurrence was defined as the start of at least one new episode of sickness absence with CMDs after complete return to work for at least 28 days. The recurrence density (RD) of sickness absence with CMDs was calculated per 1,000 person-years. RESULTS: Of the 9,904 employees with a first absence due to CMDs 1,925 (19%) had a recurrence, 90% of recurrences occurred within 3 years. The RD of sickness absence due to CMDs was 84.5 employees per 1,000 person-years (95% CI=80.7-88.3). The RD of sickness absence due to CMDs was similar in women and in men. In men, depressive symptoms were related to higher recurrence of sickness absence due to CMDs than distress symptoms and adjustment disorders. In women, no difference by diagnostic category was found. CONCLUSIONS: Employees with a previous episode of sickness absence with CMDs are at increased risk of recurrent sickness absence with CMDs. Relapse prevention consultations are recommended for a period of 3 years after return to work.

Consultation letters for medically unexplained physical symptoms in primary care.

BACKGROUND: In primary care between 10% and 35% of all visits concern patients with medically unexplained physical symptoms (MUPS). MUPS are associated with high medical consumption, significant disabilities and psychiatric morbidity. OBJECTIVES: To assess the effectiveness of consultation letters (CLs) to assist primary care physicians or occupational health physicians in the treatment of patients with MUPS and diagnostic subgroups. SEARCH STRATEGY: We searched for randomized controlled trials (RCTs) on the Cochrane Collaboration Depression, Anxiety and Neurosis Group Controlled Trials Registers, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, 2009), MEDLINE  (1966-2009), MEDLINE In Process (2009-08-17), EMBASE (1974-2009), PSYCINFO (1980-2009) and CINAHL (1982-2009). We screened the references lists of selected studies and consulted experts in the field to identify any additional, eligible RCTs. SELECTION CRITERIA: RCTs of CLs for patients with MUPS being treated in primary care settings. DATA COLLECTION AND ANALYSIS: Two authors independently screened the abstracts of the studies identified through the searches and independently assessed the risk of bias of the included studies. We resolved any disagreement by discussion with a third review author. We assessed heterogeneity and, where a number of studies reported the same outcomes, pooled results in a meta-analysis. MAIN RESULTS: We included six RCTs, with a total of 449 patients. In four studies (267 patients) the CL intervention resulted in reduced medical costs (in two studies the outcomes could be pooled: MD -352.55 US Dollars (95% CI -522.32 to -182.78)) and improved physical functioning (three studies, MD 5.71 (95% CI 4.11 to 7.31)). In two studies (182 patients) the intervention was a joint consultation with a psychiatrist in presence of the physician, and resulted in reduced severity of somatization symptoms, reduced medical consumption and improved social functioning. AUTHORS' CONCLUSIONS: There is limited evidence that a CL is effective in terms of medical costs and improvement of physical functioning for patients with MUPS in primary care. The results are even less pronounced in patients with clinically less severe, but more meaningful, forms of MUPS and the results vary for other patient-related outcomes. All studies, except one, were performed in the United States and therefore the results can not be generalized directly to countries with other healthcare systems. Furthermore all studies were small and of only moderate quality. There is very limited evidence that a joint consultation with the patient by a psychiatrist in the presence of the physician, together with the provision of a CL, reduces severity of somatization symptoms and medical consumption.

Sick-listed employees with severe medically unexplained physical symptoms: burden or routine for the occupational health physician? A cross sectional study.

BACKGROUND: The two primary objectives of this study were to the assess consultation load of occupational health physicians (OHPs), and their difficulties and needs with regard to their sickness certification tasks in sick-listed employees with severe medical unexplained physical symptoms (MUPS). Third objective was to determine which disease-, patient-, doctor- and practice-related factors are associated with the difficulties and needs of the OHPs. METHODS: In this cross-sectional study, 43 participating OHPs from 5 group practices assessed 489 sick-listed employees with and without severe MUPS. The OHPs filled in a questionnaire about difficulties concerning sickness certification tasks, consultation time, their needs with regard to consultation with or referral to a psychiatrist or psychologist, and communication with GPs. The OHPs also completed a questionnaire about their personal characteristics. RESULTS: OHPs only experienced task difficulties in employees with severe MUPS in relation to their communication with the treating physician. This only occured in cases in which the OHP attributed the physical symptoms to somatoform causes. If they attributed the physical symptoms to mental causes, the OHPs reported a need to consultate a psychiatrist about the diagnosis and treatment. CONCLUSIONS: OHPs experience few difficulties with their sickness certification tasks and consultation load concerning employees with severe MUPS. However, they encounter problems if the diagnostic uncertainties of the treating physician interfere with the return to work process. OHPs have a need for psychiatric expertise whenever they are uncertain about the psychiatric causes of a delayed return to work process. We recommend further training programs for OHPs. They should also have more opportunity for consultation and referral to a psychiatrist, and their communication with treating physicians should be improved.

Faster return to work after psychiatric consultation for sicklisted employees with common mental disorders compared to care as usual. A randomized clinical trial.

INTRODUCTION: Return to work (RTW) of employees on sick leave for common mental disorders may require a multidisciplinary approach. This article aims to assess time to RTW after a psychiatric consultation providing treatment advice to the occupational physician (OP) for employees on sick leave for common mental disorders in the occupational health (OH) setting, compared to care as usual (CAU). METHODS: Cluster randomized clinical trial evaluating patients of 12 OPs receiving consultation by a psychiatrist, compared to CAU delivered by 12 OPs in the control group. 60 patients suffering from common mental disorders and ≥ six weeks sicklisted were included. Follow up three and six months after inclusion. Primary outcome measure was time to RTW. Intention- to-treat multilevel analysis and a survival analysis were performed to evaluate time to RTW in both groups. RESULTS: In CAU, referral was the main intervention. Both groups improved in terms of symptom severity and quality of life, but time to RTW was significantly shorter in the psychiatric consultation group. At three months follow up, 58% of the psychiatric consultation group had full RTW versus 44% of the control group, a significant finding (P = 0.0093). Survival analysis showed 68 days earlier RTW after intervention in the psychiatric consultation group (P = 0.078) compared to CAU. CONCLUSION: Psychiatric consultation for employees on sick leave in the OH setting improves time to RTW in patients with common mental disorders as compared to CAU. In further research, focus should be on early intervention in patients with common mental disorders on short sick leave duration. Psychiatric consultation might be particularly promising for improvement of RTW in those patients. TRIAL REGISTRATION NUMBER: ISRCTN: 86722376.

Gender and age differences in the recurrence of sickness absence due to common mental disorders: a longitudinal study.

BACKGROUND: Common mental disorders (CMDs) are an important cause of sickness absence and long-term work disability. Although CMDs are known to have high recurrence rates, little is known about the recurrence of sickness absence due to CMDs. The aim of this study was to investigate the recurrence of sickness absence due to CMDs, including distress, adjustment disorders, depressive disorders and anxiety disorders, according to age, in male and female employees in the Netherlands. METHODS: Data on sickness absence episodes due to CMDs were obtained for 137,172 employees working in the Dutch Post and Telecommunication companies between 2001 and 2007. The incidence density (ID) and recurrence density (RD) of sickness absence due to CMDs was calculated per 1000 person-years in men and women in the age-groups of < 35 years, 35-44 years, 45-54 years, and > or = 55 years. RESULTS: The ID of one episode of CMDs sickness absence was 25.0 per 1000 person-years, and the RD was 76.7 per 1000 person-years. Sickness absence due to psychiatric disorders (anxiety and depression) does not have a higher recurrence density of sickness absence due to any CMDs as compared to stress-related disorders (distress and adjustment disorders): 81.6 versus 76.0 per 1000 person-years. The ID of sickness absence due to CMDs was higher in women than in men, but the RD was similar. Recurrences were more frequent in women < 35 years and in women between 35 and 44 years of age. We observed no differences between age groups in men. Recurrences among employees with recurrent episodes occurred within 3 years in 90% of cases and the median time-to-onset of recurrence was 11 (10-13) months in men and 10 (9-12) months in women. CONCLUSIONS: Employees who have been absent from work due to CMDs are at increased risk of recurrent sickness absence due to CMDs and should be monitored after they return to work. The RD was similar in men and in women. In women < 45 years the RD was higher than in women > or = 45 years. In men no age differences were observed.

The contribution of high levels of somatic symptom severity to sickness absence duration, disability and discharge.

INTRODUCTION: The primary objectives were to compare the duration of sickness absence in employees with high levels of somatic symptom severity (HLSSS) with employees with lower levels of somatic symptom severity, and to establish the long-term outcomes concerning return to work (RTW), disability and discharge. Secondary objective was to evaluate determinants of the duration of sickness absence in employees with HLSSS. METHODS: 489 sick-listed employees registered with five Occupational Health Physician (OHP) group practices were included in this study. We measured their baseline scores for somatic symptoms severity, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. The OHPs filled in a questionnaire on their diagnosis. A prospective 2-year follow-up was carried out to assess the long-term outcomes concerning sickness absence, and retrospective information was gathered with regard to sickness absence during the 12 months before the employees were sick-listed. RESULTS: The median duration of sickness absence was 78 days longer for employees with HLSSS. They more often remained disabled and were discharged more often, especially due to problems in the relationship between the employer and the employee. HLSSS, health anxiety and older age contributed to a longer duration of sickness absence of employees. CONCLUSION: High levels of somatic symptom severity are a determinant of prolonged sickness absence, enduring disabilities and health-related job loss. Occupational health physicians should identify employees who are at risk and adhere to guidelines for medically unexplained somatic symptoms.

Severe MUPS in a sick-listed population: a cross-sectional study on prevalence, recognition, psychiatric co-morbidity and impairment.

BACKGROUND: Medically unexplained physical symptoms (MUPS) have a high prevalence in the general population and are associated with psychiatric morbidity. There are indications that MUPS are an important determinant of frequent and long-term disability. The primary objective was to assess the prevalence of MUPS in sick-listed-employees and its associations with depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. Secondary objectives were to investigate the classification of the occupational health physicians (OHPs), their opinions about the causes as well as the attributions of the employee. METHODS: In a cross-sectional study of 489 sick-listed employees from 5 OHP group practices, MUPS, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment were assessed with the Patient Health Questionnaire (PHQ), the Whitely Index (WI), the Four-Dimensional Symptom Questionnaire (4DSQ) and the Short-Form 36 Health Survey (SF-36). We used a cut off score of 15 on the PHQ for the categorisation of severe MUPS. The opinions of the OHPs were evaluated by means of a separate questionnaire with regard to the presence of employees physical symptoms, and the symptoms attributions, and the diagnoses of the OHPs. RESULTS: Severe MUPS had a prevalence of 15.1% in this population of sick-listed employees. These employees had 4-6 times more depressive and anxiety disorders, and were more impaired. Female gender and PHQ-9 scores were determinants of severe MUPS. Most of the time the OHPs diagnosed employees with severe MUPS as having a mental disorder. The employees attributed their physical symptoms in 66% to mental or to both mental and physical causes. CONCLUSION: The prevalence of severe MUPS is higher in long-term sick-listed employees than in the non-sick- listed working population and at least equals the prevalence in the general practice population. Severe MUPS are associated with psychiatric morbidity and functional impairment and must therefore be specifically recognised as such. Validated questionnaires, such as the PHQ-15, are useful instruments in order to help OHPs to recognise severe MUPS.

Multidisciplinary collaborative care for depressive disorder in the occupational health setting: design of a randomised controlled trial and cost-effectiveness study.

BACKGROUND: Major depressive disorder (MDD) has major consequences for both patients and society, particularly in terms of needlessly long sick leave and reduced functioning. Although evidence-based treatments for MDD are available, they show disappointing results when implemented in daily practice. A focus on work is also lacking in the treatment of depressive disorder as well as communication of general practitioners (GPs) and other health care professionals with occupational physicians (OPs). The OP may play a more important role in the recovery of patients with MDD. Purpose of the present study is to tackle these obstacles by applying a collaborative care model, which has proven to be effective in the USA, with a focus on return to work (RTW). From a societal perspective, the (cost)effectiveness of this collaborative care treatment, as a way of transmural care, will be evaluated in depressed patients on sick leave in the occupational health setting. METHODS/DESIGN: A randomised controlled trial in which the treatment of MDD in the occupational health setting will be evaluated in the Netherlands. A transmural collaborative care model, including Problem Solving Treatment (PST), a workplace intervention, antidepressant medication and manual guided self-help will be compared with care as usual (CAU). 126 Patients with MDD on sick leave between 4 and 12 weeks will be included in the study. Care in the intervention group will be provided by a multidisciplinary team of a trained OP-care manager and a consultant psychiatrist. The treatment is separated from the sickness certification. Data will be collected by means of questionnaires at baseline and at 3, 6, 9 and 12 months after baseline. Primary outcome measure is reduction of depressive symptoms, secondary outcome measure is time to RTW, tertiary outcome measure is the cost effectiveness. DISCUSSION: The high burden of MDD and the high level of sickness absence among people with MDD contribute to the relevance of this study. The intervention is an innovative approach, with trained OPs in a new role as care managers in the treatment of MDD. If this intervention proves to be cost-effective, implementation will be very relevant for individual patients as well as for society. TRIAL REGISTRATION: ISRCTN78462860.

Randomised controlled trial of a psychiatric consultation model for treatment of common mental disorder in the occupational health setting.

BACKGROUND: Common mental disorders are the most prevalent of all mental disorders, with the highest burden in terms of work absenteeism and utilization of health care services. Evidence-based treatments are available, but recognition and treatment could be improved, especially in the occupational health setting. The situation in this setting has recently changed in the Netherlands because of new legislation, which has resulted in reduced sickness absence. Severe mental disorder has now become one of the main causes of work absenteeism. Occupational physicians (OPs) are expected to take an active role in diagnosis and treatment, and seem to be in need of support for a new approach to handle cases of more complex mental disorders. Psychiatric consultation can be a collaborative care model to achieve this. METHODS/DESIGN: This is a two-armed cluster-randomized clinical trial, with randomization among OPs. Forty OPs in two big companies providing medical care for multiple companies will be randomized to either the intervention group, i.e. psychiatric consultation embedded in a training programme, or the control group, i.e. only training aimed at recognition and providing Care As Usual. 60 patients will be included who have been absent from work for 6-52 weeks and who, after screening and a MINI interview, are diagnosed with depressive disorder, anxiety disorder or somatoform disorder based on DSM-IV criteria. Baseline measurements and follow up measurements (at 3 months and 6 months) will be assessed with questionnaires and an interview. The primary outcome measure is level of general functioning according to the SF-20. Secondary measures are severity of the mental disorder according to the PHQ and the SCL-90, quality of life (EQ-D5), measures of Return To Work and cost-effectiveness of the treatment assessed with the TiC-P. Process measures will be adherence to the treatment plan and assessment of the treatment provided by the Psychiatric Consultant (PC) in both groups. DISCUSSION: In the current study, a psychiatric consultation model that has already proved to be effective in the primary care setting, and aimed to enhance evidence-based care for patients with work absenteeism and common mental disorder will be evaluated for its efficacy and cost-effectiveness in the occupational health setting.