A conceptual framework for return to work for clients with major depressive disorder

Abstract

BACKGROUND:

Return to work (RTW) may be a lengthy and complex process for individuals with major depressive disorder (MDD) especially when not well managed. This increases the risk of isolation and loss of routine which negatively influences their mental health. However, for clients with MDD, a comprehensive overview of all the factors that influence RTW based on a model of occupation is lacking.

OBJECTIVE:

To develop a conceptual framework to guide an occupation-based process of RTW for clients with MDD, treated in the private sector in South Africa.

METHODS:

This paper describes the development of a conceptual framework using literature and thematic synthesis of a qualitative descriptive study based on interviews with eight participants diagnosed with MDD which were linked to constructs of Kielhofner’s Model of Human Occupation (MOHO).

RESULTS:

Qualitative data from key informant interviews were deductively analysed according to the subsystems of MOHO for waiting to RTW and experience of RTW. The conceptual framework developed included the constructs of Person and Occupational Setting from MOHO as well as the components of Occupational Identity and Competence central to intervention to achieve successful RTW.

CONCLUSION:

A successful RTW process for clients with MDD is dependent on the person and the occupational setting. The role of the occupational therapist in the RTW can be facilitated by the occupation-based conceptual framework developed on MOHO.

Keywords

Model of Human Occupation person occupational setting occupational therapy

1 Introduction

Depression has been found to account for the highest indirect costs to an economy. The indirect costs of major depressive disorder (MDD) reported in the workplace are due to loss of productivity, decline in work quality, errors and long absences from work [1]. In 2016 it was estimated that one in four South African employees was diagnosed with depression [2]. Depression therefore carries an economic burden, which in South Africa is estimated to be more than R232 billion or 5.7% loss to the country’s gross domestic product (GDP) due to absence from work or being unwell while working [3].

Extended sick leave, as reported by Corbière et al. [4], plays a role in the cost to company and the individual, and poses a serious concern in terms of temporary or permanent incapacity often resulting in the loss of employment. Therefore, individuals with MDD should be carefully and comprehensively evaluated for return to work (RTW) [5]. When RTW is delayed, not well managed or the job is terminated, employees may experience an additional sense of hopelessness, lack of purpose, poor self-esteem and loss of structure and routine, which all negatively influence their mental health. An inability to RTW may also result in unemployment, dependency, financial hardship and poverty [6].

Absence from the workplace by employees with MDD is reported to be much higher than other illnesses mainly due to a long recovery time and to the longer periods of sick leave requested and prescribed by some healthcare practitioners. Porter et al. [7] proposed that early intervention is an important strategy in curbing the disabling nature of mental illnesses including depression especially since long term work role disruption has been shown to be a barrier to successful RTW [8].

Thus, RTW following a period of sick leave for a condition such as MDD is affected by the meaning of the illness to the individual as well as the relevance of their RTW in terms of internal and external factors as they re-establish their worker role in the work environment [7]. It has been reported that being inactive, reluctance to participate in familiar activities or hesitance to return to the workplace are associated with MDD. Therefore, support during RTW and successful management of re-engaging by participating in an occupation-based programme or work tasks should be seen as part of recovery process for clients with MDD [1]. Withholding RTW until the individual is symptom free does not ensure success in RTW [7] and increases the risk of isolation, fears of dealing with stigma from colleagues and self-pity [9]. Only about 50% of employees with chronic conditions with associated health risks who have extended sick leave for up to six months, have been found to RTW [10]. When considering the needs of the role players in the process of RTW a conceptual framework could be helpful in identifying barriers and facilitators related to occupational participation, thus giving direction for a client’s successful RTW.

Research indicates that although occupational therapists implement interventions that focus on RTW [5, 11] a comprehensive overview considering the occupation-based factors for intervention that influence this RTW process is lacking. Many factors influence the ability of the employee to RTW which may be inter-linked [12]. However, there is no conceptual framework which combines the key concepts, theoretical frameworks and intervention pathways into a conceptual framework specifically for use in occupational therapy taking the perspective of employees with MDD, into account [9].

In occupational therapy Kielhofner’s Model of Human Occupation (MOHO) has been reported to support the intervention required in attaining work and RTW [13, 14]. The use of an open system within the model implies that the different components of the human system interact with and influence each other and therefore facilitate occupational performance associated with work. Both internal and external factors in relation to performance and participation in different categories of occupations within the occupational therapy domain are considered (See Fig. 1). Occupations in this model are defined as all activities in which an individual participates including care of self and others, leisure and work. The model considers internal factors representing the person which incorporate the subsystems of volition, habituation and performance capacity while external factors or occupational settings consider the socio-cultural and other environments [15].

Fig. 1

Representation of Kielhofner’s Model of Human Occupation 1 .

Internal 1 factors also include personal factors that influence RTW after an episode of MDD. Gender differences have been found to influence RTW with reports that women may take longer than men to RTW [16], particularly married women [17]. Men were thought to RTW sooner due to the traditional role that men play as breadwinners in the society. However, this may not always apply, as globally many women now head up households or contribute financially to the home [17].

Volition in MOHO includes personal causation or the cognitive awareness of one’s ability to perform that fuels associated interests and values assigned to activities and drives the desire to participate in activities [15]. Failure to perform adequately may reinforce a sense of incompetence, as many people diagnosed with MDD are reported to assume a sick role and disengage from regular activities [12]. This may be further perpetuated by ‘fear avoidance’ coping related to the fear regarding uncertainty of their capabilities in terms of RTW. Residual symptoms of MDD such as negative thoughts, poor self-efficacy or lack of belief in their work competence as well as an external locus of control, may further contribute to anxiety about and reluctance to RTW [18]. These can present as problems of intention, motivation, volition or the drive to implement intentions. Motivational and volitional deficits need different intervention strategies [19]. Based on the Model of Occupational Self-Efficacy that Soeker [20] related to RTW, motivation should be facilitated by the occupational therapist through creating a strong personal belief in the individual’s functional abilities, in the rehabilitation process since self-efficacy is a significant predictor of RTW. Volition is addressed by the creation of competency through a successful occupation-based programme and the development of a capable individual [20].

Interventions for volition should be supported within the roles associated with work activities as well as the routines required in the performance of everyday activities or habituation [15]. Avoidance behaviours, often reported in MDD sufferers, result in the disruption of routines, the inability to balance roles as well as manage work activities leading to problems with work and finances [21]. Literature indicates the disruption of routine in those with MDD, may also impact the biological rhythms of sleep and eating patterns which may contribute to the recurrence of the depressive symptoms [22]. This further exacerbates the reluctance to engage in activities which bring structure to the day such as work [21]. Factors related to performance capacity which impede RTW include the severity of the MDD symptoms. These may include impairments of mental functions including judgement, concentration and memory problems, low energy as well as co-morbid substance abuse [23].

Adequate volition, habituation and performance capacity, supported by favourable environmental factors allow the individual with MDD to use their skills to perform their occupations and participate in everyday activities including work. Occupational therapists can evaluate and facilitate engagement in graded activities, preferably in the work situation [7] so the client reconstructs a positive occupational identity with regard to their worker role and obligations as well as achieves occupational competence in their work skills to perform at work to an expected standard [13, 24]. This supports the occupational adaptation process allowing adaptive responses to meet the occupational challenge of RTW [15].

However, external or environmental factors that influence RTW are normally not under the control of the employee diagnosed with MDD but also impact on the adaptation process and work performance. Environmental press or constraints include factors such as poor support and relationship strain from the employee’s family, friends, peers and co-workers [25]. These have been associated with stigma, which remains a considerable issue in South African communities due to poor health literacy and cultural beliefs [26]. It is unfortunate that the very same people that are meant to support people with mental illnesses may stigmatise and discriminate against those with MDD, thus increasing the risk of non-adherence to medical and rehabilitation interventions and recommendations for RTW [27].

The attitude and behaviour of employers, work supervisors have been found to be one of the most significant influences of RTW for individuals with MDD [9]. If employees with MDD perceived that work stressors contributed to their illness and subsequent diagnosis, this may impact their motivation to RTW. Thus, work demands may be considered too strenuous and may require reasonable accommodation in terms of reduced hours, task or job modifications, a quiet environment or regular absences for therapy appointments. The importance of addressing psychosocial factors including work stress, lack of recognition, conflicts within the work team, fear of negative consequences and being judged by others has been also emphasised [28]. The need for remuneration is also a predictor of RTW. Some employees diagnosed with MDD do not have sufficient private medical fund benefits or have exhausted their sick leave benefits, typically 36 days in a three-year cycle under South African labour policy, and are pressed to RTW. Financial pressures therefore motivate an employee to RTW as they are unable to personally finance their private health care bills or take a longer period from work [12].

Due to the many complex factors influencing RTW this study aimed to develop a conceptual framework which provides a holistic view of the process for RTW. The framework which considers the individual client was based on the constructs of MOHO in relation to the experiences of clients with MDD treated in a private clinic, to support a comprehensive occupation-based, occupational therapy intervention for RTW.

2 Materials and method

The method for the development of a conceptual framework described in this paper was based on the steps reported by Jabareen [29]. Synthesis of the framework utilising literature and data from a qualitative descriptive study used thematic analysis of interviews with clients with MDD [30] and the constructs from MOHO.

The steps used in the development of the conceptual framework are as follows:

In Step 1: Mapping the selected data sources – a review of the literature as well data from the key informant interviews with clients diagnosed with MDD, by a registered psychiatrist using the DSM-5, were used. Purposive sampling was used to select eight participants who had experienced delayed RTW and were on extended sick leave at home for at least two months. Clients with MDD were invited to participate in the study if they had completed the vocational rehabilitation programme while hospitalised for MDD at a private clinic in Soweto and were employed at the time of admission in either in a private or a public entity. All the participants had a 21-day period of hospitalisation for MDD and were in the process of transitioning back to work.

All the participants were of the African racial group and all grew up in poor socio-economic environments during the time of the oppressive political apartheid system in South Africa. In the post-apartheid period, they all found white-collar level jobs in the mainstream economy. All were earning salaries which had improved their socio-economic status sufficiently to be classified as middle class [31].

Understandably, there are considerable social and socio-economic pressures attached to their employment and having to prove that they are able to perform at work contributed additional pressure to support their ‘new middle class’ status. This was reported by nearly all the participants. This was exacerbated by the high unemployment rate in South Africa as well as pressure to provide for the extended family whose socio-economic status may not have improved [32].

These selected clients were included as they were considered the experts who would be able to provide rich data on the internal and external factors which they experienced as affecting their RTW [33]. In-depth, semi-structured face-to-face interviews for up to one hour, at a venue convenient to the clients (either their home or the clinic), were used to collect the data. Predetermined questions that were phenomenological in nature guided the direction of the interviews as reported by Saohatse et al. [12]. All participants signed informed consent before being interviewed and the study was approved by a Human Research Ethics Committee. The data were collected over six months in 2018, which ensured that data were thoroughly scrutinised and analysed from the feedback received from the peer review. The sample size of eight participants was determined by the specificity of the sample and preliminary data analysis by appraising the information power to determine when enough relevant data were collected [34]. All interviews were audio recorded, transcribed into MS Word documents. These documents were deductively analysed by the researchers into themes based on the subsystems of MOHO [12].

Trustworthiness was determined by thick rich descriptions by participants, member checking and peer review during the data collection process, with the researcher clarifying the meaning of the participants’ information while using their home language for the interviews. To ensure credibility, theory triangulation with integration of the emerging themes and literature and a well-researched professional model of occupational performance was completed. The study has been well documented to ensure that it can be replicated [35]. The researcher bracketed her knowledge about RTW and was conscious of her biases throughout the data collection and data analysis processes.

Step 2: Categorising of the selected data – consisted of using a process of qualitative analysis. This process allowed the researcher to first review the literature and then analyse the interview data using content analysis based on the subsystems of MOHO, to assign meaning to information within the verbatim text where codes emerged [35].

Step 3: Identifying and naming concepts – interpretations from a human occupation perspective were generated so each code could be aligned with a concept which would be clearly identified for the conceptual framework [36]. Concepts were identified based on ontological assumptions or subjective reality [37], described in the literature and epistemological assumptions related to “how things really are” from the client’s perspective, and then linked to the theoretical constructs of MOHO [38].

Step 4: Deconstruction and categorisation of concepts – interview data were analysed thematically to determine the relationship between the concepts in terms of the main attributes and assumptions according to the subsystems of MOHO and RTW.

Step 5: Integrating concepts – the aim of this step was to integrate and group together concepts that had similarities to one new overarching concept or category to reduce the number of concepts and relate to RTW to the concepts from MOHO.

Table 1
Demographic characteristics of the participants (n = 8)

Participants Age (years) Gender Return to work Hours worked per week Post-secondary qualifications Type of job

1 25 F N 65 B Tech Site engineer

2 26 F Y 37.5 Higher certificate Service agent

3 27 F Y 35 Higher certificate Office administration

4 32 M Y 45 Diploma IT specialist

5 37 M Y 45 Diploma DTP operator

6 39 F Y 50 Higher certificate Office administration

7 44 F Y 40 Higher certificate Data capturer

8 46 F N 40 None Service consultant

Participants	Age (years)	Gender	Return to work	Hours worked per week	Post-secondary qualifications	Type of job
1	25	F	N	65	B Tech	Site engineer
2	26	F	Y	37.5	Higher certificate	Service agent
3	27	F	Y	35	Higher certificate	Office administration
4	32	M	Y	45	Diploma	IT specialist
5	37	M	Y	45	Diploma	DTP operator
6	39	F	Y	50	Higher certificate	Office administration
7	44	F	Y	40	Higher certificate	Data capturer
8	46	F	N	40	None	Service consultant

Step 6: Synthesis, resynthesis, and making it all make sense – concepts were synthesised into a conceptual framework using qualitative methods and repetitive synthesis until the best fit of the themes was achieved in relation to the theoretical constructs of MOHO and the lived experiences of the participants [39].

3 Results

The conceptual framework was based on the alignment of MOHO with the literature on RTW in clients with MDD and the results that emerged from the data analysis, highlighting the experiences of RTW explored in the qualitative study. At the time of the data collection six of the participants in this study had returned to work and the remaining two had not yet returned to work. Six participants were female and their ages ranged from 25 to 46 years of age. Hours worked and type of jobs varied, and only one participant did not have post-secondary qualifications.

The participants in this study each received 21 days of inpatient care including occupational therapy, as prescribed by their private medical funder [40] and were then booked off from work for up to a further four months. In the current study, neither the multidisciplinary team nor the participants were involved in the decision to RTW. This decision was made by the psychiatrist managing the case, based on their medical clinical reasoning for participants in this study who were all employees negotiating their way back into the open labour market following a period of illness with no formal vocational rehabilitation provided, other than that received while hospitalised.

The findings from the interview data were aligned to constructs from MOHO which were synthesised by the researchers for development of the conceptual framework to guide RTW for the clients. The subsystems and environmental factors related to MOHO were considered in relation to the timeline which considered the period of waiting to RTW as well as the experience of RTW.

3.1 Person

3.1.1 Volition

Personal causation was influenced by rumination and fears about returning to work prior to RTW which made most participants reluctant to RTW. Participants were preoccupied, thinking a lot about their imminent return to work and typically these thoughts were mostly negative. They agonised over many issues but common amongst all the participants were unresolved work issues.

“... it makes me feel sad. It makes me, you know, not want to go to work because I know it’s gonna be the same cycle again. I’m gonna make a mistake and someone is gonna make a big hoo-ha about it and I’m not gonna be happy” (P2).

Stress and pressure on the job, job security, the period of absence and uncertainty about what would happen upon RTW were also expressed as major concerns.

“I was consumed with such overwhelming feeling. I would go into panic mode. I was stressed so badly that I would end up not knowing whether I’m coming or going and having—you know, my mind wouldn’t be clear enough. I wouldn’t know how to cope. All I would see is just hopeless situation” (P2).

While the participants still valued work and remained interested in working, this often did not apply to their present job and workplace. Thus, the volitional issues experienced after RTW related to doubt about self-efficacy and competence were reinforced by the feeling that the participants were not coping on RTW.

“I feel like I try so hard and yet she is still not satisfied, and I am also unhappy in that process. Because with your job you are supposed to be happy but I am not” (P3).

“You are useless, you are hopeless to this particular boss. Maybe she is right I am useless” (P6).

3.1.2 Habituation

Prior to RTW the participants worker role was disrupted. Although participants indicated they wished to RTW, the many weeks of engaging in mundane activity compromised their RTW since vocational rehabilitation after discharge was not funded.

“I don’t have anything to do. If I feel like—I’m only watching TV. I like to clean, I don’t like to cook, I like to wash things but sometimes but sometimes I don’t feel like doing it” (P7).

When considering the structuring of daily habits, work as a component in daily routine was lost while waiting to RTW. Participants reported they no longer organised their time according to the previous routine which included work.

“I haven’t been to work in a long time and now ... I would take an afternoon nap. I looked at it in the way that I just need to adjust my body to get use again to the fact that I need to go to work and these are the working hours basically” (P5).

On RTW participants reported difficulties in adjusting following a long disruption in their work routine. This made it difficult to adapt to their typical working routine and environment which changed while they were on sick leave. They needed to fulfil the requirement to wake up early, travel to work and be productive.

“Those (first) two weeks were really about getting myself into a state of mind and making my body get used to waking up and being physically alert to go to work” (P5).

“(they)Brought in someone to come and help when I was in hospital ... . So, it was a little bit hard having to take things (back) to the way they were (before) I left. Back to the way. Like everything was just messy. I had to rearrange my office. Because now I don’t know where this was placed. I had to start again” (P6).

3.1.3 Performance capacity

The possibility of a relapse was feared before RTW, as participants perceived since they would be returning to the very same environment that had contributed to their illness and diagnosis of MDD, this would contribute to a relapse.

“So, I think I carry that fear every day that um ... I’m gonna go through the same and that I’m gonna go back to the hospital again” (P5).

After RTW participants reported both fatigue and difficulty with concentration and focusing on the work tasks due to the side-effects of the medication or existing work stressors.

“So, I had to take it a bit slow. I still need to sleep more. Some days at the office also I find that I get tired very quickly” (P6).

“So, I was worried that I was not going to cope with the system. Looking at the computer more than four hours. I had those (bad) feelings again. Sometimes I stare at the computer and I forget what I was doing” (P7).

3.2 Occupational setting

3.2.1 Presses

Before RTW the constraints or presses participants reported were pressures to RTW from the workplace and from their families who were concerned that the participants had to meet their financial responsibilities. Therefore, financial independence and being able to take care of their own and family’s needs was reported as a strong motivation for RTW even though they were still concerned about their condition.

“Ja um ... and I guess because bills have to be paid it’s a risk that I’m willing to take. But I don’t know how long am I willing to take that risk. For a while I try to figure out exactly if this place is the place that I wanna be. Um ... but ja” (P5).

“Both the work and the pressure. If it was the work alone it was fine because I would find ways to deal with it. But when there is someone (else) involved to put too much pressure on you ... .” (P6)

Many participants reported a negative attitude to the work environment before RTW which they perceived would not change, such as work politics including nepotism, aggression and lack of team work were also identified.

“The workplace is no longer something that you are looking forward to. I only go to work because I have to go. But no longer enjoying being there” (P7).

“Bad pressure its stuff where it’s mostly political. Someone is looking to blame someone for something that has happened or the system didn’t do what it was supposed to do ” (P6).

“There is a lot of nepotism at work. I was the only person that got there without knowing someone or having worked with anyone else within our division. So, everyone is someone’s cousin ... ... .you have a team that is also not supportive when it comes to growth and also people that try and hinder your growth, that’s not good” (P8).

Experiences commented on by all participants on RTW were the attitude of colleagues at work. Stigma of mental illness was perceived by participants as being external, emanating from co-workers or the community at large. The participants also described internal stigma, seeing themselves as weak and incapable because of their illness which affected how they interacted with others.

“Also, I think I was more worried about the stigma that goes with people who have such issues (as MDD). People look at you and think yeah, she is not in control, she is just not strong enough, or she is a mental case” (P6).

“Nothing motivated me (to RTW). Actually, I wasn’t even looking forward to it because it is like I know where I’m going. the people I work with, all the - ‘ah (shame)! So, I wasn’t looking forward to it. But personally, I’m trying to distance myself from others” (P4).

Personal and work support from management and colleagues was perceived by participants as very important in assisting them to ease back to the job and to re-establish the sense of belonging. Participants had different views regarding what ‘support’ meant but most participants reported they did not receive the ‘support’ they needed.

“Are you sure you are fine. If you are not fine just tell me. And I just felt irritated ... because I knew she was pretending. It was written all over her ... . and I have tried to talk to her about that and it’s not really helping. Because maybe she feels like am incompetent and I know I am not” (P6).

High work demands on RTW were seen as a deterrent. The need for work accommodation to manage the workload initially was expressed by participants. They perceived that the request could be made by either the participants themselves or the occupational therapist. Work tasks they felt should be limited within the first two weeks with the number of work tasks slowly being graded up. Some of the participants did not receive any accommodations due to being the only workers that held the position, poor human resource management or lack of the necessary resources for others to do a particular job.

Participants indicated the level of competence expected from them on RTW associated with work demands differed with some not being given any work while others were required to deal with their normal workload.

“When I got there (back to work), I was doing the quantity surveyor’s work. I was doing the contract manager’s work (and) I was also doing my own work. I was doing the government’s work. I was doing everyone’s work” (P3).

“In my first two weeks of going back to the office, I literally did not get any work because everybody felt that I was too fragile to give me work. So, in that manner I did not have any pressure of time to deliver” (P4).

Negative relationships in the workplace were reported as adding to the perceived inability to relate to other staff on RTW.

“Not (all) the staff because some of them I get so irritated by them. So, some of them they can see that I don’t like to talk. So, when I’m Ok I go and stand up ... because I say they’re disturbing me and they leave me alone” (P7).

The factors mentioned above resulted in a lack of work satisfaction which contributed to the loss of volition and poor motivation which was also related to poor growth and development opportunities at work with no acknowledgement.

“I would prefer to go somewhere else, start afresh. Or do something different, something more challenging. I have been doing this for the past five years and I see no growth in it” (P8).

3.2.2 Affords

Some participants felt the environment did afford or facilitate their RTW since they perceived that they received the support they needed, and so coped better than expected. This coping was associated with relationships that were viewed as positive.

“My colleagues were also very supportive, come to think of it. And they also, now more than ever, they’ve started sharing how they feel and that I shouldn’t get so overwhelmed” (P6).

“All I know is that my team leader was very happy to see me. She said I must take it easy. I mustn’t just do what I usually do and take all the breaks (I need) and all that” (P8).

Thus, support and reasonable accommodations also allowed them to ease back into the work situation allowing them to manage their workload.

Figure 2 describes the conceptual framework using the constructs of Person and Occupational setting from MOHO aligned with the concepts extracted from the literature review and qualitative study. The components of occupational identity and competence critical in the intervention to maintain, modify work performance, propose work accommodation, prevent relapse and achieve successful RTW are outlined based on these concepts.

Fig. 2

Conceptual framework for return to work for clients with major depressive disorder.

4 Discussion

A valid and current conceptual framework was developed to direct the occupational therapy management of clients with conditions such as MDD as well as prioritise care decisions based on clients’ perceptions of RTW. This conceptual framework was based on Kielhofner’s MOHO and was intended to inform optimal care management from an occupation-based occupational therapy perspective. The conceptual framework identified the key challenges perceived by the participants and recognised the need for intervention related to RTW as well as the gap in service provision for this cohort of clients with MDD in the South African context.

The conceptual framework supports the need to provide intervention after hospitalisation before RTW, during the RTW process and post RTW. This framework aims to ensure that employees themselves can cope with and manage any factors identified that will impede them performing their job as well as possible environment changes at work to support RTW. Concept mapping described by De Vries et al. [23] supported the conceptual framework development, which identified the person as one of the megaclusters related to RTW for persons with MDD.

Since the conceptual framework is an artificial construct, it inevitably involves some blurring of the various intersections which assume a link between the person or client’s ability, the occupational setting, work demands and environment which, should collectively inform the occupational therapy intervention in addressing the occupational identity and competence for persons with MDD in relation to the occupation of work. Nonetheless, as the discussion below demonstrates, an understanding of the person with MDD, the occupational settings and adaptation is needed to support a clinical perspective, where the outcome of any intervention would be a successful RTW [13].

Based on the main constructs of person and occupation setting, the conceptual framework identified the link between work ability and work demands and considered how the suggested constructs are related to intervention.

4.1 Person

4.1.1 Volitional subsystem

The participants in this study reported experiences associated with the volitional subsystem, particularly personal causation or the sense of effectiveness and confidence in occupational performance as influencing their reluctance to RTW. Prior to RTW rumination identified by participants in the study, has been associated with the recurrence of depressive episodes. This was consistent with the findings of Zetsche et al. [41] and was reported as a constant negative reflection on their perception of their ability to work and the work environment which influenced lowered motivation to RTW. Other related factors included the belief that their illness was caused by the job, unresolved issues and stressors at work and their lack of action in relation to these issues which was consistent with the findings of Woo and Postolache [42]. Some perceived their illness as a sign of weakness and failure as supported by Coppens et al. [43] and on resuming work they continued to express concerns about their competence and self-efficacy.

According to literature and as indicated by the participants in the study, self-efficacy was therefore impacted by their employment situation, their health and their confidence in doing the job. Most participants still valued the occupation of work and the need to work which has been associated with RTW [10] but participants reported a lack of interest and fear in returning to their present job which seemed to be related to how important they thought their work was within the organisation [10]. Those that had returned to work reported limited job satisfaction associated with the negative perceptions of the workplace and an inability to fit in or progress in the organisation [44].

4.1.2 Habituation subsystem

In the habituation subsystem, each participant did still appear to appreciate the importance of their worker role. Participants had retained an internalised worker role related to their unique work experience in a specific job context, since work had formed the principal role in their lives. For many weeks during their period of illness, the participants no longer followed a routine which included a worker role. After RTW participants found it difficult to re-establish their routine to include work again [10].

4.1.3 Performance capacity subsystem

Hillborg et al. [45] reported that clients find it difficult to protect themselves from exceeding their work capacity on RTW while struggling to regain mental health. The RTW was influenced by the reengaging of their performance capacity subsystem since participants felt that they had not recovered to the extent where they had the resilience to deal with their work setting. Before RTW they viewed themselves as relapsing due to perceived pressures at work which was confirmed by re-emergence of some symptoms such as the reported fatigue and lack of concentration on RTW. This resulted in ‘presenteeism’ or reduced work productivity [46] even though some participants indicated that accommodations such as reduced work hours and limiting work tasks, for these symptoms were provided at their workplace.

4.2 Occupational setting

The constructs considered under occupational setting include pressers (barriers) and affords (facilitators) in the work environment according to the participants’ experience.

4.3 Presses

Environmental press or barriers were reported by participants as occurring while still at home and these were perceived as affecting RTW as well as impacting them after RTW. Some participants who felt financial strain and fear of retrenchment or job loss due to pressure from the workplace were forced into premature RTW [47]. Some participants reported premature RTW due to a lack of further sick leave benefits as well as pressure from their family to meet their financial obligations. However, some pressure to RTW may be beneficial since it has been shown internationally when extended sick leave benefits are provided indefinitely, this has resulted in a lack of successful RTW [10].

The work environment and organisational context, was perceived by participants to have had a strong effect on RTW. The participants felt powerless to address the pressures, conflicts and nepotism at work, thus they felt these issues would remain unchanged when they returned to work. There was also a perception that those with a history of mental illness, including MDD, are often amongst those who are most likely to be retrenched and least likely to be considered for more challenging jobs and promotions [47].

The lack of awareness of about MDD and mental illness in the workplace was reported to result in stigma from both managers as well as colleagues. This added to environmental press. Participants indicated that this was an important factor in RTW as it affected their belief in themselves, added to their fear that they were no longer capable as well as reducing their satisfaction with their job [44]. Participants were therefore concerned about how they would be viewed at work and felt pressed to show themselves as competent and capable to others, even though this conflicted with their preference for gradual increasing of RTW tasks and their anxiety about how return to full duty would affect their health [18]. These conflicts need to be addressed by supporting the client before and during RTW as well as facilitating relationships at work through regular communication between supervisor and employee and clarity regarding accommodations regarding work tasks were emphasised as very important [9].

Reasonable accommodations in terms of reduced work tasks or reduced work hours were provided for some of the participants in this study by the employer either through human resources or the line-manager of the participant. Employers and managers are reported to have little awareness of the effects of MDD on workers and their work output and reasonable accommodations provided are often therefore not successful [9]. Some participants were not given any work for two weeks while other participants were not offered an option of accommodation within their job, since MDD was not viewed as disabling [48] and on RTW they were given even more work.

4.4 Affords

Participants who reported affords or facilitators experienced support and concern from those in the workplace and felt the work environment afforded them a more positive RTW experience. Environmental affords or facilitators especially a supportive manager or supervisor has been significantly associated with a higher chance of successful RTW for clients [10]. Colleagues or co-workers also have an influence on an employee’s RTW and the more supportive they are, the more likely the employee will RTW early [23].

4.5 Intervention

The conceptual framework indicates that an occupation-based intervention should consider aspects of occupational identity and conpetence. De Vries et al. [23] reported that the medical intervention alone was not a great influencer of RTW and as indicated in studies in other countries which report client centred care when dealing with RTW, the multidisciplinary team and the client should contribute to the decision to RTW [4]. A study by Porter et al. [7] indicates early supported RTW based on achieving specific work goals is preferable.

It is suggested that after initial inpatient intervention to address cognitive issues, assertiveness training and coping skills [49], RTW intervention should be started within the first six weeks of symptoms being evident and continue during and post RTW [11]. Literature reports that occupational therapists are well qualified to provide intervention or assume the role of case manager in RTW due to their knowledge of illness processes and how these impact on participation at work. Vocational rehabilitation can support the implementation of appropriate and reasonable accommodations by matching the person’s work ability, promoting occupational competence with self-efficacy and control in tasks that have been adapted allowing for successful fulfilment of expectations and performance levels [5, 50]. Work adaptations including stress reduction by temporarily eliminating stressful or complex tasks, reducing workload and the responsibilities at work are viewed as most important by those with MDD returning to work to enable the re-emergence of a sense of capacity and competence [23].

Capacity and self-efficacy should be supported in a vocational rehabilitation programme including supported employment to allow the re-emergence of a positive identity, recognition by the client of their own limitations, taking responsibility, setting work goals and commitment to work [14, 20]. Wisenthal et al. [5] indicate a work hardening programme for individuals with depression, before RTW using work simulations, had a positive impact on their participants sense of capacity and self-efficacy as a worker. Their participants, as suggested in the proposed conceptual framework, developed a sense of mastery in meeting work demands and obligations and believing they could fulfil worker expectations and job standards and this was seen as gains in the workplace in terms of work participation.

The development of an internal locus of control and the re-establishment of meaning and a sense of accomplishment in functional abilities by successful experiences of participation in work-related activities prior to RTW is also critical [20]. Being aware of future possibilities in pursuing work goals to meet personal values and interests and having a clear understanding of the work reintegration process should be ensured [23]. Soeker [20] emphasises the importance of external feedback from those at work in re-establishing the workers’ competence. While Wisenthal et al. [5] reported that participants found coaching from the occupational therapists to be more beneficial than feedback in supporting development of confidence. De Vries et al. confirmed that individuals believe in their competence related to compliments and appreciation from colleagues and management supported RTW after a depressive episode.

Since self-efficacy and feelings of depression are strongly correlated, it is essential that residual symptoms are continuously monitored during the programme and after RTW [10]. By facilitating a regular and predictable routine for individuals’ with MDD, the occupational therapist can reduce the effects of aspects such as excessive sleep and rest, activity avoidance and boredom, while re-establishing the maintenance of routine for the worker role [5]. Worker routines and enacting these before RTW was reported as the most effective element in the occupational therapy programme described by Wisenthal et al. [5]. Their participants felt an increased sense of personal control due to internalisation of their worker routines [7, 20].

Ongoing management of RTW for persons with MDD is essential before during and post RTW as participants experienced different concerns while waiting to RTW and after RTW. All components of occupational competence and identity in terms of the occupation of work post vocational rehabilitation in occupational therapy need to be addressed. Offering of supported employment is suggested as essential by De Vries et al. [23] including adequate coordination, appropriate guidance and support for the client with MDD [4] as supported by the conceptual framework described in this paper.

4.6 Strengths and limitations of the study

The conceptual framework is based on an accepted and well-researched model of human occupation and aimed to support clinical reasoning and implementation of occupation-based therapy. The study focussed on the development of a framework to support RTW intervention after hospitalisation which in South Africa is not funded and nor available for individuals with MDD.

However, this study and the development of the conceptual framework was confined to a review of the literature and the perceptions of individuals with MDD only. The small sample of participants within the qualitative study were from a unique and under researched population admitted to private health care in South Africa. This limits the transferability of the findings on which the conceptual framework is based, to clients with other mental health problems seeking intervention needing to RTW. It does not include the opinions or experiences of other health professions and employers of individuals with MDD.

5 Conclusion

A conceptual model inclusive of on the literature and findings of a qualitative study that can be used to guide the occupational therapy process for RTW in a sample of clients diagnosed with MDD was developed. The framework addresses an area of limited research in occupation-based intervention for RTW since it is based on a model of human occupation. Key knowledge gaps have been identified in guiding the intervention of RTW for employees with MDD from an occupational performance perspective in the South African context. The conceptual framework highlights that a successful RTW process for clients with MDD is dependent on many factors related to the person, their job and their occupational settings.

The conceptual framework is based on a well-accepted and researched model of human occupation and aimed to support clinical reasoning and implementation of occupation-based therapy. The clinical utility of the conceptual framework needs to be further evaluated and researched in the context for which it was developed.

Conflict of interest

None to report.

Footnotes

Model of Human Occupation. Source: [].

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