Mental health: Professional rehabilitation and the return to work

Abstract

BACKGROUND:

The problem of illnesses, sick leave and the necessary return to work and permanence at work has been determining the development of different protocols and professional rehabilitation programs in different countries.

OBJECTIVE:

We sought to identify articles that address programs for professional rehabilitation and the return to work of people laid off due to mental health problems, and to verify the results of professional rehabilitation programs and the follow-up processes for such return.

METHOD:

A systematic review was performed according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). The serial search of the articles was carried out in the electronic databases: Web of Science, MEDLINE/PubMed and Scopus. The variations in the descriptors served to find a greater range of significant results for the research.

RESULTS:

In total, 2,306 articles were found. Another two articles that met the inclusion criteria were located through manual searches, adding up to a total of 2,308. Applying the exclusion criteria resulted in a final data set of 47 peer-reviewed articles.

CONCLUSIONS:

The issues involving return to work and permanence in work were complex and multifaceted in the research articles studied. Recovery from Common Mental Disorders (CMDs) is a major cause of long-term sick leave and the granting of disability benefits. Many people with these diagnoses remain employed; however, further studies are needed with women, workers with fragile relationships, and immigrants.

Keywords

Sick leave work rehabilitation sickness absence work ability PRISMA

1 Introduction

Employment processes in several countries have been changing due to the combination of new legislation, technological innovations and new management methods. This implies an intensification of the workload, a reduction of labor rights, precariousness of work, increase in sickness and remission processes, and difficulties in returning to work after retirement. Employment is one of the central elements in the processes of integration and social affiliation of people, so exclusion from work and consequent unemployment are both strong factors involved in social exclusion [1, 2].

This situation is changing the epidemiological profiles of workers’ illnesses, intensifying the number of occupational diseases, such as repetitive strain injuries and musculoskeletal disorders (RSI/DTS) and work-related mental illnesses [1 –3]. Although the increase in psychosocial risks and mental illnesses related to work are becoming increasingly prevalent, the exclusion of such initiatives from a number of international studies and documents is still little studied, especially with regard to professional rehabilitation in general, including the processes of absenteeism and leave, the return to work and job stability [4, 5].

The problem regarding professional rehabilitation has been to determine the development of various protocols and programs for professional rehabilitation in different countries. These programs, despite local differences, legislation, public policies and cultural reality, among others, bring together as a common axis the importance of professional rehabilitation and the proposal favoring a return to work after leave has ended [6, 7].

It is noteworthy that most of the published studies on this issue focus on formal sector workers with stronger work ties, more social and labor rights, and who are actively working. This creates a contradiction in that surveys, for the most part, exclude workers who are most vulnerable to job insecurity and exclusion from work and, consequently, to sickness, absenteeism and difficulties in returning to work, especially immigrants, migrants, temporary workers, workers who are sick or who are on leave from work [8 –15]. Some studies also point out significant differences related to the size of companies, organizational cultures, regulations and policies of return to work and professional rehabilitation [9, 12].

The heterogeneity of the realities of various countries renders comparative research impossible but allows for the study of different programs so that some can contribute to the improvement of others, inspiring advances, even though they safeguard local differences. It can be observed that the better the health care is in a country, and the more developed the prevention policies for workers’ health, the better is the emphasis on programs for professional rehabilitation and return to work [7 –15].

Models and programs that seek to embrace more global approaches to the problem, including prevention of illness, attention to the health sick employees, professional rehabilitation programs, return to work and job stability can be seen in the literature. Several studies include interventions in work conditions and organization and involve managers and peers in the preparation of return programs. Several of these studies also reveal concern regarding actions related to health services; the social security system (responsible for the payment of allowances, retirements and pensions) and labor legislation [5 , 16–18]. However, it can be observed that a lot of research studies fragment these actions, focusing their attention on the rehabilitation programs themselves and disregarding the subsequent steps of their actions, such as the processes of return to work and job stability.

This integration is considered important so that the processes of work and return to work are not doomed to failure, generating further absenteeism, early retirements and complications with the worker’s job stability after the return [19, 20].

The absence of recognition of the social aspects of disease results in a lack of collective actions aimed at changing the conditions that generate such disease. This process leads to an individualization of the problem and blame of the worker. This also favors situations in which the worker suffers from prejudice because of the fact that there is sometimes a decrease in their work capacity that can interfere in work dynamics as a whole [16, 21].

It is also worth noting that despite the increase in absenteeism due to mental illness, rehabilitation and return programs do not always consider these pathologies, nor their specific natures [22, 23].

In Brazil, the historical process of development of Public Health Policies has caused deficiencies that make it difficult to overcome and build global models for guiding prevention, promotion, care and rehabilitation, especially in the field of worker’s health. The search for knowledge of the processes of return to work developed in other countries encouraged our interest in this study [6].

Systematic reviews and surveys conducted in several studies have revealed rehabilitation programs developed in numerous countries, presenting an understanding of the successes and impacts of the results of these studies that, despite local differences, can support advances in this field around the world [24, 25].

Therefore, this research aimed to identify through a systematic review, articles that address programs for professional rehabilitation and the return to work of people absent due to mental health problems. Specifically, we sought to verify from the literature the results of professional rehabilitation programs, return follow-up processes and the relational and organizational difficulties encountered after the return to work, as well as the impacts and difficulties of this process of returning to work. It is believed that a systematic review of this process focusing on the question of the professional rehabilitation of people absent from work due to mental disorders is fundamental for knowledge of the current state of research and to initiate new studies and practices inthis area.

People who are absent due to mental health problems encounter several obstacles in the process of returning to work that end up making their job stability impractical, generating further absenteeism and even early retirements. The processes of returning to work, especially for individuals with mental health problems, impact work teams and consequently interfere in the process of reintegration into the workplace. In this way, understanding how the programs in several countries address this issue, the difficulties they encounter and the solutions found, is of the utmost importance [11–14 , 25].

2 Materials and methodology

A systematic bibliographic research was carried out, using the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). According to Liberati and collaborators [26], PRISMA guides the writing of a systematic review, being essential to summarize evidence regarding the efficacy and safety of health interventions with accuracy and reliability, in compliance with the guidelines of the PRISMA-P [27] committee. The research was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on February 23, 2017 and was updated on February 11, 2018 with registration number CRD42017057521.

2.1 Search strategy

The serial search of the articles was carried out on the electronic databases: Web of Science, MEDLINE/PubMed, and Scopus. The terms used in the research were based on the descriptors of the Medical Subject Headings (MeSH), searching in the literary bibliography with the following descriptors: “Mental Health” AND “Return to Work” AND “Sick Leave” OR “Work Rehabilitation” OR “Work Team”. The variations in the descriptors served to find a greater range of significant results for the research.

2.2 Inclusion and exclusion criteria

The inclusion criteria were as follows: the article should be indexed in the selected databases, with full availability of the free and integral forms of the text; peer reviewed; published in English; with date range filtered for the years 2007 to 2017; without restrictions as to the place of origin of the manuscript.

2.3 Eligibility criteria - study selection

The studies considered fulfilled the following criteria: (1) empirical research using qualitative and/or quantitative methodologies, (2) studies that investigated return to work programs.

2.4 Extraction of data and evaluation of quality

The research selection process hierarchically included a three-step data collection procedure to identify the relevant studies: (1) screening analysis and selection; (2) analysis and selection of reading summaries, and (3) analysis and selection by full reading of texts.

After this step, a structured data extraction form was used to organize information regarding the study’s characteristics, including the following data: first-named author, year, country; design of study; sample size; population; results, success and limits. Then, after meeting the inclusion criteria, they were reviewed.

The data was first extracted by a reviewer and then analyzed and reviewed by a second researcher independently, and without intervention at the time of extraction. After analysis of the data, in case of disagreement, consensus was reached by discussion between the reviewers, there being no need for a third reviewer or a final arbitration.

The data was then extracted from each publication and summarized for a full description of the studies, and finally, the authors’ reflections on their operationalization to analyze the return to work of individuals with mental health problems.

3 Results

The research strategy is presented in Fig. 1, which describes the characteristics of each study. The initial analysis identified 2,306 articles. Another 2 articles that met the inclusion criteria were found through manual searches of bibliographies and follow-up surveys, totaling 2,308. Applying the described exclusion criteria resulted in a final data set of 47 articles reviewed by two researchers.

Fig. 1

PRISMA 2009 Flow diagram — Selection process for the studies included in the analysis.

In characterizing the studies according to the diseases that served as the basis for the research (Supplementary Table 1), it was verified that about 29 of them (63.8%) were studies on the Common Mental Disorders (CMDs), according to the International Classification of Diseases [ICD]-10 classification: manic episode (F30), bipolar disorder (F31), depressive disorder (F32), depressive episode (F33), dysthymia (F34.1), phobic anxiety disorders (F40), other anxiety disorders (F41), obsessive-compulsive disorder (F42), reaction to severe stress and adjustment disorders (F43), adjustment disorder (F43.2), stress disorder (F43.0-43.1), somatoform disorder (F54) and distress (R45) [9 , 28–52].

Specific studies addressing Mental Health Problems (MHPS) consisted of 18 (38.3%) of the studies found in this review [5 , 53–57].

Musculoskeletal Disorders appeared in 10 (21.3%) of the works, associated or compared with the CMDs and the MHPS, in the Return to Work Programs [10 , 53].

We also observed studies with workers who suffered other diseases associated with Mental Health disorders, such as: Cardiovascular problems, which were presented in four articles (8.6%) [10 , 41]. Five other studies (10.7%) mentioned other disorders, gastro-intestinal, neurological, Burnout (Z56), etc. [13 , 60].

When analyzing the research according to its characteristics and objectives, it was observed that the articles could be subdivided into three different groups: the first focused on the analysis of the rehabilitation program itself, primary success, user satisfaction, time and results of the program, etc. A second group, sought to follow the process of return longitudinally, establishing points of analysis (for example from 3 to 12 months post-return), aspects related to pathologies, maintaining a focus on individuals. A third group sought to understand aspects of the return taking into account work situations (for example, relational aspects: participation of managers and peers and/or changes in the work conditions and organization (both to facilitate return, and to prevent further sick leave).

In the first group, we found four surveys that focused on Return to Work Programs [40 , 62]. These studies dealt with the programs for return to work itself and the success of this process, and were carried out through different approaches, using qualitative and quantitative methods. For the most part, the goal was to relate the success of the Return to Work program with length of leave, company size (small and medium-sized), and whether the employer had insurance to cover the costs of sick leave and medical advice.

The comparison between group models such as Redesigning Daily Occupations (REDO), Stimulating Healthy Participation and Relapse Prevention at Work (SHARP-at work), Redesigning Daily Occupationstrademark (ReDOtrademark) and Care as Usual (CAU) were cited in five surveys [34 , 63].

In the second group, we highlight studies that consider and evaluate the return process, its weaknesses, the segment time needed to evaluate this process, the importance of social support, as much from the rehabilitation team, as from managers and companies. However, these studies maintain a focus on individuals on sick leave, their pathologies and their perception of their return to work [10 , 60]. They compare the success of return processes between people with mental disorders and other pathologies without discussing the need for specification of the programs [8 , 60].

In the third group we find research that includes aspects related to individuals who undergo professional rehabilitation, the work environment, work relations (managers, managers and peers), content and organizational aspects relating them to the success of the return to work [30 , 63].

Studies carried out with supervisors of large and medium-sized companies point to factors that facilitate or hinder the process of return to work, dividing them into three categories: worker-related factors, job context and the return to work process. The relationship with supervisors is cited as one of the most relevant aspects of this process [30 , 63].

In addition to supervisors, the engagement of rehabilitated workers, peers, and workers’ health services professionals are also important in the return process, highlighting the willingness of teams to cooperate in the process and thus facilitate their adaptation to the needs of the parties involved. Other studies also add occupational physicians and unions as important in the return process [47 , 54].

Several studies highlight the difficulty of generalizing studies for other work situations, contexts and countries. The studies point to significant differences related to the size of companies, organizational cultures, regulations and policies of return to work and professional rehabilitation [30, 48].

Some studies indicate that the processes of rehabilitation and return to work are part of broader programs focused on the general quality of life and daily life of people, emphasizing health promotion as an important process [46, 49]. A second observation was that the success of rehabilitation depended on the transition of workers from a less mechanistic view to a more functional view of health, with greater awareness of health disease processes; the relationship between health and psychological factors, physical health and other features [34 , 54].

Research shows that overwork leads to social isolation, worsening and increasing the range of mental health problems related to work. However, at the same time as medical leave helps in the recovery process, it increases the isolation and loss of the work routine, causing identity crises, drawing attention to the iatrogenic effects of medical leave [43, 51].

Another study, carried out in more than 160 companies, shows that there is no relation between the size of the company and the types of diagnoses of mental illness among those on leave. The research reports depression as the most frequent diagnosis. The mean time of leave was 275.3 days [57].

The study by Flach et al. [59] analyzes the loss of employment during medical leave due to mental disorder, considering the history of leave due to these disorders, lack of support from colleagues and supervisors, and insecurity at work, focusing on public officials and teachers. Associations vary according to gender and company size.

The predictors for return to work, workspaces and demographic characteristics of workers without a work contract were studied in seven Nordic studies, highlighting a major concern in the following countries - Netherlands, Denmark and Norway - regarding the health and well-being of workers[9 –15].

4 Discussion

The reported global prevalence of mental health problems in the working population is 10% to 18% [28]. It often affects women, immigrants and workers with fragile relationships, reducing productivity to such a degree that it results in sick leave or total loss of work. In developed countries, mental health problems are a major reason for receiving disability benefits. In up to 90% of cases, the cause is related to stress, and the use of health services is restricted mainly to primary care [8–15 , 28].

Common Mental Disorders (CMDs), according to the International Classification of Diseases (ICD) -10 classification, were discussed in 30 studies [9 , 28–52], with depression being the most frequent diagnosis among workers.

Mental disorders can be divided into two subgroups: Common Mental Disorders (CMDs) and Severe and Persistent Mental Disorders (PMTCT). Common Mental Disorders (CMD) is a comprehensive term that includes mild to moderate depression, anxiety disorders and mental exhaustion/Burnout, in-cluding subliminal symptoms [8 , 58, 60]. CMDs, especially depression and anxiety, further contribute to the economic burden of reduced working days. PMTCTs, which include psychoses, follow other types of studies because they are rarely associated as being triggered by work, and the inclusion or return of this group requires specific rehabilitation programs.

CMDs are a major cause of long-term sick leave and a main reason for disability benefits, although many people with such disorders remain in employment [8 , 60].

Factors that could hinder or facilitate the process of return to work were found in several studies, the most common being the professional rehabilitation program and the return to work process, factors related to the worker and the work context [8 , 61–63].

Doki et al. [57] associate mental illness with absence from work and support for workers returning to work in Japanese companies. A total of 161 companies responded to the survey presenting worrying results related to absenteeism at work, in which the most frequent diagnosis among workers was depression.

Also, regarding work absenteeism, Eklund [34] presents in her research that absence from work due to stress-related disorders is more common among women, possibly caused by the accumulation of their multiple tasks, such as being mothers, housewives and professionals. For Nielsen et al. [55], Common Mental Disorders, such as stress and depression, are among the main causes of incapacity for work in women, corroborating other studies [34 , 58]. For Flach et al. [59], the associations vary between gender and the size of the company.

It has been shown that the difficulty of combining household chores, childcare and paid work increases the risk of medical leave [58]. This means that a woman’s life situation, not just her paid work, needs to be considered in professional rehabilitation and makes return interventions for women a matter of urgency [29 , 56].

Various methods were used in the screening of the papers analyzed for this review and the inclusion and exclusion criteria of the participants, but we highlight the exclusion of immigrants in Nordic countries from these studies due to a lack of understanding of their native language [8 , 49].

Most of the articles investigated in this review outlined the type of work activity performed by the individuals participating in the research. Most of them are in formal employment in their countries of origin, and we found only five studies (10.4%) with immigrants working in informal activities. This is probably due to the greater difficulty of defining the sample in these studies. As work activity classification varies by country, the articles name the activities and not the professions [8–10 , 50].

In a Brazilian national article, Souza and Santana [64] show that factors that are not strictly medical: age, socioeconomic status, expectation of return to work and level of income replacement by the National Social Security Institute seem to influence the duration of the benefit.

Some studies indicate the processes of rehabilitation and return to work as part of broader programs focused on the general quality of life of people and their daily life, emphasizing the promotion of health as an important process. In this way it is part of the professional rehabilitation process to stimulate a healthier lifestyle; maintaining independence out of work; and preserving mental well-being [34]. A second observation was that the success of rehabilitation depended on the transition of workers from a less mechanistic view to a more functional view of health, with greater awareness of health disease processes; the relationship between health and psychological factors, physical health and other characteristics [31 , 54].

In addition, when interviewing the different groups (sick workers, peers, managers, professional rehabilitation teams, social security agencies and union members), Corbière et al. [53] observed transversal themes, such as: organizational culture in which mental health issues and human aspects of work are central; support and follow-up during absence from work and return to work; resources to assist the employee in returning to work and also prejudices and discomfort of involved parties in relation to depression.

The study by Verdonk et al. [48] points out that although psychological care offered alternatives to work by encouraging workers to take on other personal roles in order to achieve a better balance, this process was lost after reintegration to work, due to the difficulty of reconciling personal strategies with work demands, that is, for the authors, the success of the return depends on changes in working conditions and organizational values.

Studies show that overwork leads to mental health problems and social isolation. However, although medical leave can help recovery, it accentuates isolation, loss of work routine, and professional identity, drawing attention to the iatrogenic effects of medical leave [43, 51]. Still, for Flach et al. [59], the loss of employment during medical leave associated with mental disorders is related to the history of sick leave due to these disorders, lack of support from peers and supervisors and insecurity at work, affecting civil servants and teachers more.

Another study shows that there was no relationship between the size of the company and the types of mental illness diagnoses related to withdrawals. This study, conducted in more than 160 companies, found that the most frequent diagnosis among workers was depression, and the average number of days of medical leave was 275.3 [57].

Research of the post-professional rehabilitation sector reveals that, although many of the rehabilitated workers remained in work, many of them had functional restrictions for the exercise of certain work activities [60]. This finding corroborates the results of a study carried out with managers that points out the organizational difficulties of receiving workers on leave, overloading the workers who remain in work [43].

With regard to return to work, there were positive and negative reports. On the positive side, those who return to work contribute to the division of labor, generating solidarity and cooperation [10 , 65]. The reported negatives were related to the return of workers with labor restrictions who could not fully carry out their activities, generating conflicts in work teams and interfering in reintegration processes. Supervisors reported difficulties in the reorganization of work, in the preparation of rosters and shifts with the conciliation of the diagnoses and symptoms of the workers, the need for leave and respect for labor restrictions [11 , 59].

The Eklund study [34] points out that although mental health services offered alternatives to work by encouraging workers to take on other personal roles aiming for greater balance, this process was lost after work reintegration because of the difficulty of reconciling their personal strategies with the demands of work, that is, the success of the return depends on changes in conditions, organization and working relationships.

5 Conclusion

This research aimed to identify, through a systematic review, articles that address programs for professional rehabilitation and return to work of people absent due to mental health problems.

The publication of systematic review studies, as well as others that synthesize research results, is fundamental for changing the behavior of health professionals. This transformation implies not only making specialized literature available, but also incorporating this information into daily clinical practice, thus avoiding exclusion processes at work.

Issues involving return to and remaining in work have been much debated in the studies found for this review; leave due to Common Mental Disorders (CMDs) are a major cause of absence due to long-term illness and a reason for disability benefits, although many people with these disorders remain employed, women, workers with fragile relationships and immigrants need further research.

The present results should be evaluated with care because this review may have limitations with regard to the types of study selected, since the research was limited only to leave programs for professional rehabilitation and the return to work of people laid off due to mental health problems, and to verify the results of professional rehabilitation programs and follow-up processes for such return. In order to improve the quality of future publications and decrease the risk of possible bias, the authors suggest further reviews with the inclusion of meta-analyses, which would present evidence and characteristics regarding medical leave and return programs.

Strong and weak points

Strong points - few studies address the processes for professional rehabilitation and return to work among mental health patients, despite the growing occurrence of illness due to these pathologies. The article reveals different types of study presenting a general framework for producing and stimulating new studies. Weak points - The main difficulty, reported in several of the articles, is the generalization of results for other realities, even in the country of origin itself. This generalization and comparison between countries is even more difficult, perhaps impossible, due to the different realities, public policies regarding social security, indices of work development, etc.

Compliance with ethical standards

Ethical approval: This article does not contain any studies with human or animals participants performed by any of the authors. Because it is an article of literature review. The research was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on February 23, 2017 and was updated on February 11, 2018 with registration number CRD42017057521.

Conflict of interest

All authors performed the research equally and approved this final version. There are no conflicts of interest for this work.

Funding

This study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo – Brazil.

Footnotes

Supplementary Table 1 is available from .

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Mental health: Professional rehabilitation and the return to work - A systematic review

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Materials and methodology

2.1 Search strategy

2.2 Inclusion and exclusion criteria

2.3 Eligibility criteria - study selection

2.4 Extraction of data and evaluation of quality

3 Results

5 Conclusion

Strong and weak points

Compliance with ethical standards

Conflict of interest

Funding

Footnotes

References