Improving return to work in adults suffering from symptoms of distress

Adjustment disorders, characterised by distress symptoms and emotional disturbance as a reaction to a significant life change or stressful life event, are a frequent cause of sick leave among workers. Apart from the negative consequences for the worker, sick leave poses a heavy burden on society due to the loss of productivity of the worker and work disability claims. Different treatments have been developed to help such workers return to work. Our study assessed how effective these treatments are at enabling the sick-listed worker to return to partial or full-time work. We searched databases containing articles from different scientific journals and looked for studies that tested whether a certain type of treatment helped the worker to return to work when on sick leave because of an adjustment disorder. We found nine relevant studies. In total, 10 psychological treatments were evaluated and one combined treatment consisting of a psychological treatment and relaxation techniques. We found no studies on pharmacological interventions, exercise programmes or employee assistance programmes. The nine studies included in this review reported in total on 1546 participants. Of the 10 psychological treatments, five consisted of cognitive behavioural therapy and five of problem solving therapy, which are commonly used types of treatment for patients with mental health problems. Our results showed that workers on sick leave because of an adjustment disorder can be helped with making their first step back to work (i.e. partial return to work) by treating them with problem solving therapy. On average, workers who are offered problem solving therapy start 17 days earlier with partial return to work compared to workers who receive no treatment or the usual treatment from their occupational physician or general practitioner. However, we also found that cognitive behavioural therapy or problem solving therapy does not help the worker return to work with full-time hours any quicker than workers who receive no treatment or the usual treatment from their occupational physicians or general practitioners. These results are based on moderate-quality evidence, which implies that further research is likely to have an important impact on our confidence in the results and may change the results.

Authors' conclusions: 

We found moderate-quality evidence that CBT did not significantly reduce time until partial RTW and low-quality evidence that it did not significantly reduce time to full RTW compared with no treatment. Moderate-quality evidence showed that PST significantly enhanced partial RTW at one-year follow-up compared to non-guideline based care but did not significantly enhance time to full RTW at one-year follow-up. An important limitation was the small number of studies included in the meta-analyses and the small number of participants, which lowered the power of the analyses.

Read the full abstract...

Adjustment disorders are a frequent cause of sick leave and various interventions have been developed to expedite the return to work (RTW) of individuals on sick leave due to adjustment disorders.


To assess the effects of interventions facilitating RTW for workers with acute or chronic adjustment disorders.

Search strategy: 

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to October 2011; the Cochrane Central Register of Controlled Trials (CENTRAL) to Issue 4, 2011; MEDLINE, EMBASE, PsycINFO and ISI Web of Science, all years to February 2011; the WHO trials portal (ICTRP) and in March 2011. We also screened reference lists of included studies and relevant reviews.

Selection criteria: 

We selected randomised controlled trials (RCTs) evaluating the effectiveness of interventions to facilitate RTW of workers with adjustment disorders compared to no or other treatment. Eligible interventions were pharmacological interventions, psychological interventions (such as cognitive behavioural therapy (CBT) and problem solving therapy), relaxation techniques, exercise programmes, employee assistance programmes or combinations of these interventions. The primary outcomes were time to partial and time to full RTW, and secondary outcomes were severity of symptoms of adjustment disorder, work functioning, generic functional status (i.e. the overall functional capabilities of an individual, such as physical functioning, social function, general mental health) and quality of life.

Data collection and analysis: 

Two authors independently selected studies, assessed risk of bias and extracted data. We pooled studies that we deemed sufficiently clinically homogeneous in different comparison groups, and assessed the overall quality of the evidence using the GRADE approach.

Main results: 

We included nine studies reporting on 10 psychological interventions and one combined intervention. The studies included 1546 participants. No RCTs were found of pharmacological interventions, exercise programmes or employee assistance programmes. We assessed seven studies as having low risk of bias and the studies that were pooled together were comparable. For those who received no treatment, compared with CBT, the assumed time to partial and full RTW was 88 and 252 days respectively. Based on two studies with a total of 159 participants, moderate-quality evidence showed that CBT had similar results for time (measured in days) until partial RTW compared to no treatment at one-year follow-up (mean difference (MD) -8.78, 95% confidence interval (CI) -23.26 to 5.71). We found low-quality evidence of similar results for CBT and no treatment on the reduction of days until full RTW at one-year follow-up (MD -35.73, 95% CI -113.15 to 41.69) (one study with 105 participants included in the analysis). Based on moderate-quality evidence, problem solving therapy (PST) significantly reduced time until partial RTW at one-year follow-up compared to non-guideline based care (MD -17.00, 95% CI -26.48 to -7.52) (one study with 192 participants clustered among 33 treatment providers included in the analysis), but we found moderate-quality evidence of no significant effect on reducing days until full RTW at one-year follow-up (MD -17.73, 95% CI -37.35 to 1.90) (two studies with 342 participants included in the analysis).