Evelien P. M. Brouwers

Employment Specialist Competencies for Supported Employment Programs

Purpose Supported employment (SE) programs are evidence-based programs offered to people with severe mental illness to facilitate obtaining and keeping competitive work. However, significant variations in individuals’ vocational success may be partly explained by differences in their employment specialists’ competencies. Aim The main objectives of this study were to develop a questionnaire measuring the behaviors, attitudes and knowledge of employment specialists working in SE programs and to link specific competencies to vocational outcomes. Methods A total of 153 employment specialists working in Canadian and Dutch supported employment programs completed the Behaviors, Attitudes, and Knowledge in Employment Specialists (BAKES) questionnaire and provided information about their clients’ vocational outcomes. Results Exploratory Factor Analyses results found 90 items over 12 subscales (e.g., Relationships with employers and supervisors). Regression analyses indicated that the two most useful subscales for predicting vocational success were: (1) Relationships with employers and supervisors, and (2) support and client-centered approach. Conclusion Employment specialists require specific competencies to help people with severe mental illness obtain and maintain competitive employment. Validating the BAKES will better define the broad range of competencies expected for this position, and this tool may facilitate training of employment specialists.

An international comparison of occupational health guidelines for the management of mental disorders and stress-related psychological symptoms.

Background We compared available guidelines on the management of mental disorders and stress-related psychological symptoms in an occupational healthcare setting and determined their development and reporting quality. Methods To identify eligible guidelines, we systematically searched National Guideline Clearinghouse, Guidelines International Network Library and PubMed. Members of the International Commission on Occupational Health (ICOH), were also consulted. Guidelines recommendations were compared and reporting quality was assessed using the AGREE II instrument. Results Of 2126 titles retrieved, 14 guidelines were included: 1 Japanese, 2 Finnish, 2 Korean, 2 British and 7 Dutch. Four guidelines were of high-reporting quality. Best described was the Scope and Purpose, and the poorest described were competing interests (Editorial independence) and barriers and facilitators for implementation (Applicability). Key recommendations were often difficult to identify. Most guidelines recommend employing an inventory of symptoms, diagnostic classification, performance problems and workplace factors. All guidelines recommend specific return-to-work interventions, and most agreed on psychological treatment and communication between involved stakeholders. Discussion Practice guidelines to address work disability due to mental disorders and stress-related symptoms are available in various countries around the world, however, these guidelines are difficult to find. To promote sharing, national guidelines should be accessible via established international databases. The quality of the guidelines developmental process varied considerably. To increase quality and applicability, guideline developers should adopt a common structure for the development and reporting of their guidelines, for example Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. Owing to differences in social systems, developers can learn from each other through reviews of this kind.

To what extent does the anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) detect specific types of anxiety disorder in primary care? A psychometric study

BackgroundAnxiety scales may help primary care physicians to detect specific anxiety disorders among the many emotionally distressed patients presenting in primary care. The anxiety scale of the Four-Dimensional Symptom Questionnaire (4DSQ) consists of an admixture of symptoms of specific anxiety disorders. The research questions were: (1) Is the anxiety scale unidimensional or multidimensional? (2) To what extent does the anxiety scale detect specific DSM-IV anxiety disorders? (3) Which cut-off points are suitable to rule out or to rule in (which) anxiety disorders?MethodsWe analyzed 5 primary care datasets with standardized psychiatric diagnoses and 4DSQ scores. Unidimensionality was assessed through confirmatory factor analysis (CFA). We examined mean scores and anxiety score distributions per disorder. Receiver operating characteristic (ROC) analysis was used to determine optimal cut-off points.ResultsTotal n was 969. CFA supported unidimensionality. The anxiety scale performed slightly better in detecting patients with panic disorder, agoraphobia, social phobia, obsessive compulsive disorder (OCD) and post traumatic stress disorder (PTSD) than patients with generalized anxiety disorder (GAD) and specific phobia. ROC-analysis suggested that ≥4 was the optimal cut-off point to rule out and ≥10 the cut-off point to rule in anxiety disorders.ConclusionsThe 4DSQ anxiety scale measures a common trait of pathological anxiety that is characteristic of anxiety disorders, in particular panic disorder, agoraphobia, social phobia, OCD and PTSD. The anxiety score detects the latter anxiety disorders to a slightly greater extent than GAD and specific phobia, without being able to distinguish between the different anxiety disorder types. The cut-off points ≥4 and ≥10 can be used to separate distressed patients in three groups with a relatively low, moderate and high probability of having one or more anxiety disorders.

Effectiveness of guideline-based care by occupational physicians on the return-to-work of workers with common mental disorders: design of a cluster-randomised controlled trial

BackgroundSickness absence due to common mental disorders (such as depression, anxiety disorder, adjustment disorder) is a problem in many Western countries. Long-term sickness absence leads to substantial societal and financial costs. In workers with common mental disorders, sickness absence costs are much higher than medical costs. In the Netherlands, a practice guideline was developed that promotes an activating approach of the occupational physician to establish faster return-to-work by enhancing the problem-solving capacity of workers, especially in relation to their work environment. Studies on this guideline indicate a promising association between guideline adherence and a shortened sick leave duration, but also minimal adherence to the guideline by occupational physicians. Therefore, this study evaluates the effect of guideline-based care on the full return-to-work of workers who are sick listed due to common mental disorders.Methods/designThis is a two-armed cluster-randomised controlled trial with randomisation at the occupational physician level. During one year, occupational physicians in the intervention group receive innovative training to improve their guideline-based care whereas occupational physicians in the control group provide care as usual. A total of 232 workers, sick listed due to common mental disorders and counselled by participating occupational physicians, will be included. Data are collected via the registration system of the occupational health service, and by questionnaires at baseline and at 3, 6 and 12 months. The primary outcome is time to full return-to-work. Secondary outcomes are partial return-to-work, total number of sick leave days, symptoms, and workability. Personal and work characteristics are the prognostic measures. Additional measures are coping, self-efficacy, remoralization, personal experiences, satisfaction with consultations with the occupational physician and with contact with the supervisor, experiences and behaviour of the supervisor, and the extent of guideline adherence.DiscussionIf the results show that guideline-based care in fact leads to faster and sustainable return-to-work, this study will contribute to lowering personal, societal and financial costs.Trial registrationISRCTN86605310

Effect of an intervention to enhance guideline adherence of occupational physicians on return-to-work self-efficacy in workers sick-listed with common mental disorders

BackgroundSince a higher level of self-efficacy in common mental disorders is associated with earlier return-to-work (RTW), it is important to know if work related self-efficacy can be increased by occupational health care. The primary aim of this study was to evaluate whether an intervention to enhance guideline adherence of occupational physicians lead to an increase in RTW self-efficacy in workers three months later. The secondary aim was to evaluate whether the intervention modified the association between RTW self-efficacy and return-to-work three months later.MethodsA total of 66 occupational physicians participated in the study. They were randomized into two groups; the intervention group received a training, the control group did not. The training aimed to enhance adherence to a mental health guideline that contained strategies that are supposed to enhance RTW self-efficacy. In 128 sick-listed workers guided by these occupational physicians, RTW self-efficacy, RTW, and personal, health-related and work-related variables were measured at baseline and three months later. Generalized linear mixed models analysis and linear mixed models analysis were used for the evaluations.ResultsIn workers whose occupational physicians had received the training RTW self-efficacy increased significantly more than in workers whose occupational physicians had participated in the control group (t = −2.626, p ≤ .05). Higher baseline RTW self-efficacy scores were significantly more often associated with full RTW than with no RTW three months later (OR 2.20, 95 % CI 1.18–4.07), but the intervention did not affect this association.ConclusionsThis study showed that a training to enhance guideline adherence of occupational physicians leads to increased RTW self-efficacy in workers sick-listed with common mental disorders during the first months of sickness absence in a real-life occupational health care setting. This insight is helpful for optimizing the recovery and RTW process, and for understanding the role of RTW self-efficacy in this process.Trial registrationISRCTN86605310

Psychometric evaluation of the Dutch version of the Mental Health Recovery Measure (MHRM)

Background: During the past decade, the mental health consumer movement has drawn the attention of mental health providers, researchers and policy makers to the concept of recovery. Traditionally, recovery primarily refers to the remission of symptoms. Nowadays, recovery is also regarded in a sense that all individuals, even those with severe psychiatric disabilities, can improve. Accordingly, recovery for people with severe mental illness refers to hope and optimism, empowerment, regained control and increased self-esteem, illness self-management and engagement in meaningful daily activities (Corrigan, Giffort, Rashid, Leary & Okeke, 1999; Jacobson & Greenley, 2001; Leamy, Bird, le Boutillier, Williams & Slade, 2011; van Gestel-Timmermans, Brouwers, van Assen, Bongers & van Nieuwenhuizen, 2012). Little empirical research, however, has been done and instruments to measure recovery are scarce. Aims: In the current study, the psychometric properties of the Dutch version of the Mental Health Recovery Measure (MHRM) are explored. Convergent and divergent validity of the MHRM was assessed using standardized measures of hope (Hope Herth Index (HHI)), recovery-promoting professional competence (Recovery Promoting Relationships Scale (RPRS)) and general physical health and well-being (RAND Measure of Health-Related Quality of Life (RAND-36)). Methods: A factor analysis was conducted and Cronbach’s α of the MHRM scales was assessed. The construct validity was assessed by computing the intercorrelations of the MHRM, HHI, RPRS and RAND-36. Results: Data were available for 212 patients: 70 patients completed the MHRM, HHI and RAND 36 and 142 filled out the MHRM and RPRS. Exploratory factor analysis resulted in an interpretable three-factor solution. Cronbach’s α ranged from 0.86 to 0.94. The convergent validity of the instrument was satisfactory; the divergent validity was less clear. Conclusions: This study offers evidence to suggest that the Dutch version of the MHRM is a reliable measure (in terms of internal consistency) with a generally acceptable convergent and divergent validity. Further research is needed to clarify the extent to which the MHRM is sensitive enough to capture the individual recovery process of patients.

Improving occupational physicians’ adherence to a practice guideline: feasibility and impact of a tailored implementation strategy

BackgroundAlthough practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs’ barriers were evaluated.MethodsOPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs’ experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training.ResultsThe training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01).ConclusionsThe results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs’ knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

Blended E-health module on return to work embedded in collaborative occupational health care for common mental disorders: design of a cluster randomized controlled trial.

Background Common mental disorders (CMD) have a major impact on both society and individual workers, so return to work (RTW) is an important issue. In The Netherlands, the occupational physician plays a central role in the guidance of sick-listed workers with respect to RTW. Evidence-based guidelines are available, but seem not to be effective in improving RTW in people with CMD. An intervention supporting the occupational physician in guidance of sick-listed workers combined with specific guidance regarding RTW is needed. A blended E-health module embedded in collaborative occupational health care is now available, and comprises a decision aid supporting the occupational physician and an E-health module, Return@Work, to support sick-listed workers in the RTW process. The cost-effectiveness of this intervention will be evaluated in this study and compared with that of care as usual. Methods This study is a two-armed cluster randomized controlled trial, with randomization done at the level of occupational physicians. Two hundred workers with CMD on sickness absence for 4–26 weeks will be included in the study. Workers whose occupational physician is allocated to the intervention group will receive the collaborative occupational health care intervention. Occupational physicians allocated to the care as usual group will give conventional sickness guidance. Follow-up assessments will be done at 3, 6, 9, and 12 months after baseline. The primary outcome is duration until RTW. The secondary outcome is severity of symptoms of CMD. An economic evaluation will be performed as part of this trial. Conclusion It is hypothesized that collaborative occupational health care intervention will be more (cost)-effective than care as usual. This intervention is innovative in its combination of a decision aid by email sent to the occupational physician and an E-health module aimed at RTW for the sick-listed worker.

Process variables in organizational stress management intervention evaluation research: a systematic review.

OBJECTIVES This systematic review aimed to explore which process variables are used in stress management intervention (SMI) evaluation research. METHODS A systematic review was conducted using seven electronic databases. Studies were included if they reported on an SMI aimed at primary or secondary stress prevention, were directed at paid employees, and reported process data. Two independent researchers checked all records and selected the articles for inclusion. Nielsen and Randalls model for process evaluation was used to cluster the process variables. The three main clusters were context, intervention, and mental models. RESULTS In the 44 articles included, 47 process variables were found, clustered into three main categories: context (two variables), intervention (31 variables), and mental models (14 variables). Half of the articles contained no reference to process evaluation literature. The collection of process evaluation data mostly took place after the intervention and at the level of the employee. CONCLUSIONS The findings suggest that there is great heterogeneity in methods and process variables used in process evaluations of SMI. This, together with the lack of use of a standardized framework for evaluation, hinders the advancement of process evaluation theory development.

Profiles of individually defined recovery of people with major psychiatric problems

Background: Research on factors associated with individually defined recovery is limited. Several phases of recovery have been described in the literature. Individuals in these distinct phases have different characteristics and problems. Aims: To identify classes of people with major psychiatric problems who have comparable profiles of individually defined recovery, to relate these classes to the phases of recovery as described by Spaniol, Wewiorsky, Gagne, and Anthony (2002), and to associate the classes to demographic and psychiatric characteristics, and health-related variables. Methods: Data of 333 participants with major psychiatric problems were used. A latent class analysis was conducted on the mean scores of four proxy measures of recovery. Results: Three well-defined classes were found that differed on the recovery measures. The classes differed significantly on variables corresponding to Spaniol’s phases of recovery (Spaniol et al., 2002) and on health care utilization, health care needs and anxiety disorder, but not on demographic variables. Conclusions: It is possible to identify classes of people with major psychiatric problems who have comparable profiles of individually defined recovery that seem to correspond to phases of recovery. More knowledge of the characteristics of people in different phases of recovery will contribute to more fine-tuned and recovery-oriented health care.