Although work provide a range of benefits such as increased income, social contact, and sense of purpose, it can also have negative effects on mental health, particularly in the form of stress. The National Institute of Occupational Safety and Health in the US (NIOSH) [ 40% of American workers reported their job was very or extremely stressful, 25% view their jobs as the number one stressor in their lives, three fourths of American employees believe that workers have more on-the-job stress than a generation ago.
Given the global recession, financial strain, and job losses, greater work stress might have adverse consequences in UK. The most recent data from the NHS information centre in UK suggest an increase in the suicide rate for the first time since 1998. The number of people committing suicide rose by 329 to 5,706 in 2008. The rate among men increased from 16.8 per 100,000 in 2007 to 17.7 per 100,000 in 2008. This increase is being interpreted by politicians and the public as a consequence of the global and national recession, increased job insecurity, risk of loss of jobs, and also stress at work, where the demands on the existing workforce have increased (The Independent, 18th November, 2010).
Approximately 11 million people of working age in UK experience mental health problems. 11.4 million working days were lost in UK in 2008/2009 due to work-related stress, depression, or anxiety [
In order to consider the evidence base, there needs to be some agreement on the meaning of work stress. A popular model of stress considers “inputs” such as job characteristics; for example, excess demands, low control, poor social support, adverse life events such as bereavement or divorce, and additional demands outside of work such as carer responsibilities for a dependent relative or spouse [
The specific conceptualisations of stress adopted influence the way interventions are constructed to tackle specific mechanisms in order to alter stress and its manifestations. Cahill [
Model for categorising stress management interventions (adapted from de Jonge and Dollard) [
Level | Primary prevention | Secondary prevention | Tertiary prevention | Outcome measures |
---|---|---|---|---|
Organisational | Improving work content, fitness programmes, and career development | Improving communication and decision making and conflict management | Vocational Rehabilitation and outplacement | Productivity, turn-over, absenteeism, and financial claims |
Individual and Organizational interface | Time management, improving interpersonal skills, and Work/home Balance | Peer support groups, coaching, and career planning | Posttraumatic stress assistance programmes and group psychotherapy | Job stressors such as demands, control, support, role ambiguity, relationships, change, with burnout |
Individual | Pre-employment medical examination and didactic stress management | Cognitive behavioural techniques and relaxation | Rehabilitation after sick leave, disability management, case management, and individual psychotherapy | Mood states, psychosomatic complaints, subjective experienced stress, physiological parameters, sleep disturbances, and health behaviours |
Although preventive interventions are often advocated, what is the evidence of benefit? The evidence of effective interventions to protect individual mental health and reduce organisational absenteeism rates is difficult to summarise in a manner that is of practical relevance. Therefore, the purpose of this paper is to take the highest level of research evidence (systematic reviews providing narrative synthesis or meta-analyses) and synthesise this evidence to identify the key findings and gaps in the literature on the effectiveness of different stress management interventions for preventing anxiety and depression as the main cause of absenteeism. Consequently, this review of systematic reviews focuses on common mental health problems (anxiety, depression) and absenteeism.
Undertaking a review of systematic review is challenging methodologically for two reasons; there is not a conventional accepted process to produce a meta-review or meta-synthesis across different types of systematic reviews, for different outcomes, and different complex interventions which may defy drawing a singular scientific conclusion that requires all sources of heterogeneity be overlooked [
The review identified all systematic reviews of evidence on stress management interventions in the workplace and summaries, tabulated extracted, and then synthesized the evidence for the relative merits of different interventions. Consistent with previous work, we restricted the review to papers published since 1990, as recency in the literature is important to ensure the evidence is related to contemporary concepts of stress and work, and to ensure the current work conditions are represented in the evidence synthesis, rather than historical work conditions. The databases searched are listed in Table
Databases searched.
Medline 1950 to November Week 3 2008 | |
PsychInfo 1806 to January Week 2 2009 | |
Embase 1980 to 2009 Week 02 | |
Cochrane database of systematic reviews 4th quarter 2008 | |
ACP Journal Club 1991 to December 2008 | |
Cochrane Central Register of Controlled Trials 4th quarter 2008 | |
Cochrane Methodology Register 4th quarter 2008 | |
Allied and Complementary Medicine 1985 to January 2009 | |
British Nursing Index 1985 to January 2009 | |
Health management information consortium October 2008 |
The search terms used were: “psychological ill health or anxiety or stress or distress or burnout,” “stress management or intervention or rehabilitation or prevention,” “work or job or employee or sick leave or occupation or workplace adjustments or employee assistance programmes.”
The criteria used for inclusion were english language articles, reviews published from 1990 to July 2011, systematic reviews, reviews with data/narrative synthesis, meta-analyses.
The articles excluded were theoretical and educational reviews, those published prior to 1990.
The total number of reviews initially retrieved after excluding duplicates was 7845 (see Table
Summary of review papers.
Author (search dates) | Research aim or question | Prevention level | Intervention | Outcome | Type of review | Interventions reviewed | No. of Studies |
---|---|---|---|---|---|---|---|
Parks and Steelman 2008 (1980–2005) | Effectiveness of organisational wellness programmes for absenteeism and satisfaction (Publications 1980–2005) | PP | O | O | Meta-analysis | Fitness organisation wellness programmes | 15 papers + 2 dissertations |
Richardson and Rothstein 2008 (1976 onwards) | Effectiveness of stress management interventions: What works for whom? What has been learned and what is needed next? Includes effectiveness of SMI target by outcomes. Publications in English from 1976 onwards. updates van der Klink, 2001 | PP | I, O | I, O | Systematic with meta analysis | Interventions were categorised into: CBT, relaxation, organisation (support groups), multimodal, and alternative (biofeedback, and personal skills training) | 38 papers |
Egan et al. 2007 (up to November 2006) | Whether organisational-level interventions designed to increase employee participation/control lead to health effects predicted by the DCS model | PP | O | I | Systematic | Problem solving committees, employee representatives, delegation of more control of work scheduling, work hours and training, smaller teams with subsupervisors | 18 |
Lamontagne et al., 2007 (1990–2005) | Effectiveness of interventions categorised as primary, secondary and tertiary | PP | O, I, | O, I, | Systematic review of job stress interventions between 1990–2005 | Interventions for physical work environment (e.g., noise level), organisation (e.g., work redesign, workload reduction) individual (e.g., coping skills training), and organisation-individual interface (e.g., support group) | 90 |
Bond et al. 2006 (1989–2004) | Does increasing employee control and workplace reorganisation (HSE Management standards) affect business outcomes such as performance, absenteeism, and turnover? | — | O | O | Systematic review of interventions | Interventions to increase control including job redesign, steering or focus groups to identify ways that employee control could be increased | 5 |
Marine et al. 2006 (up to May 2005) | Evaluate effectiveness of work and person-directed interventions in preventing stress at work in healthcare workers | PP | O, I | I, O | Cochrane collaboration systematic with meta-analysis and qualitative synthesis | Person directed interventions included cognitive behavioural therapy, relaxation, music making, touch therapy/massage, multicomponent interventions consisting of mindfulness-based stress reduction, education, and exercises to enhance communication skills, stress reactivity and self-compassion and practical skills. Work directed interventions included role playing, experiential exchanges intended to improve attitudes, communication skills, mobilising support from colleagues, learning participatory problems solving and decision making, innovations in nursing delivery via changes in work organisation, knowledge and skills training, and support from supervisors | 19 |
The British Occupational Health Research Foundation, 2005 (up to April 2004) | (1) What is the evidence for preventative programmes at work and what are the conditions under which they are most effective? (2) For those at risk what is most effective to enable them to remain at work? (3) What is effective to support rehabilitation and return to work? | PP | O+I | O | Systematic review | Coworker support group, stress inoculation training, counselling, relaxation, problems solving, assertiveness training, stress awareness, self report diary, physical exercise, cognitive behavioural therapy, education, relationship orientated therapy, computerised CBT, psychodynamic therapy, cognitive analytic therapy, music making, humour, increasing employees participation and control, clarify role and responsibilities, increase job related information, feedback from supervisors about performance, training and feedback to managers, education training for primary care physicians to attune them to previously unrecognised or untreated anxiety, coping skills, inner quality management training consisting of changing interpretive styles to affect mood and stress, enhancing communication and goal clarity, creating a caring culture and job satisfaction, and quantum management: operationalsing the tools daily. Organisation development interventions consisting of 2 years of surveys, interest groups, action planning and policy intervention and review, meditation, online support group, self management, training in emotional intelligence, and telephone support from supervisor | 31 |
Michie and Williams 2003 (1987–1999) | Reducing work related psychological ill health and sickness absence | PP | O,I | I,O | Systematic review | Physical activity, skill training to increase social support and problem solving, early referral to occupational health, and communication training | 6 |
Mimura and Griffiths 2003 (1990 onwards) | The effectiveness of current approaches to workplace stress management in the nursing profession | PP | O,I | I | Systematic | Personnel support, and environmental management interventions | 11 |
Edwards and Burnard 2003 (1966–2000) | Systematically identify stressors, moderators and stress management interventions for mental health nurses | PP | O,I | O,I | Systematic | Support, education, awareness, training, ward reorganisation, and behaviour training | 77 |
Van der Klink et al. 2001 (1966–1996) | Effectiveness of individual interventions such as CBT, relaxation, multimodal programmes, and organisation focused interventions | PP | O,I, | I,O | Meta analysis | CBT, relaxation, and multimodal and organisation-focused interventions to increase control or support | 48 |
Parkes and Sparkes, 1998 | (1) effectiveness of individual targeted (2) organisational targeted interventions | PP | O,I | I,O | HSE contract research report. Literature review partially systematic | Individual stress management to change individuals ability to cope with stress and organisation focused interventions to reduce the stress exposure in work environment | 9 org studies |
Van der Hek and Plomp, 1997 (1987–1994) | Evaluate the effectiveness by level of intervention and outcome measure | PP | I,O, | I,O, | Systematic review | Individual interventions: relaxation, meditation, biofeedback, cognitive coping strategies, employee assistance programmes | 24 |
Murphy, 1996 (1974–1994) | Stress management in work settings: A critical review of the health effects | PP | I | I,O | Systematic | Progressive muscle relaxation, mediation, biofeedback, cognitive behavioural, multimodal, and miscellaneous | 64 |
Saunders et al., 1996 (1977–1991) | The effect of individual stress inoculation training for anxiety and performance | PP | I | I,O | Meta analysis | Stress inoculation training: conceptualisation and education, skill acquisition and rehearsal then application and follow through | 37 |
Giga et al., 2003 (1990–2001) | The impact of stress management interventions on the individual and the organisation based on UK-based research only | PP | I,O | I,O | Literature review | Individual: relaxation, CBT, exercise, time management, and employee assistance programme | 16 |
Caulfield et al., 2004 (1993–2003) | To investigate empirical research into occupational stress interventions conducted in Australia | PP | I,O | I,O | Systematic review | Individual: self-management training, stress management | 1 on psychological health, |
Penalba, McGuire, Leite, 2009 (electronic searches on 12/5/08 | Psychosocial interventions for preventing psychological problems in law enforcement officers (police and military policy), regardless of age, gender, and country | PP | I | I | Cochrane review: systematic review of trials | Exercise, psychological interventions, and psychosocial interventions | 19 studies reviewed, and only five contained data 3 were exercise based interventions and |
Martin 2009 | Meta-analysis of effects of health promotion intervention in the workplace on depression and anxiety symptoms | PP+SP | I+O | I | Meta-analysis | Aerobic and weight training exercise behaviour modification | 22 studies |
Conn 2009 (electronic searches 1969–2007) | Meta-analysis of physical activity interventions | PP | I+O | I+O | Meta-analysis of workplace physical activity studies | Intervention including workplace employee, whether worksite designed intervention, during employee’s paid time, fitness facilities at worksites, organisational policy present or not, motivational or educational sessions included? | 51 studies delivered interventions at the workplace, and 17 did not |
Van Wyk (2010) | Preventive staff support interventions for health workers | PP | I+O | I+O | Cochrane review | Support groups for staff | Ten studies included |
Noordik (2010) | Exposure in vivo containing interventions to improve work functioning of worker with anxiety disorders | SP | I | I+O | Systematic review | Comparison of work-based in vivo exposure versus medication, relaxation and response prevention, CBT without exposure, waiting list treatment, imaginal or interceptive exposure, and placebo care as usual (difficult to know if absenteeism affected as reported with other measures of work role) | 7 articles included |
Cancelliere et al., 2011 (1990–2010) | To determine if workplace health promotion (WHP) programmes are effective in improving presenteeism | PP | I,O | O | Systematic review | Organisational: worksite exercise, a supervisor education program on mental health promotion, “A Lifestyle Intervention Via Email” (Alive!), extra rest break time for workers engaged in highly repetitive work, a multidisciplinary occupational health programme, a multicomponent health promotion programme, participatory processes, exposure to blue-enriched light (versus white light), and a telephone intervention program for depressed workers | 14 studies on presenteism |
RCTs = randomised controlled trials.
The reviewed studies included many outcomes which ranged from physical health measures (e.g., cardiovascular measures) to psychological and psychiatric measures (e.g., well-being, psychological distress, burnout, general mental health, anxiety, depression, stress, psychiatric symptoms, and psychosomatic symptoms) to organisational measures (e.g., employee satisfaction, motivation, absenteeism). In this paper, we focus only on articles reporting, (a) individual outcomes of symptoms of anxiety and depression (including severe stress if measured by a specific rating scale of anxiety and depression) or anxiety and depressive illness formally assessed using specific diagnostic or psychometric measures and (b) absenteeism as an important organisational outcome as this has an economic cost to the employer.
We included key words of
Table
Due to the heterogeneity of the published reviews in terms of the methodology used (i.e., meta-analyses versus narrative synthesis or meta-narratives), the analysis and synthesis of meta-analytic reviews is reported first (see Table
Effectiveness of SMIs by level and outcome of intervention (results based only on meta-analyses).
Intervention | Individual | Organisational | Mixed/unspecified | |||
Outcome | Individual | Organisational | Individual | Organisational | Individual | Organisational |
Parks and Steelman, 2008 | Outcome: absenteeism | |||||
Richardson and Rothstein, 2008 | CBT for overall psychological outcomes combined | Absenteeism | Organisational (support groups and participatory action groups) for psychological outcomes combined | Organisational support groups and participatory action groups for absenteeism | Stress | |
Bond et al., 2006 | More control lead to reduced absenteeism 4 studies | |||||
Marine et al., 2006 | Person-directed interventions versus control: | GHQ symptoms reduced following combination of knowledge skills training, programme planning | ||||
Van der Klink et al., 2001 | CBT on anxiety | CBT on absenteeism | Depression | Absenteeism | Anxiety | |
Saunders et al., 1996 | Performance anxiety | |||||
Penalba, McGuire, Leite, 2009 (electronic searches on 12/5/08 | One primary prevention study Backman (1997): mental imaging training versus control | |||||
SCL-90 depression subscale | Depression outcome: MD (fixed effect) −2.14, CI: −4 to −0.28 at end point (in favour of intervention) | |||||
Martin 2009 | Depression: SMD = Small but significant effect: | Single trial of stress management programme: depression: SMD = 0.69 | Depression: SMD:0.31, CI: 0.1–0.51 | |||
Conn 2009 | Unclear which studies that were reported contributed to the effect sizes, and whether they used individual or organisational interventions | Work attendance: | ||||
Van Wyk (2010) | Career identity training in one study does not improve anxiety in nurses: mean difference: −0.06, CI: −0.44 to 0.32 | Weir (1997) assessed effect of management intervention to improve process consultation between nurse managers and staff on mean hours absence of staff in a community hospital No difference: mean difference = 20.35, CI: −10.65 to 51.35 | ||||
Noordik (2010) | Effects on Anxiety |
KEY:
When intervention types are not specified the intervention summed in the respective cell are multiple and too many to list. Bold denotes a statistically significant outcome.
Studies of interventions reaching narrative conclusions without meta-analyses of effect sizes.
Outcome | Number of studies, date range, and key objective of review | MH ↑ | MH | MH | A↑ | A | A | Narrative conclusions |
---|---|---|---|---|---|---|---|---|
Egan et al., 2007 | 18 studies | 6 | 1 | 8 | 4 | 1 | Some evidence of improved mental health as employee control increases and, less consistently, when demands decrease | |
Lamontagne et al., 2007 | 90 studies | 1 | 20 | 8 | Individual focussed, low rates systems approaches are effective at the individual level on anxiety and depression | |||
The BOHRF, 2005 | 19 experimental studies | 4 | 3 | 1 | Early psychological interventions, including CBT and a range of stress management interventions, are effective for common mental health problems | |||
Edwards and Burnard, 2003 | 70 studies | 1 | 1 | Six stress management intervention studies in UK and one in The Netherlands show that training in behavioural techniques improved levels of sickness in psychiatric nurses. Levels of psychological distress reduced following a 15 week training course in therapeutic skills | ||||
Murphy, 1996 | 64 studies | CBT was more effective for psychological outcomes, | ||||||
Giga, 2003 | 16 studies | 1 | Programs that target the individual level were less likely to have an impact on organisational measures | |||||
Van der Hek and | 24 studies | 2 | It is impossible to recommend which techniques or interventions are most effective and should be recommended | |||||
Mimura and Griffiths, 2003 | 10 studies | 3 | More evidence for personal support rather than environmental management for workplace stress | |||||
Parkes and Sparkes, | 9 studies | 3 | 6 | Studies difficult to interpret showing ambiguous findings for impact of individual or organisational interventions | ||||
Michie and Williams, 2003 | 6 intervention studies | 1 | 2 | Interventions that improve psychological health and reduce sickness absence used training and organisational approaches to increase participation in decision making and problem solving, increasing support, feedback, and improved communication | ||||
Caulfield et al., 2004 | 6 interventions studies | 1 | Interventions have been primarily individually rather than organisationally focused. Only one was organisationally focused | |||||
Cancelliere et al., 2011 | 14 studies | 10 | 4 | Exercise is beneficial in improving presenteeism (not known which specific type of exercise) |
MH = mental health, including measures of depression, anxiety, stress, psychosomatic disorder and symptoms, psychiatric symptoms, GHQ; excluding emotional well being or not, and measures of capabilities.
A = absenteeism.
↑ evidence of improvement,
Including narrative reviews permitted evaluation of in-depth information that might be overlooked in meta-analytic reviews, as this information is important for constructing appropriate interventions and implementing them in order to prevent severe stress and anxiety and depression at work. For example, components of an appropriate organisational intervention will be difficult to capture in a meta-analytic review given these interventions will vary between organisations; only in-depth descriptions can capture the components that can then be considered for similar organisational contexts.
For meta-analyses, the effect sizes and original conclusions are presented, along with the outcomes used, where these were reported (Table
Judgements about the number of studies finding a positive, negative or no effect in the narrative synthesis were challenging, as many studies tended to use words such as stress, psychological distress, psychosomatic disorders interchangeably, and negative findings may not have been reported. We only rated studies as having effects on mental health (anxiety and depression), where it was clear they had used a specific measure of mental disorders or severe stress either alone or as part of a composite measure of mental health and well-being. Where there was doubt, we did not include the study in the data. This is an advance on existing reviews which tend to group all types of stress, including that associated with anxiety and depression, and other types of measures of stress such that the findings are interpreted with reference to a large number of emotional and health states. We felt this approach would not permit us to isolate the findings of relevance to the preventing common mental disorders which are the most important cause of sickness-related absenteeism.
Eleven reviews included meta-analyses [
As set out in Table
Six reviews included studies that looked
Eleven reviews [
Of these eleven reviews, six showed that
Four reviews found
The overall conclusions from the narrative reviews support the findings from the meta-analyses that individual interventions do provide benefit at an individual level and reduce symptoms of anxiety and depression and stress, but individual interventions do not impact on absenteeism. However, organisational interventions impact at both individual and organisational levels. There are numerous studies of benefit on mental health outcomes, whereas benefit on absenteeism is mainly reported in one review [
The different types and components of interventions, and whether they are primary, secondary, or tertiary preventive interventions, are set out in Table
Murphy [
As anticipated, the evidence was in complex form. Our methods of isolating findings related to anxiety and depression, and partitioning the tabulation and extraction and synthesis by individual/organisational interventions and outcomes provides a rich, complex but authentic picture of the evidence base. There are indications for which interventions are effective and also gaps in the evidence. Reviews had to take account of many interventions that differed by their components, mode of delivery and whether they targeted individuals or organisations. This made it difficult for all of the reviews to compare benefits from any single intervention across a number of studies, except for CBT or physical activity. There were also many different outcome measures for assessing anxiety and depression, and many proxy measures of mental health, sometimes without clarity about which outcomes were used in the meta-analyses. In part, these were not specified due to the way multiple outcomes were handled in the analysis. The reviews used standardised differences including mean differences and mean effect sizes, and standardised differences and means. Using a consistent set of outcomes to measure anxiety and depression in future primary studies will ensure that future reviews and meta-analyses can overcome these challenges, such that different intervention, of varying complexity and modes of delivery, might be compared more directly for impacts on absenteeism and on anxiety and depression and interactions between the individual and organisational impacts.
Overall, individual interventions show larger effects compared with organisational interventions or mixed interventions; benefits are seen mainly at the individual level although some studies do show organisational benefits. Given that anxiety and depression are common, and mostly account for sickness absence, it is important to develop an evidence base that is specific to these manifestations of mental distress and illness, with an agreed range of acceptable outcome measures and for interventions that prevent and treat anxiety and depression promptly, as well as encourage early return to work. A small improvement in sickness absence statistics might yield substantial benefits for business viability and provision of services. Standardised methods to measure presenteeism [
Management skills training, and support for staff, along with methods to cope with work stress all seem relevant components, but the review was not convincing about a positive benefit of these and where positive impacts were seen at individual levels [
This review suggests that there is lack of evidence in comparing the relative effectiveness of stress management interventions that operate at both individual and organisational levels, or interventions that encourage an interactive or systemic effect, yet this might yield greater benefits at both levels.
However, there are still a number of evidence gaps. More research is needed in the private sector and in smaller companies as well as research comparing different job types such as education and healthcare to examine whether they respond to the same or different intervention techniques. Similarly, research needs to take into account factors such as socioeconomic status, duration of any effects of interventions, and cost effectiveness. Selection bias may be an important explanation for our findings. For example, organisations with the most stressful work environments are less likely to participate in research as opposed to organisations with little stress amongst employees. Consequently, organisations with low baseline stress levels would make any effects from targeted interventions more difficult to capture. However, preliminary support was found in one meta-analytic review that interventions conducted with employees at high levels of baseline stress appeared to be at least as effective as interventions conducted with employees at low levels of baseline stress [
Finally, there is a relative lack of studies with clinically referred employees. We did find more of these in more recent years (since 2008) and also reviews of health care workers and law enforcement officers who perhaps need specific attention given the unique circumstances and stressors to which they are exposed at work. The few methodologically rigorous studies that have been conducted with patients have not included
CBT was the most effective individual targeted intervention for individual outcomes. Encouragement of physical activity at an organisational level seems to reduce absenteeism. Interventions need to be developed that can provide consistent and stronger effects on organisational outcomes such as absenteeism. There were a number of gaps in the literature, particularly studies investigating the influence of specific occupations, and different sized organisations, different sectors of organisations (public, private, and not for profit). Studies of management practices seemed not to show strong effects, but there are still insufficient studies in this area. There were few studies of secondary and tertiary prevention.
The authors declare that they have no conflict of interests.
K. S. Bhui conceived of the study, was the principal investigator, provided day-to-day management, and along with SD read the reviews, extracted and tabulated the data and codrafted the paper. S. A. Stansfeld and P. D. White were the coinvestigators to the project, and commented on and edited all drafts of the paper. All authors contributed equally to this work.
This work was supported by the Department of Health in UK to K. S. Bhui.