Francisca Azocar, PhD

[[{"type":"media","view_mode":"media_crop","fid":"39893","attributes":{"alt":"workers with depression, Â© D13/SHUTTERSTOCK.COM","class":"media-image media-image-right","id":"media_crop_9475397464962","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4027","media_crop_rotate":"0","media_crop_scale_h":"99","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© D13/SHUTTERSTOCK.COM","typeof":"foaf:Image"}}]]Depression is a personal nightmare and a pervasive public health problem. Adults with depression have higher than average rates of job loss, job turnover, premature retirement, work absences, and impaired work performance. The associated costs reach into the billions of dollars annually. In the US, 

 in the number of disability-adjusted life years lost due to illness and costs an estimated $44 billion annually in lost work productivity.

Earlier trials have contributed to the evidence base on high-quality depression treatment, documenting its impact on symptom relief and subsequent reduction in absenteeism and presenteeism (at-work performance deficits).

 However, even if high-quality medical care were available to all working-age adults with depression, evidence from the mental health, disability and rehabilitation, and occupational medicine research fields indicates that employment problems often persist. Although treatment improves depression symptoms for many patients, it may not be sufficient to restore the ability to work; residual functional limitations may continue to interfere with work.

A series of federally sponsored studies have contributed to the development and testing of a new work-focused intervention (WFI) approach.

 Funded by the National Institute on Aging, our most recent multisite, randomized, controlled trial involved middle-aged and older adults with depression who were already experiencing work limitations.

 The patients in the study also may have been especially vulnerable to poor work outcomes because of health problems. The primary aim of the trial was to compare the effectiveness of the WFI with that of usual care for improving ability to function effectively at work. The secondary aim was to reduce work absences and improve depression symptom severity.

Workers aged 45 years and older participated in voluntary, privacy-protected, Web-based screenings for depression and for depression-related work limitations. Those who screened positive for depression and work limitations were randomly assigned to the WFI or to usual care (referral to a health care professional and an employee assistance plan). Participants randomized to WFI were provided up to 8 biweekly 50-minute telephone sessions for 4 months with a master’s-level clinician specially trained in this care model.

The WFI consists of a 3-part program that stresses coordinating the employee’s regular medical treatment with the program’s functional improvement goal; teaches strategies for coping with thoughts, feelings, and behaviors that interfere with work; and guides employees to make changes to work routines or work conditions to improve effectiveness. WFI care is customized to each employee’s unique work situation and work challenges extending beyond alleviating depression symptoms.

Four months after the intervention, the 380 study participants completed assessment interviews and questionnaires. The baseline to follow-up change in at-work productivity loss score (presenteeism) was the primary end point. Measured with the validated Work Limitations Questionnaire,

 productivity loss reflects the estimated percentage difference in at-work productivity between a person (or group) and an external benchmark sample of healthy workers (range = 0% to 27%; a higher score indicates more at-work productivity loss). Secondary measures included the baseline to follow-up change in health-related absenteeism and the Patient Health Questionnaire-9 depression severity score.

The WFI group saw a 44% improvement in their at-work productivity compared with a 13% improvement in the usual-care group. Absence days declined by 53% in the WFI group compared with 13% in the usual-care group. WFI participants also experienced a significant improvement in depression symptoms compared with the usual-care group (51% for WFI vs 26% for usual care). A preliminary analysis of the benefit to cost ratio suggests significant annual employer cost savings related to restored work productivity per dollar spent on WFI care.

Because many health problems can temporarily or permanently damage a person’s ability to participate fully and productively in employment, helping those who want and/or need to work is part of providing comprehensive, patient-centered care. Although work exerts a major influence on the quality of our lives and the economic health of nations, recovery of work function has not been given the attention it deserves in either research or clinical practice.

The evidence-based approach of the WFI to improving the functional outcomes of employees with depression offers a relatively low-cost solution to helping patients remain independent and productive. The WFI can contribute to a health care system that is struggling to be patient-centered, sensitive to the preferences of key stakeholders, and capable of delivering value.

The WFI reduced the burden of depression on working adults to a degree that surpassed results obtained in studies of 

 Results are also likely to interest many employers who prefer to invest in treatments that deliver value (such as improved work performance) over those that simply cost less. The results should be a source of optimism for the many health care providers who have felt frustrated in their ability to help patients cope with difficult work problems.

The 37% remission rate achieved with the WFI closely parallels the 37% rate of Step 1 of acute phase treatment from the STAR*D trial.

 The study also gives support to the role of technology-enabled methods in care. Both telephonic counseling and Web-based screening were fundamental to the success of the WFI. However, while the WFI was accessed primarily through the workplace, it could be accessed from an employee’s home, a computer in a physician’s office, or a clinical Web site, potentially reaching many more individuals.

Dr Adler is Professor of Psychiatry and Medicine at Tufts University School of Medicine and Senior Research Scientist, Senior Psychiatrist at Tufts Medical Center, Boston. Dr Lerner is Professor of Psychiatry and Medicine at Tufts University School of Medicine and Director of the Program on Health, Work and Productivity at Tufts Medical Center. Dr Azocar is Vice President of Research and Evaluation for Behavioral Health Sciences at OptumHealth in San Francisco. Dr Adler and Dr Lerner report that they have received funding from the National Institute on Aging, the National Institute of Mental Health, and the Centers for Disease Control and Prevention as co-investigators on studies that have led to the development of the work-focused intervention. Dr Azocar reports that she is an employee of Optum, a fully owned subsidiary of UnitedHealth Group (UHG), where the work-focused intervention study was implemented. Dr Azocar receives a salary from Optum, and she invests in UHG’s Employee Stock Purchase Program.

 Murray CJ, Lopez AD. Measuring the global burden of disease. 

 Stewart WF, Ricci JA, Chee E, et al. Cost of lost productive work time among US workers with depression [published correction appears in JAMA. 2003;290:2218]. 

 Rost K, Smith JL, Dickinson M. The effect of improving primary care depression management on employee absenteeism and productivity: a randomized trial. 

 Schoenbaum M, UnÃ¼tzer J, McCaffrey D, et al. The effects of primary care depression treatment on patients’ clinical status and employment. 

 Lerner D, Adler D, Hermann RC, et al. Impact of a work-focused intervention on the productivity and symptoms of employees with depression. 

 Lerner D, Adler DA, Rogers WH, et al. A randomized clinical trial of a telephone depression intervention to reduce employee presenteeism and absenteeism. 

 Lerner D, Amick BC 3rd, Rogers WH, et al. The Work Limitations Questionnaire. 

 Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial. 

 Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. 

Articles

In the US, depression ranks fifth in the number of disability-adjusted life years lost due to illness and employment problems often persist, even if help is sought. Helping those who want and/or need to work is part of providing comprehensive, patient-centered care. 

Francisca Azocar, PhD

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Intervention Helps Workers With Depression