Journal of Occupational Rehabilitation (2018) 28:452–464

https://doi.org/10.1007/s10926-017-9743-9

REVIEW

Work Participation Among Employees with Common Mental

Disorders: A Meta-synthesis
Cecilie Nørby Thisted1 · Claus Vinther Nielsen2 · Merete Bjerrum1

Published online: 12 December 2017

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Purpose The aim was to aggregate knowledge about the opportunities, challenges and need for support employees with
common mental disorders experience in relation to work participation in order to develop recommendations for practice.
Methods A meta-synthesis was conducted using a meta-aggregative approach to accurately and reliably present findings
that could be used to meet our aim. Qualitative inductive content analysis was used to analyze and synthesize the findings.
Results In all, 252 findings were extracted from 16 papers, and six categories were generated and aggregated into two syn-
thesized findings. One synthesized finding indicates that a strong work identity and negative perceptions regarding mental
disorders can impede work participation, creating an essential need for a supportive work environment. The other reveals
that the diffuse nature of the symptoms of mental disorders causes instability in life and loss of control, but through the use
of internal motivation and external support, employees may be able to regain control of their lives. However, external sup-
port is hampered by insufficient cooperation and coordination between vocational stakeholders. Conclusions Based on the
synthesized findings, we recommended that the employer is involved in the rehabilitation process, and that rehabilitation
professionals seek to strengthen the employee’s ability to manage work-related stress. In addition, rehabilitation professionals
should provide individualized and active support and ensure meaningful cooperation across the multidisciplinary disciplines
involved in the rehabilitation process.

Keywords Mental disorders · Vocational rehabilitation · Return to work · Review · Qualitative research

Introduction Globally, 29.2% of the population will suffer from a

CMD at some time during their lifetimes [8]. CMDs include
Work participation (WP) among people with common men- depression and anxiety as the most frequent disorders [9],
tal disorders (CMDs) is threatened because of absenteeism but other mental disorders, such as obsessive-compulsive
and inability to work fulltime [1–6]. Work disability due to disorder, adjustment disorders and mental health problems,
mental disorders is costly for society [2] and often has nega- e.g., burnout and exhaustion, can be included [6, 10–12].
tive individual consequences because work is a central factor People with a CMD suffer from symptoms related to
in identity and social status and contributes to independence emotions, cognitions and behavior [13, 14], and they are
and meaning in life [7]. often limited in their psychosocial functioning [15]. Specific
challenges relate to WP. Current research has identified the
Electronic supplementary material The online version of this symptoms and severity of CMDs [16–18], coping problems
article (https://doi.org/10.1007/s10926-017-9743-9) contains [18], stigma [19] and low social support from employer and
supplementary material, which is available to authorized users. colleagues [17–19] as barriers for WP.
Addressing the burden of mental disorders, WHO has
* Cecilie Nørby Thisted
cnth@ph.au.dk stressed the need for effective interventions [13, 20], and
OECD calls for preventing instead of reacting to problems
1
Department of Public Health, Section of Nursing, Aarhus arising from poor mental health [1, 21–23]. Effective work
University, Bartholins Allé 2, 3., 8000 Aarhus C, Denmark disability interventions should take personal and environ-
2
Section of Clinical Social Medicine and Rehabilitation, mental factors into account [21, 24–26]. Additionally, the
Department of Public Health, Aarhus University, Aarhus, International Classification of Functioning, Disability and
Denmark

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Vol:.(1234567890)
Journal of Occupational Rehabilitation (2018) 28:452–464 453

Health (ICF) has relevance in relation to WP, emphasizing complies with the need for early interventions [2, 21]. By
that the decision to stay at work or stop working is affected clarifying the perspectives of employees with CMDs and
by personal factors, e.g., coping; disorder-related factors, their experiences with WP, it may be possible to develop
e.g., severity of symptoms; and environmental factors, e.g., useful recommendations that meet their need for support
the workplace [27, 28]. Loisel et al. [24] make clear that the related to WP.
effectiveness of efforts to combat work disability is contin- This meta-synthesis aims to aggregate knowledge about
gent upon a comprehensive analysis of opportunities related the opportunities, challenges and need for support employ-
to WP and obstacles present in the work system, and if pos- ees with CMDs experience in relation to WP to develop
sible, the external context in which the practices evolve. recommendations for practice.
A range of interventions aimed at helping employees
with mental disorders has been practiced and evaluated
with mainly quantitative methods [21, 29–33]. Reviews Methods
reveal inconsistent results regarding the effectiveness of the
interventions, but stress the importance of early and mul- Design
tidisciplinary interventions [21, 30, 32]. However, quanti-
tative methods cannot provide in-depth understanding of The meta-synthesis was conducted using a meta-aggre-
the employees’ experiences related to WP or of the specific gative approach in accordance with Joanna Briggs Insti-
circumstances affecting the success of interventions [34, tute’s (JBI) approach to qualitative systematic review, i.e.
35]. To complement this quantitative evidence, knowledge to accurately and reliably present the findings of included
is needed regarding meaningfulness that provides in-depth studies as intended by the original authors [36, 42, 43].
understanding of the challenges and opportunities employ- Meta-aggregation allows capturing the complexity of WP
ees with CMDs experience in relation to WP [35, 36]. The among employees with CMDs, highlighting the influence
question is how employees with CMDs can be supported of personal and environmental factors, and not least, intends
in order to promote their WP and to prevent future work to guide stakeholders at all levels. PICo was used to clarify
absences related to mental disorders. Qualitative studies find the Population (P), the phenomena of Interest (I), and the
that support from the employer and adaptive coping ability Context (Co) guiding the clarification of inclusion criteria
can enhance WP [16, 37, 38]. The aggregation of qualita- ensuring identification of all relevant studies [42].
tive evidence on WP of employees with CMDs is needed to The meta-synthesis was conducted in six steps: (1) review
provide evidence-based recommendations that correspond to questions, (2) inclusion and exclusion criteria, (3) compre-
their needs. Furthermore, this approach respond to the need hensive literature search, (4) critical appraisal, (5) data
for narrowing the gap between scientific insights and prac- extraction and (6) categorizing and synthesizing [44].
tice because the implementation of vocational rehabilitation The aim was operationalized in the following three review
practices seems to be hampered by difficulties in translating questions: (a) which opportunities related to WP do employ-
research findings into practice [32]. ees with CMDs experience?: (b) which challenges related
A preliminary search in PubMed, CINAHL and the to WP do employees with CMDs experience?: and (c) what
Cochrane Library revealed that a meta-synthesis on employ- is their need for support related to WP? These questions
ees with CMDs and WP, broadly conceptualized, has not yet are explicitly used in the data extraction to ensure that the
been conducted, but two meta-ethnographic reviews on simi- extracted findings provide knowledge that can be used to
lar thematic topics were identified. Andersen et al. [11] per- meet the overall aim of our study.
form a meta-ethnography on CMDs that focused on return
to work (RTW), and Kinn et al. [39] explored how people Inclusion Criteria
with psychiatric disabilities, including severe mental disor-
ders, dealt with WP. Andersen et al. [11] identify obstacles Qualitative studies published in English, Swedish, Norwe-
and facilitators related to the employee’s personalities, social gian or Danish were included if they meet the following
support, and the social and rehabilitation systems through criteria: included (P) employees (18–65 years) with CMDs;
reinterpretation of findings. Kinn et al. [39] develop themes in accordance with DSM-IV-TR [45] and ICD-10 [14],
describing facilitators of and impediments to working, e.g., the diagnostic criteria included were: depression (DSM:
social cohesion, environmental factors and disclosure. In 296.20–296.26, 296.30–296.36, 311; ICD-10: F32.0–F33.9),
contrast to these reviews, the present meta-synthesis con- anxiety disorders (DSM: 300–300.02, 300.09, 300.22,
ceptualizes WP broadly, focusing on employees with CMDs 300.23, 300.29; ICD-10: F40–F41), obsessive-compulsive
at work, on sick leave or in a RTW process; thus, WP is not disorder (DSM: 300.3; ICD-10: F42), stress-related dis-
limited to RTW. This is pertinent given the recurring nature orders including acute stress reaction and adjustment dis-
of CMDs and associated work absences [6, 40, 41], which orders (DSM: 308.3, 309.81, 309.9, 309.24, 309.0, 309.3,

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454 Journal of Occupational Rehabilitation (2018) 28:452–464

309.4, 309.28, 309.89, 309.9; ICD-10: F43); mental health searched for additional papers. If further data in relevant
problems including stress, psychological distress, burn- papers were needed, CNT contacted the first author [47]
out, depressive symptoms and exhaustion. Studies with by mail.
participants with a comorbid mental health condition were
included if at least one of the above-mentioned mental health Critical Appraisal
problems was present. Furthermore, the included studies
should focus on the participants’ (I) experienced opportuni- The methodological quality of relevant papers was evalu-
ties, challenges and need for support related to WP in the ated using the standardized appraisal checklist from the JBI
(Co) context of work life. Qualitative Assessment and Review Instrument (QARI) [42,
48]. The QARI checklist consists of ten criteria that can be
Exclusion Criteria scored as being met, not met or unclear [42]. The criteria
focus on congruity addressing aspects of validity in qualita-
Studies were excluded if they dealt with severe mental dis- tive research reports [48]. CNT and MB conducted the criti-
orders (e.g., bipolar), war veterans, comorbid physical con- cal assessment independently and discussed the appraisals
ditions or substance abuse. Studies were excluded if only until consensus was reached.
other stakeholders were interviewed, e.g., employers, and if
the perspectives of other stakeholders were entwined with Data Extraction
the perspective of employees with CMDs in the analysis.
Studies that exclusively included unemployed or participants Firstly, studies’ characteristics regarding country, aim,
in costumed employment settings focusing on labor market design, participants and context were extracted. Secondly,
integration were also excluded. findings were extracted using the three review questions.
A finding is defined as an author’s statement or a text that
Search Strategy identified categories, themes, sub-themes or text concern-
ing themes. An illustration is defined as a direct quotation
A three-step search strategy was utilized [42]. The search of a participant’s voice or other supporting data such as in-
strategy was developed in cooperation with a specialized depth descriptions [42]. CNT performed the data extrac-
research librarian from Aarhus University Library, Depart- tion through repeated and in-depth reading of each included
ment of Psychiatric Research. paper in light of the three review questions, ensuring valid
Firstly, an initial search in PubMed and Scopus was answers to the study aim. Extracted findings were assigned
undertaken to identify relevant search terms, followed by a level of credibility based on supporting illustrations: une-
an analysis of the text words contained in titles, abstracts and quivocal (U); a finding beyond reasonable doubt; credible
index terms. Systematic reviews on WP and/or CMDs were (C); a finding with an illustration lacking clear association;
consulted [17, 30]. Search terms on qualitative research were and unsupported (NS), a finding not supported by illustra-
identified through a database containing database-specific tions [42]. Only unequivocal and credible findings were
search filters for qualitative research [46]. All relevant search included in the analysis to ensure an acceptable confidence
terms were divided into clusters. level in the recommendations for practice. The extractions
Secondly, a comprehensive search was undertaken in six were discussed with MB and CVN.
databases: PubMed, Embase, PsycINFO, SveMed+, Socio-
logical Abstracts and CINAHL. Databases were selected to Categorizing and Synthesizing
cover the medical, social, psychological, and public health
perspectives of employees with CMDs. The final search The extracted findings were analyzed using qualitative
strategy included search terms related to: (1) CMDs, e.g., inductive content analysis [49–51], an open and systematic
mental disorder; (2) WP, e.g., absenteeism; and (3) qualita- approach that allows the identification and aggregation of
tive research, e.g., qualitative, because this strategy has the descriptive categories among the findings and generates
potential to capture studies on the experiences of employees explanatory synthesized findings across the categorized
with CMDs in relation to WP. The use of controlled vocab- findings.
ulary terms and/or free text search was database-specific. Firstly, findings were analyzed according to their sim-
Databases were searched from their inception to September ilarity in meaning in order to develop categories. Sec-
19, 2016. The detailed search strategy in PubMed is pre- ondly, two or more categories were combined to synthe-
sented in Online Resource 1. sized findings through repeated reading of the categorized
Thirdly, the reference list of papers included after title and findings, ensuring similarity in meaning. Clarifying the
abstract screening and key references in the meta-ethnogra- practical value of synthesized findings, recommendations
phies by Kinn et al. [39] and Andersen et al. [11] were hand for practice were formulated based on each synthesized

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Journal of Occupational Rehabilitation (2018) 28:452–464 455

finding [52]. MB and CVN both took part in the analyti- Methodological Quality of Studies
cal process, ensuring validity and reliability of findings,
categories and synthesized findings. To establish confi- The 16 included papers met a minimum of seven of the
dence in the synthesized findings, an overall ranking was assessment criteria (Table 1); thus, they were all considered
conducted using the ConQual approach, which served as to have high methodological quality. Therefore, all critically
a practical tool to assist in decision-making [53]. appraised papers were included in the synthesis.

Description of Papers

Results The main characteristics of the included studies are pre-

sented in Online Resource 2. Six studies were conducted
Study Selection in Sweden [38, 54–57, 65], three in the UK [19, 58, 59],
three in Denmark [10, 23, 60], two in Canada [37, 61] and
A total of 4832 papers were identified through the system- two in the Netherlands [16, 62]. Five studies used grounded
atic search; 32 duplicates were removed. A hand search theory [23, 38, 61, 62, 65], two used an approach based on
resulted in three additional papers. A total of 4803 papers grounded theory [16, 60], three used interpretive phenom-
were screened by title and abstract; 38 were retrieved full- enological analysis [10, 19, 58], two performed qualitative
text, of which 22 were excluded, mainly because stud- content analysis [55, 56], one used descriptive interpretive
ies did not responded to the diagnostic criteria. In total, analysis [37], one used a narrative approach [57], one used a
16 papers matched inclusion criteria and were critically focus group study design [54], and one performed a qualita-
appraised. The flow diagram (Fig. 1) illustrates the selec- tive realistic evaluation [59]. Fifteen studies were based on
tion process. individual interviews [10, 16, 19, 23, 37, 38, 55–62, 65],
and one was based on focus group interviews [54]. In total,

Fig. 1  Flow diagram

Records identified through Additional records identified
Idenficaon

database searching through other sources

(n=4832) (n=3)

Records after duplicates removed

(n=4803)
Screening

Records screened Records excluded

(n=4803) (n=4765)

Full-text articles Full-text articles

assessed for eligibility excluded, with reasons
Eligibility

(n = 38) (n=22)

Studies assessed for

methodological quality
(n=16)
Included

Studies included in
meta-synthesis
(n=16)

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456 Journal of Occupational Rehabilitation (2018) 28:452–464

Table 1  Critical appraisal Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Andersen et al. [10] Y Y Y Y Y Y Y Y Y Y

Corbière et al. [37] Y Y Y Y Y Y Y Y Y Y
Cowls and Galloway [61] Y Y Y Y Y Y Y Y Y Y
Eriksson et al. [65] U Y Y Y Y Y N Y Y Y
Hjarsbech et al. [23] Y Y Y Y Y Y Y Y Y Y
Holmgren and Ivanoff [54] N Y Y Y Y U Y Y Y Y
Jansson et al. [55] Y Y Y Y Y Y Y Y Y Y
Millward et al. [58] Y Y Y Y Y Y Y Y Y Y
Nielsen et al. [60] Y Y Y Y Y Y Y Y Y Y
Noordik et al. [16] N Y Y N N Y Y Y Y Y
Norlund et al. [38] Y Y Y Y Y Y Y Y Y Y
Pittam et al. [59] Y Y Y Y Y Y Y Y Y Y
Sallis and Birkin [19] Y Y Y Y Y Y U Y Y Y
Sandmark and Renstig [56] Y Y Y Y Y Y Y Y Y Y
Ståhl et al. [57] Y Y Y Y Y Y N Y Y Y
Verdonk et al. [62] Y Y Y U Y Y Y Y N Y

Y yes, N no, U unclear

the studies contain findings based on 272 employees: 199 unsupportive work environment. The categories are based on
women and 48 men (one study did not report gender [61]). In findings providing knowledge about the challenges, oppor-
13 studies, all the employees had been or were on sick leave tunities or need for support that employees with CMDs
when interviewed [10, 12, 16, 19, 37, 38, 54, 56–58, 61, 62, experience related to WP; thus, the categories summarize
65]. One study included employees at work [23], while two the meaning of the findings of content to further establish
studies included employees at work and on sick leave [55, explanatory synthesized findings that correspond to the over-
59]. Four studies did not report employees’ educational level all aim of the study.
or occupation [19, 55, 58, 59], two studies included women
with higher education and/or white-collar jobs [56, 62], and Handling Work Tasks and Demands
most employees in the rest of the studies had a middle to
long education [16, 23, 37, 38, 54, 60, 65]. The majority Discrepancies between personal factors, e.g., values and
were employed in the public sector in various occupations competencies, and work tasks and demands can present a
[10, 23, 37, 38, 57, 61, 65]. barrier to WP. Difficulties handling work tasks and demands
Eight studies focused on RTW [10, 16, 38, 54, 57, 59–61], are often paired with personal factors.
four of which were performed in close relation to a RTW Difficulties handling a heavy work load can impede WP
intervention [10, 54, 59, 61]; three studies focused on the and disrupt private life [16, 19, 23, 37, 54–56, 60, 62, 65].
period prior to sick leave [37, 56, 65]; three studies focused Additionally, perfectionism and a strong work identity make
on the period of sick leave [19, 58, 62]; one study focused it difficult to set limits, e.g., decline to perform work tasks
on coping with CMDs at work [23]; and one study focus on when time is short [16, 23, 37, 56, 57, 60, 61]. Perfectionism
the impact of intervention practices on work ability [55]. was a common trait among female employees with CMDs
and might be associated with to a gender-related understand-
Categories ing of the roles they had been raised to fulfill as both women
and as good workers [56, 60]. Struggling with a threatened
In all, 252 findings were extracted of which five findings work identity and trying to maintain a certain self-image, the
were not supported, i.e. five findings were assigned a poor employees might refrain from adjusting their limited work
level of credibility, and therefore not included in the pro- capacity to meet work demands.
cess of categorizing and synthesizing. The inductive con- Problems encountered at work are often paired with
tent analysis of the 247 supported findings revealed six cat- personal problems and characteristics, inducing a dynamic
egories: (1) handling work tasks and demands; (2) facing tension that influences the way the employees handle their
unpredictability and disability; (3) prejudices and negative work tasks and demands [60]. Supporting this statement,
perceptions; (4) readiness for change; (5) need for support one article on female white-collar employees reported that
from professionals and like-minded; and (6) troubled by an some are high-achievers in every aspect of life, which led

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Journal of Occupational Rehabilitation (2018) 28:452–464 457

to a feeling of being overloaded and finally the inability to reinforcing feelings of blame and guilt, thus impeding their
complete work tasks and stay at work [56]. WP.

Readiness for Change

Facing Unpredictability and Disability
Being ready for change and a willingness to utilize healthy
The diffuse and fluctuating nature of symptoms make it dif- strategies are of great importance for WP, and this is
ficult to stay at work and plan for the future, e.g., when to expressed through different strategies related to staying at
RTW. work, going on sick leave or RTW.
Seven studies reported that the employees experience Withdrawal from work can give time to reflect and
difficulties related to interpreting and understanding their regain strength [59, 60, 62, 65], but distancing oneself
mental health symptoms [10, 19, 37, 57, 58, 60, 65]. Some from a sick role can also provide opportunities for WP [19,
employees confuse their symptoms of mental disorders with 57, 58]. Whether employees with CMDs decide to stay
other diseases [37, 65], which can lead to a delay in the at work, go on sick leave or RTW, it appears that being
provision of active treatment and symptom deterioration conscious about personal needs and reacting to them cre-
and may result in long-term sick leave. Understanding the ates opportunities for WP. This implies recapturing control
impact of the symptoms of mental disorders on work abil- over the situation, expressed through different strategies
ity is perceived as being difficult because of the fluctuating including focusing on self-care and leisure [61]; making
and diffuse nature of the symptoms. Some employees are meaningful changes in daily routines, e.g., exercising
troubled by being unable to provide objective proof of their and eating regularly [55]; using sick leave as a preven-
disorder, and this makes them uncertain about the serious- tive act [60]; regaining a sense of a capable self [60] and
ness of their disorder and chances for recovery [10, 55, 57, strengthening their ability to manage work-related stress
58]. One study emphasized that the perceived nature of their [59, 60]. Additionally, work attitude and motivation among
symptoms complicated planning the future [58], e.g., when employees with CMDs appear to be important personal
to RTW, which left them with a feeling of loss of control ingredients in their readiness for change [58]. Some pos-
over themselves and their work situation. ses a positive work attitude and motivation for WP, while
others experience a need for external support to promote
their inner strength in order to stay at work or RTW [54].
Prejudices and Negative Perceptions

Employees have prejudices and negative perceptions regard- Need for Support from Professionals and Like‑Minded
ing mental disorders that make it difficult to accept and dis-
close symptoms of mental disorders, which inhibits WP. Individualized professional support and being with like-
This is expressed through different strategies and fears, minded people is considered valuable, although some fear
e.g., denying symptoms and fear of being perceived as a being retained in a sick role.
weak person or a burden to the workplace. Being in denial is Ten articles report that active support from rehabili-
expressed in different ways, e.g., ignoring symptoms, insist- tation professionals is valuable [10, 16, 19, 38, 55–57,
ing on going to work and refusing to accept the diagnosis of 60–62]. Employees involved in structured WP interven-
a mental disorder due to pride or prejudice [19, 37, 57, 65]. tions express that trust, i.e. being focused on as a unique
Fears related to disclosure, e.g., not being believed because person and feeling understood, is an important factor for
of the physical invisibility of the symptoms of mental disor- successful treatment promoting WP [10, 55, 56]. Their
ders, being labeled by colleagues and employers and having need for support is emotional, e.g., feeling understood and
their work identity damaged, make them distance themselves practical, e.g., need for professionals to take responsibility
from their disorder and avoid disclosure [19, 37, 57, 60]. in the rehabilitation process [38]. Emotional support can
Some employees are troubled by feelings of blame and also be gained from being with like-minded people, e.g.,
guilt for becoming ill and going on sick leave [10, 57, 60, 62, in group therapy [10, 54, 55, 60], although it might also
65]. They feel guilty about receiving sickness benefits [57] hamper WP through enforcement of a sick role [58]. Sup-
or becoming a burden to their employer [54] or colleagues port from family and friends is rarely mentioned, and one
who have to take over their duties [60]. They blame them- study reports it to be of minor importance for WP [38].
selves for becoming sick and perceive their sick leave as a Cooperation and coordination between rehabilitation
failure [57, 62, 65] because they are unable to fulfill their stakeholders, e.g., health professionals and employers, is
perception of a successful employee. They perceive their considered valuable, although some find it insufficient as
sick leave as a failure and as a threat to their work identity, a factor to promote WP [10, 16].

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458 Journal of Occupational Rehabilitation (2018) 28:452–464

Troubled by an Unsupportive Work Environment categories were aggregated into two explanatory synthesized
findings: (1) need for acceptance and recognition to ease a
Feeling unsupported by workplace organizational structures threatened work identity, and (2) taking control by means of
and workplace relations can hinder WP. motivation and support. The first synthesis underlines that
Organizational structures are important for establishing a a strong work identity and negative perceptions regarding
supportive work environment [19, 23, 37, 38, 54–56, 59, 65]. mental disorders can impede WP, creating an essential need
WP is especially impacted by organizational changes when for a supportive work environment. The second synthesis
decision-making moves further away from the employee, emphasizes that taking control provides opportunities for
which can lead to lack of information [55], low job satisfac- WP, and that control can be gained through internal moti-
tion [19] and low ability to influence the work situation [54]. vation and external support. An example of the process of
Most of the employees in the reviewed articles were public categorizing and synthesizing is presented in Table 2.
sector employees who are seemly more exposed to organi-
zational problems, e.g., cutbacks and reorganizations, than Need for Acceptance and Recognition to Ease
private sector employees [65]. There is a need for organi- a Threatened Work Identity
zational structure and a certainty of what is required [54];
thus, a stable and supportive work environment can create This synthesis was aggregated from three categories, “Han-
opportunities for WP. dling work tasks and demands”, “Prejudices and negative
Furthermore, all studies contain evidence regarding the perceptions” and “Troubled by an unsupportive work envi-
importance of supportive workplace relations. A unsupport- ronment”, which illustrate that the need for acceptance and
ive employer can be a great challenge for WP [19, 23, 38, recognition appears to be due to a work identity threatened
54–57, 59, 61, 62, 65]. Lack of recognition and appreciation by mental symptoms. Personal factors and the work environ-
can lead to a lack of faith in one’s own competencies and ment are found to be of importance for WP. These contextual
diminished self-esteem [54, 65]. Poor collegial relationships factors are captured in the ICF [29], forming a useful frame-
can result in distrust and insecurity [23, 37], while support- work for understanding the interaction between contextual
ive workplace relations provide emotional support, buffer- factors and work disability [64, 66, 67]. In concordance with
ing the risk of work disability [23, 37, 65]. Acceptance and these concepts, one study finds that work factors, e.g., high
recognition from the workplace are needed to ameliorate a job-related stress, reorganizational stress and social status,
threatened work identity, which may motivate the employee prevent RTW, but that demographics, including material
to stay at work or RTW. status, age, gender and education also influence WP [68].
Interestingly, a study [69] reports that factors impacting
WP among employees with mental disorders are mainly
Discussion personal, e.g., older age; gender or environmental, e.g.,
changing work tasks, and concluded that factors related to
The aim was to aggregate knowledge about the opportuni- mental health, e.g., symptoms, seem to play a minor role for
ties, challenges and need for support employees with CMDs long-term disability.
experience in relation to WP to develop recommendations Prejudices and negative perceptions regarding CMDs can
for practice (an overview of the phases of the meta-aggre- prevent employees disclosing that they have a mental health
gative approach enhancing the reliability of the meta-syn- problem, thereby constituting a barrier to WP. In agreement
thesis [36, 63] is presented in Online Resource 3). The six with this, Brohan et al. [70] report reasons for nondisclosure,

Table 2  An example of the process of categorizing and synthesizing

Findings Categories Synthesized finding

Some people had no plans for the future owing to Facing unpredictability and disability Taking control by means of motivation and support
fluctuating symptom severity. These people were
unable to think of their future past their illness
(…) [58] (p. 568). (U)
Sickness absence also gave them an opportunity Readiness for change
to wind down. For some of them it marked the
beginning of a much-longed-for change in their
lives [65] (p. 628). (U)
Alan found Cognitive Behavioural Therapy Need for support from professionals
provided him with strategies to perform more and like-minded
effectively at work [19] (p. 474). (C)

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Journal of Occupational Rehabilitation (2018) 28:452–464 459

e.g., fear of being treated differently and stigmatized in the jobs, indicating that they might experience other challenges
workplace; thus, nondisclosure by employees of their mental than lower educated, e.g., difficulties setting limits. The
health problems at the workplace may be a feature of their employees in the included studies were mostly women with
mental disorder [70, 71]. Additionally, the synthesis relates a moderate or long education and findings may therefore be
to the comprehensive literature on stigma associated with transferred to similar groups.
mental disorders and acknowledges that stigma as an impor- Nine of the included studies were conducted in Sweden
tant barrier for help-seeking and disclosure [70, 72–74]. This and Denmark [10, 23, 38, 54–57, 60, 65], which could have
stigma can be a personal factor, captured as self-stigma [75, influenced the experienced challenges, opportunities and
76], and an environmental factor, e.g., where the environ- need for support. In this regard, the welfare system may play
ment perceives mental illness as a weakness of character a role because the high educational level of the employees
[77]; thus, stigma might impede potential acceptance and might imply that they were used to and took pride in caring
recognition from oneself and the workplace. In agreement for themselves, reinforcing the feeling of guilt for going on
with our findings, a number of studies find that a support- sick leave and receiving sickness benefits.
ive employer can provide opportunities for WP [78–81],
but employers appear to have negative perceptions regard- Taking Control by Means of Motivation and Support
ing CMDs [70, 71]. Since the employer’s attitude highly
influences workplace culture [71], the employer may have This synthesis was aggregated from three categories, “Fac-
a key role in providing a supportive work environment that ing unpredictability and disability”, “Readiness for change”
meets the employees’ need for acceptance and recognition. and “Need for support from professionals and like-minded”.
Additionally, a Swedish study [82] finds that employers tend This synthesis reveals that the diffuse nature of the symp-
to engage in WP activities depending on how valued sick- toms of mental disorders cause instability in life and loss of
listed employees are considered to be to their business, and control, but through the use of internal motivation and exter-
on the nature of the job, e.g., availability of suitable work nal support, employees with CMDs may be able to regain
adjustments, indicating that acceptance and recognition from control of their lives. Findings suggest that sick leave can
the employer might differ according to employee’s occupa- be a preventive act supporting a proactive self-image or an
tional status, thereby establishing a need for further atten- opportunity to wind down and reflect on possibilities for
tion to organizational conditions for employers to take social WP. Related to the expanded ICF scheme, this is captured
responsibility for their employees. in the work-related personal factors of importance for WP
Findings indicate that public employed might be more [64]. However, with the risk of isolation and maintaining
exposed to organizational problems than private sector a sick role, sick leave can hamper WP [39, 86]. Thus, sick
employees. Additionally, other studies [40, 83, 84] find a leave may be perceived as a complex concept imbued with
higher sick leave rate in the public sector compared to the meaning and impact on WP depending on contextual factors
private sector, pointing to the importance of organizational [87]. Sick leave has been conceptualized as a personality
factors. trait categorized in problem-solving or reactive-passive cop-
Moreover, our findings suggest that high job demands and ing strategies [88], and the synthesis provides examples of
a strong work identity can result in nondisclosure of mental both types; thus, the decision to stay at work or go on sick
health problems and a struggling to stay a work, reinforcing leave may depend on the interaction between personal fac-
the risk of sick leave. Correspondingly, Janssen et al. [85] tors and the work environment.
find that high job demands may be a problem for WP, and Work attitude can influence WP, which is supported by
consequently, employees may risk symptom deterioration one of the excluded studies [89] that focused on employees
and repeated sick leave if their WP is not carefully adjusted with severe and persistent mental illness. However, in con-
to how they function in the workplace. Conversely, a study trast to our findings, the authors find other challenges to be
finds limited evidence that changing work tasks is associated important; thus, employees with severe and persistent men-
with symptom recovery among employees with CMDs and tal illness may feel that illness awareness plays a role with
points to the influence of personal and other environmental regard to WP, supporting our choice of exclusion criteria.
factors [69]. Brouwer et al. [90] find that work attitude, social support
Our findings suggest that personal factors of special and willingness to initiate behavior promote RTW, and that
importance are gender, education, employment and the abil- active and individualized support can be beneficial. How-
ity to manage work tasks and demands, which are also cap- ever, we found a need for improved coordination between
tured in the expanded ICF scheme as general personal fac- vocational stakeholders, similar to findings in other meta-
tors influencing WP [64]. Additionally, perfectionism and a syntheses [12, 40]. Additionally, Kinn et al. [39] state that
strong work identity appear to be especially common among rehabilitation professionals tend to have different perspec-
women with moderate to high education and/or white-collar tives on functioning and disability, calling for a common

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460 Journal of Occupational Rehabilitation (2018) 28:452–464

Table 3  Recommendations
for rehabilitation professionals Need for acceptance and recognition to ease a threatened work identity
promoting WP among Carefully involve the employer in the rehabilitation process
employees with CMDs Consider personal factors, e.g., gender, education, employment and coping strategies, and the interaction
with environmental factors, e.g., organizational structures, workplace culture and workplace relations
Uncover and defuse any prejudices and negative perceptions regarding CMDs the employee might carry
Taking control by means of motivation and support
Establish a trusting relationship through individualized support
Promote a positive work attitude to prevent the employee from adopting and maintaining a sick role
Ensure meaningful corporation with other rehabilitation professionals through sufficient communication
and mutual understanding
Promote the employee’s ability to manage work-related stress

understanding and language to promote cooperation and Agreement between the five unsupported findings and the
coordination. ICF can be a valuable tool to strength internal categories appears to be sound, and therefore these findings
communication, offering a basis for improved coordination imply meaning regarding the handling of work demands,
[64, 91]. work attitude and support [16, 19, 54, 56].

Implications for Practice Implications for Research

Using the ConQual approach, the synthesized findings were Further work needs to be done regarding the exploration
found to have moderate confidence (Online Resource 4); of the perspectives of employees with a lower education.
therefore, rehabilitation professionals may consider the Moreover, employers’ experienced challenges and oppor-
recommendations given in Table 3, which were based on tunities with employees with CMDs should be investigated
these findings, to be of use in practice (Table 3). Moreo- to clarify their perspectives regarding the development of
ver, we highly recommended that rehabilitation stakehold- preventive workplace practices.
ers and policy makers focus on the provision of stable and
meaningful organizational structures and supportive work Acknowledgements The authors would like to thank Helene Sogn-
strup, AU Library Health, Psychiatry, for providing guidance regarding
environments. the systematic search strategy.

Methodological Reflections Funding This study was funded by the Department of Public Health,
Aarhus University and the Jascha Foundation.
This is the first time the meaningfulness of WP among
employees with CMDs has been addressed through meta- Compliance with Ethical Standards
aggregation with the aim of providing an evidence base for
recommendations for practice. Due to the inclusion criteria Conflict of interest Cecilie Nørby Thisted, Claus Vinther Nielsen and
Merete Bjerrum declare that they have no conflict of interest.
on diagnosis and employment, some studies of employees
with CMDs were excluded because the information reported Research Involving Human and Animal Participants This article does
was entwined with evidence provided by other groups. How- not contain any studies with human participants or animals performed
ever, studies excluded due to diagnoses support the synthesis by any of the authors.
[92–101] because they relate to personal factors, e.g., gen-
der, coping, prejudices, social support and the work environ-
ment. Excluded studies regarding unemployed people [59, References
96–98, 102, 103] report other difficulties related to WP, e.g.,
inability to get jobs reinforcing mental health symptoms and 1. OECD. Mental health and work: Denmark. Paris: OCED Publish-
loss of income and meaning, implying that the synthesized ing; 2013.
2. OECD. Sick on the job? Myths and realities about mental health
findings may not be applicable for the unemployed. and work, mental health and work. Paris: OCED Publishing;
Most of the included studies contributed evidence on 2012.
employees on sick leave. Most of the employees were 3. Lerner D, Henke RM. What does research tell us about
women with a work-related disorder, mostly depression, depression, job performance, and work productivity? J Occup
Environ Med. 2008;50(4):401–410. https://doi.org/10.1097/
anxiety, stress or a stress-related disorder; moderate or long jom.0b013e31816bae50.
education; and public sector employed, and our findings may 4. Ahola K, Virtanen M, Honkonen T, Isometsä E, Aromaa A,
be transferred to similar groups. Lönnqvist J. Common mental disorders and subsequent work

13
Journal of Occupational Rehabilitation (2018) 28:452–464 461

disability: a population-based Health 2000 Study. J Affect 19. Sallis A, Birkin R. Experiences of work and sickness absence
Disord. 2011;134(1–3):365–372. https://doi.org/10.1016/j. in employees with depression: an interpretative phenomeno-
jad.2011.05.028. logical analysis. J Occup Rehabil. 2014;24(3):469–483. https://
5. Knudsen AK, Øverland S, Aakvaag HF, Harvey SB, Hotopf doi.org/10.1007/s10926-013-9481-6.
M, Mykletun A. Common mental disorders and disability 20. WHO. World Report on Disability. Geneva: WHO; 2011.
pension award: seven year follow-up of the HUSK study. J 21. Pomaki G, Franche R-L, Murray E, Khushrushahi N, Lampinen
Psychosom Res. 2010;69(1):59–67. https://doi.org/10.1016/j. TM. Workplace-based work disability prevention interventions
jpsychores.2010.03.007. for workers with common mental health conditions: a review
6. Koopmans PC, Bültmann U, Roelen CAM, Hoedeman R, van of the literature. J Occup Rehabil. 2012;22(2):182–195. https://
der Klink JJL, Groothoff JW. Recurrence of sickness absence doi.org/10.1007/s10926-011-9338-9.
due to common mental disorders. Int Arch Occup Envi- 22. Lagerveld SE, Blonk RWB, Brenninkmeijer V, Wijngaards-de
ron Health. 2011;84(2):193–201. https://doi.org/10.1007/ Meij L, Schaufeli WB. Work-focused treatment of common
s00420-010-0540-4. mental disorders and return to work: a comparative outcome
7. Waddell G, Burton AK. Is work good for your health and well- study. J Occup Health Psychol. 2012;17(2):220–234. https://
being? London: The Stationery Office; 2006. doi.org/10.1037/a0027049.
8. Steel Z, Marnane C, Iranpour C, Chey T, Jackson JW, Patel V, 23. Hjarsbech PU, Nielsen MBD, Andersen MF, Rugulies R,
et al. The global prevalence of common mental disorders: a sys- Christensen U. Struggling at work: a qualitative study of
tematic review and meta-analysis 1980–2013. Int J Epidemiol. working Danes with depressive symptoms. Disabil Rehabil.
2014;43(2):476–493. https://doi.org/10.1093/ije/dyu038. 2015;37(18):1674–1682. https://doi.org/10.3109/09638288.2
9. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, 014.973970.
Brugha TS, Bryson H, et al. Prevalence of mental disor- 24. Loisel P, Durand M, Berthelette D, Vézina N, Baril R, Gagnon
ders in Europe: results from the European Study of the D, et al. Disability prevention: new paradigm for the manage-
Epidemiology of Mental Disorders (ESEMeD) project. ment of occupational back pain. Dis Manag Health Outcomes.
Acta Psychiatr Scand. 2004;109(420):21–27. https://doi. 2001;9(7):351–360.
org/10.1111/j.1600-0047.2004.00327.x. 25. Loisel P. Developing a new paradigm: work disability preven-
10. Andersen MF, Nielsen K, Brinkmann S. How do work- tion. Occup Health. 2009;15(2):56–60.
ers with common mental disorders experience a multidisci- 26. Briand C, Durand M-J, St-Arnaud L, Corbiére M. Work and
plinary return-to-work intervention? A qualitative study. J mental health: learning from return-to-work rehabilitation
Occup Rehabil. 2014;24(4):709–724. https://doi.org/10.1007/ programs designed for workers with musculoskeletal disor-
s10926-014-9498-5. ders. Int J Law Psychiatry. 2007;30(4–5):444–457. https://doi.
11. Andersen MF, Nielsen KM, Brinkmann S. Meta-synthesis of org/10.1016/j.ijlp.2007.06.014.
qualitative research on return to work among employees with 27. Brütt AL, Schulz H, Andreas S. Development of an
common mental disorders. Scand J Work Environ Health. ICF-based core set of activities and participation for
2012;38(2):93–104. https://doi.org/10.5271/sjweh.3257. patients with mental disorders: an approach based upon
12. Nielsen MBD, Bültmann U, Amby M, Christensen U, data. Clin Rehabil. 2013;27(8):758–767. https://doi.
Diderichsen F, Rugulies R. Return to work among employ- org/10.1177/0269215513475805.
ees with common mental disorders: study design and 28. WHO. The international classification of functioning, disability
baseline findings from a mixed-method follow-up study. and health. Vol 18. Geneva: WHO; 2001.
Scand J Public Health. 2010;38(8):864–872. https://doi. 29. Rebergen DS, Bruinvels DJ, Bezemer PD, van der Beek AJ, van
org/10.1177/1403494810384424. Mechelen W. Guideline-based care of common mental disor-
13. WHO. The World Health Report 2001 mental health: new under- ders by occupational physicians (CO-OP-study): a randomized
standing, new hope. Geneva: WHO; 2001. controlled trial. J Occup Environ Med. 2009;51(3):305–312.
14. WHO. The ICD-10 classification of mental and behavioural dis- https://doi.org/10.1097/jom.0b013e3181990d32.
orders: clinical descriptions and diagnostic guidelines. Geneva: 30. Furlan AD, Gnam WH, Carnide N, Irvin E, Amick
WHO; 1992. BC, DeRango K, et al. Systematic review of interven-
15. Lochner C, Mogotsi M, Du Toit PL, Kaminer D, Niehaus DJ, tion practices for depression in the workplace. J Occup
Stein DJ. Quality of life in anxiety disorders: a comparison of Rehabil. 2012;22(3):312–321. https://doi.org/10.1007/
obsessive-compulsive disorder, social anxiety disorder, and s10926-011-9340-2.
panic disorder. Psychopathology. 2003;36(5):255–262. https:// 31. Arends I, van der Klink JJ, Bültmann U. Prevention of recur-
doi.org/10.1159/000073451. rent sickness absence among employees with common mental
16. Noordik E, Nieuwenhuijsen K, Varekamp I, van der Klink JJ, disorders: design of a cluster-randomised controlled trial with
van Dijk FJ. Exploring the return-to-work process for workers cost-benefit and effectiveness evaluation. BMC Public Health.
partially returned to work and partially on long-term sick leave 2010;10(1):132. https://doi.org/10.1186/1471-2458-10-132.
due to common mental disorders: a qualitative study. Disabil 32. Hoefsmit N, Houkes I, Nijhuis FJN. Intervention characteristics
Rehabil. 2011;33(17–18):1625–1635. https://doi.org/10.3109/0 that facilitate return to work after sickness absence: a systematic
9638288.2010.541547. literature review. J Occup Rehabil. 2012;22(4):462–477. https://
17. Lagerveld SE, Bültmann U, Franche RL, van Dijk FJH, Vlasveld doi.org/10.1007/s10926-012-9359-z.
MC, van der Feltz-Cornelis CM, et al. Factors associated with 33. Noordik E, van der Klink JJ, Geskus RB, de Boer MR, van Dijk
work participation and work functioning in depressed workers: a FJH, Nieuwenhuijsen K. Effectiveness of an exposure-based
systematic review. J Occup Rehabil. 2010;20(3):275–292. https:// return-to-work program for workers on sick leave due to com-
doi.org/10.1007/s10926-009-9224-x. mon mental disorders: a cluster-randomized controlled trial.
18. de Vries G, Hees HL, Koeter MWJ, Lagerveld SE, Schene AH. Scand J Work Environ Health. 2013;39(2):144–154. https://doi.
Perceived impeding factors for return-to-work after long-term org/10.5271/sjweh.3320.
sickness absence due to major depressive disorder: a concept 34. Briand C, Durand M-J, St-Arnaud L, Corbière M. How well
mapping approach. PLoS ONE. 2014;9(1):e85038. https://doi. do return-to-work interventions for musculoskeletal condi-
org/10.1371/journal.pone.0085038. tions address the multicausality of work disability? J Occup

13
462 Journal of Occupational Rehabilitation (2018) 28:452–464

Rehabil. 2008;18(2):207–217. https://doi.org/10.1007/ 53. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A.

s10926-008-9128-1. Establishing confidence in the output of qualitative research
35. Pearson A, Wiechula R, Court A, Lockwood C. The JBI synthesis: the ConQual approach. BMC Med Res Methodol.
model of evidence-based healthcare. Int J Evid Based Healthc. 2014;14(1):1–7. https://doi.org/10.1186/1471-2288-14-108.
2005;3(8):207–215. 54. Holmgren K, Ivanoff SD. Women on sickness absence—views of
36. Korhonen A, Hakulinen-Viitanen T, Jylhä V, Holopainen A. possibilities and obstacles for returning to work. A focus group
Meta-synthesis and evidence-based health care—a method for study. Disabil Rehabil. 2004;26(4):213–222. https://doi.org/10.
systematic review. Scand J Caring Sci. 2013;27(4):1027–1034. 1080/09638280310001644898.
https://doi.org/10.1111/scs.12003. 55. Jansson I, Perseius K, Gunnarsson AB, Bjorklund A. Work and
37. Corbière M, Samson E, Negrini A, St-Arnaud L, Durand everyday activities: experiences from two interventions address-
M-J, Coutu M-F, et al. Factors perceived by employees ing people with common mental disorders. Scand J Occup Ther.
regarding their sick leave due to depression. Disabil Rehabil. 2014;21(4):295–304. https://doi.org/10.3109/11038128.2014.8
2016;38(6):511–519. https://doi.org/10.3109/09638288.2015 94572.
.1046564. 56. Sandmark H, Renstig M. Understanding long-term sick leave in
38. Norlund S, Fjellman-Wiklund A, Nordin M, Stenlund T, Ahlgren female white-collar workers with burnout and stress-related diag-
C. Personal resources and support when regaining the ability noses: a qualitative study. BMC Public Health. 2010;10(1):210.
to work: an interview study with exhaustion disorder patients. https://doi.org/10.1186/1471-2458-10-210.
J Occup Rehabil. 2013;23(2):270–279. https://doi.org/10.1007/ 57. Ståhl C, Stiwne EE. Narratives of sick leave, return to work
s10926-012-9396-7. and job mobility for people with common mental disorders in
39. Kinn LG, Holgersen H, Aas RW, Davidson L. “Balanc- Sweden. J Occup Rehabil. 2014;24(3):543–554. https://doi.
ing on skates on the icy surface of work”: a metasynthesis of org/10.1007/s10926-013-9480-7.
work participation for persons with psychiatric disabilities. J 58. Millward LJ, Lutte A, Purvis RG. Depression and the perpetua-
Occup Rehabil. 2014;24(1):125–138. https://doi.org/10.1007/ tion of an incapacitated identity as an inhibitor of return to work.
s10926-013-9445-x. J Psychiatr Ment Health Nurs. 2005;12(5):565–573. https://doi.
40. Bergström G, Bodin L, Hagberg J, Aronsson G, Joseph- org/10.1111/j.1365-2850.2005.00875.x.
son M, Bergstrom G. Sickness presenteeism today, sick- 59. Pittam G, Boyce M, Secker J, Lockett H, Samele C. Employ-
ness absenteeism tomorrow? A prospective study on sick- ment advice in primary care: a realistic evaluation. Health
ness presenteeism and future sickness absenteeism. J Occup Soc Care Commun. 2010;18(6):598–606. https://doi.
Environ Med. 2009;51(6):629–638. https://doi.org/10.1097/ org/10.1111/j.1365-2524.2010.00929.x.
jom.0b013e3181a8281b. 60. Nielsen MBD, Rugulies R, Hjortkjaer C, Bültmann
41. Corbiére M, Negrini A, Dewa CS. Mental health problems and U, Christensen U. Healing a vulnerable self: explor-
mental disorders: linked determinants to work participation and ing return to work for women with mental health prob-
work functioning. In: Loisel P, Anema JR, editors. Handbook lems. Qual Health Res. 2013;23(3):302–312. https://doi.
of work disability prevention and management. New York: org/10.1177/1049732312468252.
Springer; 2013. p. 267–288. 61. Cowls J, Galloway E. Understanding how traumatic re-enact-
42. The Joanna Briggs Institute. Reviewers’ manual: 2014 edition. ment impacts the workplace: assisting clients’ successful return
Adelaide: The Joanna Briggs Institute; 2014. to work. Work. 2009;33(4):401–411. https://doi.org/10.3233/
43. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: wor-2009-0889.
methodological guidance for systematic reviewers utilizing meta- 62. Verdonk P, de Rijk A, Klinge I, de Vries A. Sickness absence
aggregation. Int J Evid Based Healthc. 2015;13(3):179–187. as an interactive process: gendered experiences of young,
https://doi.org/10.1097/xeb.0000000000000062. highly educated women with mental health problems. Patient
44. Aromataris E, Pearson A. The systematic review: an overview. Educ Couns. 2008;73(2):300–306. https://doi.org/10.1016/j.
Am J Nurs. 2014;114(3):53–58. https://doi.org/10.1097/01. pec.2008.06.003.
naj.0000444496.24228.2c. 63. Venning A, Elliott J, Wilson A, Kettler L. Understanding young
45. American Psyciatric Association. Diagnostic and statistical peoples’ experiences of chronic illness: a systematic review. Int
manual of mental disorders DSM-IV-TR. Washington: American J Evid Based Healthc. 2008;6(3):321–336.
Psyciatric Association; 2011. 64. Heerkens Y, Engels J, Kuiper C, Van der Gulden J, Oostendorp
46. Videncenteret [Internet]. Accessed 2 Mar 2016. R. The use of the ICF to describe work related factors influenc-
47. Macaia AAS, Fischer FM. Teachers returning to work after sick ing the health of employees. Disabil Rehabil. 2004;26(17):1060–
leave for mental disorders. Saude Soc Sao Paulo. 2015;24(3):841– 1066. https://doi.org/10.1080/09638280410001703530.
852. https://doi.org/10.1590/s0104-12902015130569. 65. Eriksson U, Star rin B, Janson S. Long-term sick-
48. Hannes K, Lockwood C, Pearson A. A comparative analysis of ness absence due to burnout: absentees’ experiences.
three online appraisal instruments’ ability to assess validity in Qual Health Res. 2008;18(5):620–632. https://doi.
qualitative research. Qual Health Res. 2010;20(12):1736–1743. org/10.1177/1049732308316024.
https://doi.org/10.1177/1049732310378656. 66. Sanderson K, Nicholson J, Graves N, Tilse E, Oldenburg B. Men-
49. Schreier M. Qualitative content analysis in practice. London: tal health in the workplace: using the ICF to model the prospec-
Sage; 2012. p. 1–272. tive associations between symptoms, activities, participation and
50. Elo S, Kyngäs H. The qualitative content analysis pro- environmental factors. Disabil Rehabil. 2008;30(17):1289–1297.
cess. J Adv Nurs. 2008;62(1):107–115. https://doi. https://doi.org/10.1080/09638280701654690.
org/10.1111/j.1365-2648.2007.04569.x. 67. Escorpizo R, Finger ME, Glässel A, Gradinger F, Lückenkemper
51. Dey I. Qualitative data analysis. A user-friendly guide for social M, Cieza A. A systematic review of functioning in vocational
scientists. London: Routledge; 1993. rehabilitation using the International Classification of Function-
52. Hannes K, Lockwood C. Pragmatism as the philosophical foun- ing, Disability and Health. J Occup Rehabil. 2011;21(2):134–
dation for the Joanna Briggs meta-aggregative approach to quali- 146. https://doi.org/10.1007/s10926-011-9290-8.
tative evidence synthesis. J Adv Nurs. 2011;67(7):1632–1642. 68. Blank L, Peters J, Pickvance S, Wilford J, MacDonald E.
https://doi.org/10.1111/j.1365-2648.2011.05636.x. A systematic review of the factors which predict return to

13
Journal of Occupational Rehabilitation (2018) 28:452–464 463

work for people suffering episodes of poor mental health. J 2005–2012. Epidemiol Psychiatr Sci. 2016;26(6)1–11. https://
Occup Rehabil. 2008;18(1):27–34. https://doi.org/10.1007/ doi.org/10.1017/s2045796016000597.
s10926-008-9121-8. 84. Hussey L, Turner S, Thorley K, McNamee R, Agius R. Work-
69. Cornelius LR, van der Klink JJL, Groothoff JW, Brouwer S. related sickness absence as reported by UK general practition-
Prognostic factors of long term disability due to mental disor- ers. Occup Med. 2012;62(2):105–111. https://doi.org/10.1093/
ders: a systematic review. J Occup Rehabil. 2010;21(2):259–274. occmed/kqr205.
https://doi.org/10.1007/s10926-010-9261-5. 85. Janssen N, van den Heuvel WPM, Beurskens AJHM, Nijhuis FJN,
70. Brohan E, Henderson C, Wheat K, Malcolm E, Clement S, Bar- Schroer CAP, van Eijk JTM. The demand-control-support model
ley E, et al. Systematic review of beliefs, behaviours and influ- as a predictor of return to work. Int J Rehabil Res. 2003;26(1):1–
encing factors associated with disclosure of a mental health prob- 9. https://doi.org/10.1097/01.mrr.0000054811.81886.ac.
lem in the workplace. BMC Psychiatry. 2012;12(1):11. https:// 86. Netto JA, Yeung P, Cocks E, Mcnamara B. Facilitators and
doi.org/10.1186/1471-244x-12-11. barriers to employment for people with mental illness: a quali-
71. Krupa T, Kirsh B, Cockburn L, Gewurtz R. Understanding the tative study. J Vocat Rehabil. 2016;44(1):61–72. https://doi.
stigma of mental illness in employment. Work. 2009;33(4):413– org/10.3233/jvr-150780.
425. https://doi.org/10.3233/wor-2009-0890. 87. Wilday S, Dovey A. Occupational mental health and the real
72. Collins KA, Westra HA, Dozois DJA, Burns DD. Gaps in access- cost of sickness absence: a cognitive behavioural perspective.
ing treatment for anxiety and depression: challenges for the deliv- http://www.working-minds.org.uk/documents/sickness-absence.
ery of care. Clin Psychol Rev. 2004;24(5):583–616. https://doi. pdf. Accessed 25 Nov 2017.
org/10.1016/j.cpr.2004.06.001. 88. van Rhenen W, Schaufeli WB, van Dijk FJH, Blonk RWB.
73. Seelig MD, Katon W. Gaps in depression care: why primary care Coping and sickness absence. Int Arch Occup Envi-
physicians should hone their depression screening, diagnosis, and ron Health. 2008;81(4):461–472. https://doi.org/10.1007/
management skills. J Occup Environ Med. 2008;50(4):451–458. s00420-007-0238-4.
https://doi.org/10.1097/jom.0b013e318169cce4. 89. Cunningham K, Wolbert R, Brockmeier MB. Moving beyond the
74. Aromaa E, Tolvanen A, Tuulari J, Wahlbeck K. Personal stigma illness: factors contributing to gaining and maintaining employ-
and use of mental health services among people with depres- ment. Am J Commun Psychol. 2000;28(4):481–494.
sion in a general population in Finland. BMC Psychiatry. 90. Brouwer S, Krol B, Reneman MF, Bültmann U, Franche RL,
2011;11(1):52. https://doi.org/10.1186/1471-244x-11-52. Van Der Klink JJL, et al. Behavioral determinants as pre-
75. Pattyn E, Verhaeghe M, Sercu C, Bracke P. Public stigma and dictors of return to work after long-term sickness absence:
self-stigma: differential association with attitudes toward formal an application of the theory of planned behavior. J Occup
and informal help seeking. Psychiatr Serv. 2014;65(2):232–238. Rehabil. 2009;19(2):166–174. https://doi.org/10.1007/
https://doi.org/10.1176/appi.ps.201200561. s10926-009-9172-5.
76. Barney LJ, Griffiths KM, Jorm AF, Christensen H. Stigma 91. Kostanjsek N. Use of the international classification of function-
about depression and its impact on help-seeking inten- ing, disability and health (ICF) as a conceptual framework and
tions. Aust N Z J Psychiatry. 2006;40(1):51–54. https://doi. common language for disability statistics and health information
org/10.1111/j.1440-1614.2006.01741.x. systems. BMC Public Health. 2011;4(Suppl 4):S3. https://doi.
77. Jorm AF, Griffiths KM. The public’s stigmatizing attitudes org/10.1186/1471-2458-11-s4-s3.
towards people with mental disorders: how important are biomed- 92. Hatchard K, Henderson J, Stanton S. Workers’ perspectives on
ical conceptualizations? Acta Psychiatr Scand. 2008;118(4):315– self-directing mainstream return to work following acute mental
321. https://doi.org/10.1111/j.1600-0447.2008.01251.x. illness: reflections on partnerships. Work. 2012;43(1):43–52.
78. Johnston V, Way K, Long MH, Wyatt M, Gibson L, Shaw WS. https://doi.org/10.3233/wor-2012-1446.
Supervisor competencies for supporting return to work: a mixed- 93. Saint-Arnaud L, Saint-Jean M, Damasse J. Towards an enhanced
methods study. J Occup Rehabil. 2015;25(1):3–17. https://doi. understanding of factors involved in the return-to-work process
org/10.1007/s10926-014-9511-z. of employees absent due to mental health problems. Can J Com-
79. Lemieux P, Durand MJ, Hong QN. Supervisors’ perception of the mun Ment Health. 2006;25(2):303–315.
factors influencing the return to work of workers with common 94. Irvine A. Managing mental health and employment. London:
mental disorders. J Occup Rehabil. 2011;21(3):293–303. https:// Department for Work and Pensions; 2008.
doi.org/10.1007/s10926-011-9316-2. 95. Barnes MC, Buck R, Williams G, Webb K, Aylward M. Beliefs
80. Reavley NJ, Ross A, Killackey EJ, Jorm AF. Development of about common health problems and work: a qualitative study.
guidelines to assist organisations to support employees return- Soc Sci Med. 2008;67(4):657–665. https://doi.org/10.1016/j.
ing to work after an episode of anxiety, depression or a related socscimed.2008.05.008.
disorder: a Delphi consensus study with Australian professionals 96. Donnell CM, Sosulski MR. Stark realities: examining african
and consumers. BMC Psychiatry. 2012;12(1):135. https://doi. American women with mental illness and balancing employment
org/10.1186/1471-244x-12-135. in recovery. Am J Psychiatr Rehabil. 2013;16(1):66–83. https://
81. Schreuder JAH, Groothoff JW, Jongsma D, Van Zweeden doi.org/10.1080/15487768.2013.762308.
NF, Van Der Klink JJL, Roelen CA. Leadership effective- 97. Honey A. Benefits and drawbacks of employment: perspectives
ness: a supervisor’s approach to manage return to work. J of people with mental illness. Qual Health Res. 2004;14(3):381–
Occup Rehabil. 2013;23(3):428–437. https://doi.org/10.1007/ 395. https://doi.org/10.1177/1049732303261867.
s10926-012-9409-6. 98. Honey A. The impact of mental illness on employment: consum-
82. Seing I, MacEachen E, Ekberg K, Ståhl C. Return to work or job ers’ perspectives. Work. 2003;20(3):267–276.
transition? Employer dilemmas in taking social responsibility 99. Norvoll R. Jeg vil ikke stå utenfor Arbeid og utdanning sett med
for return to work in local workplace practice. Disabil Rehabil. brukernes øyne. In English: I will not be outside Employment
2015;37(19):1760–1769. https://doi.org/10.3109/09638288.201 and education from users’ perspectives. 2011. https://www.erfar-
4.978509. ingskompetanse.no/wp-content/uploads/2015/08/Jeg-vil-ikke-
83. Rantonen O, Alexanderson K, Pentti J, Kjeldgård L, Hämäläinen stå-utenfor.-Arbeid-og-utdanning.pdf. Accessed 25 Nov 2017.
J, Mittendorfer-Rutz E, et al. Trends in work disability with men- 100. Ockander MK, Timpka T. Women’s experiences of long term
tal diagnoses among social workers in Finland and Sweden in sickness absence: implications for rehabilitation practice and

13
464 Journal of Occupational Rehabilitation (2018) 28:452–464

theory. Scand J Public Health. 2003;31(2):143–148. https://doi. project. Scand J Occup Ther. 2014;21(2418):172–180. https://
org/10.1080/14034940210134095. doi.org/10.3109/11038128.2014.882981.
101. Simpson GW, Byrne P, Gabbay MB, Rannard A. Understand- 103. Sutton DJ, Hocking CS, Smythe L. A phenomenological study of
ing illness experiences of employees with common mental occupational engagement in recovery from mental illness. Can
health disorders. Occup Med. 2015;65(5):367–372. https://doi. J Occup Ther. 2012;79(3):142–150. https://doi.org/10.2182/
org/10.1093/occmed/kqv047. cjot.2012.79.3.3.
102. Mikkelsgård KA, Granerud A, Høye S. People with mental ill-
ness returning to work: a qualitative evaluation of a Norwegian

13