I want to get back to work… I want to get back to my life.

A patient recently made this comment to me. Before his depression, he had thrived at a government job and taken great pride in his work. (He showed me iPhone pictures of an event he had helped organize which was keynoted by the premier.) But in the cloud of depression, he left his job, and worried that he would never have another one.

This raises a simple question: how do you get patients like this back to work?

It seems like an obvious question to ask – and very relevant one. After all, many people with depression are off work, or have left the workforce altogether. A Towers Watson report considered disability in North America; mental health issues (typically “depression, anxiety and stress”) contribute to 78% of short-term and 67% of long-term disability claims in Canada. Let’s put that in perspective: for short-term disability, cancer was well under half that.

Yet if the burden of illness is great, little has been written about interventions to get patients with depression back to work. A 2008 Cochrane review identified only 11 randomized controlled trials (RCTs) on interventions aimed at reducing work disability in workers with major depressive disorder (and just four studies including work functioning as an outcome measure). A more recent Cochrane review considered 13 randomized controlled trials; only three studies, for example, looked at antidepressant therapy.

That’s why this week’s Reading is so interesting. “Gains in employment status following antidepressant medication or cognitive therapy for depression” by Jay C. Fournier et al. compares drug management with psychological interventions (CBT).

Jay C. Fournier

It’s a short, clever paper that has just appeared in the British Journal of Psychiatry. It’s also clinically relevant.

Find the paper here:

http://bjp.rcpsych.org/content/206/4/332

Here’s what they did.

· Between 1996 and 2003, outpatients at two sites (Vanderbilt and the University of Pennsylvania) were selected.

· Patients were assigned to receive cognitive behavioural therapy (actually, a variant: cognitive therapy) or antidepressant therapy or a placebo (though this group wasn’t part of this study).

· First, patients had acute treatment. The antidepressant group was given monotherapy for 8 weeks, then – depending on how they did – patients could be given some form of augmentation (lithium or desipramine); the CBT patients were provided the psychotherapy, assigned to 1 of 6 therapists, over 8 weeks.

· After acute treatment, antidepressant patients either continued their medications or were randomized to a placebo group. CBT patients stopped contact with their therapist, but were allowed up to 3 boasters sessions.

· After 12 months, all recovered patients were withdrawn from treatment and followed for an additional 12 months.

· The analysis focused on the majority of patients who recovered; that is, the 58 people in the antidepressant group (vs. the 35 who didn’t respond to treatment) and the 30 in the CBT group (vs. the 19 who didn’t respond to treatment). Different metrics were used, including for employment status (LIFE includes 11 employment status codes).

What they found:

· Overall, patients tended to do well with the majority responding to either the medications or the psychotherapy (with roughly equal effectiveness – as measured by symptom reduction using scales); responders overwhelmingly gained employment (only 5.3% didn’t and all in the antidepressant group) – though not necessarily full-time employment.

· “Individuals who responded to a 4-month course of cognitive therapy were more likely to be employed full time 2 years later than were participants who responded to antidepressant medication.” (!)

· Indeed, the authors note: “across the 28-month assessment window, the rate of full-time employment improved by 33 percentage points in the cognitive therapy group, from 56% at intake to 89% at the end of follow-up, whereas the rate of full-time employment improved by only 5 percentage points, from 66% at intake to 71% at the end of follow-up, in the antidepressant group.” (!)

The authors then conclude:

Insofar as it increases the likelihood that patients who are unemployed will not only respond to treatment but also achieve a higher vocational status, given the right context, cognitive therapy would appear to be the treatment of choice for patients who are unemployed, all else equal.

It’s a big result – and a refreshing result. This paper looks at a real-life outcome (employment), as opposed to the usual measures. But the paper seems to have problems. Let me explain. Remember: patients were either treated at Vanderbilt University or the University of Pennsylvania. After acute treatment (either antidepressant therapy or psychotherapy), patients’ ability to achieve full-time employment at the two sites differed markedly – somewhat unusual, suggesting more was at play than just treatments. (In fact, more curiously, at one site, patients seem to have done worse in terms of full-time employment right after CBT.)

Location, location, location: Vanderbilt University patients differed from the other site’s patients in terms of post-acute treatment employment

The study authors wonder about local labour markets. It should be pointed out that the study wasn’t just about the effects of employment after acute treatment – the study period stretched for another two years after that first phase. Still the impact of site on early results suggests deeper problems with methodology. Local labour markets are probably one of several confounding factors, like patients’ life skills, previous work experiences, etc. – none of which was really accounted for. (Many thanks to Dr. Mark Fefergrad – the University of Toronto Department of Psychiatry’s Postgraduate Education Program Director and my Reading of the Week Partner-in-Crime – for helping me understand this paper better.)

Three take-away points:

· Many studies suggest that CBT has a lasting effect and that medication management doesn’t (at least, if patients stop their meds). This study indicates that there may be an additional advantage of talk over pills: CBT could be superior in terms of return to full-time work.

· Though it’s a well-designed study, it wasn’t a brilliant study. The difference between the sites after acute treatment was one problem. And there are others, as mentioned above. Also, add to the list: the age of the dataset (patients were treated when Jean Chretien was the prime minister and I had a full head of hair).

· Depression and employment is an understudied area. This paper suggests that further research is needed – and one wonders about how the combination of medications and psychotherapy would help patients over simply one treatment modality.

So, then, returning to the original question: how do you get your depressed patients back to work? Aggressive treatment of depression is important – and there is growing evidence that it should involve more than just medication management.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.