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best predictor of RTW was recovery from fatigue,
and the degree of fatigue was related to a reduction
in the number of arousals per hour measured by po-
lysomnography (11). This is in line with a study from
Sonnenschein et al. (70), showing that quality of sleep
plays an important role both in symptom improvement
and in RTW among employees on extended sick leave
due to clinical burnout.
A review summarizing meta-analytic and double-
blind RCTs on treatments for insomnia found that
behavioural interventions are as effective as medica-
tion in short-term follow-up studies, but more effective
in long-term follow-up studies (71). Other ways to
decrease symptoms of insomnia seem to be reducing
working time. One study among full-time working
employees in the public sector, comparing a 25%
reduction in work together with retained salary with
controls, showed increased quality of sleep as well as
less sleepiness and perceived stress (72). Another study
found improved sleep quality with 6-h working days
compared with 8-h working days (73).
In summary, quality of sleep plays an important role
both in symptom improvement and RTW among per-
sons with SED. In general, behavioural interventions
for insomnia are more effective than medication for
long-term effect. There is a lack of evidence regarding
interventions for improving quality of sleep in patients
with SED.
Pharmacological treatment
Patients with SED often have symptoms of depression
and anxiety at the start of rehabilitation (26). Depres-
sive symptoms may be a reaction to decreased function
and exhaustion, but exhaustion might also cause a
transient depressive state (74). A study from a stress
clinic in Sweden showed that one-third of patients
with SED scored high symptoms for depression, and
two-thirds scored high symptoms for anxiety when
referred to the clinic. After 3 months of rehabilitation
there was a significant decrease in patients scoring high
symptoms for both depression and anxiety, although
high scores for burnout were still present. Antidepres-
sant medication did not predict the course of burnout
symptoms but, according to clinical observation,
patients on antidepressant medication reported fewer
symptoms of depression and anxiety (26).
In summary, there is an absence of evidence re-
garding the effects of pharmacological treatment in
patients with SED.
WORKPLACE INTERVENTIONS
Workplace interventions (WI) aim to reduce barriers
to RTW and to prevent disability. WI focus on RTW
www.medicaljournals.se/jrm
instead of symptom reduction. The interventions are
closely linked to the workplace and might include work
adaptations or involvement of stakeholders at work (75).
Focus on RTW early in the rehabilitation process
seems to speed up RTW. In a study with quasi-expe-
rimental design by Lagerveld et al. (76) the effective-
ness of CBT and work-focused CBT that integrated
work aspects early into the treatment, was compared.
Patients (n = 168) were employees on sick leave due to
common mental disorders, including adjustment dis-
order, and 12-month follow-up 12 data was collected.
Both partial and full RTW occurred significantly earlier
in the group that received work-focused CBT (12 days
earlier and 65 days earlier), without an increase in
psychological complaints (76). According to a review
by Vargas-Prada et al. there is limited evidence for
very early (delivered < 15 days of sickness absence)
workplace interventions compared with usual care in
patients with mental health problems (77).
Karlson et al. (78) explored the effect of a workpla-
ce-oriented intervention for patients on long-term sick
leave due to SED (n = 74). The controls were matched
patients who were not interested in participating in
the intervention (n = 74), which probably introduced a
selection bias in the study. The core intervention was
a convergence dialogue meeting between the patient
and the supervisor at the workplace, with the aim of
finding solutions to facilitate RTW. At follow-up after
1.5 years RTW was increased in the intervention group
compared with controls (78). However, in a follow-up
after 2.5 years the difference in RTW remained only
in subjects younger than 46 years (79). In an RCT by
Willert et al. (80) patients with stress-related disease
(n = 102) were randomized to a stress management in-
tervention or waitlist. The goal of the intervention was
to cope with stressful situations at work and, despite
their difficulties, to be active at work. At follow-up
after 16 weeks, patients in the intervention group self-
reported lower absenteeism compared with controls.
However, no significant evidence was found for RTW
(80). In a controlled designed study by Lander et al.
(81) stress-management intervention did not improve
RTW in patients sick-listed for emotional distress. Nor
did a Minimal Intervention for Stress-related mental
disorders with Sick leave (MISS) improve RTW in
a cluster randomized controlled educational trial in
patients on less than 3 months of sick leave due to
stress-related mental disorder. Primary healthcare prac-
titioners were randomized to short training sessions,
including, for instance, how to encourage patients’
recovery and active RTW (82).
An RCT by Finnes et al. (83) compared acceptance
and commitment therapy (ACT) and a workplace
dialogue intervention (WDI), standalone and in com-
bination and TAU among persons on sick leave due