There’s no doubt about it, mental health is rising up the priority list for HR (human resources) managers and occupational health specialists. We’ve had many business cases, none more compelling than the analysis conducted by Deloitte (Hampson et al, 2017) as part of the Thriving at Work Review into Mental Health at Work commissioned by the Prime Minister (Stephenson and Farmer, 2017).

We’ve seen moves to increase the profile of mental health in working life. The recommendations in the Thriving at Work report outline a set of actions employers can take, which chime with the international evidence and the practice research undertaken over the last ten years. I’ve blogged on Samuel Harvey’s excellent review of risk factors for common mental health problems at work, which set out a daring new model describing the pinch points of modern working life that our preventions strategies should focus on. I’ve also reviewed Sarah Miligan-Savile’s groundbreaking RCT on training effectiveness in an Australian fire service, which demonstrated the potential of good quality, skills-focused line manager training to make a difference. It’s time for action.

Two rate-limiting steps for employers implementing mental health programmes are the budget to deliver to all staff at scale, and the ability to manage demand for support created by mental health awareness campaigns when NHS services are stretched. Digital tools are often cited with hope (or relief) as accessible, scalable tools that employers can offer.

The market is being flooded with new tools and re-purposed versions of existing tools. These are targeted at employees and sold into a market very keen on low cost, high volume solutions. In October 2017, I blogged about Stephany Carolan’s review of digital interventions for improving wellbeing and work effectiveness, which welcomed innovation in this field and drew out the necessity of digital interventions to be tested in and adapted for workplace settings for maximum effectiveness.

This recent review from Elizabeth Stratton and her team adds further to the evidence, this time examining eHealth interventions for mental health conditions, targeted at employees and delivered in the workplace. They cite the lack of evidence-based workplace-focused tools, and the differences in population between employed people and the populations most frequently recruited for both general and clinical eHealth studies.

Methods

The authors conducted a robust systematic review, compliant with the PRISMA guidelines for reporting. It aimed to identify all published, peer reviewed RCTs, controlled trials and pre/post trials that used an eHealth Intervention (a website, or app) and reported outcomes on a standardised measure of depression, anxiety or stress. Participants had to be in current, paid employment and between the ages of 18 and 65.

Searches were conducted using a range of databases and by manual screening of content tables of major journals on eHealth. Studies had to be in English, and published between 1975 and November 2016 (the earliest eHealth intervention identified was from 2004)

The mean and standard deviation of standardised measures of distress, depression and/or anxiety and the sample size in each arm at baseline and follow-up were collected. The studies were also categorised by intervention type, with three main types identified:

1. Cognitive behavioural therapy (CBT)
2. Mindfulness-based treatments
3. Stress management

Robust statistical analysis was conducted, using the standard mean difference (SMD) of change between baseline and follow-up. A positive SMD indicated that the intervention group had superior effect to the control group.

Results

The search uncovered 1,147 articles, 871 of which were reviewed by the authors. 108 potential studies were then reviewed by two independent researchers, leaving 32 articles included in the qualitative synthesis. The 32 were assessed for quality and 23 studies were included in the meta-analysis.

Overall, amongst the 23 studies there was a small, significant positive effect post-intervention compared to control. However, there was a large degree of heterogeneity (due to different intervention types and outcome measures) and there was a significant difference between the types of intervention.

• CBT interventions showed a very small, significant positive effect size and virtually no heterogeneity (a small effect but reliably seen across studies)
• Mindfulness based interventions showed a moderate to large positive effect size with no heterogeneity
• Stress management interventions showed a non-significant small effect size, with large heterogeneity.

At follow up, there was still an overall small, significant positive effect, with moderate to high heterogeneity. Looking at the different types of intervention:

• CBT interventions did not retain post-intervention positive effect
• Mindfulness based interventions retained a small positive effect, but it wasn’t statistically significant
• Stress management interventions showed a moderate, statistically significant effect, but with large heterogeneity.

There was no difference in the effect size for CBT interventions when delivered to universal populations or targeted to those with indicated need. All of the mindfulness-based interventions were universally targeted. The effect of stress management interventions did vary between universal and indicated populations. There was a small, significant negative effect at follow-up for stress management interventions delivered to non-targeted populations, and a moderate to large significant positive effect for those delivered to targeted populations.

Conclusions

The authors conclude that:

…certain types of eHealth interventions delivered to employees via their workplace can be effective at reducing mental health and stress symptoms although the evidence base is affected by a small study effect that seems to inflate effectiveness.

If an eHealth intervention is to be offered to all employees, in a universal fashion, then Mindfulness approaches appear to have a stronger effect than the other types. There is little to recommend Stress Management approaches delivered to the whole workforce, and one study suggests that providing this type of intervention may even be harmful. In contrast the use of Stress Management eHealth interventions by workers who are reporting high levels of stress may have a positive effect, despite few studies.

Strengths and limitations

This review benefits from a robust search strategy, strong inclusion and exclusion criteria and rigorous assessment of quality of the included studies.

There were several limitations:

• Despite the widespread use of eHealth tools in workplace settings, only 23 studies could be included in this meta-analysis. This in turn meant that for some subgroups there were too few studies to draw strong conclusions
• The initial screening of abstracts was one by only one author and it may be that some studies were missed
• Intervention descriptions in studies were sometimes misleading, meaning the authors had to decide how to categorise them, e.g. ‘Mindfulness with aspects of stress management’. This in part explains the higher levels of heterogeneity across the included studies.

Implications for practice

The authors draw out several areas for consideration in terms of practice and future research:

Consider the population being targeted

That consideration is given to the population targeted for an eHealth intervention at work – given that universal and indicated tools are available and have different efficacy in different populations.

• This is a significant point. We need commissioners in workplaces, and organisations that support workplaces to scope their needs to be able to communicate clearly a public mental health model that recognises prevention at primary, secondary and indicated levels. This enables organisations to construct holistic mental health approaches that promote and protect good mental health in a universal population whilst responding rapidly to emergent distress and ensuring that the ongoing needs of staff with mental health problems are addressed.

Evidence-based commissioning

That the evidence base should be used to inform commissioning decisions, bearing in mind that some interventions seem to have little effect in workplace populations and others may have negative effects.

• The evidence base is patchy and heterogenous; perhaps inevitable when many the interventions in the field are developed ad hoc using a collage of theoretical and clinical underpinnings.
• There’s a paradox here. App developers and existing eHealth providers wishing to move into the workplace market have no templates for how the various psychological approaches translate to workplace contexts from general and clinical populations. It is hard to develop interventions that are tailored in such a way that they are informed by the evidence coming through.
• Equally, it could be helpful if researchers in these areas could create a framework onto which evidence could be grafted and made available to developers and commissioners so that as evidence-based interventions for populations and problems are developed, they become better known. This is key to the final recommendation made by the authors of the review (see below).

More RCTs please!

That more RCT studies are carried out on eHealth interventions in the workplace to enable stronger conclusions to be drawn from meta-analyses. This was especially true for mindfulness-based interventions for those working and experiencing symptoms; a subgroup for which no studies were included in the meta-analysis.

• Researchers always want more research, but it is important that eMental Health tools are robustly evidenced from the start. In this case it’s very important that workplace tools are evidenced, as the market demand and lower burden of proof of effectiveness compared to health service adoption means more rapid uptake, even of less efficacious tools. Our eMen programme is supporting action in this regard.

Digital tools are certainly important for addressing workplace mental health at scale. That said, as both the study and the earlier review (Carolan et al, 2017) have stated, we need to do more to understand the factors that affect roll-out in workplace settings. The ideal scenario is creating a crucible where agile development, service design and robust evidence can combine to create products and services that meet an obvious need.

We must be aware of the problem or opportunity being addressed, the audience, and the evidence of effectiveness in this context before deploying tools in the workplace. That means collecting good data and engaging employees as well as reviewing the evidence base…and not just buying in an app or intervention that has a ‘nice’ user interface or a favourable price point.

Conflicts of interest

Chris O’Sullivan works for the Mental Health Foundation. In partnership with WellMind Media Ltd, the Foundation offers Be Mindful Online, an MBCT/MBSR based digital mental health intervention that is sold to individuals, employers and health services. Be Mindful Online was not used in any of the studies included in this review.

Links

Primary paper

Stratton E, Lampit A, Choi I, Calvo RA, Harvey SB, et al. (2017) Effectiveness of eHealth interventions for reducing mental health conditions in employees: A systematic review and meta-analysis. PLOS ONE 12(12): e0189904. https://doi.org/10.1371/journal.pone.0189904

Other references

Milligan-Saville JS, Tan L, Gayed A, Barnes C, Madan I, Dobson M, Bryant RA, Christensen H, Mykletun A, Harvey SB. (2017) Workplace mental health training for managers and its effect on sick leave in employees: a cluster randomised controlled trial. The Lancet Psychiatry, Available online 12 October 2017 https://doi.org/10.1016/S2215-0366(17)30405-4

Workplace mental health training works, but do you have the confidence to act?

Harvey SB, Modini M, Joyce S, et al (2017) Can work make you mentally ill? A systematic meta-review of work-related risk factors for common mental health problems. Occup Environ Med Published Online First: 20 January 2017. doi: 10.1136/oemed-2016-104015 [Abstract]

Work can make you mentally ill, but we still have a lot to learn about the links between employment and mental health

Farmer, P and Stephenson, D (2017). Thriving at Work: The Stevenson/Farmer Review of Mental Health and Employers; HM Government; London. Available online at: https://www.gov.uk/government/publications/thriving-at-work-a-review-of-mental-health-and-employers (accessed Jul 18)

Hampson, L et al (2017). Mental Health and Employers: The Case for Action; Deloitte; London. Available online at https://www2.deloitte.com/content/dam/Deloitte/uk/Documents/public-sector/deloitte-uk-mental-health-employers-monitor-deloitte-oct-2017.pdf (Accessed Jul 18)

Photo credits

• Photo by Charles Koh on Unsplash
• US Airman 1st Class Sahara L. Fales CC BY 2.0
• Photo by rawpixel on Unsplash