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Hindawi Publishing CorporationJournal of Environmental and Public HealthVolume 2012, Article ID 515874, 21 pagesdoi:10.1155/2012/515874

Review Article

A Synthesis of the Evidence for Managing Stress at Work:A Review of the Reviews Reporting on Anxiety, Depression,and Absenteeism

Kamaldeep S. Bhui, Sokratis Dinos, Stephen A. Stansfeld, and Peter D. White

Centre for Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London,London E14NS, UK

Correspondence should be addressed to Kamaldeep S. Bhui, [email protected]

Received 19 May 2011; Revised 3 August 2011; Accepted 5 August 2011

Academic Editor: David Vlahov

Copyright © 2012 Kamaldeep S. Bhui et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Background. Psychosocial stressors in the workplace are a cause of anxiety and depressive illnesses, suicide and family disruption.Methods. The present review synthesizes the evidence from existing systematic reviews published between 1990 and July 2011. Weassessed the effectiveness of individual, organisational and mixed interventions on two outcomes: mental health and absenteeism.Results. In total, 23 systematic reviews included 499 primary studies; there were 11 meta-analyses and 12 narrative reviews. Meta-analytic studies found a greater effect size of individual interventions on individual outcomes. Organisational interventions showedmixed evidence of benefit. Organisational programmes for physical activity showed a reduction in absenteeism. The findingsfrom the meta-analytic reviews were consistent with the findings from the narrative reviews. Specifically, cognitive-behaviouralprogrammes produced larger effects at the individual level compared with other interventions. Some interventions appeared tolead to deterioration in mental health and absenteeism outcomes.Gaps in the literature include studies of organisational outcomeslike absenteeism, the influence of specific occupations and size of organisations, and studies of the comparative effectiveness ofprimary, secondary and tertiary prevention. Conclusions. Individual interventions (like CBT) improve individuals’ mental health.Physical activity as an organisational intervention reduces absenteeism. Research needs to target gaps in the evidence.

1. Introduction

Although work provide a range of benefits such as increasedincome, social contact, and sense of purpose, it can also havenegative effects on mental health, particularly in the formof stress. The National Institute of Occupational Safety andHealth in the US (NIOSH) [1] estimate the following:

(i) 40% of American workers reported their job was veryor extremely stressful,

(ii) 25% view their jobs as the number one stressor intheir lives,

(iii) three fourths of American employees believe thatworkers have more on-the-job stress than a genera-tion ago.

Given the global recession, financial strain, and job loss-es, greater work stress might have adverse consequences inUK. The most recent data from the NHS information centrein UK suggest an increase in the suicide rate for the first timesince 1998. The number of people committing suicide roseby 329 to 5,706 in 2008. The rate among men increased from16.8 per 100,000 in 2007 to 17.7 per 100,000 in 2008. Thisincrease is being interpreted by politicians and the public asa consequence of the global and national recession, increasedjob insecurity, risk of loss of jobs, and also stress at work,where the demands on the existing workforce have increased(The Independent, 18th November, 2010).

Approximately 11 million people of working age in UKexperience mental health problems. 11.4 million workingdays were lost in UK in 2008/2009 due to work-related stress,depression, or anxiety [2]. There are also indirect costs,

2 Journal of Environmental and Public Health

Table 1: Model for categorising stress management interventions (adapted from de Jonge and Dollard) [17].

Level Primary prevention Secondary prevention Tertiary prevention Outcome measures

Organisational

Improving workcontent, fitnessprogrammes, andcareer development

Improvingcommunication anddecision making andconflict management

VocationalRehabilitation andoutplacement

Productivity, turn-over,absenteeism, and financial claims

Individual andOrganizationalinterface

Time management,improvinginterpersonal skills,and Work/homeBalance

Peer support groups,coaching, and careerplanning

Posttraumatic stressassistanceprogrammes andgroup psychotherapy

Job stressors such as demands,control, support, role ambiguity,relationships, change, withburnout

Individual

Pre-employmentmedical examinationand didactic stressmanagement

Cognitive behaviouraltechniques andrelaxation

Rehabilitation aftersick leave, disabilitymanagement, casemanagement, andindividualpsychotherapy

Mood states, psychosomaticcomplaints, subjectiveexperienced stress, physiologicalparameters, sleep disturbances,and health behaviours

for example, through “presenteeism” when employees areat work but are too unwell to function fully [3]. Stress atwork also can lead to physical illness, psychological distressand illness, and sickness absence [3, 4]. Stress, depression,or anxiety accounts for 46% of days lost due to illness andare the single largest cause of all absences attributable towork-related illness [5]. Psychosocial work stressors such asjob strain, low decision latitude, low social support, highpsychological demands, effort-reward imbalance, and highjob insecurity have all been implicated as causes of workstress-related anxiety and depressive illnesses [6]. However,psychosocial work stressors can only be tackled by organisa-tional and systemic strategies and policies.

2. The Conceptualisation of Occupational Stress

In order to consider the evidence base, there needs to be someagreement on the meaning of work stress. A popular modelof stress considers “inputs” such as job characteristics; forexample, excess demands, low control, poor social support,adverse life events such as bereavement or divorce, and addi-tional demands outside of work such as carer responsibilitiesfor a dependent relative or spouse [7–10]. Stress has alsobeen recognised by symptoms or “outputs” such as tension,frustration, or emotional distress. An alternative approachis to theorise that stress is a manifestation of the poor fitbetween a person and their environment [11]. Stress is thenseen to arise due to a discrepancy between the inputs andoutputs and the mediating appraisal of stress, personal skillsto manage it, and environmental demands and rewards.Transactional models, as those proposed by Lazarus [12] andCox and Ferguson [13], conceptualise stress as somethingthat unfolds over time within a series of transactions betweenthe person and their environment. Stress is, therefore, elicitedand maintained by the individual’s actions and perceptionsas well as the characteristics of their work environment.

The specific conceptualisations of stress adopted influ-ence the way interventions are constructed to tackle specificmechanisms in order to alter stress and its manifestations.

Cahill [14], Cooper et al. [15], and Marine et al. [16] describecategories of stress management interventions that target theindividual or the organisation and specify actions at primary,secondary, or tertiary preventive levels (see Table 1) [17].Individual interventions include stress awareness training orcognitive behavioural therapy for psychological and emo-tional stress. Organisational interventions are those thataffect whole populations or groups of people and includeworkplace adjustments or conflict management approachesin a specific organisation. Some interventions target both theindividual and organisation, for example, policies to secure abetter work-life balance and peer-support groups. Primaryinterventions aim to prevent the causal factors of stress,secondary interventions aim to reduce the severity or dura-tion of symptoms, and tertiary or reactive interventions aimto provide rehabilitation and maximise functioning amongthose with chronic health conditions [18].

Although preventive interventions are often advocated,what is the evidence of benefit? The evidence of effectiveinterventions to protect individual mental health and reduceorganisational absenteeism rates is difficult to summarise in amanner that is of practical relevance. Therefore, the purposeof this paper is to take the highest level of research evidence(systematic reviews providing narrative synthesis or meta-analyses) and synthesise this evidence to identify the keyfindings and gaps in the literature on the effectiveness of dif-ferent stress management interventions for preventing anx-iety and depression as the main cause of absenteeism. Con-sequently, this review of systematic reviews focuses on com-mon mental health problems (anxiety, depression) and ab-senteeism.

Undertaking a review of systematic review is challengingmethodologically for two reasons; there is not a conventionalaccepted process to produce a meta-review or meta-synthesisacross different types of systematic reviews, for differentoutcomes, and different complex interventions which maydefy drawing a singular scientific conclusion that requires allsources of heterogeneity be overlooked [19]. Secondly, theambition of the review and the form the findings take have,

Journal of Environmental and Public Health 3

Table 2: Databases searched.

Medline 1950 to November Week 3 2008 (N = 2,470)

PsychInfo 1806 to January Week 2 2009 (N = 1,911)

Embase 1980 to 2009 Week 02 (N = 2,313)

Cochrane database of systematic reviews 4th quarter 2008 (N = 110)

ACP Journal Club 1991 to December 2008 (N = 12)

Cochrane Central Register of Controlled Trials 4th quarter 2008 (N = 432)

Cochrane Methodology Register 4th quarter 2008 (N = 3)

Allied and Complementary Medicine 1985 to January 2009 (N = 335)

British Nursing Index 1985 to January 2009 (N = 41)

Health management information consortium October 2008 (N = 218)

in part, to reflect the subject matter and the types of interven-tions that are being reviewed. So, for complex interventionsfor managing stress at work, there will be organizationaland individual interventions, and different disciplinary ap-proaches to the task of meta-synthesis of narrative findings.The notion of a meta-synthesis of narrative findings is itselfcontested by different qualitative research disciplines fromwhich such approaches have evolved [20, 21]. The purposeof this paper is then to draw together literature and findingswhich are consistent across reviews and methodologicallyvariant studies, where this is possible in order to demonstratethe strength of the findings. However, given the complexnature of interventions to tackle stress at work and thatstress itself and mental health are so ill-defined in studies,we also wish to highlight findings that emerge from a criticalcomparison of reviews; we also wish to highlight the findingsthat are pertinent to well-defined common mental disorders(anxiety and depressive states); we also wish to acknowledgethat narrative synthesis (or meta-synthesis, as it is sometimescalled) may reveal complexities in the field of study suchthat the findings cannot be neatly expressed as a singlestatement of efficacy or effectiveness, but that interventionsmight need to be developed to target specific subpopulations.The findings can, thus, signal the methodological issues thatfuture research must tackle.

3. Methods

The review identified all systematic reviews of evidenceon stress management interventions in the workplace andsummaries, tabulated extracted, and then synthesized theevidence for the relative merits of different interventions.Consistent with previous work, we restricted the review topapers published since 1990, as recency in the literature isimportant to ensure the evidence is related to contemporaryconcepts of stress and work, and to ensure the current workconditions are represented in the evidence synthesis, ratherthan historical work conditions. The databases searched arelisted in Table 2.

The search terms used were:

“psychological ill health or anxiety or stress or distressor burnout,”

“stress management or intervention or rehabilitationor prevention,”

“work or job or employee or sick leave or occupa-tion or workplace adjustments or employee assistanceprogrammes.”

3.1. Inclusion and Exclusion Criteria. The criteria used for in-clusion were

(a) english language articles,

(b) reviews published from 1990 to July 2011,

(c) systematic reviews,

(d) reviews with data/narrative synthesis,

(e) meta-analyses.

The articles excluded were

(a) theoretical and educational reviews,

(b) those published prior to 1990.

3.2. Types of Reviews. The total number of reviews initiallyretrieved after excluding duplicates was 7845 (see Table 1).Twenty three reviews that met the inclusion criteria included499 primary studies/publications. Data were extracted usingthe headings set out in Table 3 by two researchers workingindependently. A third researcher checked for and resolvedany discrepancies with reference to the original publications.

3.3. Outcome Domains. The reviewed studies included manyoutcomes which ranged from physical health measures (e.g.,cardiovascular measures) to psychological and psychiatricmeasures (e.g., well-being, psychological distress, burnout,general mental health, anxiety, depression, stress, psychiatricsymptoms, and psychosomatic symptoms) to organisationalmeasures (e.g., employee satisfaction, motivation, absen-teeism). In this paper, we focus only on articles reporting, (a)individual outcomes of symptoms of anxiety and depression(including severe stress if measured by a specific rating scaleof anxiety and depression) or anxiety and depressive illnessformally assessed using specific diagnostic or psychometricmeasures and (b) absenteeism as an important organisa-tional outcome as this has an economic cost to the employer.


We included key words of anxiety and depression andsevere stress as inclusion criteria, but many studies and re-views are not flagged on this basis, and the findings pertain-ing to these outcomes are often hidden in tables of results.Piloting showed that searches specifically for anxiety anddepression did not easily permit us to identify all studies thatmight include anxiety and depression as outcomes; this wasonly possible after reviewing the full-text paper. Thus, wekept our original searches broad in order to be satisfied allsuch paper that met our inclusion criteria would be included.

3.4. Analysis. Table 3 presents descriptive information on thetwenty three reviews including the dates of published stud-ies/papers included in the reviews, the number of publishedstudies/papers, the prevention level (i.e., primary, secondary,and tertiary), whether the interventions were targeting theindividual (I) or the organisation (O) level, and which levelthe outcomes specified: individual mental health (I) and/orabsenteeism (O).

Due to the heterogeneity of the published reviews interms of the methodology used (i.e., meta-analyses versusnarrative synthesis or meta-narratives), the analysis and syn-thesis of meta-analytic reviews is reported first (see Table 4;11 reviews), then the narrative synthesis reviews (Table 5; 12reviews), each annotated to indicate individual and organ-isational interventions, and individual and organisationaloutcomes (see Table 3).

Including narrative reviews permitted evaluation of in-depth information that might be overlooked in meta-analyticreviews, as this information is important for constructingappropriate interventions and implementing them in orderto prevent severe stress and anxiety and depression at work.For example, components of an appropriate organisationalintervention will be difficult to capture in a meta-analyticreview given these interventions will vary between organi-sations; only in-depth descriptions can capture the compo-nents that can then be considered for similar organisationalcontexts.

For meta-analyses, the effect sizes and original conclu-sions are presented, along with the outcomes used, wherethese were reported (Table 4). For narrative reviews, wepresent the key narrative conclusions (or evidence summarystatement), along with the number of studies finding im-provement (↑), deterioration (↓), or no effect (↔). This wasdone for the same two outcomes: mental health and for ab-senteeism (Table 5).

Judgements about the number of studies finding a posi-tive, negative or no effect in the narrative synthesis were chal-lenging, as many studies tended to use words such as stress,psychological distress, psychosomatic disorders interchange-ably, and negative findings may not have been reported. Weonly rated studies as having effects on mental health (anxietyand depression), where it was clear they had used a specificmeasure of mental disorders or severe stress either alone oras part of a composite measure of mental health and well-being. Where there was doubt, we did not include the studyin the data. This is an advance on existing reviews which tendto group all types of stress, including that associated with

anxiety and depression, and other types of measures of stresssuch that the findings are interpreted with reference to a largenumber of emotional and health states. We felt this approachwould not permit us to isolate the findings of relevance tothe preventing common mental disorders which are the mostimportant cause of sickness-related absenteeism.

4. Results

Eleven reviews included meta-analyses [16, 22–31]; 12 in-cluded a systematic or literature review [32–43] with meta-narrative conclusions (see Table 5).

As set out in Table 3, of the twenty three reviews, fourreported on individual interventions only (three with a meta-analysis) [26, 27, 31, 36]; three of these assessed their impacton individual and organisational outcomes [26, 31, 36],whilst the other one assessed impact on individual outcomesonly [27]. There were three reviews that examined the effect-iveness of only organisational interventions [24, 32, 40]. Ofthese, Parkes and Sparkes [40] and Bond et al. [24] reviewedorganisational outcomes, whereas Egan et al. [32] reportedon individual outcomes.

Six reviews included studies that looked separately atindividual and organisational interventions in the same stud-ies [16, 37, 39–42]. Of these, Mimura and Griffiths [39]reported only on individual outcomes, the rest reported onboth individual and organisational outcomes. The remainingseven reviews assessed interventions at both individual andorganisational levels [23, 25, 29, 30, 33–35]. Of these, onelooked only at organisational outcomes [34], and one lookedat individual outcomes [28]. There were no studies that as-sessed interactions between the two levels of outcome.

4.1. Reviews Reporting Meta-Analysis of Effect Sizes. Elevenreviews [16, 22–31] reported effect sizes from meta-analyses(Table 4) on mental health and absenteeism. The overallimpression from the meta-analytic reviews is that the effectsize is greater at the individual level for individual interven-tions compared with organisational interventions, and thatorganisational or mixed interventions can also impact on themental health of individuals.

4.2. Individual Outcomes: Mental Health. Of these elevenreviews, six showed that individual interventions lead to ben-efit on individual mental health outcomes [16, 23, 25–27,31]. Five reviews of organisational interventions [16, 23, 25,28, 30] together showed mixed evidence of benefit on indi-vidual outcomes; thus Richardson and Rothstein [23] andvan der Klink et al. [25] showed no benefit, whilst Marineet al. [16], Martin et al. [28] and van Wyk and Pillay-VanWyk [30] showed some benefit. Richardson and Rothstein[23] and van der Klink et al. [25] also reviewed mixed inter-ventions, both of which showed benefit at the individual levelon mental health status.

4.3. Organisational Outcomes: Absenteeism. Four reviewsfound individual interventions did not impact on absentee-ism [23, 25, 28, 30]. There was mixed evidence of benefit


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plic

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yle

Inte

rven

tion

Via

Em

ail”

(Aliv

e!),

extr

are

stbr

eak

tim

efo

rw

orke

rsen

gage

din

hig

hly

repe

titi

vew

ork,

am

ult

idis

cipl

inar

yoc

cupa

tion

alh

ealt

hpr

ogra

mm

e,a

mu

ltic

ompo

nen

th

ealt

hpr

omot

ion

prog

ram

me,

part

icip

ator

ypr

oces

ses,

expo

sure

tobl

ue-

enri

ched

ligh

t(v

ersu

sw

hit

elig

ht)

,an

da

tele

phon

ein

terv

enti

onpr

ogra

mfo

rde

pres

sed

wor

kers

14st

udi

eson

pres

ente

ism

RC

Ts=

ran

dom

ised

con

trol

led

tria

ls.


Ta

ble

4:E

ffec

tive

nes

sof

SMIs

byle

vela

nd

outc

ome

ofin

terv

enti

on(r

esu

lts

base

don

lyon

met

a-an

alys

es).

Inte

rven

tion

Indi

vidu

alO

rgan

isat

ion

alM

ixed

/un

spec

ified

Ou

tcom

eIn

divi

dual

Org

anis

atio

nal

Indi

vidu

alO

rgan

isat

ion

alIn

divi

dual

Org

anis

atio

nal

Park

san

dSt

eelm

an,

2008

Ou

tcom

e:ab

sen

teei

sm

Wel

lnes

spr

ogra

mm

eeff

ect

size

(mea

ndi

ffer

ence

betw

een

thos

ew

ith

and

wit

hou

ta

wel

lnes

spr

ogra

mm

e,w

eigh

ted

for

sam

ple

size

)

d=−0

.3,9

5%C

I:−0

.48,

−0.2

2∗∗∗

Ric

har

dson

and

Rot

hst

ein

,200

8G

HQ

,STA

I,

SCL-

90,v

ario

us

anxi

ety

mea

sure

s;T

Q4,

anxi

ety

mea

sure

byB

endi

ng

1956

CB

Tfo

rov

eral

lpsy

chol

ogic

alou

tcom

esco

mbi

ned

d=

1.15

4∗∗

An

xiet

yd=

2.39

0∗∗∗

For

psyc

hol

ogic

alou

tcom

esco

mbi

ned

d=

0.50

7∗∗∗

An

xiet

yd=

0.61

1∗∗∗

Abs

ente

eism

d=

0.21

3

Org

anis

atio

nal

(su

ppor

tgr

oups

and

part

icip

ator

yac

tion

grou

ps)

for

psyc

hol

ogic

alou

tcom

esco

mbi

ned

d=

0.13

4

Men

talH

ealt

hd=

0.16

7

Org

anis

atio

nal

supp

ort

grou

psan

dpa

rtic

ipat

ory

acti

ongr

oups

for

abse

nte

eism

d=−0

.159

Stre

ssd=

7.27

∗∗∗

An

xiet

yd=

0.67

8∗∗∗

Men

talH

ealt

hd=

0.44

1∗∗∗

Bon

det

al.,

2006

Mor

eco

ntr

olle

adto

redu

ced

abse

nte

eism

4st

udi

esd=−.

1195

%C

I:−.

15to−.

08

Smal

lan

dsi

gnifi

can

t

Mor

esu

ppor

tle

ads

tole

ssab

sen

teei

sm1

stu

dyd=−1

695

%C

I:−.

24to−.

09

Smal

lan

dsi

gnifi

can

tC

omm

un

icat

ion

lead

sto

less

abse

nte

eism

d=−.

23Sm

all-

to-m

ediu

meff

ect

and

sign

ifica

nt


Ta

ble

4:C

onti

nu

ed.

Inte

rven

tion

Indi

vidu

alO

rgan

isat

ion

alM

ixed

/un

spec

ified

Ou

tcom

eIn

divi

dual

Org

anis

atio

nal

Indi

vidu

alO

rgan

isat

ion

alIn

divi

dual

Org

anis

atio

nal

Mar

ine

etal

.,20

06

Mea

sure

sof

stat

ean

dtr

ait

anxi

ety

STA

I,G

HQ

,Bec

k

Pers

on-d

irec

ted

inte

rven

tion

sve

rsu

sco

ntr

ol:

Stat

ean

xiet

y:W

MD

=−9

.42,

CI:−1

6.92

to−1

.93

Trai

tan

xiet

yW

MD

=−6

.91;

95%

CI:−1

2.80

,−1.

01

Fin

din

gssu

stai

ned

inm

ediu

mte

rm:

Stat

ean

xiet

y:W

MD

=−0

.831

,C

I:−1

1.49

to−5

.13

Trai

tan

xiet

y:W

MD

=−4

.09,

CI:−7

.6to−0

.58

GH

Q:p

erso

ndi

rect

edin

terv

enti

ons

did

not

redu

cesy

mpt

oms:

WM

D=

−11.

87,C

I:−2

7.24

to3.

49

GH

Qsy

mpt

oms

redu

ced

follo

win

gco

mbi

nat

ion

ofkn

owle

dge

skill

str

ain

ing,

prog

ram

me

plan

nin

g

WM

D:−

2.9,

CI:

−5.1

6to−0

.64.

An

xiet

yn

otm

easu

red

Oth

ersi

ngl

est

udi

esu

sin

gSC

Lan

dG

HQ

did

not

chan

gere

sult

s

Van

der

Klin

ket

al.,

2001

Not

liste

d

CB

Ton

anxi

ety

d=

0.70

∗∗∗

Rel

axat

ion

onan

xiet

yd=

0.25

∗

Sum

mat

ion

onan

xiet

yd=

0.54

∗∗∗

CB

Ton

depr

essi

ond=

0.23

Rel

axat

ion

onde

pres

sion

d=

0.11

Sum

mat

ion

onde

pres

sion

d=

0.33

∗∗

CB

Ton

abse

nte

eism

d=−0

.18

Rel

axat

ion

onab

sen

teei

smd=−0

.09

Sum

mat

ion

onab

sen

teei

smd=−0

.12

Dep

ress

ion

d=

0A

bsen

teei

smd=

0

An

xiet

yd=

0.50

∗∗∗

Dep

ress

ion

d=

0.59

∗∗∗

Sau

nde

rset

al.,

1996

Mea

sure

sof

stat

eor

trai

tan

xiet

y,ST

AI.

Oth

ers

not

liste

d

Perf

orm

ance

anxi

ety

r=

0.50

9∗∗

Stat

ean

xiet

yr=

0.37

3∗∗

Pen

alba

,McG

uir

e,Le

ite,

2009

(ele

ctro

nic

sear

ches

on12

/5/0

8

Han

dse

arch

es19

73–1

990)

On

epr

imar

ypr

even

tion

stu

dyB

ackm

an(1

997)

:men

tali

mag

ing

trai

nin

gve

rsu

sco

ntr

ol

14 Journal of Environmental and Public HealthT

abl

e4:

Con

tin

ued

.

Inte

rven

tion

Indi

vidu

alO

rgan

isat

ion

alM

ixed

/un

spec

ified

Ou

tcom

eIn

divi

dual

Org

anis

atio

nal

Indi

vidu

alO

rgan

isat

ion

alIn

divi

dual

Org

anis

atio

nal

SCL-

90de

pres

sion

subs

cale

GH

Q

Dep

ress

ion

outc

ome:

MD

(fixe

deff

ect)−2

.14,

CI:−4

to−0

.28

aten

dpo

int

(in

favo

ur

ofin

terv

enti

on)

18m

onth

sla

ter:

MD

=−0

.97,

CI:−2

.43

to0.

49

GH

Qou

tcom

e:M

D=

2.74

,C

I:0.

78–4

.7(i

nfa

vou

rof

con

trol

)

18m

onth

follo

wu

p:M

D=

1.3,

CI:−0

.61

to3.

21

On

ese

con

dary

prev

enti

onst

udy

inte

rven

tion

vers

us

con

trol

:N

orve

ll(1

993)

Dep

ress

ion

:MD=−7

.32,

CI:−1

1.79

to−2

.85

infa

vou

rof

inte

rven

tion

An

xiet

y:M

D=−3

.1,C

I:−6

.94

to0.

6in

favo

ur

ofin

terv

enti

on

All

prev

enti

onve

rsu

sco

ntr

olpo

sth

ocse

lect

edou

tcom

es:

Dep

ress

ion

:(B

ackm

an,1

977;

Nor

vell,

1993

)

Dep

ress

ion

outc

ome:

MD

=−0

.8,

CI:−1

.36

to−0

.24,

infa

vou

rof

inte

rven

tion

Mar

tin

2009

Pu

blis

hed

1997

–200

0

Stan

dard

ised

mea

sure

s,an

xiet

y,de

pres

sion

and

com

posi

tem

easu

re

CE

S-D

BSI

Dep

ress

ion

:SM

D=

Smal

lbu

tsi

gnifi

can

teff

ect:

Dep

ress

ion

:SM

D=

0.28

,CI:

0.12

–0.4

4

An

xiet

y:SM

D=

0.29

,CI:

0.06

–0.5

1

Sin

gle

tria

lofs

tres

sm

anag

emen

tpr

ogra

mm

e:de

pres

sion

:SM

D=

0.69

Dep

ress

ion

:SM

D:0

.31,

CI:

0.1–

0.51

An

xiet

y

SMD

:0.2

5,C

I:0.

03–0

.53

Impr

ovem

ent

mai

nta

ined

atfo

llow

up

(on

ly9

of17

stu

dies

repo

rtfo

llow

up)

5st

udi

esh

addi

ffer

ent

met

hod

s:

Dep

ress

ion

insm

okin

gce

ssat

ion

tria

l:w

orse

nin

gSM

D=−0

.08

(on

CE

SDsc

ale)

,no

diff

eren

cein

BSI

outc

omes

ofde

pres

sion

:SM

D=

0.03

,an

xiet

ySM

D=

0.05

Journal of Environmental and Public Health 15T

abl

e4:

Con

tin

ued

.

Inte

rven

tion

Indi

vidu

alO

rgan

isat

ion

alM

ixed

/un

spec

ified

Ou

tcom

eIn

divi

dual

Org

anis

atio

nal

Indi

vidu

alO

rgan

isat

ion

alIn

divi

dual

Org

anis

atio

nal

Con

n20

09

(ele

ctro

nic

sear

ches

1969

–200

7)

Moo

d(s

elfr

epor

t-m

easu

ren

otre

port

ed)

Wor

kat

ten

dan

ce

Un

clea

rw

hic

hst

udi

esth

atw

ere

rep

orte

dco

ntr

ibu

ted

toth

eeff

ect

size

s,an

dw

het

her

they

use

din

divi

dual

oror

gan

isat

ion

alin

terv

enti

ons

Moo

d

2gr

oup

post

test

:mea

nof

effec

tsi

ze(M

ES)

:0.1

3,C

I:−0

.05

to0.

31(N

S)

2gr

oup

pre-

and

post

test

:ME

S=

0.21

,CI:

0.07

to0.

36∗∗

Trea

tmen

tpr

ean

dpo

st:

ME

S+

0.31

,CI:

0.22

to0.

4∗∗∗

Wor

kat

ten

dan

ce:

2gr

oup

post

test

:ME

S=

0.19

,CI:

0.11

to0.

27∗∗∗

2gr

oup

pre

pos

tte

st:

ME

S=

0.05

,CI:−0

.19

to0.

29

Trea

tmen

tpr

ep

ost

test

:M

ES

0.02

,CI:−0

.08

to0.

13(N

S)

Wor

kpla

cein

terv

enti

ons

had

bett

erre

sult

s,as

did

inte

rven

tion

inpa

idti

me,

stu

dies

wit

hon

site

fitn

ess

faci

litie

s

Van

Wyk

(201

0)

Stat

ean

dtr

ait

anxi

ety

inde

x

Car

eer

iden

tity

trai

nin

gin

one

stu

dydo

esn

otim

prov

ean

xiet

yin

nu

rses

:mea

ndi

ffer

ence

:−0

.06,

CI:−0

.44

to0.

32

Von

Bae

yer’

s3

sess

ion

stre

ssm

anag

emen

ttr

ain

ing

show

edm

argi

nal

ben

efit.

Stan

dard

ised

mea

ndi

ffer

ence

:−1

.45,

CI:−2

.67

to0.

22

Wei

r(1

997)

asse

ssed

effec

tof

man

agem

ent

inte

rven

tion

toim

prov

epr

oces

sco

nsu

ltat

ion

betw

een

nu

rse

man

ager

san

dst

affon

mea

nh

ours

abse

nce

ofst

affin

aco

mm

un

ity

hos

pita

lNo

diff

eren

ce:m

ean

diff

eren

ce=

20.3

5,C

I:−1

0.65

to51

.35

Noo

rdik

(201

0)

Spec

ific

outc

omes

not

liste

d

Abs

ente

eism

not

give

nas

sepa

rate

outc

ome

from

wor

kfu

nct

ion

Eff

ects

onA

nxi

ety

2st

udi

esin

met

a-an

alys

is,

SMD

=−0

.54,

CI:−1

.26

to0.

16

Gro

up

expo

sure

CB

Tan

dm

edic

atio

nve

rsu

son

lym

edic

atio

n:S

MD

=0.

87,

CI:

0.34

to1.

39

Exp

osu

rein

vivo

and

med

icat

ion

vers

us

only

med

icat

ion

:1,C

I:0.

52to

1.49

Larg

eeff

ect

size

d(>

0.8)

judg

edto

indi

cate

sign

ifica

nt

resu

ltw

ith

out

form

alst

atis

tica

ltes

ts

KE

Y:d=

effec

tsi

ze,S

MD

=st

anda

rdis

edm

ean

diff

eren

ce,W

MD

=w

eigh

ted

mea

ndi

ffer

ence

,CI=

con

fide

nce

inte

rval

.∗∗∗

P=

0.00

1,∗∗

P=

0.01

,∗P=

0.05

.W

hen

inte

rven

tion

typ

esar

en

otsp

ecifi

edth

ein

terv

enti

onsu

mm

edin

the

resp

ecti

vece

llar

em

ult

iple

and

too

man

yto

list.

Bol

dde

not

esa

stat

isti

cally

sign

ifica

nt

outc

ome.


Ta

ble

5:St

udi

esof

inte

rven

tion

sre

ach

ing

nar

rati

veco

ncl

usi

ons

wit

hou

tm

eta-

anal

yses

ofeff

ect

size

s.

Ou

tcom

eN

um

ber

ofst

udi

es,d

ate

ran

ge,

and

key

obje

ctiv

eof

revi

ewM

H↑

MH↓

MH↔

A↑

A↓

A↔

Nar

rati

veco

ncl

usi

ons

Ega

net

al.,

2007

18st

udi

es

1981

–200

6

Psyc

hos

ocia

lan

dh

ealt

heff

ects

ofw

orkp

lace

reor

gan

isat

ion

Org

anis

atio

nal

leve

lin

terv

enti

ons

toim

prov

eem

ploy

eeco

ntr

ol

61

84

1So

me

evid

ence

ofim

prov

edm

enta

lhea

lth

asem

ploy

eeco

ntr

olin

crea

ses

and,

less

con

sist

entl

y,w

hen

dem

ands

decr

ease

Lam

onta

gne

etal

.,20

07

90st

udi

es

1990

–200

5

Job

stre

ssin

terv

enti

onlit

erat

ure

201

2021

18

Indi

vidu

alfo

cuss

ed,l

owra

tes

syst

ems

appr

oach

esar

eeff

ecti

veat

the

indi

vidu

alle

velo

nan

xiet

yan

dde

pres

sion

Org

anis

atio

nal

lyfo

cuss

edh

igh

and

mod

erat

ely

rate

dsy

stem

sap

proa

chin

terv

enti

ons

for

job

stre

sssh

owfa

vou

rabl

eim

pact

sat

both

orga

nis

atio

nal

and

indi

vidu

alle

vels

.Ofh

igh

rate

dst

udi

es,a

lmos

tal

lsh

owed

decl

ine

inab

sen

teei

sm

Th

eB

OH

RF,

2005

19ex

peri

men

tals

tudi

es

12n

onex

peri

men

tals

tudi

es

Up

un

tilA

pril

2004

Wor

kpla

cein

terv

enti

ons

for

peop

lew

ith

com

mon

men

tal

hea

lth

prob

lem

s

171

43

1

Ear

lyps

ych

olog

ical

inte

rven

tion

s,in

clu

din

gC

BT

and

ara

nge

ofst

ress

man

agem

ent

inte

rven

tion

s,ar

eeff

ecti

vefo

rco

mm

onm

enta

lhea

lth

prob

lem

s

Indi

vidu

alst

ress

man

agem

ent

appr

oach

esw

ere

effec

tive

and

pref

erab

leto

mu

ltim

odal

inte

rven

tion

sfo

rre

duci

ng

stre

ssC

BT

effec

tive

for

sick

nes

sab

sen

ces

asso

ciat

edw

ith

com

mon

men

tal

hea

lth

prob

lem

s

Edw

ards

and

Bu

rnar

d,20

03

70st

udi

es

1966

–200

0

Eff

ecti

ven

ess

ofst

ress

man

agem

ent

for

nu

rsin

gin

UK

51

1

Six

stre

ssm

anag

emen

tin

terv

enti

onst

udi

esin

UK

and

one

inT

he

Net

her

lan

dssh

owth

attr

ain

ing

inbe

hav

iou

ralt

ech

niq

ues

impr

oved

leve

lsof

sick

nes

sin

psyc

hia

tric

nu

rses

.Lev

els

ofps

ych

olog

ical

dist

ress

redu

ced

follo

win

ga

15w

eek

trai

nin

gco

urs

ein

ther

apeu

tic

skill

s

Agr

eat

deal

iskn

own

abou

tst

ress

atw

ork,

how

tom

easu

reit

,an

dim

pact

onm

any

outc

omes

.How

ever

,we

lack

rese

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from organisational interventions on absenteeism. Parks andSteelman [22] and Bond et al. [24] found some evidenceof benefit, whereas Richardson and Rothstein [23] and vander Klink et al. [25] found no benefit. However, Conn et al.[29] showed clear benefit of organisational physical activityinterventions on absenteeism. There were no studies ofmixed individual-organisational interventions and impact onabsenteeism.

4.4. Reviews Reporting Narrative Conclusions. The overallconclusions from the narrative reviews support the findingsfrom the meta-analyses that individual interventions doprovide benefit at an individual level and reduce symptomsof anxiety and depression and stress, but individual interven-tions do not impact on absenteeism. However, organisationalinterventions impact at both individual and organisation-al levels. There are numerous studies of benefit on mentalhealth outcomes, whereas benefit on absenteeism is mainlyreported in one review [33] including a number of highquality studies (Table 5). Worryingly, some interventionsappeared to lead to deterioration in mental health [16, 32–35] and absenteeism [33, 36] outcomes (see Table 5). For ex-ample, Marine et al. [16] identifies smoking cessation to beassociated with depression. Although not directly mappingon to absenteeism, preliminary evidence from Cancelliereet al. [43] suggested that some workplace health promotionprogrammes can reduce presenteeism (being at work whilstunwell). Presenteeism correlated with being overweight, apoor diet, a lack of exercise, high stress levels, poor relation-ships with coworkers and management.

4.5. The Effectiveness of Specific Interventions. The differenttypes and components of interventions, and whether they areprimary, secondary, or tertiary preventive interventions, areset out in Table 3. The majority of studies were of primaryprevention. The meta-analytic reviews found that cognitivebehavioural programmes consistently produced larger effectsat the individual level compared to other types of interven-tions (e.g., relaxation). Cognitive behavioural programmeswere also suggested to be more effective by some of the nar-rative reviews [27, 31, 34–36] as well as by some of the meta-analyses [23, 25].

Murphy [36] found that multimodal interventions (orcombination strategies), which involved CBT produced themost consistent, significant results; a result which was notsupported by one meta-analytic review [25]. Overall, thereviews suggested that organisational level interventions aretoo scarce and there is also a lack of studies that assess organi-sational-level outcomes. However, two meta-analytic reviews[22, 29] found that participation in organisational wellnessprogrammes was associated with decreased absenteeism andincreased job satisfaction. These were the only meta-analyticreviews of organisational based interventions and organisa-tional-level outcomes. Finally, there are insufficient studies tocomment on the potential complementarity of interventionsthat operate at primary, secondary, and tertiary preventionlevels [33]. Four studies investigated both primary and

secondary prevention but not their interaction [23, 27, 33,34].

5. Discussion

As anticipated, the evidence was in complex form. Ourmethods of isolating findings related to anxiety and depres-sion, and partitioning the tabulation and extraction andsynthesis by individual/organisational interventions and out-comes provides a rich, complex but authentic picture of theevidence base. There are indications for which interventionsare effective and also gaps in the evidence. Reviews had totake account of many interventions that differed by theircomponents, mode of delivery and whether they targetedindividuals or organisations. This made it difficult for all ofthe reviews to compare benefits from any single interventionacross a number of studies, except for CBT or physical ac-tivity. There were also many different outcome measures forassessing anxiety and depression, and many proxy measuresof mental health, sometimes without clarity about whichoutcomes were used in the meta-analyses. In part, these werenot specified due to the way multiple outcomes were handledin the analysis. The reviews used standardised differencesincluding mean differences and mean effect sizes, and stand-ardised differences and means. Using a consistent set of out-comes to measure anxiety and depression in future primarystudies will ensure that future reviews and meta-analyses canovercome these challenges, such that different intervention,of varying complexity and modes of delivery, might becompared more directly for impacts on absenteeism and onanxiety and depression and interactions between the individ-ual and organisational impacts.

Overall, individual interventions show larger effectscom-pared with organisational interventions or mixed interven-tions; benefits are seen mainly at the individual level al-though some studies do show organisational benefits. Giventhat anxiety and depression are common, and mostly ac-count for sickness absence, it is important to develop anevidence base that is specific to these manifestations ofmental distress and illness, with an agreed range of acceptableoutcome measures and for interventions that prevent andtreat anxiety and depression promptly, as well as encour-age early return to work. A small improvement in sick-ness absence statistics might yield substantial benefits forbusiness viability and provision of services. Standardisedmethods to measure presenteeism [43] are needed. Theonly organisational intervention to show convincing effectson absenteeism was physical activity programmes [29], butmental imaging, CBT, and in vivo exposure, each have auseful role, especially in secondary prevention. Althoughbetter quality studies should be given greater weight, thequality of individual primary studies was selectively reported,making it difficult to know whether the positive findingsreflected better quality studies; certainly, CBT and physicalactivity interventions are more well defined than say stressmanagement standards or management practices or stressinoculation. Even counselling can take many forms, andthere is not a standardised process. Similarly, the duration of


the interventions and timing of measurement of outcomeswas not a characteristic on which reviews drew conclusions;we were unable to draw any metaevidence about timingunless we had looked at primary studies. Strikingly, althoughmany reviews on face value were reviewing the same evi-dence, the reviews did not all identify the same primary stud-ies, and therefore did not always reach the same conclusions;our meta-review, for the first time, brings together all of thestrongest findings. We reviewed 23 reviews, after identifying7845 potential publications for inclusion. These included499 primary studies; the majority of reviews made the pointthat drawing metanarrative or meta-analytic conclusions wasdifficult because of this diversity in outcomes, intervention,and methods. Had we undertaken a review of 499 primarystudies, it is likely we would draw the same conclusions.

Management skills training, and support for staff, alongwith methods to cope with work stress all seem relevantcomponents, but the review was not convincing about a pos-itive benefit of these and where positive impacts were seenat individual levels [16, 28]; the effect could not entirely beattributed to improved management standards or workingrelationships. There has been insufficient research on organ-isational interventions. These studies are difficult to designand implement and require further research. On the otherhand, more and more interest has been generated towardshealth promotion in the workplace (e.g., exercise) and en-couraging individuals to take ownership of health risk be-haviours and decisions about health, well-being, and familyoutside of work. This may be promising, as it requires theworkforce to maintain healthy lifestyles generally and withinthat context to consider work stress rather than considerwork as the only venue for health interventions. Organisa-tional measures to increase physical activity show promisingresults [43].

This review suggests that there is lack of evidence incomparing the relative effectiveness of stress managementinterventions that operate at both individual and organisa-tional levels, or interventions that encourage an interactiveor systemic effect, yet this might yield greater benefits at bothlevels.

However, there are still a number of evidence gaps. Moreresearch is needed in the private sector and in smaller compa-nies as well as research comparing different job types such aseducation and healthcare to examine whether they respondto the same or different intervention techniques. Similarly,research needs to take into account factors such as socioeco-nomic status, duration of any effects of interventions, andcost effectiveness. Selection bias may be an important ex-planation for our findings. For example, organisations withthe most stressful work environments are less likely to par-ticipate in research as opposed to organisations with littlestress amongst employees. Consequently, organisations withlow baseline stress levels would make any effects from tar-geted interventions more difficult to capture. However, pre-liminary support was found in one meta-analytic review thatinterventions conducted with employees at high levels ofbaseline stress appeared to be at least as effective as inter-ventions conducted with employees at low levels of baseline

stress [25]. What works for whom and the maintenance ofthese effects need further research [32].

Finally, there is a relative lack of studies with clinicallyreferred employees. We did find more of these in morerecent years (since 2008) and also reviews of health careworkers and law enforcement officers who perhaps need spe-cific attention given the unique circumstances and stressorsto which they are exposed at work. The few methodologicallyrigorous studies that have been conducted with patientshave not included nontreatment control groups but havecompared 2 treatment types. More work might, therefore,be undertaken on populations at risk using secondary andtertiary prevention interventions.

6. Conclusions

CBT was the most effective individual targeted interventionfor individual outcomes. Encouragement of physical activityat an organisational level seems to reduce absenteeism. In-terventions need to be developed that can provide consistentand stronger effects on organisational outcomes such as ab-senteeism. There were a number of gaps in the literature, par-ticularly studies investigating the influence of specific occu-pations, and different sized organisations, different sectors oforganisations (public, private, and not for profit). Studies ofmanagement practices seemed not to show strong effects, butthere are still insufficient studies in this area. There were fewstudies of secondary and tertiary prevention.

Conflict of Interests

The authors declare that they have no conflict of interests.

Authors’ Contribution

K. S. Bhui conceived of the study, was the principal inves-tigator, provided day-to-day management, and along withSD read the reviews, extracted and tabulated the data andcodrafted the paper. S. A. Stansfeld and P. D. White were thecoinvestigators to the project, and commented on and editedall drafts of the paper. All authors contributed equally to thiswork.

Acknowledgment

This work was supported by the Department of Health in UKto K. S. Bhui.

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OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinson’s Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

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