Workplaces are an important location for population mental health interventions. Screening to detect employees at risk of or experiencing mental ill health is increasingly common. This systematic review and meta-analysis examined the efficacy of workplace mental health screening programmes on employee mental health, work outcomes, user satisfaction, positive mental health, quality of life, help-seeking and adverse effects. PubMed, PsycINFO, EMBASE, CENTRAL, Global Index Medicus, Global Health and SciELO were searched (database inception-10 November 2022) and results screened by two independent reviewers. Controlled trials evaluating screening of workers' mental health as related to their employment were included. Random effects meta-analysis was performed to calculate pooled effect sizes for each outcome of interest. Grading of Recommendations Assessment, Development and Evaluation was conducted to evaluate the certainty of findings. Of the 12 328 records screened, 11 were included. These reported 8 independent trials collectively assessing 2940 employees. Results indicated screening followed by advice or referral was ineffective in improving employee mental health symptoms (n=3; d=-0.07 (95% CI -0.29 to 0.15)). Screening followed by facilitated access to treatment interventions demonstrated a small improvement in mental health (n=4; d=-0.22 (95% CI -0.42 to -0.02)). Limited effects were observed for other outcomes. Certainty ranged from low to very low. The evidence supporting workplace mental health screening programmes is limited and available data suggest mental health screening alone does not improve worker mental health. Substantial variation in the implementation of screening was observed. Further research disentangling the independent effect of screening alongside the efficacy of other interventions to prevent mental ill health at work is required.
Background
Healthcare workers can suffer from work-related stress as a result of an imbalance of demands, skills and social support at work. This may lead to stress, burnout and psychosomatic problems, and deterioration of service provision. This is an update of a Cochrane Review that was last updated in 2015, which has been split into this review and a review on organisational-level interventions.
Objectives
To evaluate the effectiveness of stress-reduction interventions targeting individual healthcare workers compared to no intervention, wait list, placebo, no stress-reduction intervention or another type of stress-reduction intervention in reducing stress symptoms.
Search methods
We used the previous version of the review as one source of studies (search date: November 2013). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Web of Science and a trials register from 2013 up to February 2022.
Selection criteria
We included randomised controlled trials (RCT) evaluating the effectiveness of stress interventions directed at healthcare workers. We included only interventions targeted at individual healthcare workers aimed at reducing stress symptoms.
Data collection and analysis
Review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We categorised interventions into ones that:
1. focus one's attention on the (modification of the) experience of stress (thoughts, feelings, behaviour);
2. focus one's attention away from the experience of stress by various means of psychological disengagement (e.g. relaxing, exercise);
3. alter work-related risk factors on an individual level; and ones that
4. combine two or more of the above.
The crucial outcome measure was stress symptoms measured with various self-reported questionnaires such as the Maslach Burnout Inventory (MBI), measured at short term (up to and including three months after the intervention ended), medium term (> 3 to 12 months aGer the intervention ended), and long term follow-up (> 12 months aGer the intervention ended).
Main results
This is the second update of the original Cochrane Review published in 2006, Issue 4. This review update includes 89 new studies, bringing the total number of studies in the current review to 117 with a total of 11,119 participants randomised.
The number of participants per study arm was >= 50 in 32 studies. The most important risk of bias was the lack of blinding of participants.
Focus on the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention
Fifty-two studies studied an intervention in which one's focus is on the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (standardised mean difference (SMD) -0.37, 95% confidence interval (CI) -0.52 to -0.23; 41 RCTs; 3645 participants; low-certainty evidence) and medium term (SMD -0.43, 95% CI -0.71 to -0.14; 19 RCTs; 1851 participants; low-certainty evidence). The SMD of the short-term result translates back to 4.6 points fewer on the MBI-emotional exhaustion scale (MBI-EE, a scale from 0 to 54). The evidence is very uncertain (one RCT; 68 participants, very low-certainty evidence) about the long-term effect on stress symptoms of focusing one's attention on the experience of stress.
Focus away from the experience of stress versus no intervention/wait list/placebo/no stress-reduction intervention
Forty-two studies studied an intervention in which one's focus is away from the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (SMD -0.55, 95 CI -0.70 to -0.40; 35 RCTs; 2366 participants; low-certainty evidence) and medium term (SMD -0.41 95% CI -0.79 to -0.03; 6 RCTs; 427 participants; low-certainty evidence). The SMD on the short term translates back to 6.8 fewer points on the MBI-EE. No studies reported the long-term effect.
Focus on work-related, individual-level factors versus no intervention/no stress-reduction intervention
Seven studies studied an intervention in which the focus is on altering work-related factors. The evidence is very uncertain about the short-term effects (no pooled effect estimate; three RCTs; 87 participants; very low-certainty evidence) and medium-term effects and long-term effects (no pooled effect estimate; two RCTs; 152 participants, and one RCT; 161 participants, very low-certainty evidence) of this type of stress management intervention.
A combination of individual-level interventions versus no intervention/wait list/no stress-reduction intervention
Seventeen studies studied a combination of interventions. In the short-term, this type of intervention may result in a reduction in stress symptoms (SMD -0.67 95%, CI -0.95 to -0.39; 15 RCTs; 1003 participants; low-certainty evidence). The SMD translates back to 8.2 fewer points on the MBI-EE. On the medium term, a combination of individual-level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect (SMD -0.48, 95% CI -0.95 to 0.00; 6 RCTs; 574 participants; low-certainty evidence). The evidence is very uncertain about the long term effects of a combination of interventions on stress symptoms (one RCT, 88 participants; very low-certainty evidence).
Focus on stress versus other intervention type
Three studies compared focusing on stress versus focusing away from stress and one study a combination of interventions versus focusing on stress. The evidence is very uncertain about which type of intervention is better or if their effect is similar.
Authors' conclusions
Our review shows that there may be an effect on stress reduction in healthcare workers from individual-level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. Long-term effects of individual-level stress management interventions remain unknown. The same applies for interventions on (individual-level) work-related risk factors.
The bias assessment of the studies in this review showed the need for methodologically better-designed and executed studies, as nearly all studies suffered from poor reporting of the randomisation procedures, lack of blinding of participants and lack of trial registration. Better-designed trials with larger sample sizes are required to increase the certainty of the evidence. Last, there is a need for more studies on interventions which focus on work-related risk factors.
Workplaces are an important location for population mental health interventions. Screening to detect employees at risk of or experiencing mental ill health is increasingly common. This systematic review and meta-analysis examined the efficacy of workplace mental health screening programmes on employee mental health, work outcomes, user satisfaction, positive mental health, quality of life, help-seeking and adverse effects. PubMed, PsycINFO, EMBASE, CENTRAL, Global Index Medicus, Global Health and SciELO were searched (database inception-10 November 2022) and results screened by two independent reviewers. Controlled trials evaluating screening of workers' mental health as related to their employment were included. Random effects meta-analysis was performed to calculate pooled effect sizes for each outcome of interest. Grading of Recommendations Assessment, Development and Evaluation was conducted to evaluate the certainty of findings. Of the 12 328 records screened, 11 were included. These reported 8 independent trials collectively assessing 2940 employees. Results indicated screening followed by advice or referral was ineffective in improving employee mental health symptoms (n=3; d=-0.07 (95% CI -0.29 to 0.15)). Screening followed by facilitated access to treatment interventions demonstrated a small improvement in mental health (n=4; d=-0.22 (95% CI -0.42 to -0.02)). Limited effects were observed for other outcomes. Certainty ranged from low to very low. The evidence supporting workplace mental health screening programmes is limited and available data suggest mental health screening alone does not improve worker mental health. Substantial variation in the implementation of screening was observed. Further research disentangling the independent effect of screening alongside the efficacy of other interventions to prevent mental ill health at work is required.
