HealthcarePapers

HealthcarePapers 5(2) October 2004 : 91-94.doi:10.12927/hcpap..16827
Researcher Response

Research Priorities Are Critical

William H. Gnam

Abstract

Building on the review by Goldner et al., I argue that the first research tasks for disability management in Canada should be to articulate conceptual models; define promising disability management interventions and characterize the current longitudinal health and labour market trajectories of Canadians disabled by mental conditions. Research should next emphasize pilot studies of novel interventions and observational studies that examine the relationship between treatment, workplace interventions, work environments and disability outcomes. Selective randomized trials of disability management interventions should be considered downstream. Mental health treatment optimization should be assigned a lower funding priority than research on workplace interventions.
At the outset, allow me to congratulate the authors of this review paper for their admirable work in pulling together and organizing a very sparse and scattered literature on disability management and return to work for mental health problems, substance abuse and mental illness (hereafter referred to collectively as mental conditions). Without doubt the research directions identified by the authors are appropriate and cover much of the important terrain. The review did not assign priorities or suggest a logical sequence for the evolution of future research. The primary objective of this discussion is to suggest priorities and sequences within the multiple directions identified. I also argue on behalf of additional research programs, and I identify the broad implications of the research agenda for methodology and data development. The discussion is selective, but it assumes that there is no minimally adequate and coherent foundation of research pertaining to disability management and return to work for mental conditions in Canada. I believe that the synthesis by Goldner et al. supports this view. I focus primarily upon the disability management of moderately severe mental conditions - the types of conditions experienced by those who have had or would have meaningful labour force participation. This approach does not discount the importance of disability management research for the severe mental conditions, but it acknowledges that research on disability management strategies (such as supported employment) for persons with severe mental conditions is considerably further advanced (Latimer 2001) than the research on moderately severe conditions.

The first tasks of disability management research in Canada should be threefold: (1) articulating conceptual frameworks and models for the disability management of mental conditions; (2) defining promising disability management interventions, possibly adapted from approaches used for physical disabilities; and (3) characterizing the current longitudinal health and labour market trajectories of Canadians who become disabled by mental health problems. The first two tasks address the need to identify what may be unique to the disability management of mental conditions, without necessarily discarding the extant approaches developed to manage physical disabilities.

The last task requires more elaboration. The agenda here includes describing the incidence and patterns of short-term disability durations and outcomes, and transitions to long-term disability, in relation to sex, age, occupation, economic sector and geographical region. The results of this research would enhance subsequent research on disability management by establishing baseline performance, defining high-risk working populations and characterizing the longitudinal aspect. The longitudinal trajectory may be particularly important in moderately severe mental conditions, which by nature are chronic but episodic; if researchers do not understand the risk of repeated disability episodes over time, disability management interventions may become too focused on short-term objectives and outcomes. Describing the trajectories of mental disability may also create the opportunity to stage mental conditions - that is, empirically define critical intervals in the elapsed time from onset that can guide the nature of disability management interventions. Staging has significantly enhanced the disability management of low back injury by defining the intervals during which interventions have the greatest impact (Hogg-Johnson et al. 2000). Staging is also consistent with the evolution in mental condition treatment research, which increasingly emphasizes early intervention at the time of first episode. One implication of this task is that innovative partnerships will be required, since most of the relevant data on disability that is related primarily to mental conditions resides with private insurers.

Upon completion of the initial tasks, disability management research in Canada should next emphasize pilot and feasibility studies of novel interventions, as well as cross-sectional and prospective studies that examine more systematically the relationship between treatment, workplace interventions, work environments and disability outcomes, including return-to-work and downstream labour market outcomes. The emphasis at this stage should not be on experimental (i.e., randomized) designs, given their enormous incremental costs, but on the spectrum of longitudinal and quasi-experimental methods.

The above agendas establish the foundations for selective randomized trials of disability management interventions, which in my opinion should comprise an important but downstream component of intervention research in disability management. Even now, however, it may be worthwhile to assign a higher research funding priority to certain kinds of intervention research. Goldner et al. note that established disability management principles have never been systematically applied to disabling mental conditions. The term "disability management" encompasses a wide range of interventions, including attempts to optimize clinical treatment. On the basis of direct and indirect evidence, I believe that the optimization of mental health treatment (Goldner et al.'s sixth research direction) should be assigned a lower funding priority than research to develop and validate workplace interventions. The review paper concludes that organizational interventions to improve the clinical treatment of depression have had a minimal or negligible impact upon return to work. The studies demonstrating this were all conducted in the United States, but I believe that the implications are equally compelling for Canada. Further (indirect) support for assigning priority to workplace interventions comes from back injury research. The most rigorous disability management research on back injury conducted in Canada (Loisel et al. 1997; Yassi et al. 1995) demonstrates that workplace interventions are far more effective than clinical interventions in facilitating return to work. The active elements in workplace interventions include work modification and accommodation, enhanced communication between healthcare providers and workplace participants, and a supportive and helpful environment for injured workers when they return to work (Brooker et al. 2000). For soft tissue injuries these elements are well defined, but for mental conditions they remain completely undefined. Developing innovative workplace interventions related to mental conditions will likely result in far greater advances in disability reduction than attempts to improve clinical treatment.

Finally, I would argue that almost all disability management research for mental conditions in Canada should be informed by careful consideration of certain organizational structures of work. For many Canadian workers with disabilities arising primarily from mental conditions, disability management consists of a highly fragmented insurance and service system. In large companies, the responsibility for disability management services may be shared by the worker, employee assistance programs, human resource departments and the public healthcare system. There are virtually no incentives or traditions that encourage coordination of services between these entities. Insurance benefits may be provided by companies, several private insurers, workers compensation boards or other public disability insurance programs. In large companies, pharmaceutical benefits and disability payments are frequently provided by separate insurers. This fragmentation likely results in poor coordination of benefits and services, as well as differential incentives that may not optimally support a timely return to work. Understanding these organizational structures is imperative as researchers appraise the feasibility and dissemination potential of interventions they wish to study. Of course, this analysis also suggests that policy research on innovative organization structures should also be added to the somewhat daunting list of research priorities.

About the Author(s)

William H. Gnam, MD, FRCP(C), PhD
Centre for Addiction and Mental Health,
Health Systems Research and Consulting Unit
University of Toronto, Department of Psychiatry

References

Brooker, A-S, J. Clarke, S. Sinclair,V. Pennick and S. Hogg-Johnson. 2000. "Effective Disability Management and Return-to-Work Practices." In Terrence Sullivan, ed., Injury and the New World of Work. Vancouver: UBC Press.

Hogg-Johnson, S., D. Cole, P. Cote and J. Frank. 2000. "Staging Treatment Interventions Following Soft Tissue Injuries." In Terrence Sullivan ed., Injury and the New World of Work. Vancouver: UBC Press.

Goldner, E., D. Bilsker, M. Gilbert, L. Myette, M. Corbière and C.S. Dewa. 2004. "Disability Management, Return to Work and Treatment." Paper prepared for the Canadian Institutes of Health Research Invited Workshop on Mental Health and the Workplace. April 28-29, 2004. Toronto, Ontario.

Latimer, E. 2001. "Economic Impacts of Supported Employment for Persons with Severe Mental Illness." Canadian Journal of Psychiatry 46(6): 495-505.

Loisel, P., L. Abenhaim, P. Durand, J.M. Esdaile, S. Suissa, L. Gosselin, R. Simard, J. Turcotte and J. Lemaire. 1997. "A Population-Based Randomized Controlled Trial on Back Pain Management." Spine 22(24): 2911-18.

Yassi, A.R., R. Tate, J.E. Cooper, C. Snow, S. Vallentyne and J.B. Khokhar. 1995. "Early Intervention for Back-Injured Nurses at a Large Canadian Tertiary Care Hospital: An Evaluation of the Effectiveness and Cost Benefits of a Two-Year Pilot Project." Occupational Medicine 45(4): 209-14.

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