Stress-related absence from work is expensive for employers and difficult for the people living through it. CBT is the recommended treatment, but there has never been enough of it to meet demand, which is part of why computerised versions were developed in the first place.
Paul Grime ran one of the first tests of that idea inside a workplace. His 2004 randomised trial recruited 48 public sector employees through an NHS occupational health department in London, all of whom had taken at least ten cumulative days of stress-related absence in the previous six months. Half were offered an eight-session computerised CBT program alongside conventional care, and half received conventional care alone.
At the end of treatment, and again a month later, the computerised CBT group had significantly lower depression scores and a less negative attributional style, meaning they were less inclined to explain bad events in fixed, self-blaming terms. Anxiety scores were significantly lower at the one-month point. By three and six months the differences between the groups were no longer statistically significant.
Non-participation was common, and the reasons are as informative as the results. People cited difficulty getting access, a preference for a different kind of treatment, the time it took, doubt about whether it would work, and discomfort with the fact that it came through their employer.
The reasonable conclusion is the one Grime drew: the program may speed up recovery rather than change where a person ends up.
The rationale
Emotional distress carries major costs for employees and employers alike. Cognitive behavioural therapy is a recommended treatment, but demand exceeds supply, and CBT is well suited to computerisation because it is structured and skills-based. At the time of this study, most employee assistance programmes had not been systematically evaluated, and computerised CBT had not been studied in a workplace setting at all.
Design
This was an open randomised trial run in an occupational health department of a London NHS trust, with recruitment between April 1999 and October 2000 and follow-up to March 2001. Forty-eight public sector employees with 10 or more cumulative days of stress-related absence in the previous six months were randomised equally, 24 to each arm.
The intervention arm received an eight-week computerised CBT programme, Beating The Blues, in addition to conventional care. The control arm received conventional care alone. Most participants, 74%, were recruited through the occupational health clinics; the remainder responded to promotion of the study.
Outcome measures were the Hospital Anxiety and Depression Scale and the Attributional Style Questionnaire, taken at the end of treatment and again at 1, 3 and 6 months afterwards. Analyses adjusted for the relevant baseline scores and for the sex ratio of the groups.
At baseline the intervention group had a mean age of 41, a sex ratio close to even at 11 women to 13 men, and was drawn from both NHS and local authority employers. Mean baseline scores in that group were 11.75 on HADS anxiety, 7.96 on HADS depression, 15.37 on positive attributional style and 13.92 on negative attributional style.
Uptake and completion
Of the 24 randomised to Beating The Blues, 16 completed all eight sessions. One completed six, two completed four, one completed three and four completed two. Reasons given for not completing included attrition, inability to commit the time, and simply not wanting to continue. Of the eight who did not complete the programme, four completed follow-up questionnaires and four were lost to follow-up. One person completed all eight sessions but returned none of the follow-up questionnaires.
Results
At the end of treatment and again one month later, adjusted mean depression scores and adjusted mean negative attributional style scores were significantly lower in the intervention group than in the control group. One month post-treatment, adjusted mean anxiety scores were also significantly lower in the intervention group.
At 3 and 6 months post-treatment, the differences between groups were not statistically significant.
Why non-participation is part of the finding
The study explicitly set out to explore why people did not take part, and the answers form a coherent picture. Access problems, preference for other forms of treatment, the time commitment involved, scepticism about whether a computer programme could help, and unease about the employer connection were all cited.
The last of these is specific to the workplace setting. A programme offered through occupational health carries an implication about who knows and who might find out, whatever the confidentiality arrangements say. Any workplace mental health offering has to contend with that.
Interpretation
Grime's stated conclusion is measured: Beating The Blues may accelerate psychological recovery in employees with recent stress-related absenteeism, and greater flexibility and accessibility might improve uptake.
The pattern of results supports that reading. An early advantage that converges by three months is consistent with the intervention group getting to a better place sooner, while the control group arrives later through conventional care and ordinary recovery. Faster recovery has real value in this context, both for the person and in terms of time away from work, even if the end point is similar.
Limits
The trial is small, with 24 per arm, and unblinded. Analyses at later time points are based on fewer participants because of loss to follow-up, which reduces the power to detect a difference. The convergence at 3 and 6 months should therefore be read as an absence of demonstrated difference rather than as proof that the groups had become equivalent. The sample was public sector employees in one English city, and results may not transfer to other workforces. HADS and the Attributional Style Questionnaire measure symptoms and thinking style rather than functioning or return to work.
If stress has kept you away from work and you are deciding what help to seek, a conversation with a psychologist about what would suit your situation is a sound first step.