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Occupational health guidelines for mental disorders and stress-related complaints, a challenge for occupational health
  1. Carel T J Hulshof
  1. Correspondence to Professor Dr Carel T J Hulshof, Academic Medical Center, Coronel Institute of Occupational Health, University of Amsterdam, Amsterdam, The Netherlands; c.t.hulshof{at}

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The late Dutch critic, writer and journalist, Jan Blokker, once ironically said: “I hate information, you can't even trust your own prejudices anymore.” In spite of this, information is needed, in particular from well-conducted research, to make informed decisions in healthcare. Gaps between evidence from research and decision-making in daily practice occur in all important stakeholders in healthcare: healthcare professionals, patients and policy-makers.1 One of the strategies to close this gap is the systematic development and implementation of clinical practice guidelines.2 Also, in the field of occupational health (OH), professionals should strive to achieve an evidence-based practice by integrating the best available scientific evidence with their own expertise, and the values and preferences of their clients. An important instrument in the enhancement of evidence-based practice in OH is the development and implementation of evidence-based practice guidelines.

In a well-written international collaboration, Joosen et al3 report the results of a review of available guidelines on a key topic in OH: the management of mental disorders and stress-related psychological problems in an occupational healthcare setting. The authors searched for guidelines in databases and in their network of researchers and practitioners, compared the content, and evaluated the reporting quality. Mental disorders are a major cause of sick leave and disability in many countries, but only 14 guidelines could be found and included in the study, mostly by contacting experts in the field of OH. Although the contents of many guideline recommendations were comparable, the process of development and the reporting quality showed large variation. The authors therefore recommend that guideline developers in OH adopt a common structure for the development and reporting of guidelines and call for better international collaboration. Moreover, more attention to work-related aspects in multidisciplinary clinical guidelines should be stimulated.

The varying reporting quality of guidelines in OH is in accordance with earlier studies.4 ,5 A few years ago, the Netherlands Organization for Health Research and Development, ZonMw, included the introduction of work-related aspects as an obligatory requirement in a national programme for funding of multidisciplinary guidelines in healthcare.6 Therefore, the over-representation of Dutch guidelines in the study sample (7 out of 14) is not surprising. Some of the choices made in the methodology of the review can be disputed. For inclusion, selected guidelines had to meet the definition of a guideline given by Field and Lohr in 1992.7 The definition and processing of clinical practice guidelines has, however, since evolved. The US Institute of Medicine8 and the Dutch Council for Quality of Healthcare9 define guidelines as ‘documents with recommendations to assist healthcare practitioners and healthcare users, intended to optimise quality of care, based on a systematic review of evidence and an assessment of the benefits and harms of the various care options, supplemented with expertise and experiences of both practitioners and users’. Also, the Guidelines International Network (G-I-N) has proposed a set of minimal standards for guideline development based on this.10 If the authors had used this recent definition or set of criteria, some of the selected guidelines could have been excluded from the sample, probably resulting in higher AGREE scores, in particular on ‘rigor of development’. Some of the included guidelines were rather dated, being over 10 years old. The formal policy in many guideline development organisations is that guidelines should be updated every 5 years, an intention that, in practice, is difficult to fulfil.11 As long as the selected guidelines were still available in their country, the choice of the authors to select them can be defended.

I absolutely agree with Joosen et al that guideline developers should publish their background study, preferably in English, and should seek more international collaboration. In particular, the evidence reviews performed within the guideline development process could be shared. Developing guidelines is laborious and costly. Why are we inventing the wheel again everywhere? As the context and organisation of the needed care may vary between countries, this may occasionally, even when based on more or less the same evidence, lead to different recommendations. Simple translation of guidelines is therefore not possible, but a more effective and efficient use of collected evidence surely is. Organisations such as G-I-N and the Cochrane Collaboration can be of great help in this.

Developing good-quality guidelines is one thing, making them work is an even bigger challenge. Adherence to the guidelines in daily practice may vary considerably. A process evaluation with performance indicators on adherence to one of the selected guidelines in the review showed that the mean score of guideline adherence in a group of occupational physicians was 50%.12 Is the glass half full or half empty then? From this and earlier studies on this topic we know that better guideline adherence showed a statistically significant association with a shorter time to return to work after sickness absence. This is a promising result.

Practice guidelines are not a panacea for all problems. Future challenges include implementation of guidelines in shared decision-making and amending of what are often generally formulated recommendations for use in personalised medicine. In addition, more effort will be needed to improve development and implementation of guidelines for OH.



  • Competing interests As the coordinator of the guideline programme of the Netherlands Society of Occupational Medicine CTJH is involved in the development of some of the guidelines included in the review by Joosen et al.

  • Provenance and peer review Commissioned; internally peer reviewed.

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