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Original Article
Effects of internet-based cognitive behavioural therapy and physical exercise on sick leave and employment in primary care patients with depression: two subgroup analyses
  1. Viktor Kaldo1,
  2. Andreas Lundin2,
  3. Mats Hallgren2,
  4. Martin Kraepelien1,
  5. Catharina Strid3,
  6. Örjan Ekblom4,
  7. Catharina Lavebratt5,6,
  8. Nils Lindefors1,
  9. Agneta Öjehagen7,
  10. Yvonne Forsell2
  1. 1 Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council, Huddinge Hospital, Stockholm, Sweden
  2. 2 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  3. 3 Department of Psychology, Lund University, Lund, Sweden
  4. 4 Åstrand Laboratory of Work Physiology, Swedish School of Sport and Health Sciences (GIH), Stockholm, Sweden
  5. 5 Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
  6. 6 Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
  7. 7 Department for Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden
  1. Correspondence to Dr Viktor Kaldo, Internetpsykiatrienheten M46, Huddinge hospital, Stockholm, Sweden; viktor.kaldo{at}


Objectives Depression can negatively impact work capacity, but treatment effects on sick leave and employment are unclear. This study evaluates if internet-based cognitive behavioural therapy (ICBT) or physical exercise (PE), with already reported positive effects on clinical outcome and short-term work ability, has better effects on employment, sick leave and long-term work ability compared with treatment as usual (TAU) for depressed primary care patients (German clinical trials: DRKS00008745).

Methods After randomisation and exclusion of patients not relevant for work-related analysis, patients were divided into two subgroups: initially unemployed (total n=118) evaluated on employment, and employed (total n=703) evaluated on long-term sick leave. Secondary outcomes were self-rated work ability and average number of sick days per month evaluated for both subgroups. Assessments (self-reports) were made at baseline and follow-up at 3 and 12 months.

Results For the initially unemployed subgroup, 52.6% were employed after 1 year (response rate 82%). Both PE (risk ratio (RR)=0.44; 95% CI 0.23 to 0.87) and ICBT (RR=0.37; 95% CI 0.16 to 0.84) showed lower rates compared with TAU after 3 months, but no difference was found after 1 year (PE: RR=0.97; 95% CI 0.69 to 1.57; ICBT: RR=1.23; 95% CI 0.72 to 2.13). For those with initial employment, long-term sick leave (response rate 75%) decreased from 7.8% to 6.5%, but neither PE (RR=1.4; 95% CI 0.52 to 3.74) nor ICBT (RR=0.99; 95% CI 0.39 to 2.46) decreased more than TAU, although a temporary positive effect for PE was found. All groups increased self-rated work ability with no differences found.

Conclusions No long-term effects were found for the initially unemployed on employment status or for the initially employed on sick leave. New types of interventions need to be explored.

  • return to work
  • internet therapy
  • physical exercise
  • cognitive behavioral therapy
  • depression

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  • Contributors VK was coinvestigator and took part in the design of the study, implemented the ICBT arm together with NL, coded, analysed and interpreted the data, and wrote the first draft of the majority of the paper. AL helped in interpreting data, wrote the first draft of the introduction, provided critical comments and contributed to writing the paper. MK designed the ICBT programme together with VK, aided in coding and analyses of data, and provided critical comments on the paper. MH aided in coding and analyses of data, and provided critical comments on the paper. CS coordinated the study in one of the regions, aided in data collection and provided critical comments on the paper. ÖE designed the physical exercise intervention, coordinated and monitored it, and provided critical comments on the paper. CL took part in the design of the study and provided critical comments on the paper. NL took part in the design of the study and provided critical comments on the paper. AÖ took part in the design and implementation of the study, interpreted the data and contributed to writing the paper. YF, the principal investigator, designed, implemented and led the entire study, interpreted the data, and contributed to writing the paper.

  • Funding The Regassa project is funded by Stockholm, Skåne, Kronoberg, Västra Götaland, Blekinge and Västmanlands county councils, REHSAM through the Vårdal Foundation and the Brain Foundation. The funding source had no role in study design, data collection, data analysis, data interpretation or writing of the report. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit for publication.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The regional ethical review board at Karolinska Institutet, Stockholm (Dnr 2010/1779-31/4).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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