The number of patients with difficulty in resuming work after long-term sick leave has increased in several European countries including Sweden. The general aim of this study was a comprehensive description--based on multidisciplinary diagnostics and assessments--of patients with the common feature of marked difficulty in resuming working life after a long absence. A particular aim was to elucidate the possible effect of comorbidity on pain descriptors, disability, quality of life, assessed working ability and rehabilitation needs. Six hundred and thirty-five long-term sick leavers were referred from National Insurance Offices and consecutively accepted for investigation. Several self-report questionnaires were used. All patients were examined by three board-certified specialist physicians in psychiatry, orthopaedic surgery and rehabilitation medicine, respectively. Fifty-five percent of the patients had psychiatric-somatic comorbidity. The three most frequent combinations of diagnoses in the comorbidity group were fibromyalgia/myalgia and depressive episode, fibromyalgia/myalgia and recurrent depression, spinal pain and depressive episode, whereas the three most frequent in those with psychiatric diagnosis only were depressive episode, recurrent depression, phobias/anxiety. Differences in pain descriptors and in difficulties with activities were found among the three groups. All had lower health-related quality of life than references. Only one-sixth had no assessed working capacity and only 3% were assessed as able to resume work without rehabilitation; 80% were multidisciplinarily assessed as needing rehabilitation. Patients with psychiatric diagnoses, with or without concomitant somatic diagnoses, need medical rehabilitation or medical/vocational rehabilitation in combination to a greater extent than patients with somatic diagnoses only. This implies that medical rehabilitation programmes ought to adapt increasingly to the needs of patients with psychiatric-somatic comorbidity.

The aim of this review is to describe aspects of vocational rehabilitation relevant for a physician aiming to become a specialist in physical and rehabilitation medicine (PRM). The review discusses the epidemiology of incapacity for work, the major patient groups in vocational rehabilitation (musculoskeletal and psychiatric diagnoses comprise approximately 50-70% of the patients), the influence of different kinds of environmental and individual risk factors on work resumption (such as the legal framework, application of the law, resources for rehabilitation and its effectiveness, the degree of co-operation between vocational rehabilitation agencies, economic factors/labour market situation, medical and personal factors). The review describes different models of vocational rehabilitation, the effectiveness of various vocational rehabilitation programmes on work resumption or sick leave (where strong evidence is reported for multi-modal rehabilitation programmes for patients with long-lasting musculoskeletal pain). Finally, there are sections about the PRM physician's history-taking in vocational rehabilitation (using the International Classification of Functioning, Disability and Health (ICF)), and report writing with a structure where ICF body functions and activity limitations are reported separately.

The study group had 5.7 fewer days on sick-leave per month and person over the 6-year period (p=0.003). The estimated average economic benefit of the intervention was euro36,600 per person over the 6-year period. In conclusion, those who received systematic co-operation in vocational rehabilitation had fewer days on sick-leave than their "treatment-as-usual" peers. This effect persisted over 6 years, generating substantial net economic gains for society.

Intra-county differences occur in handling people on sick-leave who undergo vocational rehabilitation. The local social insurance offices with the highest and lowest outcome rates of work resumption and disability pension, respectively, select clients for vocational rehabilitation from different categories of cases. Social insurance officers from different local offices differ in their attitudes towards the social insurance system and its clients.

Objective:The aim was to describe the differences in symptoms, functioning and quality of life between women on long-term sick-leave due to protracted musculoskeletal pain with and without concomitant depression.Design:Descriptive and comparisons with/without comorbid depression.Methods:332 female patients were examined by three specialist physicians in psychiatry, orthopedic surgery, and rehabilitation medicine and assigned to four groups according to the ICD-10 diagnoses: low back/joint disorders (LBJ, n = 150), myalgia (M, n = 43), fibromyalgia (FM, n = 87), or depression without somatic pain diagnosis (DE, n = 52).Results:Patients with somatic pain conditions LBJ, M, or FM showed more activity-related difficulties if concomitant depression was present during the activities ‘focusing attention’, ‘making decisions’, and ‘undertaking a single task’; and in the domains ‘energy level’, ‘memory functions’, ‘emotional functions’, and ‘optimism/pessimism’. Patients with FM and concomitant depression perceived higher pain intensity than patients in group DE. No statistically significant differences in physically related activities were noted between each of the somatic pain conditions with and without coexisting depression. FM patients with coexisting depression reported fewer painful sites on their pain drawings compared with FM-patients without depression. Patients with LBJ or FM and concomitant depression reported lower quality of life in the dimensions vitality, social functioning, emotional role, and mental health. Comorbid depression affected disability and restricted working capacity by reducing mental activity and functioning but not by affecting physical activity problems.Conclusion:Women on long-term sick-leave, who have concomitant depression with LBJ or FM, also have more difficulties in focusing attention, making decisions, and carrying out tasks, and with memory functions and optimism/pessimism, as well as reduced quality of life in the dimensions of vitality, social functioning, emotional role, and mental health, than female patients without comorbid depression. As a consequence we suggest further efforts to integrate somatic and psychiatric interventions in the same rehabilitation program.