Mental disorders are a major and increasing public health concern (Global Burden of Disease, 2022) and the main reason of sickness absence and work disability pension in most high-income countries (Blomgren and Perhoniemi, 2022).
Management should include a holistic evidence-based approach, which incorporates a range of quality-of-life goals, including returning to work via stigma-free facilitatory contact between employee and employer (Eder et al, 2023).
However, in many countries, such care is fragmented and unevenly distributed, with long waits for specialist services and unclear professional responsibilities, making the transition back to work especially difficult (Alonso et al, 2018; Evans et al, 2018; Hetemaa et al, 2021).
Collaborative care models aim to improve this via coordinated efforts between primary, occupational, and specialised care providers. However, implementation is challenging due to its complexity and few studies have qualitatively examined this process from the perspective of specialised mental health care.
This study, set in Finland, aimed to explore the barriers and facilitators in implementing a new referral model that connects specialised mental health care with occupational health services (OHS) to help patients return to work earlier. To the authors’ knowledge, this is the first study to assess such a model across different health care sectors.
Few studies have explored how psychiatric and occupational teams actually work together to help people return to work. This one dives into the reality.
Methods
Seventeen participants, comprised of the developers of a referral model and the psychiatrists and OHS physicians delivering it between 2021 and 2023 in Finland, consented to complete semi-structured group and individual interviews.
Interprofessional collaboration dynamics were examined, using the Quality Implementation Framework (QIF) and the Consolidated Framework for Implementation Research (CFIR).
5 analytical steps were undertaken, informed by grounded theory:
- Post-interview sessions: analysing perspectives in their regional contexts;
- Systematic deductive coding: of transcribed texts, according to the main domains of the CFIR;
- Inductive derivation: conducted by thematic analysis;
- Thematic identification: across CFIR domains;
- Eliciting dynamic mechanisms: underlying collaborative care models, identifying facilitators and barriers.
Whose voice is missing? This study explored clinicians’ perspectives on care collaboration, but not the patients/workers it was meant to help.
Results
The study identified three main themes and six key factors, regarding the facilitators and barriers to collaborative care models.
The three main themes were:
- The scope and boundaries of cooperation in the new referral model: What was the innovation? Uncertainty emerged about the model, with individual practitioners unclear about what it consistently included. Some saw it as just an e-referral, others expected broader cooperation, including with employers. This ambiguity regarding the roles and responsibilities between psychiatric services and OHS, created a barrier to collaborative functioning.
- Size of target group smaller than expected: Although many workers were thought to benefit from the collaborative referral system, only a few referrals actually occurred. The number of eligible patients was also unclear, and thus actual adoption and utilization were adversely affected.
- Importance of stigma in the return-to-work process: Reports of self-stigma and societal stigma occurred both for treatment and onward referral in relation to mental health disorders around the workplace. This represented a major barrier to successful collaborative care delivery at every stage.
Six supporting factors were identified:
- Shared belief in the model: Most professionals agreed the collaborative model was helpful and would improve outcomes. Of note, while beliefs eschewed the medical model for a more holistic consideration of the employee — priorities were somewhat focused on occupational and employer prerogatives, rather than the employee, such as, “unnecessary long sick leaves [which] could be avoided. [and] returning to work could then be possible earlier, for instance.”
- Need for clear roles: clearly defining roles and scopes of practice enhanced practitioners’ ability to collaborate.
- System and timing issues: E-referral delays due to IT system problems, and healthcare reforms made implementation harder. Greater infrastructure cohesion and robustness would improve collaboration.
- Mixed views on OHS readiness: Some professionals questioned if OHS had adequate and specific training or resources for targeted mental health support.
- Unaddressed factors affecting return to work: Important issues like stigma, flexible work options, and employer attitudes were not fully addressed by the model of collaborative care provision. Intra- and interpersonal variables were summarised aptly in one quote: “…some of these recovering individuals may suffer from intense feelings of shame…failure, inadequacy, and disappointment with themselves for having to take time off work due to this type of illness. It would be easier if they had a broken leg […]This project demonstrates] how important it is […] that a supervisor has a positive attitude towards [the] employee when returning to work [and] the opportunity to arrange work conditions in a way that provides flexibility”.
- Hard to estimate how many patients qualify: a lack of collated or stratified demographic data on which types of patients fitted the referral criteria, limited the applicability and generalisability of this collaborative model.
Overall, the study did identify some facilitators that supported implementation. There also appeared to be trust in those who developed the model, contributing to its acceptance and implementation. Despite this, the new referral system faced confusion, practical challenges, and deeper social challenges that limited its effectiveness.
Referral pathways flounder when responsibilities aren’t clear. This research reveals the infrastructure and training gaps we need to fix.
Conclusion
The study highlighted the growing global occupational challenges posed by mental health disorders, impacting individuals’ ability to work, leading to prolonged sickness absences and reduced quality of life. A new referral model was developed in Finland, aiming to enhance collaboration between psychiatric services and occupational health services (OHS) to facilitate earlier return to work for patients with mental health conditions.
The study concluded that for collaborative models in mental health care to be successful, they must involve various stakeholders across different sectors. Addressing individual, workplace-related, and sociocultural factors, including stigma, is essential to strengthen collaboration and improve return to work outcomes for patients with mental health conditions.
Psychiatrists, occupational health services and employers must work together to help people return to work safely and sustainably.
Strengths and limitations
This was the first study to examine how a new referral system for employees with mental health issues was put into practice. The analysis was longitudinal and combined different research methods, which helped strengthen the findings. Similarly, three researchers each looked at the data separately to make sure the analysis was fair and thorough.
Although only 17 of the 40 invited people participated, the group included nearly half of those most involved in creating and using the model, giving valuable insights into both the development and delivery sides of the referral system. The study also used both group and individual interviews, to analyse the breadth and depth of professionals’ experience.
Since occupational health services (OHS) and psychiatric services are organised similarly across Finland, the findings from these professionals, designing a referral pathway in a local system, are highly relevant for other regions in the country. However, generalising the findings outside of Finland, especially beyond Europe, may be limited due to differences in health care systems.
One limitation not identified by the authors of the study, is the conflicts of interest that may arise by solely sampling the views and experiences of professionals like developers, psychiatrists, and OHS doctors, but not patients. Although the collaborative referral system studied here was targeted at improving care for “workers with mental health difficulties”, priorities discussed in service delivery aligned “more closely with employers’ needs than employees’” – i.e. reducing length of sick leave, accelerating return to work. It is important to acknowledge a potential conflict of interest for OHS providers in this respect, because in Finland (and in much of Europe) OHS are either contracted or locally appointed by an employer themselves. This can reduce their incentive to advocate for infrastructural changes, or changes needed by workers with mental health difficulties, where those needs are at odds with those of the mutual employer.
Nonetheless, the study highlights how important collaboration is between mental health services and the workplace, and how better understanding stigma, timing, and responsibilities could further improve return-to-work efforts.
Implementing a new model is one thing — translating it into real-world impact across settings is another.
Implications for practice
Return to work in the context of mental health difficulty, should not be seen as a simple endpoint of recovery; it is a process of adaptation, learning, and often re-exposure to stressors.
Historically, evidence demonstrates that mental health services can be too focused on symptom reduction (Secker 2003) and less on quality-of-life factors such as employment, whereas it is increasingly understood that individuals do not always need to be symptom-free before returning to work (Henderson et al., 2011).
In this context, this study offers useful advice for improving collaboration and teamwork between mental health services and occupational health services, in delivering support to people living and working with mental health conditions. Understanding the barriers and facilitators highlighted in this study can help improve care delivery, return-to-work support, and cooperation across sectors. More resources and better systems might be needed to track patients and support joint mental health efforts. Trust in the model and its developers helped, but problems like unclear goals, limited e-referral systems, and lack of focus on stigma made it harder to use.
For the model to work more reliably, psychiatrists need more support about when to refer patients and occupational health services (OHS) staff may need better mental health training. All stakeholders, including patients, employers, and healthcare providers should be informed about helpful workplace changes and how to reduce mental health stigma.
More research is needed to understand how this model fits with existing programs, how many patients could benefit, and what resources are needed to put it in place effectively.
As a psychologist working within the National Health Service, I am struck by how important early intervention and joint working are when individuals return to work after or while they are accessing mental health support, and this stage presents a critical and sensitive phase in one’s recovery. For many, work is not just about employment; it signifies normalcy, identity, and reintegration into society after a period of isolation, illness, or disconnection.
Reflecting on my clinical practice, my role has extended beyond therapy rooms.
I have found myself engaging in collaborative, systemic work which includes liaising with vocational services, occupational health teams, and employers to ensure that return-to-work plans are realistic, supportive, and individualised. I often use a range of psychological frameworks like CBT to help clients manage workplace-related anxiety or build confidence, but it is equally important for employers (and other providers) to structure their environment and for them to complement and extend, generalise the therapeutic work, especially when the workplace can also be a site of stress, stigma, and vulnerability, particularly if employers lack mental health awareness.
Therefore, a greater emphasis on collaboration with employers, employment specialists, and mental health teams is essential, not only to facilitate access to work for employees with mental health concerns, but to ensure sustainability and prevent further mental health challenges arising.
Returning to work is about more than being “better.” It’s about feeling safe, understood, and supported — by everyone.
Statement of Interests
None declared.
Links
Primary Paper
Henriksson, M., Tikka, C., Juvonen-Posti, P. et al. Referring psychiatric patients to occupational health services for earlier return to work – a qualitative implementation study of barriers and facilitators. BMC Health Serv Res 25, 109 (2025). https://doi.org/10.1186/s12913-025-12238-2
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