Appendix C: The evidence

This appendix links the recommendations to the two reviews of effectiveness provided by external contractors and to the expert reports that were used to develop the recommendations (see evidence reviews and expert reports sections below for details). It also set out a brief summary of the findings from the economic analysis.

If a recommendation is not directly taken from the evidence reviews or expert reports, but is inferred from the evidence, this is indicated by the letter 'IDE' below.

Recommendation 1: R1 (evidence statements 5 and 6), R2, ER 1, 2, 3

Recommendation 2: R2, ER1, 2

Recommendation 3: R2, ER2

Recommendation 4: R2, ER1, 2

Recommendation 5: IDE

Evidence reviews

Review 2 (R2)

The thematic review ('Mental wellbeing through productive and healthy working conditions') identified characteristics of work content and work context that can act as stressors (see table below). These characteristics interrelate with employee's attributes. The extent to which employee experiences stress is dependent on their own resources and capacity as well as the adequacy of support and supervision.

Associations between work and mental wellbeing: organisational sources of stress

Work context

Work content

Management style

Work demand over level of control

Organisational justice

Effort and reward

Workplace support



Working schedule


Sense of fulfilment

Job stability

Three theoretical models underpin much of the evidence on the associations between workplace and psychological outcomes. The effort–reward balance and demand–control models have been used to establish that adverse psychosocial work environments are high demand and low control, and high effort and low reward. The model of organisational justice is an important extension on these models, encompassing issues of equity and experience of unfair treatment in procedures and relationships. Justice and fair treatment create a sense of psychological security, control and stability; experience of unfairness can increase stress and risks to mental health.

Review 1 (R1)

Review 1 ('A review of workplace interventions that promote mental wellbeing in the workplace') included evidence statements summarising the evidence on the key questions. (Note R2 reported themes and did not use evidence statements.)

R1 Evidence statement 5

Eight studies that were graded positively evaluated different types of stress-management training,six of these found a positive impact on mental wellbeing as measured by questionnaire. One Australian randomised trial found a positive effect that was close to being, but was not, statistically significant (++) and one study with 54 volunteer German bus drivers found no significant effects. The differences among studies in interventions, populations and study quality mitigate against definitive conclusions. However, there is reasonable evidence that multi-faceted training covering stress awareness, coping and stress reduction is an effective format.

Six of the eight studies had training programmes involving a trainer or facilitator, of which four found a positive impact on mental wellbeing, again measured by questionnaire. Two small randomised control trials (+) and (+) found that small group sessions have a positive impact on mental wellbeing.

There is evidence from one randomised trial undertaken in the USA (++) that compared web materials with paper based materials, that paper based training materials are more effective for improving mental wellbeing.

R1 Evidence statement 6

A UK randomised control trial (+) with 90 volunteers from a media company found that three half-day sessions of therapy and counselling delivered during work time had a positive impact on mental wellbeing in the short term as measured by questionnaire. A UK randomised trial with 24 cases and 24 controls who were NHS and local authority workers with 10 or more days absence resulting from stress, anxiety or depression in the previous 6 months (+) found that eight weekly sessions using a computerised cognitive behavioural therapy programme had a positive impact on mental wellbeing in the short term as measured by questionnaire.

Expert reports

  • ER1: 'A business case for the management standards for stress: conclusions based on meta analyses' (prepared by Goldsmith College, University of London), Health and Safety Executive (2006).

  • ER2: 'Final project report', Foresight Mental Capital and Wellbeing Project (2008).

  • ER3: 'Dame Carol Black's review of the health of Britain's working age population. Working for a healthier tomorrow', Health, Work and Wellbeing Programme (2008).

Cost-effectiveness evidence

Although the overall business case for investment in promoting the mental wellbeing of employees is well established (see section 1), the evidence on the cost effectiveness of specific interventions is very limited. In particular there is a lack of evidence on the cost effectiveness of organisation-wide approaches to promoting mental wellbeing of employees.

Consequently PHIAC considered wider sources of economic analyses when assessing the cost effectiveness of the recommendations. It drew on the work of the Foresight Project: Mental Capital and Wellbeing Project (2008). Cost–benefit calculations for organisation-wide approaches were conducted to provide UK estimates as part of the Foresight Project. This analysis was based on existing evidence (if available) and the guidance of a panel of experts. The analysis covered the impact of interventions on mental health and on absenteeism, presenteeism, productivity and incapacity benefit. It involved using a set of assumptions relating to these factors as follows.

Overall the cost–benefit analysis conducted by the Foresight Project suggested that certain components of organisation-wide approaches to promoting mental wellbeing can produce important net economic benefits.

The analysis indicated that just performing annual audits of employee wellbeing would produce financial gains; of the order of £100 million per annum. These gains would be increased by investment of resources in preventive measures in response to the findings of audits (accruing £275 million).

The estimated total economic benefit associated with giving employees the opportunity to request flexible working might be in the region of £165 million per annum, which is equivalent to a benefit–cost ratio of approximately 2.5.

Overall such estimates were consistent with the economic analysis performed in phase 1 of the development of this guidance. The results of the economic modelling supported the business case for implementing work-site interventions to promote the mental wellbeing of employees (a combination of organisation-wide and stress-management interventions).

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and feasibility of putting the recommendations into practice. PHIAC considered the findings when developing the final recommendations. For details, go to the fieldwork section in appendix B and 'Consultation on NICE draft recommendations on the promotion of mental wellbeing in the workplace'. Overall the recommendations were viewed as positive and a helpful step forward. However, a number of areas should be given further consideration. The main areas included:

  • The need to position the guidance more clearly in the context of other national policies and strategies as well as employment legislation.

  • Greater emphasis on the opportunities for promoting mental wellbeing at work, and less focus on 'risk reduction'.

  • Clearer definition of work-related stress.

  • Greater emphasis on the business case for investment in the mental wellbeing of employees.

  • The importance of addressing the stigma relating to mental health problems at work.

  • Clearer referencing of the evidence relating to the specific recommendations.

  • The need to consider how the guidance and recommendations could best take account of the needs of micro, small and medium-sized businesses, including the use of appropriate language and terminology.

A range of suggestions were also made with respect to the dissemination of the guidance and support for its implementation.

  • National Institute for Health and Care Excellence (NICE)