-->PONE-D-25-30340-->-->Variation in Mental Health-Related Sickness Absence: The Role of Occupational Health Professionals and Organizations-->-->PLOS ONE

Dear Dr. Timp,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR:

I appreciate the opportunity to evaluate this manuscript, which addresses a relevant topic in occupational and public health. Both reviewers provided constructive and detailed feedback, and I kindly request that the authors revise the manuscript thoroughly, addressing all points below to ensure the work meets PLOS ONE's publication standards.

Comments from Reviewer 1:

1) The authors make conclusions that are not strongly supported by their data. In particular, they state that their “findings suggest that interventions aiming to improve sickness absence management should focus primarily on enhancing OHP practices rather than on organizational reforms.” However, they studied a very narrow slice of organizations and specifically tried to reduce the amount of variation between organizations. As stated by the authors “Furthermore, we minimized variation at other levels by selecting employees working in the same sector in the same country, which strengthens the reliability of the result.” Given that the authors explicitly sought to minimize variation at the organizational level in their analyses, it is not surprising that their results show greater variation at the provider level than at the organizational level. It is likely that variation at the level of the organization would be much larger if data were not restricted only to organizations in the educational sector. This design is useful to show that there is large variation in sickness absence at the level of the provider within one employment sector. However, concluding broadly that organizational level interventions should be ignored in favor of provider level interventions is a serious over-generalization of their findings.

2) The literature review is rather sparse and some of the citations were puzzling. For instance, citation #4 was cited in conjunction with this sentence “At the job level, several studies have investigated work-related factors and employer characteristics”. However, the goal of this paper was to determine “whether adherence to the Dutch occupational mental health guideline by occupational physicians was associated with time to return to work in workers sick-listed due to common mental disorders” – i.e. the paper focused on provider behavior not on employer organizational characteristics. Largely ignored by the authors is the rather large literature demonstrating variations in the incidence/prevalence of mental health issues between workers in different industries, and the role of organizational effects and organizational level interventions to promote mental health among working populations.

3) This paper focuses narrowly on the duration of sickness absence (what happens after you take time off from work for a mental health disorder). It would also be important to report if there was variation in the proportion of workers who took sickness absence between organizations, not just the duration of illness.

Given the complexity of return-to-work, this research would benefit from a robust theoretical framework to conceptualize the determinants of RTW, as well as better alignment between observational findings and policy recommendations. The study addresses an important question but requires substantial revision given the narrow slice of employers that were studied.

4) There are some analytic points that could be better explained. The authors provided complete and exhaustive descriptions of the variation in sick leave duration by provider and by organization. As noted above, they unfortunately restricted their analysis to one employment sector, limiting their ability to support their broader conclusions about the relative importance of organization level factors vs. provider factors.

5) Another ambiguity was noted. When an employee had multiple periods of absence, each period was included in the dataset as a single case. It is not clear to the reader if one individual could contribute multiple periods to the data (and if so, were these absences treated as independent or clustered events?)

6) The reader does not know what diagnoses or types of mental health disorders included in the cases analyzed. It is likely that different OHPs saw different mixes of cases, which might have different expected recovery times. Variation in OHP performance might be in part attributable to differences in the types of mental health conditions that they saw.

7) The authors' decision to include data from 2016 to December of 2020 data to avoid COVID-19 effects is questionable, as the pandemic's psychological and workplace impacts likely began influencing mental health and absence patterns well before the December 2020 cutoff for their study. Most people would not consider this to represent a "pre-pandemic" sample.

8) One point is unclear – the authors never defined what they meant by the term “organization.” This appears to mean the employers of the workers studied, but could also mean a trade union or other labor organization. It is not clear the type or size of the employers or organizations.

9) There are a few minor misspellings (cardiopulmonair, Februari).

10) This study addresses an important occupational health question using substantial data, but several fundamental issues prevent it from supporting its conclusions. As pointed out above, the finding of greater variation by provider than by organization is unsurprising, given the narrow bounding of organizations. A theoretical framework to explain findings would be helpful. A major revision is needed to align methodology with conclusions, before this manuscript can adequately inform occupational health practice. A deeper dive into the characteristics of OHPs that predicted variation in absence time would be interesting. The current conclusion that “interventions aiming to improve sickness absence management should focus primarily on enhancing OHP practices rather than on organizational reforms” is not supported by the data provided.

Comments from Reviewer 2:

1) Which model parameter estimation method was used: Maximum Likelihood or Monte Carlo?

2) Which function from the lme4 package was used? And what were the arguments adopted in this function?

3) I would like to see the cross-classification table to be able to assess the degree of cross-hierarchy.

4) The sentence "...However, applying this model requires that the data follow either a two-level hierarchical structure (with observations nested within a single clustering variable) or strictly nested clusters..." The Cox proportional hazard model does not require a hierarchical structure. This sentence seems inappropriate, or I didn't understand the meaning the authors intended.

Academic Editor:

In summary, while the manuscript addresses a relevant topic in occupational health and is based on a robust dataset, several critical issues raised by Reviewer 1 must be carefully addressed before the work can be reconsidered for publication. Most notably, the main conclusion - suggesting that interventions should focus primarily on enhancing OHP practices rather than on organizational reforms - does not appear to be sufficiently supported by the data presented. This inference appears overstated, particularly given that the study design deliberately restricted organizational-level variation by including only organizations within the education sector.

It seems to me that the greater variation observed at the OHP level is to be expected in this context and does not, in itself, justify prioritizing provider-focused interventions over organizational ones. Additionally, the manuscript does not investigate or describe specific practices or characteristics of OHPs that could explain the observed differences in outcomes, limiting the practical utility of this recommendation.

I would also like to reinforce the reviewer’s concern regarding the lack of clarity about what constitutes an “organization” in the analysis. Although organizations are a central comparative unit in the study, the manuscript does not provide a clear definition of what constitutes an “organization”. It appears to refer to the employer of the employee, likely individual schools or educational institutions, but this is not explicitly stated. Furthermore, no details are provided regarding the type (e.g., primary, secondary, higher education), size, or structural features of these organizations. This lack of specificity weakens the interpretation of “organizational-level effects” and limits the reader’s ability to assess the plausibility and relevance of the comparisons made.

Given these issues, I encourage the authors to revise the manuscript substantially, aligning the conclusions more closely with the scope and limitations of the data, clarifying key definitions, and addressing the methodological and conceptual concerns raised by the reviewers.

Please submit your revised manuscript by Sep 06 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

João Marcos Bernardes, Ph.D. in Public Health

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

Reviewer #2: Yes

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Is the manuscript technically sound, and do the data support the conclusions?

The authors make conclusions that are not strongly supported by their data. In particular, they state that their “findings suggest that interventions aiming to improve sickness absence management should focus primarily on enhancing OHP practices rather than on organizational reforms.” However, they studied a very narrow slice of organizations and specifically tried to reduce the amount of variation between organizations. As stated by the authors “Furthermore, we minimized variation at other levels by selecting employees working in the same sector in the same country, which strengthens the reliability of the result.” Given that the authors explicitly sought to minimize variation at the organizational level in their analyses, it is not surprising that their results show greater variation at the provider level than at the organizational level. It is likely that variation at the level of the organization would be much larger if data were not restricted only to organizations in the educational sector. This design is useful to show that there is large variation in sickness absence at the level of the provider within one employment sector. However, concluding broadly that organizational level interventions should be ignored in favor of provider level interventions is a serious over-generalization of their findings.

The literature review is rather sparse and some of the citations were puzzling. For instance, citation #4 was cited in conjunction with this sentence “At the job level, several studies have investigated work-related factors and employer characteristics”. However, the goal of this paper was to determine “whether adherence to the Dutch occupational mental health guideline by occupational physicians was associated with time to return to work in workers sick-listed due to common mental disorders” – i.e. the paper focused on provider behavior not on employer organizational characteristics. Largely ignored by the authors is the rather large literature demonstrating variations in the incidence/prevalence of mental health issues between workers in different industries, and the role of organizational effects and organizational level interventions to promote mental health among working populations.

This paper focuses narrowly on the duration of sickness absence (what happens after you take time off from work for a mental health disorder). It would also be important to report if there was variation in the proportion of workers who took sickness absence between organizations, not just the duration of illness.

Given the complexity of return-to-work, this research would benefit from a robust theoretical framework to conceptualize the determinants of RTW, as well as better alignment between observational findings and policy recommendations. The study addresses an important question but requires substantial revision given the narrow slice of employers that were studied.

Has the statistical analysis been performed appropriately and rigorously?

There are some analytic points that could be better explained –

The authors provided complete and exhaustive descriptions of the variation in sick leave duration by provider and by organization. As noted above, they unfortunately restricted their analysis to one employment sector, limiting their ability to support their broader conclusions about the relative importance of organization level factors vs. provider factors.

Another ambiguity was noted. When an employee had multiple periods of absence, each period was included in the dataset as a single case. It is not clear to the reader if one individual could contribute multiple periods to the data (and if so, were these absences treated as independent or clustered events?)

The reader does not know what diagnoses or types of mental health disorders included in the cases analyzed. It is likely that different OHPs saw different mixes of cases, which might have different expected recovery times. Variation in OHP performance might be in part attributable to differences in the types of mental health conditions that they saw.

The authors' decision to include data from 2016 to December of 2020 data to avoid COVID-19 effects is questionable, as the pandemic's psychological and workplace impacts likely began influencing mental health and absence patterns well before the December 2020 cutoff for their study. Most people would not consider this to represent a "pre-pandemic" sample..

Is the manuscript presented in an intelligible fashion and written in standard English?

The manuscript is clear and well-written in standard English.

One point is unclear – the authors never defined what they meant by the term “organization.” This appears to mean the employers of the workers studied, but could also mean a trade union or other labor organization. It is not clear the type or size of the employers or organizations.

There are a few minor misspellings (cardiopulmonair, Februari).

Review Comments to the Author

This study addresses an important occupational health question using substantial data, but several fundamental issues prevent it from supporting its conclusions. As pointed out above, the finding of greater variation by provider than by organization is unsurprising, given the narrow bounding of organizations. A theoretical framework to explain findings would be helpful. A major revision is needed to align methodology with conclusions, before this manuscript can adequately inform occupational health practice. A deeper dive into the characteristics of OHPs that predicted variation in absence time would be interesting.

The current conclusion that “interventions aiming to improve sickness absence management should focus primarily on enhancing OHP practices rather than on organizational reforms” is not supported by the data provided.

Reviewer #2: 1- Which model parameter estimation method was used: Maximum Likelihood or Monte Carlo?

2- Which function from the lme4 package was used? And what were the arguments adopted in this function?

3- I would like to see the cross-classification table to be able to assess the degree of cross-hierarchy.

4- The sentence "...However, applying this model requires that the data follow either a two-level hierarchical structure (with observations nested within a single clustering variable) or strictly nested clusters..." The Cox proportional hazard model does not require a hierarchical structure. This sentence seems inappropriate, or I didn't understand the meaning the authors intended.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-25-30340R1

Variation in Mental Health-Related Sickness Absence: The Role of Occupational Health Professionals

PLOS One

Dear Dr. Timp,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has been further evaluated by two reviewers, and their comments are available below.

Could you please carefully revise the manuscript to address all comments raised?

Please submit your revised manuscript by May 15 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols..

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We look forward to receiving your revised manuscript.

Kind regards,

Ilse Bloom

Staff Editor

PLOS One

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1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors made substantial improvements in response to the previous feedback. The revisions significantly strengthened the paper through several key changes: the dataset was refined (adjusting the COVID time period and broadening the industry representation), the analysis was enhanced with better controls for organizational level and industry differences, and the focus on occupational health providers was maintained with improved justification and explanation of the interplay between organizational and OHP factors. The paper is now much clearer and more robust than the previous version. I congratulate the authors on the results of their extensive re-working of their paper to address the major criticisms of the reviewers.

There are a few minor issues with the manuscript as reviewed -

Clarification needed: In 3.1 Dataset, there appears to be a contradiction regarding the sickness absence period used in the analysis (2 years versus 3 years). Please clarify which time period was actually applied in the analysis.

Reference formatting: Some references appear inconsistent without mentioning the year (e.g., Salet et al… Barker et al…Di Martin et al. ).

Discussion is missing some references (question marks are in place instead of the reference)

Two minor suggestions for the discussion –

In this sentence “Third, OHPs in occupational health often have more autonomous decision making authority….” Suggest changing “often have” to “may have” as no data were provided to support the assertion that OHP’s have more autonomy than hospital-based physicians. (having practiced in both settings in my country, this was not my experience).

“At the organization level, factors such as HR policies, return-to work procedures, case-management capacity and firm size may play a role.” I would suggest adding “industry sector” to this list.

Reviewer #2: I believe that intentionally delimiting sector variation does indeed reduce generalizability, as noted by reviewer 1. However, the authors had already addressed this in the limitations section of the first draft of the manuscript. In any case, including the effect of sectors in the modeling brought greater realism and allowed for updated estimates of the variation due to occupational health professionals (OHPs) and highlighted the variation due to organizations, allowing for a review of the conclusions and the impact of each source of variation, enabling more informed decision-making. Furthermore, the authors addressed my questions satisfactorily, including the presentation of the cross-classification table, allowing readers to assess the relevance of the modeling adopted.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our  For information about this choice, including consent withdrawal, please see our Privacy Policy..

Reviewer #1: No

Reviewer #2: No

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Variation in Mental Health-Related Sickness Absence Duration: The Role of Occupational Health Professionals

PONE-D-25-30340R2

Dear Dr. Timp,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Marianne Clemence

Staff Editor

PLOS One

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