Long term sickness absence is a major public health and economic problem. In 2003, 176 million working days were lost; up 10 million on the previous year. Each year, ??13bn are spent on benefits, and the reduction of long term sick leave is now a top government priority.

Until recently, the most common causes of long term sickness absence were musculoskeletal disorders, in particular low back pain, but over the last decade, the contribution of psychiatric disorders has increased markedly. Since 1995, the number of people reporting stress that was caused or made worse by their work has doubled, and common mental disorders are now the leading cause of sickness absence.

These disorders are managed almost entirely in primary care, but with limited capacity for psychological therapies, waiting times are often long. The United Kingdom also has very poor provision of occupational physicians (one specialist for every 43,000 workers) compared with the rest of Europe.

Both employers and patients require a speedier response than is currently delivered, as the longer an individual remains off work, the more difficult a return becomes.

If the government is serious about tackling the consequences of common mental disorders then innovative policies, including a major expansion in occupational health and psychological therapy services in primary care, will be required alongside research into the most effective and cost effective methods of delivering service, say the authors.

This would be a wise investment given the substantial economic and social costs engendered by the current service framework, they conclude.

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Dr Fazel states: ???Our overall estimates will need to be used judiciously, in view of the fact that it is difficult to know whether the diverse refugee groups contributing to this analysis were representative of the refugee populations resettled in western countries. Nevertheless, our review suggests that at least several tens of thousands of current refugees in western countries have post-traumatic stress disorder.???

In an accompanying Comment Michael Hollifield (University of Louisville, KY, USA) states: ???This information warrants attention by investigators, funding agencies, and service organisations. As world conflicts march on, people will probably continue to be traumatised and displaced. Because resources are scarce, it would be wise to ensure that data collected to make inferences, policies, and services are sound.???

An accompanying Editorial in this week??ôs issue of The Lancet states that the mental health of refugees and other displaced people is a ???major global health problem??? that should be addressed by the United Nations new High Commissioner for Refugees.

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