Biomarkers in burnout: a systematic review

Endocrine and mood responses to two working days in female teachers

Currently, a considerable amount of work stress is present in school teachers, one of the occupational groups with the highest levels of job strain and burnout. As chronic stress produces significant modifications in emotional adjustment and neuroendocrine functioning, we aimed to investigate the role of these work stress constructs in the endocrine and mood responses of a group of female teachers during two working days (WD) at different moments in the academic year. We studied mood as well as levels of cortisol and testosterone, representative of a predominant catabolic or anabolic balance. Our results showed that higher "control" was associated with higher positive mood (p = .028 on WD1 and p = .057 on WD2) and salivary testosterone (Tsal) (p = .022 on WD1), whereas "demands" and "total job strain" were related to negative mood (p = .011 and p = .015, respectively). Participants with higher scores on "total burnout" and "emotional exhaustion" also had higher negative mood (p < .05 in all cases). Depersonalization correlated positively with negative mood (p = .019 and p = .006 on WD1 and WD2, respectively). Finally, personal accomplishment showed an inverse relationship with negative mood (p = .038 on WD2). These results are useful for job risk prevention and interventions that should focus on the control dimension of the job strain questionnaire and on personal accomplishment from the burnout scale.

Burnout-depression overlap: a review

Whether burnout is a form of depression or a distinct phenomenon is an object of controversy. The aim of the present article was to provide an up-to-date review of the literature dedicated to the question of burnout-depression overlap. A systematic literature search was carried out in PubMed, PsycINFO, and IngentaConnect. A total of 92 studies were identified as informing the issue of burnout-depression overlap. The current state of the art suggests that the distinction between burnout and depression is conceptually fragile. It is notably unclear how the state of burnout (i.e., the end stage of the burnout process) is conceived to differ from clinical depression. Empirically, evidence for the distinctiveness of the burnout phenomenon has been inconsistent, with the most recent studies casting doubt on that distinctiveness. The absence of consensual diagnostic criteria for burnout and burnout research's insufficient consideration of the heterogeneity of depressive disorders constitute major obstacles to the resolution of the raised issue. In conclusion, the epistemic status of the seminal, field-dominating definition of burnout is questioned. It is suggested that systematic clinical observation should be given a central place in future research on burnout-depression overlap.

Burnout and Hypocortisolism - A Matter of Severity? A Study on ACTH and Cortisol Responses to Acute Psychosocial Stress

BACKGROUND

Common consequences of long-term psychosocial stress are fatigue and burnout. It has been suggested that burnout could be associated with hypocortisolism, thus, inability to produce sufficient amounts of cortisol. This study aimed to investigate whether patients with clinical burnout exhibit aberrant ACTH and cortisol responses under acute psychosocial stress compared with healthy individuals.

METHODS

Nineteen patients (9 men and 10 women) and 37 healthy subjects (20 men and 17 women), underwent the Trier Social Stress Test. Blood samples and saliva samples were collected before, after, and during the stress test for measurements of plasma ACTH, serum cortisol, and salivary cortisol. Several statistical analyses were conducted to compare the responses between patients and controls. In addition, in order to investigate the possibility that burnout patients with more severe symptoms would respond differently, sub-groups of patients reporting higher and lower burnout scores were compared.

RESULTS

In both patients and healthy controls, we observed elevated levels of ACTH and cortisol after exposure to the stressor. There were no differences in responses of ACTH, serum cortisol, or salivary cortisol between patients and controls. Patients reporting higher burnout scores had lower salivary cortisol responses than controls, indicating that patients with more severe burnout symptoms may be suffering from hypocortisolism. In addition, patients with more severe burnout symptoms tended to have smaller ACTH responses than the other patients. However, there was no corresponding difference in serum cortisol.

CONCLUSION

This study indicates that hypocortisolism is not present in a clinical burnout patient group as a whole but may be present in the patients with more severe burnout symptoms.

School burnout: increased sympathetic vasomotor tone and attenuated ambulatory diurnal blood pressure variability in young adult women

Two studies examined autonomic and cardiovascular functioning that may link school burnout to cardiovascular risk factors in young healthy adult females. Study 1 (N = 136) investigated whether school burnout was related to resting values of blood pressure (BP) and blood pressure variability (BPV) through laboratory beat-to-beat BP assessment. Study 2 (N = 94) examined the link between school burnout and diurnal BPV through ambulatory BP monitoring. Controlling for anxiety and depressive symptomatology, school burnout demonstrated strong positive relationships with indices of cardiac sympathovagal tone, sympathetic vasomotor tone, inefficient myocardial oxygen consumption, increased 24-h ambulatory heart rate and BP, blunted BP diurnal variability, and increased arterial stiffness. These studies establish cardiovascular biomarkers of school burnout and suggest that even in a seemingly healthy sample school burnout may predispose females to increased cardiovascular risk. Several future lines of research are outlined.

The psychological and physiological effects of acute occupational stress in new anesthesiology residents: a pilot trial

BACKGROUND

Occupational stress in resident physicians has profound implications for wellness, professionalism, and patient care. This observational pilot trial measured psychological and physiological stress biomarkers before, during, and after the start of anesthesia residency.

METHODS

Eighteen physician interns scheduled to begin anesthesia residency were recruited for evaluation at three time points: baseline (collected remotely before residency in June 2013); first-month visit 1 (July); and follow-up visit 2 (residency months 3 to 5, September-November). Validated scales were used to measure stress, anxiety, resilience, and wellness at all three time points. During visits 1 and 2, the authors measured resting heart-rate variability, responses to laboratory mental stress (hemodynamic, catecholamine, cortisol, and interleukin-6), and chronic stress indices (C-reactive protein, 24-h ambulatory heart rate and blood pressure, 24-h urinary cortisol and catecholamines, overnight heart-rate variability).

RESULTS

Thirteen interns agreed to participate (72% enrollment). There were seven men and six women, aged 27 to 33 yr. The mean ± SD of all study variables are reported.

CONCLUSION

The novelty of this report is the prospective design in a defined cohort of residents newly exposed to the similar occupational stress of the operating environment. Because of the paucity of literature specific to the measures and stress conditions in this investigation, no data were available to generate a priori definition of primary outcomes and a data analytic plan. These findings will allow power analysis for future design of trials examining occupational stress and stress-reducing interventions. Given the importance of physician burnout in our country, the impact of chronic stress on resident wellness requires further study.

Correlation between Surgeon's experience, surgery complexity and the alteration of stress related physiological parameters

Introduction

In the present work we analyzed the hormonal (salivary Cortisol; sC), immune (salivary Immunoglobulin A; sIgA) and cardiovascular (Heart rate, HR, and systolic blood pressure, SBP) responses induced by stress conditions in oral surgeons, randomly recruited according to their expertise level.

Materials and methods

Each surgeon performed three different surgical procedures with increasing degrees of technical difficulty and under time-limited conditions, to assess whether these variants may influence the risks of stress-induced secondary hypertension among the involved health professionals. sC and sIgA samples and cardiovascular function measurements were taken up before, during, and two hours after every surgery. Salivary samples and cardiovascular measurements were taken also during non-surgical days, as baseline controls.

Results

We observed that more experienced surgeons showed a higher stress management ability compared to those with less experience or, generally, younger, which are more exposed to the risks of developing secondary hypertension. Nevertheless, indipendently of sex and experience, oral surgeons are constantly exposed to high risks of developing stress-related diseases.

Conclusions

On the basis of the issues addressed and the results obtained, we have highlighted the importance of the investigated stress biomarkers to monitor and to prevent stress-related pathologies among oral surgeons. This approach is aimed to emphasize the significance of these specific stress-biomarkers, which represent a powerful instrument to evaluate stress levels in oral surgeons, and that may help to reduce the most severe life-threatening risks to which they are daily exposed. In conclusion, final goal of this study is to suggest an useful guideline to monitor the stress levels of oral and maxillofacial surgeons in order to improve their quality of life, which is inevitably reflected on the quality of the performances provided and, finally, to prevent possible mistakes in their daily activities.

Physician health and wellness

Physician health and wellness is a critical issue gaining national attention because of the high prevalence of physician burnout. Pediatricians and pediatric trainees experience burnout at levels equivalent to other medical specialties, highlighting a need for more effective efforts to promote health and well-being in the pediatric community. This report will provide an overview of physician burnout, an update on work in the field of preventive physician health and wellness, and a discussion of emerging initiatives that have potential to promote health at all levels of pediatric training. Pediatricians are uniquely positioned to lead this movement nationally, in part because of the emphasis placed on wellness in the Pediatric Milestone Project, a joint collaboration between the Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. Updated core competencies calling for a balanced approach to health, including focus on nutrition, exercise, mindfulness, and effective stress management, signal a paradigm shift and send the message that it is time for pediatricians to cultivate a culture of wellness better aligned with their responsibilities as role models and congruent with advances in pediatric training. Rather than reviewing programs in place to address substance abuse and other serious conditions in distressed physicians, this article focuses on forward progress in the field, with an emphasis on the need for prevention and anticipation of predictable stressors related to burnout in medical training and practice. Examples of positive progress and several programs designed to promote physician health and wellness are reviewed. Areas where more research is needed are highlighted.

Characteristics and trends in peer-reviewed publications in the field of psychosomatic medicine

BACKGROUND

The field of psychosomatic medicine/consultation-liaison psychiatry, now a subspecialty in psychiatry, has focused its efforts on clinical care, education, and research at the interface of psychiatry, medicine, and neurology.

OBJECTIVE

We sought to categorize characteristics and trends (over the past decade) in several journals intended primarily for practitioners of psychosomatic medicine.

METHODS

We reviewed all articles published in 3 peer-reviewed journals (i.e., Psychosomatics, General Hospital Psychiatry, and the Journal of Psychosomatic Research) in 2002 and 2012.

RESULTS

Each of the 3 journals has a different approach to publication of original research, clinical reviews, and case reports.

CONCLUSIONS

The 3 journals demonstrate differing levels of international involvement, publish a different number of articles of different types (e.g., case reports, reviews, and original research), and focus on different types of medical-psychiatric problems.

Increased objectively assessed vigorous-intensity exercise is associated with reduced stress, increased mental health and good objective and subjective sleep in young adults

The role of physical activity as a factor that protects against stress-related mental disorders is well documented. Nevertheless, there is still a dearth of research using objective measures of physical activity. The present study examines whether objectively assessed vigorous physical activity (VPA) is associated with mental health benefits beyond moderate physical activity (MPA). Particularly, this study examines whether young adults who accomplish the American College of Sports Medicine's (ACSM) vigorous-intensity exercise recommendations differ from peers below these standards with regard to their level of perceived stress, depressive symptoms, perceived pain, and subjective and objective sleep. A total of 42 undergraduate students (22 women, 20 men; M=21.24years, SD=2.20) volunteered to take part in the study. Stress, pain, depressive symptoms, and subjective sleep were assessed via questionnaire, objective sleep via sleep-EEG assessment, and VPA via actigraphy. Meeting VPA recommendations had mental health benefits beyond MPA. VPA was associated with less stress, pain, subjective sleep complaints and depressive symptoms. Moreover, vigorous exercisers had more favorable objective sleep pattern. Especially, they had increased total sleep time, more stage 4 and REM sleep, more slow wave sleep and a lower percentage of light sleep. Vigorous exercisers also reported fewer mental health problems if exposed to high stress. This study provides evidence that meeting the VPA standards of the ACSM is associated with improved mental health and more successful coping among young people, even compared to those who are meeting or exceeding the requirements for MPA.

Dexamethasone stimulated gene expression in peripheral blood indicates glucocorticoid-receptor hypersensitivity in job-related exhaustion

Work-related stress can lead to various health problems ranging from job-related exhaustion to psychiatric and somatic diseases. Biomarkers of job-related exhaustion could help to improve our understanding of the biological mechanisms and might be useful to guide prevention and treatment strategies. The present study included 12 male cases suffering from job-related exhaustion and 12 matched healthy controls. Severity of exhaustion was assessed with the Maslach Burnout Inventory (MBI) and the Shirom-Melamed Burnout Measure (SMBM). Whole genome expression profiles derived from whole blood cells (baseline and following glucocorticoid-receptor (GR) stimulation with 1.5mg dexamethasone p.o.) and corresponding plasma cortisol levels were analyzed. All cases participated in regular aerobic exercise for 12 consecutive weeks and were then re-assessed at follow-up for exhaustion symptoms as well as for cortisol levels and gene expression profiles. At baseline, we found increased basal cortisol levels and an enhanced suppression of plasma cortisol concentrations following dexamethasone in cases suffering from job-related exhaustion. Gene expression analysis revealed that 1.6-fold more transcripts were significantly regulated by dexamethasone in cases as compared to controls. At follow-up after 12 weeks of regular exercise training which was accompanied by significantly improved exhaustion severity scores, cortisol levels and gene expression profiles of cases normalized to the levels observed in controls. In conclusion, we detected GR-induced neuroendocrine and gene expression changes in cases suffering from job-related exhaustion which are in line with an increased sensitivity of GR function. This GR dysregulation normalized with symptom recovery.

The effects of perceived stress on biological parameters in healthcare professionals: A systematic review

We synthesised evidence on biological correlates of psychological stress in hospital-based healthcare professionals, and examined whether there was evidence of consistent biological changes. Electronic databases were searched for empirical studies; 16 articles (0.6%) met the inclusion criteria. Evidence of a relationship between indices of psychological stress and biological parameters was limited and inconsistent. There was some evidence of a consistent relationship between natural killer cells and lymphocyte subpopulations. Considerable heterogeneity in the methods used was seen. Future prospective studies examining the relationship between indices of psychological stress and natural killer cells, including lymphocyte subsets, is required.

Burnout among physicians

Burnout is a common syndrome seen in healthcare workers, particularly physicians who are exposed to a high level of stress at work; it includes emotional exhaustion, depersonalization, and low personal accomplishment. Burnout among physicians has garnered significant attention because of the negative impact it renders on patient care and medical personnel. Physicians who had high burnout levels reportedly committed more medical errors. Stress management programs that range from relaxation to cognitive-behavioral and patient-centered therapy have been found to be of utmost significance when it comes to preventing and treating burnout. However, evidence is insufficient to support that stress management programs can help reducing job-related stress beyond the intervention period, and similarly mindfulness-based stress reduction interventions efficiently reduce psychological distress and negative vibes, and encourage empathy while significantly enhancing physicians' quality of life. On the other hand, a few small studies have suggested that Balint sessions can have a promising positive effect in preventing burnout; moreover exercises can reduce anxiety levels and exhaustion symptoms while improving the mental and physical well-being of healthcare workers. Occupational interventions in the work settings can also improve the emotional and work-induced exhaustion. Combining both individual and organizational interventions can have a good impact in reducing burnout scores among physicians; therefore, multidisciplinary actions that include changes in the work environmental factors along with stress management programs that teach people how to cope better with stressful events showed promising solutions to manage burnout. However, until now there have been no rigorous studies to prove this. More interventional research targeting medical students, residents, and practicing physicians are needed in order to improve psychological well-being, professional careers, as well as the quality of care provided to patients.

Burnout symptom sub-types and cortisol profiles: what's burning most?

The current study assessed which specific burnout symptoms were most predictive of distinct diurnal cortisol profiles. Participants included 401 day-shift workers employed in a random sampling of 34 Canadian workplaces. The 16-item Maslach Burnout Inventory was used to extract burnout sub-scales that included emotional exhaustion, cynicism, professional inefficacy, as well as a global burnout average. Consenting workers provided five saliva samples a day (awaking, 30 min after awaking, 1,400 h, 1,600 h, and bedtime) repeated three times over the course of a week (Saturday, Tuesday, Thursday) to capture workday and non-workday variations. Multilevel regression models were estimated from cortisol measurements at each occasion within a day at level-1, workers at level-2, and workplaces at level-3. Multilevel regression analyses found that emotional exhaustion and a global burnout showed the strongest and consistent negative associations to cortisol in the afternoon and evening. In a separate analysis using regression coefficients, emotional exhaustion and a global burnout average were associated with low cortisol levels 30 min upon awakening. By contrast, professional inefficacy was associated only with lower bedtime cortisol. No associations were detected for cynicism and sex did not emerge as a moderator in secondary analyses. Our findings are discussed in a theoretical framework postulating different pathophysiological stages of burnout development. Specifically, professional inefficacy may be the earliest warning signal culminating with emotional exhaustion that may dampen diurnal cortisol levels.

School burnout and cardiovascular functioning in young adult males: a hemodynamic perspective

This study investigated aortic and brachial hemodynamic functioning that may link school burnout to cardiovascular risk factors. Methodological improvements from previous research were implemented including (1) statistical control of depressive and anxiety symptoms (2) resting, stress-induced and cardiac recovery condition comparisons and (3) use of pulse wave analysis. Forty undergraduate young adult males completed self-report measures of school burnout, trait anxiety and depressive symptoms. Participants then completed a protocol consisting of a 10-min seated rest, 5-min baseline (BASE), 3-min cold pressor test (CPT) and a 3-min recovery period (REC). Indices of brachial and aortic hemodynamics were obtained by means of pulse wave analysis via applanation tonometry. Controlling for anxiety and depressive symptoms, planned contrasts identified no differences in cardiovascular parameters at BASE between participants in burnout and non-burnout groups. However, negative changes in hemodynamic indices occurred in burnout participants at CPT and REC as evidenced by increased aortic and brachial systolic and diastolic blood pressures, increased left ventricular work and increased myocardial oxygen consumption. Findings suggest that school burnout symptoms are associated with cardiac hyperactivity during conditions of cardiac stress and recovery and therefore may be associated with the early manifestations of cardiovascular disease. Future studies are suggested to reveal underlying autonomic mechanisms explaining hemodynamics functioning in individuals with school burnout symptomatology.

Systematic review of the evidence of a relationship between chronic psychosocial stress and C-reactive protein

INTRODUCTION

C-reactive protein (CRP) is an acute-phase reactant with an increasing number of clinical functions. Studies in recent years have identified several social, economic, demographic, and psychological factors that contribute to baseline inflammation. Psychosocial stress represents a significant contributor to baseline inflammation. Given the importance of understanding background drivers of CRP levels, we conducted this review to assess the impact of chronic psychosocial stress on CRP levels.

METHODS

Medline was searched through February 2013 for human studies examining CRP levels with respect to chronic psychosocial stress.

RESULTS

The initial search identified 587 articles from which 129 potentially appropriate articles were reviewed. Of these 129 articles, 41 articles were included in the review. These studies were published between 2003 and 2013. Of these studies, 6 analyzed employment stress, 2 analyzed unemployment stress, 6 analyzed burnout and vital exhaustion, 6 analyzed caregiver stress, 3 analyzed interpersonal stress, 17 analyzed socioeconomic position, and 2 analyzed discrimination.

CONCLUSION

We conclude that psychosocial stress significantly impacts CRP and should be considered when interpreting the meaning of CRP elevations.

Cardiorespiratory fitness protects against stress-related symptoms of burnout and depression

OBJECTIVE

To examine how cardiorespiratory fitness and self-perceived stress are associated with burnout and depression. To determine if any relationship between stress and burnout/depression is mitigated among participants with high fitness levels.

METHODS

197 participants (51% men, mean age=39.2 years) took part in the study. The Åstrand bicycle test was used to assess cardorespiratory fitness. Burnout was measured with the Shirom-Melamed Burnout Questionnaire (SMBQ), depressive symptoms with the Hospital Anxiety and Depression Scale (HAD-D). A gender-matched stratified sample was used to ensure that participants with varying stress levels were equally represented.

RESULTS

Participants with moderate and high fitness reported fewer symptoms of burnout and depression than participants with low fitness. Individuals with high stress who also had moderate or high fitness levels reported lower scores on the SMBQ Tension subscale and the HAD-D than individuals with high stress, but low fitness levels.

CONCLUSION

Better cardiovascular fitness seems to be associated with decreased symptoms of burnout and a better capacity to cope with stress.

PRACTICAL IMPLICATIONS

Promoting and measuring cardiorespiratory fitness can motivate employees to adopt a more physically active lifestyle and thus strengthen their ability to cope with stress exposure and stress-related disorders.

Increased neurosteroid sensitivity--an explanation to symptoms associated with chronic work related stress in women?

Work related psychosocial stress can be accompanied by so called burnout syndrome with symptoms of mental exhaustion, physical fatigue, and cognitive dysfunction. Underlying mechanisms for acquiring burnout syndrome are not clear. Animal studies show that chronic stress is associated with altered release of GABA-A receptor modulating steroids (GAMS), altered composition of the GABA-A receptor and altered sensitivity to GAMS. In the present study we investigated if such changes occur in women with burnout syndrome. We further asked whether flumazenil (a benzodiazepine antagonist, but with positive modulating effects on GABA-A receptors with altered subunit composition) can block the effect of the GAMS allopregnanolone. Ten women with occupational psychosocial stress and burnout syndrome were compared with twelve healthy controls in an experimental setting. Saccadic eye velocity (SEV) was measured after an injection of allopregnanolone, followed by an injection of flumazenil and a second injection of allopregnanolone. The sensitivity to allopregnanolone was significantly higher in the patients compared to controls after the first injection (p=0.04) and the difference increased when the response per allopregnanolone concentration unit was compared (p=0.006). Following the flumazenil injection the burnout patients (p=0.016), but not controls, showed a decrease in SEV and flumazenil acted like a positive modulator that is agonistic. There was no significant difference between the groups after second allopregnanolone injection. In conclusion, patients with work related psychosocial stress and burnout syndrome show a different response to GABA-A receptor modulators than controls suggesting a changed GABA-A receptor function in these patients. More precisely we hypothesize that the α4 and delta subunits are up-regulated elevating the responsiveness to allopregnanolone and change the effect of flumazenil, which provides a potential explanation to the burnout syndrome. Flumazenil does not block the effect of allopregnanolone.

Aerobic exercise training and burnout: a pilot study with male participants suffering from burnout

Background

Occupational burnout is associated with severe negative health effects. While stress management programs proved to have a positive influence on the well-being of patients suffering from burnout, it remains unclear whether aerobic exercise alleviates burnout severity and other parameters related to occupational burnout. Therefore, the main purpose of this study was to pilot-test the potential outcomes of a 12-week exercise training to generate hypotheses for future larger scale studies.

Methods

The sample consisted of 12 male participants scoring high on the MBI emotional exhaustion and depersonalization subscales. The training program took place in a private fitness center with a 17.5 kcal/kg minimum requirement of weekly energy expenditure.

Results

The key findings are that increased exercise reduced overall perceived stress as well as symptoms of burnout and depression. The magnitude of the effects was large, revealing changes of substantial practical relevance. Additionally, profiles of mood states improved considerably after single exercise sessions with a marked shift towards an iceberg profile.

Conclusion

Among burnout patients, the findings provide preliminary evidence that exercise has the potential to reduce stress and prevent the development of a deeper depression. This has important health implications given that burnout is considered an antecedent of depressive disorders.

Trial registration

ClinicalTrials.gov Identifier: ISRNCT01575743

Burnout and risk of coronary heart disease: a prospective study of 8838 employees

OBJECTIVE

Burnout is a negative affective state consisting of emotional exhaustion, physical fatigue, and cognitive weariness symptoms. This study was designed to evaluate prospectively the association between burnout and coronary heart disease (CHD) incidence and to test the possibility that this association is nonlinear.

METHODS

Participants were 8838 apparently healthy employed men and women, aged 19 to 67 years, who came for routine health examinations at the Tel Aviv Sourasky Medical Center. They were followed up for 3.4 years on average. Burnout was measured by the Shirom-Melamed Burnout Measure. CHD incidence was defined as a composite of acute myocardial infarction, diagnosed ischemic heart disease, and diagnosed angina pectoris.

RESULTS

During follow-up, we identified 93 new cases of CHD. Baseline levels of burnout were associated with an increased risk of CHD, after adjustment for various risk factors (hazard ratio = 1.41; 95% confidence interval = 1.08-1.85). In addition, we observed a significant threshold effect of burnout on CHD incidence. Participants who scored high on burnout (scores in the upper quintile of the Shirom-Melamed Burnout Measure scores distribution) had a higher risk (hazard ratio = 1.79; 95% confidence interval = 1.05-3.04) of developing CHD on follow-up compared with others.

CONCLUSIONS

Burnout is an independent risk factor for future incidence of CHD. Individuals with high levels of burnout (upper quintile) have a significantly higher risk of developing CHD compared with those with low levels of burnout.

Do waking salivary cortisol levels correlate with anesthesiologist's job involvement?

Anesthetists' work carries great responsibility and can be very stressful. Cognitive appraisal plays a central role in stress responses; however, little is known about the relationship between stress appraisal and biological markers of stress, particularly among anesthesiologists. Stress response may be associated with increased levels of systemic cortisol, which can be conveniently measured in saliva and used as a marker for the extent of stress. The objective of this study was to examine the correlation between work-related cognitive variables and waking salivary cortisol, a possible stress marker, in anesthesiologists. Thirty-eight anesthesiologists were assessed for work-related thought intrusions and perceived "mental distance" between themselves and their work, using the pictorial representation of illness self-measure (PRISM), and underwent an implicit association test reflecting implicit job-stress associations. Salivary cortisol was measured twice upon awakening and an hour later, in saliva samples, using a kit based on chemoluminescence competition assay. Only implicit job-stress associations were correlated with waking cortisol (r = 0.35, p < 0.05). Furthermore, high implicit job-stress was related to elevated cortisol only among anesthesiologists reporting large "mental distance" from work, which may represent limited job involvement related to burnout. Anesthesiologists with a low degree of job involvement who have high implicit job-stress associations have higher levels of waking salivary cortisol. Further studies are necessary to assess the impact of stress management techniques on anesthesiologists' personal and professional behavior as well as on the quality of medical care.

Long-term follow-up of cortisol awakening response in patients treated for stress-related exhaustion

OBJECTIVES

Studies on hypothalamus-pituitary-adrenal (HPA) axis activity in stress-related exhaustion and burnout have revealed incongruent results, and few longitudinal studies on clinical populations have been performed. This study was designed to investigate differences in HPA axis activity between patients with stress-related exhaustion and healthy controls and to investigate longitudinal changes in HPA axis activity in the patient group as they entered a multimodal treatment programme.

DESIGN

HPA axis activity was assessed through the cortisol awakening response (CAR). Salivary cortisol was sampled at awakening and after 15 min. Follow-up measurements were performed in the patient group after 3, 6, 12 and 18 months.

SETTING

An outpatient clinic specialising in stress-related illness.

PARTICIPANTS

Patients with clinically diagnosed stress-related exhaustion (n=162) and healthy controls (n=79).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary measure was CAR measured as the difference between the two salivary cortisol samples. Changes in CAR during follow-up were related to changes in symptoms of burnout, depression and anxiety.

RESULTS

Patients showed similar CAR as the controls and their CAR did not change significantly during treatment. No association was found between CAR and symptom development during treatment.

CONCLUSIONS

The authors conclude that CAR does not seem to discriminate clinically defined patients with exhaustion from healthy controls and it appears not to change during treatment. CAR, measured as salivary cortisol, at awakening and after 15 min, is thus not a valid marker for stress-related exhaustion.