Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

Increased prevalence of burnout symptoms in parents of chronically ill children

AIM

To examine the prevalence of burnout symptoms in the context of parenting a chronically ill child.

METHODS

A total of 252 parents of children with Type 1 Diabetes Mellitus and 38 parents of children with Inflammatory Bowel Diseases participated in a population-based study. A control group consisted of 124 randomly selected parents of healthy children. We used self-report questionnaires to assess symptoms of burnout.

RESULTS

The main finding was that significantly more parents of children with chronic diseases (36%) scored for clinical burnout, compared with parents of healthy children (20%). Burnout symptoms were most prominent among mothers of children with diabetes, although fathers of children with diabetes and mothers and fathers of children with inflammatory bowel diseases also reported higher levels of various burnout symptoms.

CONCLUSION

Burnout may be a useful model for understanding long-term parental responses and should be acknowledged among the different types of psychological consequences of the multi-faceted experience of parenting a child with chronic illness. Gender seems to influence the risk of burnout symptoms. Continued research about other background factors, and how the parents' situation changes over time are warranted. In the clinic, we need to draw attention to the group of parents who may suffer from burnout.

Conflict between the work and family domains and exhaustion among vocationally active men and women

Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job strain more often, which may constitute a partial explanation for this phenomenon, but experienced shortcomings in combining work and family demands may also contribute to ill health. The aim of this study was to investigate, and analyse by gender, how work-related and family-related factors, as well as the interface between them, i.e. work-to-family conflict (WFC) and family-to-work conflict (FWC), are related to exhaustion. The study was cross-sectional with self-administered questionnaires assessing exposures and outcome with previously well-validated instruments. The participants were 2726 men and 2735 women, aged 45-64, vocationally active, and residing in Malmö, Sweden. Sixteen percent of the women and 8% of the men considered themselves exhausted. WFC, FWC, job strain, and low job support were all strongly correlated to exhaustion in both genders. In the multivariate analyses, adjusting for other work and family risk factors, WFC and FWC remained statistically significant risk factors for exhaustion in both men and women. Job strain, low job support, and having a somatic disorder were also independently associated with exhaustion. While WFC was more prevalent among men, it was more strongly associated with exhaustion in women than in men. In women, WFC and FWC contributed to a larger part of the explanatory power of the model, which amounted to 22% of the variance in women and 14% in men. The results imply that the concept of 'work stress' should be regarded in a wider context in order to understand gender related issues of exhaustion among vocationally active individuals.

A cognitive behavioural model for maintaining processes in burnout

Can a cognitive behavioural approach offer a fresh understanding of the maintaining processes in burnout? This paper considers the enduring nature of burnout symptoms over time. It examines the hypothesis that some of the actions associated with ‘coping’ in burnout may conversely serve to perpetuate burnout symptoms. This model is considered in the context of mental-health workers and is discussed in the light of current research. It implies the need to adopt an approach to burnout that incorporates the challenging of burnout-related cognitions and the elimination of safety behaviours, rather than having a sole focus on self-care strategies.

Burnout during residency training: a literature review

OBJECTIVE

Burnout is a state of mental and physical exhaustion related to work or care giving activities. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. This article reviews the relevant literature on burnout in order to provide information to educators about its prevalence, features, impact, and potential interventions.

METHODS

Studies were identified through a Medline and PsychInfo search from 1974 to 2009. Fifty-one studies were identified. Definition and description of burnout and measurement methods are presented followed by a thorough review of the studies.

RESULTS

An examination of the burnout literature reveals that it is prevalent in medical students (28%-45%), residents (27%-75%, depending on specialty), as well as practicing physicians. Psychological distress and physical symptoms can impact work performance and patient safety. Distress during medical school can lead to burnout, which in turn can result in negative consequences as a working physician. Burnout also poses significant challenges during early training years in residency. Time demands, lack of control, work planning, work organization, inherently difficult job situations, and interpersonal relationships, are considered factors contributing to residents' burnout. Potential interventions include workplace-driven and individual-driven measures. Workplace interventions include education about burnout, workload modifications, increasing the diversity of work duties, stress management training, mentoring, emotional intelligence training, and wellness workshops. Individual-driven behavioral, social, and physical activities include promoting interpersonal professional relations, meditation, counseling, and exercise.

CONCLUSIONS

Educators need to develop an active awareness of burnout and ought to consider incorporating relevant instruction and interventions during the process of training resident physicians.

Mental health and occupational wellbeing of Australian gynaecologic oncologists

OBJECTIVE

To investigate the prevalence of psychiatric morbidity and occupational burnout among Australian gynaecologic oncologists and to assess job stress and job satisfaction in this group.

METHOD

Anonymous, self-report questionnaires containing validated measures were sent to all practicing Australian gynaecologic oncologists in October 2008.

RESULTS

The response rate was 78.4% (N=29). More than one-third (35.7%) had high levels of emotional exhaustion, the central component of burnout. In the past 6 months, 42.9%, 57.1%, and 28.6% had seriously considered leaving for another position, reducing the number of hours worked, and taking early retirement, respectively. The most commonly reported source of stress (80.8%) was home-life disruption due to work. Compared to general population data and recommended national guidelines, rates of alcohol consumption were high. Psychological morbidity, global job stress and burnout were significantly correlated and each was associated with harmful alcohol use. Other factors associated with burnout were administrative/organizational demands and patient volume. More than half of respondents (58.6%) had high levels of job satisfaction and most had high levels of personal accomplishment (70.4%). Perceived adequacy of the training curriculum and proposed changes to the curriculum are reported.

CONCLUSION

Australian gynaecologic oncologists experience considerable occupational distress while possessing high levels of personal accomplishment and job satisfaction. To maintain a healthy workforce, it is important to build on existing supports while conducting further research to identify suitable evidence-based strategies for improving the mental health of these surgeons.

Monocyte chemotactic protein-1 (MCP-1) and growth factors called into question as markers of prolonged psychosocial stress

BACKGROUND

Psychosocial stress is becoming a major contributor to increased mental ill-health and sick leave in many countries. Valid markers of chronic stress would be valuable for diagnostic and prognostic purposes. A recent study suggested monocyte chemotactic protein-1 (MCP-1), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) as markers of chronic stress. We aimed to confirm these potential biomarkers of prolonged psychosocial stress in female patients.

METHODOLOGY/PRINCIPAL FINDINGS

Circulating levels of MCP-1, EGF and VEGF, along with several other cytokines, were measured in plasma from 42 female patients suffering from exhaustion due to prolonged psychosocial stress and 42 control subjects, using a protein biochip immunoassay. There were no significant differences between patients and controls in any of the cytokines or growth factors analyzed. Furthermore, when using a different protein bioassay and reanalyzing MCP-1 and VEGF in the same samples, markedly different levels were obtained. To further explore if inflammation is present in patients with exhaustion, the classical inflammatory marker C-reactive protein (CRP) was measured in another group of patients (n=89) and controls (n=88) showing a small but significant increase of CRP levels in the patients.

CONCLUSIONS/SIGNIFICANCE

MCP-1, EGF and VEGF may not be suitable markers of prolonged psychosocial stress as previously suggested. Furthermore, significant differences were obtained when using two different protein assays measuring the same samples, indicating that comparing studies where different analytic techniques have been used might be difficult. Increased levels of CRP indicate that low-grade inflammation might be present in patients with exhaustion due to prolonged stress exposure but this inflammation does not seem to be reflected by increase in circulating MCP-1 or other cytokines measured.

Cortisol secretion and fatigue: associations in a community based cohort

The association between fatigue and reduced activity in the hypothalamo-pituitary-adrenal (HPA) axis has been described. However the temporal association between fatigue and HPA activity is under debate. We examine whether alterations in cortisol secretion play a role in the development of fatigue or whether changes occur later as a consequence of fatigue in a longitudinal cohort study of 4299 community dwelling adults (mean age 61). Cortisol secretion was measured from saliva samples collected waking, waking + 0.5, 2.5, 8, 12 h and bedtime at phase 7 (2003-2004) of the Whitehall II study. Fatigue was measured at phase 6 (2001), phase 7 and phase 8 (2006) of the Whitehall II study. Three elements of secretion were examined: waking cortisol, the cortisol awakening response and diurnal slope in cortisol secretion. Fatigue was determined using the vitality sub-scale of the Short Form-36. A wide variety of co-variates were measured. We find that fatigue measured at phase 6 was not associated with cortisol secretion at phase 7. At phase 7, low waking cortisol levels and a flat slope in diurnal cortisol secretion were associated with fatigue independently of co-variates. In participants low or free of fatigue at phase 7 low waking cortisol and flatter slope in cortisol secretion were associated with new-onset fatigue at phase 8 (for example, odds ratio for lowest vs. highest tertile of waking cortisol 1.50; 95% confidence intervals, 1.08, 2.09 after adjusting for all co-variates). In conclusion, we find that low waking salivary cortisol and a flat slope in cortisol secretion is associated with fatigue. Cortisol is also associated with future onset of fatigue suggesting that changes in cortisol secretion are etiologic or occur early in the genesis of fatigue.

Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty

BACKGROUND

A pilot study of two academic training programs revealed concerning levels of resident burnout and psychological dysfunction. The purpose of the present study was to determine the quality of life of orthopaedic residents and faculty on a national scale and to identify risk factors for decompensation.

METHODS

Three hundred and eighty-four orthopaedic residents and 264 full-time orthopaedic faculty members completed a voluntary, anonymous survey consisting of three validated instruments (the Maslach Burnout Inventory, the General Health Questionnaire-12, and the Revised Dyadic Adjustment Scale) and question sets assessing demographic information, relationship issues, stress reactions/management, and work/life balance.

RESULTS

High levels of burnout were seen in 56% of the residents and 28% of the faculty members. Burnout risk was greatest among second-postgraduate-year residents and residents in training programs with six or more residents per postgraduate year. Sixteen percent of residents and 19% of faculty members reported symptoms of psychological distress. Sleep deprivation was common among the residents and correlated positively with every distress measure. Faculty reported greater levels of stress but greater satisfaction with work and work/life balance. A number of factors, such as making time for hobbies and limiting alcohol use, correlated with decreased dysfunction for both residents and faculty.

CONCLUSIONS

Despite reporting high levels of job satisfaction, orthopaedic residents and faculty are at risk for burnout and distress. Identification of protective factors and risk factors may provide guidance to improve the quality of life of academic orthopaedic surgeons in training and beyond.

Association of vital exhaustion and depressive symptoms with changes in fibrin D-dimer to acute psychosocial stress

OBJECTIVE

Vital exhaustion and depression are psychosocial risk factors of coronary artery disease. A hypercoagulable state in response to acute psychosocial stress contributes to atherothrombotic events. We aimed to investigate the hypothesis that vital exhaustion and depression correlate with stress-induced changes in the hypercoagulability marker D-dimer.

METHODS

Thirty-eight healthy and nonsmoking school teachers (mean age 50+/-8 years, 55% women) completed the nine-item Maastricht Vital Exhaustion Questionnaire and the seven-item depression subscale of the Hospital Anxiety and Depression Scale. Within 1 week, subjects twice underwent the Trier Social Stress Test (i.e., preparation phase, mock job interview, and mental arithmetic that totaled 13 min). Plasma D-dimer levels were determined at five time points during the protocol.

RESULTS

Vital exhaustion (P=.022; eta(2)=.080) and depressive symptoms (P=.011; eta(2)=.090) were associated with stress-induced changes in D-dimer levels over time controlling for sex and age. Elevated levels of vital exhaustion (r=-.46, P=.005) and of depression (r=-.51, P=.002) correlated with reduced D-dimer increase from pre-stress to immediately post-stress. Also, elevated vital exhaustion (r=.34, P=.044) and depression (r=.41, P=.013) were associated with increase (i.e., attenuated recovery) of D-dimer levels between 20 and 45 min post-stress. Controlling for stress hormone and blood pressure reactivity did not substantially alter these results.

CONCLUSION

The findings suggest an attenuated immediate D-dimer stress response and delayed recovery of D-dimer levels post-stress with elevated vital exhaustion and depressive symptoms. In particular, the prolonged hypercoagulability after stress cessation might contribute to the atherothrombotic risk previously observed with vital exhaustion and depression, even at subclinical levels.

A newly proposed disease condition produced by light exposure during night: asynchronization

The bedtime of preschoolers/pupils/students in Japan has become progressively later with the result sleep duration has become progressively shorter. With these changes, more than half of the preschoolers/pupils/students in Japan recently have complained of daytime sleepiness, while approximately one quarter of junior and senior high school students in Japan reportedly suffer from insomnia. These preschoolers/pupils/students may be suffering from behaviorally induced insufficient sleep syndrome due to inadequate sleep hygiene. If this diagnosis is correct, they should be free from these complaints after obtaining sufficient sleep by avoiding inadequate sleep hygiene. However, such a therapeutic approach often fails. Although social factors are often involved in these sleep disturbances, a novel clinical notion--asynchronization--can further a deeper understanding of the pathophysiology of these disturbances. The essence of asynchronization is a disturbance in various aspects (e.g., cycle, amplitude, phase and interrelationship) of the biological rhythms that normally exhibit circadian oscillation, presumably involving decreased activity of the serotonergic system. The major trigger of asynchronization is hypothesized to be a combination of light exposure during the night and a lack of light exposure in the morning. In addition to basic principles of morning light and an avoidance of nocturnal light exposure, presumable potential therapeutic approaches for asynchronization involve both conventional ones (light therapy, medications (hypnotics, antidepressants, melatonin, vitamin B12), physical activation, chronotherapy) and alternative ones (kampo, pulse therapy, direct contact, control of the autonomic nervous system, respiration (qigong, tanden breathing), chewing, crawling). A morning-type behavioral preference is described in several of the traditional textbooks for good health. The author recommends a morning-type behavioral lifestyle as a way to reduce behavioral/emotional problems, and to lessen the likelihood of falling into asynchronization.

Turnover intention and emotional exhaustion "at the top": adapting the job demands-resources model to leaders of addiction treatment organizations

Compared with the large literature on subordinate employees, there are few studies of emotional exhaustion and turnover intention for organizational leaders. There is little research that has extended the job demands-resources (JD-R) model of emotional exhaustion to leaders. In this study, the authors adapted the JD-R framework to analyze data collected from a sample of 410 leaders of addiction treatment organizations. The authors considered whether two job demands (performance demands and centralization) and two job resources (innovation in decision making and long-range strategic planning) were associated with emotional exhaustion and turnover intention. The authors also examined whether emotional exhaustion fully or partially mediated the associations between the job-related measures and turnover intention. The results supported the partially mediated model. Both job demands were positively associated with emotional exhaustion, and the association for long-range strategic planning was negative. Emotional exhaustion was positively associated with turnover intention. Centralization and innovation in decision making were also directly associated with turnover intention. Future research should continue to examine this theoretical framework among leaders of other types of organizations using more refined measures of demands and resources.

Organizational traits, care processes, and burnout among chronic hemodialysis nurses

In light of evidence linking registered nurse (RN) staffing levels to patient outcomes in chronic hemodialysis facilities, U.S. government regulations have set minimum RN staffing requirements during dialysis. Consequently, facility administrators are focused on decreasing nurse attrition in this crucial practice setting. This study used a cross-sectional, correlational design to investigate the effects of workload, practice environment, and care processes on burnout among nurses in U.S. chronic hemodialysis centers and to determine the association between burnout and nurses' intentions to leave their jobs. Findings indicate that predictors were associated with an increased likelihood of nurse burnout and that nurses experiencing burnout were more likely to be planning to leave their jobs. Findings have important implications for retention of nurses, enhancement of patient safety, and adherence to new federal staffing requirements in chronic hemodialysis units.

Clinical supervision, emotional exhaustion, and turnover intention: a study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse

An intriguing hypothesis is that clinical supervision may protect against counselor turnover. This idea has been mentioned in recent discussions of the substance abuse treatment workforce. To test this hypothesis, we extend our previous research on emotional exhaustion and turnover intention among counselors by estimating the associations between clinical supervision and these variables in a large sample (N = 823). An exploratory analysis reveals that clinical supervision was negatively associated with emotional exhaustion and turnover intention. Given our previous findings that emotional exhaustion and turnover intention were associated with job autonomy, procedural justice, and distributive justice, we estimate a structural equation model to examine whether these variables mediated clinical supervision's associations with emotional exhaustion and turnover intention. These data support the fully mediated model. We found that the perceived quality of clinical supervision is strongly associated with counselors' perceptions of job autonomy, procedural justice, and distributive justice, which are, in turn, associated with emotional exhaustion and turnover intention. These data offer support for the protective role of clinical supervision in substance abuse treatment counselors' turnover and occupational well-being.

Japanese clinical guidelines for juvenile orthostatic dysregulation version 1

This clinical practice guideline provides recommendations for the assessment, diagnosis and treatment of school-aged children and juveniles with orthostatic dysregulation (OD), usually named orthostatic intolerance in USA and Europe. This guideline is intended for use by primary care clinicians working in primary care settings. The guideline contains the following recommendations for diagnosis of OD: (i) initial evaluation composed of including and excluding criteria, the assessment of no evidence of other disease including cardiac disease and so on; (ii) a new orthostatic test to determine four different subsets: instantaneous orthostatic hypotension, postural tachycardia syndrome, neurally mediated syncope and delayed orthostatic hypotension; (iii) evaluation of severity; and (iv) judgment of psychosocial background with the use of rating scales. The guideline also contains the following recommendations for treatment of OD on the basis of the result of an orthostatic test in addition to psychosocial assessment: (i) guidance and education for parents and children; (ii) non-pharmacological treatments; (iii) contact with school personnel; (iv) use of adrenoceptor stimulants and other medications; (v) strategies of psychosocial intervention; and (vi) psychotherapy. This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OD. Rather, it is designed to assist primary care clinicians by providing a framework for decision making of diagnosis and treatments.

Recognizing and preventing burnout among orthopaedic leaders

Stress, emotional exhaustion, and burnout are widespread in the medical profession in general and in orthopaedic surgery in particular. We attempted to identify variables associated with burnout as assessed by validated instruments. Surveys were sent to 282 leaders from orthopaedic surgery academic departments in the United States by e-mail and mail. Responses were received from 195 leaders for a response rate of 69%. The average surgeon worked 68.3 hours per week and more than (1/2) of this time was allocated to patient care. Highest stressors included excessive workload, increasing overhead, departmental budget deficits, tenure and promotion, disputes with the dean, and loss of key faculty. Personal-professional life imbalance was identified as an important risk factor for emotional exhaustion. Withdrawal, irritability, and family disagreements are early warning indicators of burnout and emotional exhaustion. Orthopaedic leaders can learn, and potentially model, ways to mitigate stress from other high-stress professions. Building on the strength of marital and family bonds, improving stress management skills and self-regulation, and improving efficiency and productivity can combine to assist the orthopaedic surgery leader in preventing burnout and emotional exhaustion.

Chronic work stress and exhaustion is associated with higher allostastic load in female school teachers

Epidemiological studies have shown that chronic work stress or unfavourable psychosocial work conditions are prospectively associated with different adverse health outcomes. The aim of the present cross-sectional study was to investigate the relationship between work-related chronic stress as well as exhaustion and a cumulative measure of physiological wear-and-tear called allostastic load (AL). AL could be a possible biological pathway for how chronic work stress and exhaustion lead to health impairments in the long run. As the teaching profession has been proposed to be a potentially high stressful occupation, chronic work stress (effort-reward-imbalance) and exhaustion were assessed in 104 female school teachers. AL was first analyzed according to McEwen's classical model comprised of ten parameters including cortisol, epinephrine and norepinephrine, dehydroepiandrosterone-sulphate (DHEA-S), waist/hip-ratio (WHR), glycosylated haemoglobin (HbA1c), high-density lipoprotein (HDL), total cholesterol/HDL-ratio, and systolic and diastolic blood pressure. Additionally it was extended to include tumor-necrosis-factor-alpha (TNF-alpha), C-reactive protein (CRP), fibrinogen, D-dimer, percent-body-fat, triglycerides, and glucose levels. A substantial proportion of our sample was highly exhausted whereas relatively few teachers showed high effort-reward-imbalance. AL scores were significantly higher in women high on effort-reward-imbalance or suffering from exhaustion. Although all teachers had been in a good health status, chronic work stress as well as exhaustion appears to be associated with changes in a multi-system summary indicator of physiological risk.

Why do we respond so differently? Reviewing determinants of human salivary cortisol responses to challenge

Stress and stress-related health impairments are major problems in human life and elucidating the biological pathways linking stress and disease is of substantial importance. However, the identification of mechanisms underlying a dysregulation of major components of the stress response system is, particularly in humans, a very challenging task. Salivary cortisol responses to diverse acute challenge paradigms show large intra- and interindividual variability. In order to uncover mechanisms mediating stress-related disorders and to potentially develop new therapeutic strategies, an extensive phenotyping of HPA axis stress responses is essential. Such a research agenda depends on substantial knowledge of moderating and intervening variables that affect cortisol responses to different stressors and stimuli. The aim of this report is, therefore, to provide a comprehensive summary of important determinants of, in particular, human salivary cortisol responses to different kinds of laboratory stimuli including acute psychosocial stress as well as pharmacological provocation procedures. This overview demonstrates the role of age and gender, endogenous and exogenous sex steroid levels, pregnancy, lactation and breast-feeding, smoking, coffee and alcohol consumption as well as dietary energy supply in salivary cortisol responses to acute stress. Furthermore, it briefly summarizes current knowledge of the role of genetic factors and methodological issues in terms of habituation to repeated psychosocial stress exposures and time of testing as well as psychological factors, that have been shown to be associated with salivary cortisol responses like early life experiences, social factors, psychological interventions, personality as well as acute subjective-psychological stress responses and finally states of chronic stress and psychopathology.

Effort-reward-imbalance and overcommitment are associated with hypothalamus-pituitary-adrenal (HPA) axis responses to acute psychosocial stress in healthy working schoolteachers

In this study, we examined HPA axis responses to acute psychosocial stress in relation to effort-reward-imbalance (ERI) and overcommitment (OC) to test whether chronic stress at work is accompanied by altered HPA axis stress responses in teachers. According to Siegrist's work stress model, ERI reflects stress due to a lack of reciprocity between personal costs and gains at work, whereas OC is conceptualized as a personality trait mainly characterized by the inability to withdraw from work obligations. Fifty-three medication-free, non-smoking, healthy teachers (33 women, 20 men, 29-63 years, mean age 49.9+/-8.58 years) were confronted with the Trier Social Stress Test (TSST), a widely used standardized stress protocol to induce acute psychosocial stress in the laboratory. ACTH (five samples), total plasma (six samples) and free salivary cortisol (eight samples) were repeatedly measured before and after challenge. In the total group, ERI and OC were only marginally associated with HPA axis responses to acute stress. However, in the subgroup of responders (N=30) high levels of OC were significantly associated with lower ACTH (p=0.03) as well as plasma (p=0.02) and salivary cortisol (p<0.001) responses and results remained significant controlling for depressive symptoms. When additionally controlling for acute perceived stressfulness of the TSST, significant associations between OC and HPA axis responses emerged in responders as well as the total study sample. In respect to ERI, higher stress levels were solely related to significantly stronger plasma cortisol increases after TSST exposure, but this effect became non-significant controlling for depressive symptomatology. In sum, our findings support the notion of HPA axis hyporeactivity in highly overcommitted schoolteachers.

Qigong stress reduction in hospital staff

OBJECTIVE

The aim of this study was to investigate the effectiveness of a qigong training program in reducing stress in hospital staff.

METHODS

Subjects were randomly assigned to a 6-week intervention of either qigong practice (n = 16) or a waiting list (n = 21). The primary measure of stress was the Perceived Stress Scale. Secondary measures included the Short Form 36 (SF-36) quality-of-life measure and a 100-mm analog pain scale.

RESULTS

The qigong group demonstrated a statistically significant reduction of perceived stress compared to the control group (p = 0.02). On the Social Interaction subscale of the SF-36, the qigong group demonstrated greater improvement compared to controls (p = 0.04). Within-groups analyses demonstrated that the qigong group (p = 0.03), but not the control group, experienced a significant reduction of pain intensity. A regression analysis demonstrated an association between higher baseline stress levels and greater improvement within the qigong group (R(2) = 0.34; p = 0.02).

CONCLUSIONS

These results suggest that short-term exposure to qigong was effective in reducing stress in hospital staff. Further studies are needed to evaluate the possible effectiveness of qigong in reducing pain and in improving quality of life.

Demand, control and social climate as predictors of emotional exhaustion symptoms in working Swedish men and women

AIMS

Most studies on burnout have been cross-sectional and focused on specific occupations. In the present study we prospectively investigated the association between demands, control, support and conflicts as well as downsizing and emotional exhaustion in men and women derived from a representative sample of the working population in Sweden.

METHODS

The study comprised working men (1,511) and women (1,493), who participated in the Swedish Work Environment Survey (SWES) in 2003 and had no physical exhaustion and prior sick leave at baseline. These participants were followed up in 2006 as part of the Swedish Longitudinal Occupational Survey of Health (SLOSH). Demands, decision authority, support from fellow workers and superiors, conflicts with fellow workers and superiors, and downsizing were utilized as predictors and the Maslach Burnout Inventory subscale of emotional exhaustion as the outcome in multiple logistic regression analyses.

RESULTS

High demands were a highly significant predictor of symptoms of emotional exhaustion (>/=75th percentile). Downsizing and lack of support from superiors were also independent predictors for men as well as lack of support from fellow workers and low decision authority for women.

CONCLUSIONS

This study indicates that high demands, low decision authority, lack of support at work and downsizing could be important predictors of emotional exhaustion symptoms among working men and women.

Burnout and physical and mental health among Swedish healthcare workers

AIM

This paper is a report of a study to investigate how burnout relates to self-reported physical and mental health, sleep disturbance, memory and lifestyle factors.

BACKGROUND

Previous research on the possible relationship between lifestyle factors and burnout has yielded somewhat inconsistent results. Most of the previous research on possible health implications of burnout has focused on its negative impact on mental health. Exhaustion appears to be the most obvious manifestation of burnout, which also correlates positively with workload and with other stress-related outcomes.

METHOD

A cross-sectional study was conducted, using questionnaires sent to all employees in a Swedish County Council (N = 6118) in 2002. The overall response rate was 65% (n = 3719). A linear discriminant analysis was used to look for different patterns of health indicators and lifestyle factors in four burnout groups (non-burnout, disengaged, exhausted and burnout).

RESULTS

Self-reported depression, anxiety, sleep disturbance, memory impairment and neck- and back pain most clearly discriminated burnout and exhausted groups from disengaged and non-burnout groups. Self-reported physical exercise and alcohol consumption played a minor role in discriminating between burnout and non-burnout groups, while physical exercise discriminated the exhausted from the disengaged group.

CONCLUSION

Employees with burnout had most symptoms, compared with those who experienced only exhaustion, disengagement from work or no burnout, and the result underlines the importance of actions taken to prevent and combat burnout.

Positive and negative work characteristics associated with burnout among primary care pediatricians

BACKGROUND

There is little research regarding specific work features that might cause chronic stress and burnout among primary care pediatricians. The aim of the present study was first, to assess specific negative and positive characteristics of the job that might be related to burnout; and second, to compare burnout levels and work characteristics among board-certified versus general pediatricians; and clinic directors versus non-directors.

METHODS

Questionnaires were sent to 200 pediatricians employed full-time in pediatric primary care community centers in the largest Israeli Health Maintenance Organization (HMO). Respondents replied anonymously. The questionnaires assessed sociodemographic details, burnout levels, and negative and positive job characteristics.

RESULTS

There were no differences in burnout levels between board-certified and general pediatricians. Positive job features had stronger associations with burnout than negative features. Compared with general pediatricians, board-certified pediatricians reported significantly higher levels of negative features (e.g. conflicts between the medical and administrative system in the HMO; parents disregarding instructions); but higher levels of autonomy and appreciation from patients. Compared with regular pediatricians, clinic directors had significantly higher levels of negative job features (e.g. less access to resources); and higher levels of positive work features.

CONCLUSIONS

The absence of positive job features (e.g. autonomy, recognition for one's work and utilization of skills) may be more important in causing burnout than the presence of negative characteristics (e.g. overload, demanding and noisy parents). It is consistent with recent suggestions that in the presence of positive features, employees can better tolerate stressful aspects of the job and still feel motivated and engaged.

Association between burnout and circulating levels of pro- and anti-inflammatory cytokines in schoolteachers

OBJECTIVE

The burnout syndrome has been associated with an increased risk of cardiovascular disease. The physiological mechanisms potentially involved in this link are underexplored. Knowing that a chronic low-grade systemic inflammatory state contributes to atherosclerosis, we investigated circulating cytokine levels in relation to burnout symptoms.

METHODS

We studied 167 schoolteachers (median, 48 years; range, 23-63 years; 67% women) who completed the Maslach Burnout Inventory with its three subscales emotional exhaustion (EE), lack of accomplishment (LA), and depersonalization (DP). Levels of the proinflammatory cytokine tumor necrosis factor (TNF)-alpha and of the anti-inflammatory cytokines interleukin (IL)-4 and IL-10 were determined in fasting morning plasma samples. The TNF-alpha/IL-4 ratio and the TNF-alpha/IL-10 ratio were computed as two indices of increased inflammatory activity. Analyses were adjusted for demographic factors, medication, lifestyle factors (including sleep quality), metabolic factors, and symptoms of depression and anxiety.

RESULTS

Higher levels of total burnout symptoms aggregating the EE, LA, and DP subscales independently predicted higher TNF-alpha levels (DeltaR(2)=.024, P=.046), lower IL-4 levels (DeltaR(2)=.021, P=.061), and a higher TNF-alpha/IL-4 ratio (DeltaR(2)=.040, P=.008). Higher levels of LA predicted decreased IL-4 levels (DeltaR(2)=.041, P=.008) and a higher TNF-alpha/IL-4 ratio (DeltaR(2)=.041, P=.007). The categorical dimensions of the various burnout scales (e.g., burnout yes vs. no) showed no independent relationship with any cytokine measure.

CONCLUSION

Burnout was associated with increased systemic inflammation along a continuum of symptom severity rather than categorically. Given that low-grade systemic inflammation promotes atherosclerosis, our findings may provide one explanation for the increased cardiovascular risk previously observed in burned-out individuals.

On the nature of burnout-insomnia relationships: a prospective study of employed adults

OBJECTIVE

This prospective study was designed to test the hypothesis that burnout and insomnia predict each other's incidence and intensification across time. Burnout is conceptualized as representing individuals' unique affective response to their exposure to chronic stressors.

METHOD

Apparently healthy respondents (1356) completed questionnaires during periodic health examinations undergone at two time points T(1) and T(2), about 18 months apart. Burnout was assessed by the Shirom-Melamed Burnout Measure, while insomnia was assessed by the Brief Athens Insomnia Scale. Depressive symptomatology, neuroticism, body mass index, age, gender, follow-up duration, and T(1) levels of the criterion were controlled.

RESULTS

Burnout and insomnia were found to be only moderately associated at T(1). However, logistic regression results indicated that burnout significantly predicted the development of new cases of insomnia at 18-month follow-up [odds ratio (OR)=1.93; 95% confidence interval (95% CI)=1.45-2.58], even after adjusting for depression and other potent confounders. Likewise, insomnia significantly predicted the onset of new cases of burnout at 18-month follow-up (OR=1.64; 95% CI=1.30-2.08). Hierarchical regression results indicted that T(1) burnout significantly predicted an increase in T(2) insomnia (beta=.05, P<.05), and that T(1) insomnia significantly predicted an increase in T(2) burnout (beta=.07, P<.05).

DISCUSSION

The results indicate that burnout and insomnia recursively predict each other's development and intensification over time, thus suggesting that either might be a risk factor for the other across time. Possible mechanisms of link between burnout and insomnia, as well as the clinical implications of the findings, were suggested.

Circulating fibrinogen but not D-dimer level is associated with vital exhaustion in school teachers

Meta-analyses have established elevated fibrinogen and D-dimer levels in the circulation as biological risk factors for the development and progression of coronary artery disease (CAD). Here, we investigated whether vital exhaustion (VE), a known psychosocial risk factor for CAD, is associated with fibrinogen and D-dimer levels in a sample of apparently healthy school teachers. The teaching profession has been proposed as a potentially high stressful occupation due to enhanced psychosocial stress at the workplace. Plasma fibrinogen and D-dimer levels were measured in 150 middle-aged male and female teachers derived from the first year of the Trier-Teacher-Stress-Study. Log-transformed levels were analyzed using linear regression. Results yielded a significant association between VE and fibrinogen (p = 0.02) but not D-dimer controlling for relevant covariates. Further investigation of possible interaction effects resulted in a significant association between fibrinogen and the interaction term "VE x gender" (p = 0.05). In a secondary analysis, we reran linear regression models for males and females separately. Gender-specific results revealed that the association between fibrinogen and VE remained significant in males but not females. In sum, the present data support the notion that fibrinogen levels are positively related to VE. Elevated fibrinogen might be one biological pathway by which chronic work stress may impact on teachers' cardiovascular health in the long run.

Insomnia and sleep quality among primary care physicians with low and high burnout levels

OBJECTIVE

The aim of this study was to assess insomnia and sleep quality in primary care physicians with low and high burnout scores.

METHODS

A representative sample of 240 physicians was drawn from 70 medical centers in Madrid, Spain. Based on quartile splits of the overall index of the Shirom-Melamed Burnout Questionnaire, 55 participants were allocated to a low-burnout group, and 58 were included in a high-burnout group. The questionnaire also included sociodemographic data, insomnia symptomatology, and the Pittsburgh Sleep Quality Index.

RESULTS

Of the total sample, 18.8% met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for insomnia diagnoses. More individuals with high burnout scores (21.1%) than individuals with low burnout scores (6.9%) fulfilled these criteria. Results of multivariate logistic regression analyses showed that burnout was the only variable related to insomnia diagnoses (odds ratio=7.56; 95% confidence interval=2.38-14.02). Furthermore, the results of multivariate analysis of covariance, after adjustments for sociodemographic variables, indicated that subjects from the high-burnout group scored significantly higher than subjects from the low-burnout group on the global sleep quality index and its components, indicating significantly greater disturbed sleep for the former.

CONCLUSION

The results of the present study provide support for a clear relationship between burnout and disturbed sleep, as shown by the high prevalence of insomnia and poor sleep quality among physicians with high levels of burnout.

Behavioral Medicine Review: Psychological Risks for Metabolic Syndrome

Despite their ubiquity in primary care, psychological disorders often are overlooked as cues to heightened risk for metabolic syndrome (MetS), potentially leading to the suboptimal management of patients with these comorbid conditions. Accordingly, this review discusses psychological dysfunction as an under-appreciated MetS hazard and the strategic implications for cardiometabolic risk reduction in primary care.

Is burnout related to allostatic load?

BACKGROUND

Burnout has a negative impact on physical health, but the mechanisms underlying this relation remain unclear. To elucidate these mechanisms, possible mediating physiological systems or risk factors for adverse health in burned-out employees should be investigated.

GOAL

The aim of the present study among 290 Dutch managers was to explore whether allostatic load mediates the relationship between burnout and physical health.

METHOD

Burned-out managers, as identified with the Maslach Burnout Inventory General Survey (MBI-GS), were compared with a healthy control group with regard to their allostatic load. The allostatic load index included eight parameters: Body-mass index (BMI), systolic and diastolic blood pressure (SBP and DBP), C-reactive protein (CRP), high-density lipoprotein (HDL), cholesterol, glycosylated hemoglobin (HbA1C) and glucose.

RESULTS

Contrary to expectations, burned-out managers did not differ from healthy managers with regard to their scores on the allostatic load index. An additional analysis, using groups of managers in the extreme deciles of exhaustion (the core symptom of burnout), did also not reveal differences in allostatic load.

CONCLUSION

Burnout seems not to be associated with this proxy measure of allostatic load. The mediating physiological mechanisms between burnout and objective physical health remain to be elucidated.

Burnout among women: associations with demographic/socio-economic, work, life-style and health factors

This study examined the occurrence of low/high burnout among women and the demographic/socio-economic, work, life-style, and health "correlates" of high burnout. The sample consisted of 6.000 randomly selected women from the general population, of which 3.591 participated. The design was cross-sectional. The univariate analyses showed that about 21% of the women had high burnout, and compared to those with low burnout, they were more often younger, divorced, blue-collar workers, lower educated, foreigners, on unemployment/retirement/sick-leave, financially strained, used more medication and cigarettes, reported higher work demands and lower control/social support at work, more somatic problems (e.g. pain) and depression. The regression analysis showed that only age, sick-leave, financial strain, medication, work demands, depression and somatic ailments were independently associated with high burnout. Thus, women with high burnout were apparently faring poorly financially, emotionally and physically. Considering our findings, interventions to alleviate their problems may be necessary. We may have provided new insights into women's burnout experiences, but longitudinal studies are warranted to firmly identify "determinants" of burnout.

Exhaustion and endocrine functioning in clinical burnout: An in-depth study using the experience sampling method

The current study investigates the relationship between HPA-axis functioning and burnout symptoms by employing an electronic symptom diary. This diary method circumvents the retrospection bias induced by symptom questionnaires and allows to study relationships within-in addition to between-subjects. Forty two clinically burned-out participants completed the exhaustion subscale of the Maslach burnout inventory and kept an electronic diary for 2 weeks to assess momentary exhaustion and daily recovery through sleep. On 3 consecutive weekdays within the diary period, saliva was sampled to determine the cortisol awakening response (CAR), levels of dehydroepiandrosterone-sulphate (DHEAS) on the first 2 weekdays, and to conduct the dexamethasone suppression test (DST) on the third weekday. We found significant relationships between endocrine values and general momentary symptom severity as assessed with the diary, but not with the retrospective questionnaire-assessed burnout symptoms. Simultaneous assessments of endocrine values and burnout symptoms assessed with the diary after awakening rendered significant associations between persons, and a trend within persons. More severe burnout symptoms were consistently associated with a lower level and smaller increase of CAR, higher DHEAS levels, smaller cortisol/DHEAS ratios and a stronger suppression after DST. Burnout symptoms were significantly related to endocrine functioning in clinical burnout under the best possible conditions of symptom measurement. This adds support to the view that severity of burnout symptoms is associated with HPA-axis functioning.

Evidence that impaired sleep recovery may complicate burnout improvement independently of depressive mood

OBJECTIVE

This article examines recovery through sleep in relation to sleep quality, exhaustion, and depression in clinical burnout. We focus on actual recovery per night, given its relevance to burnout improvement.

METHODS

Sixty clinically burned-out participants and 40 healthy controls recorded symptoms with an electronic diary for 2 weeks at random times per day. Recovery through sleep was defined as the difference in fatigue between late evening and the next morning.

RESULTS

In clinical burnout, sleep quality and recovery are impaired, and depression is elevated. Poor recovery through sleep is associated with poor same-night sleep quality, clarifying the mechanisms underlying poor recovery. Individual differences in recovery though sleep were related to differences in refreshed awakening, but not to other sleep problems. Impaired recovery was also related to severity of exhaustion, but not to severity of depressive mood, indicating that, in burnout, nonprofit from sleep is a symptom of energy depletion, not a sign of depression.

CONCLUSION

Impaired recovery through sleep may hamper recovery from burnout independently of the influence of depression.

Burnout and risk of type 2 diabetes: a prospective study of apparently healthy employed persons

OBJECTIVE

This prospective study was designed to test the extent to which the onset of type 2 diabetes in apparently healthy individuals was predicted by burnout, a unique affective response to combined exposure to chronic stressors.

METHODS

The study participants were 677 employed men and women who were followed up for 3 to 5 years (mean = 3.6 years) for the onset of diagnosed type 2 diabetes. Burnout was assessed by the Shirom-Melamed Burnout Measure with its three subscales: emotional exhaustion, physical fatigue, and cognitive weariness.

RESULTS

The burnout symptoms were remarkably consistent over the follow-up period irrespective of changes in place of work and in employment status. During the follow-up period, 17 workers developed type 2 diabetes. Logistic regression results indicated that burnout was associated with a 1.84-fold increased risk of diabetes (95% confidence interval [CI] = 1.19-2.85) even after adjusting for age, sex, body mass index, smoking, alcohol use, leisure time physical activity, initial job category, and follow-up duration. In a subsample of 507 workers, the relative risk of diabetes was found to be much higher after additional control for blood pressure levels (odds ratio = 4.32, 95% CI = 1.75-10.67), available only for this subsample.

CONCLUSIONS

These findings suggest that chronic burnout might be a risk factor for the onset of type 2 diabetes in apparently healthy individuals.

The job demands-resources model of burnout

The job demands-resources (JD-R) model proposes that working conditions can be categorized into 2 broad categories, job demands and job resources. that are differentially related to specific outcomes. A series of LISREL analyses using self-reports as well as observer ratings of the working conditions provided strong evidence for the JD-R model: Job demands are primarily related to the exhaustion component of burnout, whereas (lack of) job resources are primarily related to disengagement. Highly similar patterns were observed in each of 3 occupational groups: human services, industry, and transport (total N = 374). In addition, results confirmed the 2-factor structure (exhaustion and disengagement) of a new burnout instrument--the Oldenburg Burnout Inventory--and suggested that this structure is essentially invariant across occupational groups.