Increased plasma levels of neuro-related proteins in patients with stress-related exhaustion: A longitudinal study.

Exhaustion disorder (ED) is a stress-related disorder characterized by physical and mental symptoms of exhaustion. Recent data suggest that pathophysiological processes in the central nervous system are involved in the biological mechanisms underlying ED. The aims of this study were to investigate if plasma levels of neuro-related proteins differ between patients with ED and healthy controls, and, if so, to investigate if these differences persist over time. Using the Olink Neuro Exploratory panel, we quantified the plasma levels of 92 neuro-related proteins in 163 ED patients at the time of diagnosis (baseline), 149 patients at long-term follow-up (7-12 years later, median follow-up time 9 years and 5 months), and 100 healthy controls. We found that the plasma levels of 40 proteins were significantly higher in the ED group at baseline compared with the control group. Out of these, the plasma levels of 36 proteins were significantly lower in the ED group at follow-up compared with the same group at baseline and the plasma levels of four proteins did not significantly differ between the groups. At follow-up, the plasma levels of two proteins were significantly lower in the ED group compared with the control group. These data support the hypothesis that pathophysiological processes in the central nervous system are involved in the biological mechanisms underlying ED.

The ultra-short version of the Burnout Assessment Tool (BAT4)-development, validation, and measurement invariance across countries, age and gender.

Given that burnout is a major problem in many societies and that employers are legally obliged to act in preventing job stress, there is a need of validated and reliable short self-report instruments. The Burnout Assessment Tool (BAT) is developed to measure burnout as a syndrome with four core components (exhaustion, mental distance, cognitive and emotional impairment). So far, the BAT was tested in over 40 studies with encouraging results. Although a short, 12-item version of the BAT exists, there is need for an ultra-short version with even less items. The overall aim is to develop an ultra-short 4-item version of the BAT (BAT4) and to evaluate its construct validity using Rasch analysis in samples from various countries along with its measurement invariance regarding country, age and gender. The BAT4 was developed using mixed methods, i.e. combining the results from a Rasch analysis, a subject matter analysis and expert judgements. Construct validity was tested on data from national representative samples from eight countries (the Netherlands, Belgium (Flanders), Austria, Czech Republic, Finland, Germany, Ireland, and Japan) and in a pooled sample combing the data from all eight countries. Differential item functioning regarding age, gender and country was investigated. The BAT4 fulfilled all the criteria required by the Rasch measurement model to constitute a valid measure in the pooled and country specific samples, except Austria and Japan. In the pooled sample, measurement invariance between the eight countries as well as between gender and age was found. Analyses within different countries showed occasional gender and age DIF for some items. The results were promising regarding BAT4's construct validity and measurement invariance. Although the BAT4 includes only four items, its content coverage is acceptable. The BAT4 can be used as a short screening instrument for burnout complaints at the group or organisational level.

Effectiveness of a person-centred eHealth intervention in reducing symptoms of burnout in patients with common mental disorders - secondary outcome analysis of a randomized controlled trial.

BACKGROUND: The number of people with common mental disorders (CMDs), especially stress-related disorders, has increased in several countries, including Sweden, during the past decade. Patients seeking care for long-term stress report severe symptoms. Although person-centred care (PCC) has shown several benefits, studies evaluating the effects of a PCC eHealth intervention on patients with CMDs are scarce. OBJECTIVE: The aim of this study was to compare levels of self-reported symptoms of burnout between a control group receiving treatment as usual (TAU) and an intervention group receiving TAU with the addition of a person-centred eHealth intervention, in patients on sick leave for CMDs. METHODS: This study reports analysis of a secondary outcome measure from a randomized controlled trial. Patients (n = 209) on sick leave for CMDs were recruited from nine primary health care centres and allocated to either a control group (n = 107) or an intervention group (n = 102). The intervention consisted of phone support and an interactive digital platform built on PCC principles. Self-reported symptoms of burnout were assessed using the Shirom-Melamed Burnout Questionnaire (SMBQ) at baseline and at 3 and 6 months. RESULTS: Our findings showed changes in SMBQ scores over time in both the control and the intervention group. There was no significant difference in SMBQ scores between the groups; however, a difference in change over time between the groups was observed. The SMBQ scores decreased significantly more in the intervention group than in the controls between 0 and 3 months and between 0 and 6 months. No differences in change between the two groups were seen between the 3- and 6-month follow-ups. CONCLUSION: This person-centred eHealth intervention for patients on sick leave for CMDs showed a slight initial effect in reducing symptoms of burnout. Taking into account that both groups reported comparable SMBQ scores throughout the study period, the overall effect may be considered limited. TRIAL REGISTRATION: The trial was registered in ClinicalTrials.gov (Identifier NCT03404583). Date of registration: 19/01/2018. https://clinicaltrials.gov/ct2/show/NCT03404583 .

The COPE Staff study: Study description and initial report regarding job satisfaction, work-life conflicts, stress, and burnout among Swedish maternal and neonatal healthcare workers during the COVID-19 pandemic.

OBJECTIVE: To describe the study design of the COPE Staff cohort study on working conditions for maternal and neonatal healthcare workers (MNHCWs), and present baseline data regarding job satisfaction, work-life conflicts, stress, and burnout. METHODS: Between January and April 2021, 957 MNHCWs (administrative and medical staff) completed a baseline survey. Average levels of job satisfaction, work-life conflicts, stress, and burnout, and associations to perceived workload were assessed. RESULTS: The average levels of job satisfaction, work-life conflicts, stress, and burnout were 68.6 (95% confidence interval [CI] 64.3-72.8), 42.6 (95% CI 37.3-48.0), 42.0 (95% CI 37.7-46.3), and 1.9 (95% CI 1.6-2.2), respectively. The respondents scoring above critical values indicating clinical burnout ranged between 3% and 18%, respectively, for the four burnout sub-dimensions. Women reported significantly higher levels of stress and burnout. Younger participants had lower job satisfaction and higher levels of work-life conflicts, stress, and burnout. Higher perceived workload was significantly associated with lower job satisfaction levels and higher levels of work-life conflicts, stress, and burnout. CONCLUSIONS: Our results indicate associations between MNHCWs perceived workload and job satisfaction, work-life conflicts, stress, and burnout during the COVID-19 pandemic. Eighteen percent scored above critical values for exhaustion.

Burnout among midwives-the factorial structure of the burnout assessment tool and an assessment of burnout levels in a Swedish national sample.

BACKGROUND: Many workplaces, within the healthcare sector, experience high rates of mental health problems such as burnout, anxiety, and depression, due to poor psychosocial working conditions and midwives are not an exception. To develop preventive interventions, epidemiologic surveillance of burnout levels, and their relation to professional specific working conditions is needed. Aims of this study is to assess the construct validity of the Burnout Assessment Tool (BAT) in the context of Swedish midwives, to evaluate whether the item responses can be combined into a single score and differential item functioning regarding age. Another aim was to assess the burnout levels of Swedish midwives. METHODS: Data come from a national cohort of Swedish midwives (n = 1664). The construct validity was evaluated using Rasch analysis. Burnout levels were presented by median and first (Q1) and third (Q3) quartiles for the BAT total score and the four subscales (exhaustion, mental distance, cognitive and emotional impairment). RESULTS: In the analysis including all 23 items the fit to the Rasch model was not obtained. Items within each subscale clustered together in a residual correlation matrix in a pattern consistent with the underlying conceptualization of the BAT, indicating multidimensionality. The Rasch analysis was re-run using the four testlets as input variables which resulted in a good fit. The median burnout level was 2.0 (Q1 = 1.6, Q3 = 2.4). The four subscales differentiated the picture (elevated levels on exhaustion and low levels on the other three subscales). CONCLUSIONS: The construct validity of the BAT for use in the context of Swedish midwives was confirmed. The results indicated a strong general factor, meaning that the responses can be combined into a single burnout score. The scale works invariantly for different age groups. The results of this study secure access to a validated instrument to be used for accurate assessment of the burnout levels among midwives in Sweden.

Effects of Additional Individually Tailored Interventions on Sick-Leave and Symptoms in Patients with Exhaustion Disorder: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of adding individually tailored interventions to a standard treatment in patients with stress-related exhaustion disorder, with regard to sick-leave days and symptoms of burnout. The study design was a 2-armed randomized controlled intervention, with follow-up after 15 months. Data were obtained from patients referred to the Institute of Stress Medicine, and were collected between 2011 and 2014 in western Sweden. METHODS: Inclusion criteria were scoring above cut-off in at least 1 of 4 dimensions; mental and physical exhaustion, disturbed sleep, reduced cognitive function and perceived poor self-esteem. The total study population comprised 142 patients (112 females, 30 males) allocated through block randomization to either the intervention group (n = 71) or the control group (n = 71). The intervention group received 1-4 individually tailored interventions (physical activity, cognitive behaviour therapy for insomnia, computerized memory training, cognitive behavioural therapy for self-esteem), based on the results of screening assessments. The interventions were additional to a standard treatment. The control group received solely the standard treatment. The primary outcome measure was the proportion of participants not sicklisted at the 15-month follow-up. RESULTS: At the 15-month follow-up, 30% of subjects in the intervention group and 34% in the control group had 0% sick-listed (p = 0.58). No change between baseline and follow-up was seen in 42% of the intervention group and 39% of the control group, while an increased sick-leave rate was seen in 1% of the intervention group and 4% of the control group. However, no statistically significant difference was seen between groups. CONCLUSION: Adding individually tailored interventions to a standard treatment in patients with stress-related exhaustion did not reduce sick-leave days or burnout symptoms.

Shortening of the Burnout Assessment Tool (BAT)-from 23 to 12 items using content and Rasch analysis.

BACKGROUND: Burnout is related to huge costs, for both individuals and organizations and is recognized as an occupational disease or work-related disorder in many European countries. Given that burnout is a major problem it is important to measure the levels of burnout in a valid and reliable way. The Burnout Assessment Tool (BAT) is a newly developed self-report questionnaire to measure burnout. So far, studies concerning the psychometric properties of the original version of the Burnout Assessment Tool (BAT) including 23 items show promising results and suggest that the instrument can be used in many different settings. For various reasons there is a need of a shorter instrument. For example, burnout questionnaires are typically included in employee surveys to evaluate psychosocial risk-factors, which according to the European Occupational Safety and Health Framework Directive, should be carried out in organizations on a regular basis. The aims of this paper are to develop a shorter version of the BAT, including only 12 items (BAT12) and to evaluate its construct validity and differential item functioning regarding age, gender and country. METHODS: Using data from representative samples of working populations in the Netherlands and Belgium (Flanders) a shorter version of the BAT was developed by combining quantitative (Rasch analysis) and qualitative approaches (item content analysis and expert judgements). Construct validity of the new BAT12 was evaluated by means of Rasch analysis. RESULTS: In an iterative procedure, deleting one item from each subscale at each step, a short version of the BAT - BAT12 was developed. The BAT12 fulfils the measurement criteria according to the Rasch model after accounting for local dependency between items within each subscale. The four subscales can be combined into a single burnout score. CONCLUSION: The new BAT12 developed in the present study maintains the breath of item content of the original version of the BAT. The new BAT12 has sound psychometric properties. The scale works invariantly for older and younger, women and men and across two countries. A shorter version of the BAT is timesaving compared to the BAT23 and can be used in e.g. employee surveys.

A Rasch analysis of the Burnout Assessment Tool (BAT).

Burnout as a concept indicative of a work-related state of mental exhaustion is recognized around the globe. Numerous studies showed that burnout has negative consequences for both individuals and organizations but also for society at large, especially in welfare states where sickness absence and work incapacitation are covered by social funds. This underlines the importance of a valid and reliable tool that can be used to assess employee burnout levels. Although the Maslach Burnout Inventory is by far the most frequently used questionnaire for assessing burnout, it is associated with several shortcomings and has been criticized on theoretical as well as empirical grounds. Thus, there is a need for an alternative questionnaire with a strong conceptual basis and proper psychometric qualities. This challenge has been taken up by introducing the Burnout Assessment Tool (BAT), according to which burnout is conceived as a work-related state of exhaustion among employees, characterized by extreme tiredness, reduced ability to regulate cognitive and emotional processes, and mental distancing. Given that the BAT is a new measure of burnout, its psychometric properties need to be evaluated. This paper focuses on an evaluation of the internal construct validity of the BAT using Rasch analysis in two random samples (n = 800, each) drawn from larger representative samples of the working population of the Netherlands and Flanders (Belgium). The BAT has sound psychometric properties and fulfils the measurement criteria according to the Rasch model. The BAT score reflects the scoring structure indicated by the developers of the scale and the BAT's four subscales can be summarized into a single burnout score. The BAT score also works invariantly for women and men, younger and older respondents, and across both countries. Hence, the BAT can be used in organizations for screening and identifying employees who are at risk of burnout.

Longitudinal associations between cardiorespiratory fitness and stress-related exhaustion, depression, anxiety and sleep disturbances.

BACKGROUND: In the last few years, so-called "common mental disorders", including adjustment disorder and stress-related exhaustion, have outrivalled musculoskeletal disorders as being the leading cause of long-term sick leave in Sweden. Cardiorespiratory fitness level defined as "the maximal amount of physiological work that an individual can do as measured by oxygen consumption" has in many studies shown to reduce the risk of several life-style related diseases and moreover to improve mood, well-being and physical performance. The aim of the present study was to investigate, longitudinal associations between cardiorespiratory fitness and self-reported physical activity levels and the severity of symptoms connected to stress-related exhaustion, depression, anxiety, and sleep disturbances among women clinically diagnosed with stress-related exhaustion disorder (ED). METHODS: The study was that of a longitudinal cohort study consisting of women (n = 88) diagnosed with stress-related ED in a specialist clinic in Gothenburg, Sweden. Cardiorespiratory fitness was measured with the Åstrand indirect test of maximal oxygen uptake (VO2max) and subjective measures of physical activity levels were rated on 4-graded physical activity scale. To measure and follow symptoms of ED over time the SMBQ-questionnaire (Shirom Melamed Burnout Questionnaire) was used. The Hospital Anxiety and Depression Scale (HADS) was used to measure depression and anxiety. A proxy variable for capturing overall disturbed sleep used to measure sleep. Longitudinal associations for continuous outcome variables and the dichotomous variable sleep were analysed using mixed- effects regression models with random intercepts. Regression coefficients along with the 95% confidence interval (CI) are presented as measures of association. Both exposures and the outcome were measured simultaneously over six waves (T1-T6). RESULTS: The results showed statistically significant associations between level of fitness and reduced symptoms of stress-related exhaustion over time. Best improvements over time were seen in patients having a medium cardiorespiratory fitness level. No associations could be found between cardiorespiratory fitness level over time and anxiety, depression or sleep disturbances. CONCLUSION: Having medium cardiorespiratory fitness was positivity associated with a more sustained reduction in symptoms of ED overtime compared to those having low or high cardiorespiratory fitness levels. The clinical implication following this result is that an individual recommendation based on a medium level of physical activity in line with the recommendations from ACSM (American College of Sports Medicine) is preferable compared to recommendations including more vigorous physical activity in order to restore and sustainably reduce symptoms of exhaustion disorder over time.

Construct validity of a global scale for Workplace Social Capital based on COPSOQ III.

BACKGROUND AND AIM: Workplace Social Capital has been suggested as a useful concept when addressing organizational and social factors of the work environment. The overall aim of the present study is to establish and evaluate the construct validity of a measure of Workplace Social Capital based on the operationalization suggested in the third version of the Copenhagen Psychosocial questionnaire. METHODS: The present study is based on data collected as part of a validation and development project for the use of the Swedish version of COPSOQ at workplaces and includes responses from 1316 human service workers answering a workplace survey. Six items from scales for organizational justice, vertical trust and horizontal trust in COPSOQ III were included in the analyses. Rasch Analysis was used for scale validation. RESULTS: The analyses showed that the psychometric properties of the suggested COPSOQ scale for Workplace Social Capital were satisfactory after accommodation for local dependency. Each individual item worked as intended, the scale was unidimensional and functioned invariantly for women and men, and for younger and older employees. The scale was furthermore found to be valid for use for distinguishing groups, not individuals. CONCLUSION: We have established that the scale for Workplace Social Capital measured by COPSOQ III is valid for distinguishing groups, e.g. work teams. The scale exhibits good construct validity as it satisfies the measurement criteria defined by the Rasch model.

Concurrent and lagged effects of psychosocial job stressors on symptoms of burnout.

PURPOSE: Burnout is a mental condition described as being a result of long-term stressors commonly related to psychosocial factors at work. The aim of the present study was to investigate longitudinal relationships between job demands, decision authority, effort and reward, and symptoms of burnout, as well as the joint effects of job demands and decision authority, and of effort and reward. METHODS: The data came from a four-wave longitudinal cohort study of Swedish health care workers. Longitudinal associations were analysed using mixed effects regression models with random intercept. RESULTS: The concurrent analysis showed that demand and decision authority, as well as effort and reward, were associated with symptoms of burnout over time. Evidence of the lagged effects of workplace factors on burnout symptoms was limited to reward. No clear effect modification was found. CONCLUSION: An increase in unfavourable working conditions implied increasing scores on the burnout measure over time. The concurrent effects of job demands, decision authority, effort and reward on symptoms of burnout were seen. The evidence of lagged effects was limited to the low-reward condition. Regularly monitoring these work environment conditions at workplaces can help identify risk situations for burnout and thus be useful in the prevention of work-related mental illness. Lastly, a new approach to defining the risk groups was proposed, which is consistent across different populations and time points.

Self-reported activity of Swedish persons with haemophilia: Change over 2.5 years.

OBJECTIVES: To describe self-reported activity using the Haemophilia Activity List (HAL) for Swedish adults with haemophilia and to detect any changes over time. METHOD: The HAL was sent to the adult population with haemophilia A and B, moderate and severe form, living in Sweden (n = 260). Participants completed the HAL and a questionnaire on sociodemographic and medical information. From a previous study cohort, 61 persons had responded twice to the HAL. The investigated group was divided into early and later treatment onset groups with regard to access to medication. RESULTS: The response rate was 50%. There was a significant difference (p < 0.001) between the early and later treatment groups in all domains in HAL. When analysing HAL "question by question" from the 2 reported time-points, the most prominent outcome was that the reported ability in activities was stable over time at the group level, except for participants who had no access to the clotting factor early in life. They reported greater limitations in some of the activities in the challenging domain "leisure activities and sport". CONCLUSION: The early treatment group reported a significantly better ability in all activities compared with the late treatment group.

Affective stress responses during leisure time: Validity evaluation of a modified version of the Stress-Energy Questionnaire.

BACKGROUND: Psychosocial stress at work is one of the most important factors behind increasing sick-leave rates. In addition to work stressors, it is important to account for non-work-related stressors when assessing stress responses. In this study, a modified version of the Stress-Energy Questionnaire (SEQ), the SEQ during leisure time (SEQ-LT) was introduced for assessing the affective stress response during leisure time. The aim of this study was to investigate the internal construct validity of the SEQ-LT. A second aim was to define the cut-off points for the scales, which could indicate high and low levels of leisure-time stress and energy, respectively. METHODS: Internal construct validity of the SEQ-LT was evaluated using a Rasch analysis. We examined the unidimensionality and other psychometric properties of the scale by the fit to the Rasch model. A criterion-based approach was used for classification into high and low stress/energy levels. RESULTS: The psychometric properties of the stress and energy scales of the SEQ-LT were satisfactory, having accommodated for local dependency. The cut-off point for low stress was proposed to be in the interval between 2.45 and 3.02 on the Rasch metric score; while for high stress, it was between 3.65 and 3.90. The suggested cut-off points for the low and high energy levels were values between 1.73-1.97 and 2.66-3.08, respectively. CONCLUSIONS: The stress and energy scale of the SEQ-LT satisfied the measurement criteria defined by the Rasch analysis and it provided a useful tool for non-work-related assessment of stress responses. We provide guidelines on how to interpret the scale values.

Internal construct validity of the stress-energy questionnaire in a working population, a cohort study.

BACKGROUND: Psychosocial stress at work has been recognised as one of the most important factors behind the increase in sick leave due to stress-related mental disorders. It is therefore important to be able to measure perceived work stress in a way that is both valid and reliable. It has been suggested that the Stress-Energy Questionnaire (SEQ) could be a useful tool for measuring mood (stress and energy) at work and it has been used in many Scandinavian studies. The aim of the study is to examine the internal construct validity of the SEQ in a working population and to address measurement issues, such as the ordering of response categories and potential differences in how women and men use the scale - what is termed differential item functioning (DIF). METHODS: The data used in the present study is baseline data from a longitudinal cohort study aimed at evaluating psychosocial working conditions, stress, health and well-being among employees in two human service organisations in Western Sweden. A modern psychometric approach for scale validations, the Rasch model, was used. RESULTS: Stress items showed a satisfactory fit to the model. Problems related to unidimensionality and local dependence were found when the six stress items were fitted to the model, but these could be resolved by using two testlets. As regards the energy scale, although the final analysis showed an acceptable fit to the model some scale problems were identified. The item dull had disordered thresholds and DIF for gender was detected for the item passive. The items were not well targeted to the persons, with skewness towards high energy. This might explain the scale problems that were detected but these problems need to be investigated in a group where the level of energy is spread across the trait, measured by the SEQ. CONCLUSION: The stress scale of the SEQ has good psychometric properties and provides a useful tool for assessing work-related stress, on both group and individual levels. However, the limitations of the energy scale make it suitable for group evaluations only. The energy scale needs to be evaluated further in different settings and populations.

Work attendance among healthcare workers: prevalence, incentives, and long-term consequences for health and performance.

AIM: This paper is a report of a cohort study of healthcare workers' work attendance, and its long-term consequences' on health, burnout, work ability and performance. BACKGROUND: Concepts and measures of work attendance have varied in the scientific literature. Attending work in spite of being sick can have serious consequences on health. There is little knowledge on which individual and work-related conditions that increase work attendance and the long-term impact on health and performance. METHOD: Prospective analyses of three measures of work attendance i.e. sickness attendance, uninterrupted long-term attendance and balanced attendance (≤7 days of sick leave per year and no sickness attendance) were done using questionnaire data from a 2-year cohort study (2004-2006) of randomly selected healthcare workers (n = 2624). Incentives (e.g. effort-reward balance, social support, meaningfulness) and requirements (e.g. time-pressure, dutifulness, high responsibility) to attend work as well as general health, burnout, sick leave, work ability and performance were assessed. RESULTS: There was a positive relation between balanced work attendance and incentives, whereas high sickness attendance was associated with requirements. Follow up after 2 years showed that balanced attendance was associated with sustained health and performance while sickness attendance was associated with poor health, burnout, sick-leave and decreased performance. CONCLUSION: It is important to distinguish between measures of work attendance as they differ in relation to incentives, and health- and performance-related consequences. Sickness attendance seems to be an important risk indicator. A balanced work attendance should be promoted for sustained health and performance in healthcare organisations.

A prospective study of leisure-time physical activity and mental health in Swedish health care workers and social insurance officers.

OBJECTIVE: This study analyzes longitudinal associations between self-reported leisure-time physical activity (PA) and perceived stress, burnout and symptoms of depression and anxiety. METHOD: Cohort data collected in 2004 and 2006 from health care and social insurance workers in western Sweden (2694 women; 420 men) were analyzed. Cox regression was conducted to examine associations between baseline levels of PA and mental health (MH) problems 2 years later. RESULTS: Cross-sectional analysis show that individuals reporting either light physical activity (LPA) or moderate-to-vigorous physical activity (MVPA) were less likely to report high levels of perceived stress, burnout and symptoms of depression and anxiety, as compared to individuals reporting a sedentary lifestyle. The risks of symptoms of depression, burnout, and high stress levels at follow-up were significantly lower for those reporting LPA or MVPA at baseline. For symptoms of anxiety, an activity level corresponding to MVPA was required. CONCLUSION: Participation in PA appeared to lower the risk of developing MH problems two years later. This relationship involved LPA and MVPA regarding feelings of depression, burnout and perceived stress, and exclusively MVPA regarding feelings of anxiety. The implications of these findings are important, as preventive strategies for psychosocial stress and mental health problems are needed.