Associations between psychosocial work environment factors and first-time and recurrent treatment for depression: a prospective cohort study of 24,226 employees.

AIMS: Adverse factors in the psychosocial work environment are associated with the onset of depression among those without a personal history of depression. However, the evidence is sparse regarding whether adverse work factors can also play a role in depression recurrence. This study aimed to prospectively examine whether factors in the psychosocial work environment are associated with first-time and recurrent treatment for depression. METHODS: The study included 24,226 participants from the Danish Well-being in Hospital Employees study. We measured ten individual psychosocial work factors and three theoretical constructs (effort-reward imbalance, job strain and workplace social capital). We ascertained treatment for depression through registrations of hospital contacts for depression (International Statistical Classification of Diseases and Related Health Problems version 10 [ICD-10]: F32 and F33) and redeemed prescriptions of antidepressant medication (Anatomical Therapeutic Chemical [ATC]: N06A) in Danish national registries. We estimated the associations between work factors and treatment for depression for up to 2 years after baseline among those without (first-time treatment) and with (recurrent treatment) a personal history of treatment for depression before baseline. We excluded participants registered with treatment within 6 months before baseline. In supplementary analyses, we extended this washout period to up to 2 years. We applied logistic regression analyses with adjustment for confounding. RESULTS: Among 21,156 (87%) participants without a history of treatment for depression, 350 (1.7%) had first-time treatment during follow-up. Among the 3070 (13%) participants with treatment history, 353 (11%) had recurrent treatment during follow-up. Those with a history of depression generally reported a more adverse work environment than those without such a history. Baseline exposure to bullying (odds ratio [OR] = 1.72, 95% confidence interval [95% CI]: 1.30-2.32), and to some extent also low influence on work schedule (OR = 1.27, 95% CI: 0.97-1.66) and job strain (OR = 1.24, 95% CI: 0.97-1.57), was associated with first-time treatment for depression during follow-up. Baseline exposure to bullying (OR = 1.40, 95% CI: 1.04-1.88), lack of collaboration (OR = 1.31, 95% CI: 1.03-1.67) and low job control (OR = 1.27, 95% CI: 1.00-1.62) were associated with recurrent treatment for depression during follow-up. However, most work factors were not associated with treatment for depression. Using a 2-year washout period resulted in similar or stronger associations. CONCLUSIONS: Depression constitutes a substantial morbidity burden in the working-age population. Specific adverse working conditions were associated with first-time and recurrent treatment for depression and improving these may contribute to reducing the onset and recurrence of depression.

Associations between combinations of job demands and job control among 6,16,818 people aged 55-64 in paid work with their labour market status 11 years later: a prospective cohort study.

BACKGROUND: Given current discussions about extending working lives, more knowledge is needed on working conditions associated with labour market status in older age. OBJECTIVE: To explore associations between combinations of job demands and job control among workers aged 55-64 years and their labour market status 11 years later. METHODS: A population-based prospective cohort study using nationwide register data. The 616,818 individuals in Sweden aged 55-64 who in 2001 were in paid work were categorised using a job exposure matrix based on tertiles (reference = medium control/medium demands). Participants were followed up in 2012 regarding their main labour market status (paid work, old-age pension, no income/social assistance, sickness absence/disability pension, emigrated, dead; reference = old-age pension) using multinomial logistic regression for odds ratios (OR) and 95% confidence intervals (CI). The fully adjusted analyses included adjustment for sociodemographic factors and unemployment or sickness absence/disability pension for more than half the year in 2001. RESULTS: Those in occupations with low job control at baseline were less likely to be in paid work at follow-up (OR low demands/low control 0.74, CI 0.71-0.78; high demands/low control 0.81, CI 0.75-0.87). Those in occupations with baseline high demands were less likely to have no income/social assistance at follow-up (OR high demands/low control 0.71, CI 0.52-0.96; high demands/high control 0.59, CI 0.47-0.75). CONCLUSION: Job demands and control when aged 55-64 were associated with labour market status 11 years later: high control was associated with greater chance of being in paid work, and high demands were associated with lower risk of no income/social assistance.

Informal caregiving as a risk factor for type 2 diabetes in individuals with favourable and unfavourable psychosocial work environments: A longitudinal multi-cohort study.

AIM: To examine whether informal caregiving is associated with increased risk of type 2 diabetes (T2D), and whether job strain and social support at work modify the association. METHODS: Individual participant's data were pooled from three cohort studies-the French GAZEL study, the Swedish Longitudinal Occupational Survey of Health (SLOSH) and the British Whitehall II study-a total of 21,243 study subjects. Informal caregiving was defined as unpaid care for a closely related person. Job strain was assessed using the demand-control model, and questions on co-worker and supervisor support were combined in a measure of social support at work. Incident T2D was ascertained using registry-based, clinically assessed and self-reported data. RESULTS: A total of 1058 participants developed T2D during the up to 10 years of follow-up. Neither informal caregiving (OR: 1.09, 95% CI: 0.92-1.30) nor high job strain (OR: 1.04, 95% CI: 0.86-1.26) were associated with T2D risk, whereas low social support at work was a risk factor for T2D (OR: 1.18, 95% CI: 1.02-1.37). Also, informal caregivers who were also exposed to low social support at work were at higher risk of T2D (OR: 1.40, 95% CI: 1.08-1.82) compared with those who were not informal caregivers and had high social support at work (multiplicative test for interaction, P=0.04; additive test for interaction, synergy index=10). CONCLUSION: Informal caregiving was not independently associated with T2D risk. However, low social support at work was a risk factor, and informal caregivers with low social support at work had even higher risks of T2D.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data.

BACKGROUND: Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression. METHOD: We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol. RESULTS: We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32). CONCLUSIONS: Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

Screening instruments for predicting return to work in long-term sickness absence.

BACKGROUND: Multiple somatic symptoms are common and may cause prolonged sickness absence (SA) and unsuccessful return to work (RTW). AIMS: To compare three instruments and their predictive and discriminative abilities regarding RTW. METHODS: A longitudinal cohort study of participants recruited from two municipal job centres, with at least 8 weeks of SA. The instruments used were the Symptom Check List of somatic distress (SCL-SOM) (score 0-48 points), the Bodily Distress Syndrome Questionnaire (BDSQ) (0-120 points) and the one-item self-rated health (SRH) (1-5 points). The instruments' predictive value was explored in a time-to-event analysis. Different cut-points were analysed to find the highest number of correctly classified RTW cases, identified in a register on public transfer payments. RESULTS: The study involved 305 subjects. The adjusted relative risk regarding prediction of RTW was 0.89 [95% confidence interval (CI) 0.83-0.95], 0.89 (95% CI 0.83-0.95) and 0.78 (95% CI 0.70-0.86) per 5-, 10- and 1-point increase in the SCL-SOM, BDSQ and SRH, respectively. After mutual adjustment for the three instruments, only the prediction of RTW from SRH remained statistically significant 0.81 (95% CI 0.72-0.92). The highest sensitivity (86%) was found by SRH at the cut-point ≤5, at which 62% were correctly classified. CONCLUSIONS: All three instruments predicted RTW, but only SRH remained a significant predictor after adjustment for the SCL-SOM and BDSQ. The SRH provides an efficient alternative to more time-consuming instruments such as SCL-SOM or BDSQ for estimating the chances of RTW among sickness absentees.

Risk of depressive disorder following disasters and military deployment: systematic review with meta-analysis.

BACKGROUND: Numerous studies describe the occurrence of post-traumatic stress disorder following disasters, but less is known about the risk of major depression. AIMS: To review the risk of depressive disorder in people surviving disasters and in soldiers returning from military deployment. METHOD: A systematic literature search combined with reference screening identified 23 controlled epidemiological studies. We used random effects models to compute pooled odds ratios (ORs). RESULTS: The average OR was significantly elevated following all types of exposures: natural disaster OR = 2.28 (95% CI 1.30-3.98), technological disaster OR = 1.44 (95% CI 1.21-1.70), terrorist acts OR = 1.80 (95% CI 1.38-2.34) and military combat OR = 1.60 (95% CI 1.09-2.35). In a subset of ten high-quality studies OR was 1.41 (95% CI 1.06-1.87). CONCLUSIONS: Disasters and combat experience substantially increase the risk of depression. Whether psychological trauma per se or bereavement is on the causal path is unresolved.

Work participation and health-related characteristics of sickness absence beneficiaries with multiple somatic symptoms.

OBJECTIVES: The primary aim was to study whether high levels of multiple symptoms influenced sick-listed individuals' employment status or desire to return to work (RTW) and whether this was associated with social relations at work. STUDY DESIGN: A cross-sectional study nested in a clinical trial. METHODS: In 2011-2012, 736 (34%) of 2172 sick-listed individuals completed a posted questionnaire and were included. Main outcome was self-reported employment status. The Symptom Check List (SCL-SOM)'s sum score (0-48) was categorized in high (>18) and low (≤18) levels. Previous employment, sick-listing, and use of health care were register-data. Multivariate logistic regression analyses with adjustments were performed. RESULTS: Beneficiaries with high SCL-SOM score (n = 218, 33%) reported poorer health, job satisfaction, a lower desire to RTW and more problems with supervisors. The risk of being unemployed was higher for this group than for those with a low score. Adjusting for general health reduced the association between symptoms and unemployment, whereas problems with social relations only affected it marginally. CONCLUSIONS: Sick-listed individuals reporting high levels of symptoms were more often unemployed and less frequently desired to RTW than those with few symptoms. The association could not be explained by problems with social relations at work. TRIAL REGISTRATIONS: ISRCTN43004323, and ISRCTN51445682.

Individual and work-unit measures of psychological demands and decision latitude and the use of antihypertensive medication.

PURPOSE: To analyse whether psychological demands and decision latitude measured on individual and work-unit level were related to prescription of antihypertensive medication. METHODS: A total of 3,421 women and 897 men within 388 small work units completed a questionnaire concerning psychological working conditions according to the job strain model. Mean levels of psychological demands and decision latitude were computed for each work unit to obtain exposure measures that were less influenced by reporting bias. Dispensed antihypertensive medication prescriptions were identified in The Danish National Prescription Registry. Odds ratios (OR) comparing the highest and lowest third of the population at individual and work-unit level, respectively, were estimated by multilevel logistic regression adjusted for confounders. Psychological demands and decision latitude were tested for interaction. Supplementary analyses of 21 months follow-up were conducted. RESULTS: Among women, increasing psychological demands at individual (adjusted OR 1.54; 95 % CI 1.02-2.33) and work-unit level (adjusted OR 1.41; 95 % CI 1.04-1.90) was significantly associated with purchase of antihypertensive medication. No significant association was found for decision latitude. Follow-up results supported an association with psychological demands but they were not significant. All results for men showed no association. Psychological demands and decision latitude did not interact. CONCLUSION: High psychological work demands were associated with the purchase of prescribed antihypertensive medication among women. This effect was present on both the work-unit and the individual level. Among men there were no associations. The lack of interaction between psychological demands and decision latitude did not support the job strain model.

Job strain and the risk of severe asthma exacerbations: a meta-analysis of individual-participant data from 100 000 European men and women.

BACKGROUND: Many patients and healthcare professionals believe that work-related psychosocial stress, such as job strain, can make asthma worse, but this is not corroborated by empirical evidence. We investigated the associations between job strain and the incidence of severe asthma exacerbations in working-age European men and women. METHODS: We analysed individual-level data, collected between 1985 and 2010, from 102 175 working-age men and women in 11 prospective European studies. Job strain (a combination of high demands and low control at work) was self-reported at baseline. Incident severe asthma exacerbations were ascertained from national hospitalization and death registries. Associations between job strain and asthma exacerbations were modelled using Cox regression and the study-specific findings combined using random-effects meta-analyses. RESULTS: During a median follow-up of 10 years, 1 109 individuals experienced a severe asthma exacerbation (430 with asthma as the primary diagnostic code). In the age- and sex-adjusted analyses, job strain was associated with an increased risk of severe asthma exacerbations defined using the primary diagnostic code (hazard ratio, HR: 1.27, 95% confidence interval, CI: 1.00, 1.61). This association attenuated towards the null after adjustment for potential confounders (HR: 1.22, 95% CI: 0.96, 1.55). No association was observed in the analyses with asthma defined using any diagnostic code (HR: 1.01, 95% CI: 0.86, 1.19). CONCLUSIONS: Our findings suggest that job strain is probably not an important risk factor for severe asthma exacerbations leading to hospitalization or death.

Does work-site physical activity improve self-reported psychosocial workplace factors and job satisfaction? A randomized controlled intervention study.

PURPOSE: To investigate whether a work-site strength-training program has a positive effect on self-reported psychosocial workplace factors and job satisfaction. METHODS: We conducted a randomized controlled trial among laboratory technicians implementing neck and shoulder exercises for pain relief, with 199 participants in the training group and 228 in the control group. Influence at work, sense of community, time pressure, and job satisfaction were measured with the Copenhagen Psychosocial Questionnaire at baseline and post-intervention after 20 weeks. RESULTS: There was no statistically significant change in any of the four variables in the training group from baseline to follow-up (all p ≥ 0.39). When we used MANOVA to test for between-group effects over time, we did not find any statistically significant result (all p > 0.14). CONCLUSIONS: This study does not provide evidence for an effect of a work-site strength-training program on self-reported psychosocial workplace factors and job satisfaction.

Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies.

BACKGROUND: Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses. OBJECTIVES: To examine the association between job strain and body mass index (BMI) in a large adult population. METHODS: We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies (n = 42 222). RESULTS: A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m(-2) ), 2149 were underweight (BMI < 18.5 kg m(-2) ), 56 572 overweight (BMI 25.0-29.9 kg m(-2) ) and 13 523 class I (BMI 30-34.9 kg m(-2) ) and 3073 classes II/III (BMI ≥ 35 kg m(-2) ) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up. CONCLUSIONS: In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level.

Functional recovery following musculoskeletal injury in hospital workers.

BACKGROUND: Hospital workers are at high risk of work-related musculoskeletal disorders (WRMSDs), but outcomes following such injuries have not been well studied longitudinally. AIMS: To ascertain functional recovery in hospital workers following incident WRMSDs and identify predictors of functional status. METHODS: Cases (incident WRMSD) and matched referents from two hospitals were studied at baseline and at 2 year follow-up for health status [SF-12 physical component summary (PCS)], lost workdays, self-rated work effectiveness and work status change (job change or work cessation). Predictors included WRMSD and baseline demographics, socio-economic status (SES), job-related strain and effort-reward imbalance. Logistic regression analysis tested longitudinal predictors of adverse functional status. RESULTS: The WRMSD-associated risk of poor (lowest quartile) PCS was attenuated from a baseline odds ratio (OR) of 5.2 [95% confidence interval (CI) 3.5-7.5] to a follow-up OR of 1.5 (95% CI 1.0-2.3) and was reduced further in multivariate modelling (OR = 1.4; 95% CI 0.9-2.2). At follow-up, WRMSD status did not predict significantly increased likelihood of lost workdays, decreased effectiveness or work status change. In multivariate modelling, lowest quintile SES predicted poor PCS (OR = 2.0; 95% CI 1.0-4.0) and work status change (OR = 2.5; 95% CI 1.1-5.8). High combined baseline job strain/effort-reward imbalance predicted poor PCS (OR = 1.7; 95% CI 1.1-2.7) and reduced work effectiveness (OR = 2.6; 95% CI 1.6-4.2) at follow-up. CONCLUSIONS: Baseline functional deficits associated with incident WRMSDs were largely resolved by 2 year follow-up. Nonetheless, lower SES and higher combined job strain/effort-reward imbalance predicted adverse outcomes, controlling for WRMSDs.

Job insecurity and the use of antidepressant medication among Danish employees with and without a history of prolonged unemployment: a 3.5-year follow-up study.

BACKGROUND: A study was undertaken to investigate whether job insecurity predicts incident use of antidepressant medication and whether the association is modified by a history of prolonged unemployment. METHODS: A prospective follow-up study was performed in 5142 Danish employees, including 632 employees with and 4510 without a history of prolonged unemployment. Participants were drawn from a random 10% sample of the Danish population. Survey data on job insecurity were linked with register data on history of unemployment and dispensing of antidepressant medication between June 2000 and December 2003 retrieved from the Danish Medicinal Product Statistics. Respondents with major depression at baseline or antidepressant use in the 5 years preceding baseline were excluded. RESULTS: Job insecurity predicted use of antidepressants after adjustment for sex, age, cohabitation, socioeconomic position and alcohol consumption (OR 1.43, 95% CI 1.09 to 1.88). The effect was attenuated after further adjustment for baseline depressive symptoms (OR 1.15, 95% CI 0.87 to 1.52). A history of prolonged unemployment predicted use of antidepressants in both models (OR 1.62, 95% CI 1.14 to 2.30 and OR 1.49, 95% CI 1.04 to 2.13, respectively) Compared with participants with neither job insecurity nor unemployment history, the OR for the joint effect of job insecurity and history of prolonged unemployment was substantially higher (OR 1.79, 95% CI 1.15 to 2.79) than the OR for job insecurity (OR 1.02) and unemployment history (OR 1.10) alone in the fully adjusted model. CONCLUSION: Job insecurity predicts incident use of antidepressants among Danish employees with a history of prolonged unemployment.

Misclassification and the use of register-based indicators for depression.

OBJECTIVE: To study the degree to which depression indicators based on register data on hospital and antidepressant treatment suffer from differential misclassification with respect to gender, age and social group. METHOD: Data on 7378 persons were obtained by linking a cross-sectional survey of Danish adults aged 40 and 50 years with population-based registers. Misclassification was analysed by comparing survey data to register data on major depression using the method proposed by Rothman and Greenland. RESULTS: Differential misclassification was found. Adjustment for misclassification reduced women's odds ratios from 2.18 to 1.00 for hospital treatment and from 1.70 to 1.10 for antidepressants. For the lower social group, the corresponding odds ratios increased from 1.18 to 3.52, and from 1.35 to 2.32 respectively, whereas odds ratios with respect to age remained almost unchanged. CONCLUSION: Differential misclassification should be considered when register-based information about hospital and antidepressant treatment are used as depression indicators.

Job insecurity, chances on the labour market and decline in self-rated health in a representative sample of the Danish workforce.

OBJECTIVE: To investigate if job insecurity and poor labour market chances predict a decline in self-rated health in the Danish workforce. DESIGN: Job insecurity, labour market chances, self-rated health and numerous covariates were measured in 1809 women and 1918 men who responded to a questionnaire in 1995 and again in 2000. Multivariate logistic regression analyses were used to analyse the impact of job insecurity and labour market chances measured in 1995 on decline in health in 2000. SETTING: Prospective cohort study with a representative sample of the Danish workforce using the Danish Work Environment Cohort Study (DWECS). All participants were employed at baseline. MAIN RESULTS: Women with job insecurity had an increased risk of a decline in health at follow-up, after adjustment for all covariates (OR = 1.78, 95% CI: 1.24 to 2.54). Effect estimates were strongest among women 50 years of age or younger with poor labour market chances (OR = 2.13, 95% CI: 1.32 to 3.45). Among men, there was no main effect for job insecurity. However, men aged 50 years or younger with poor labour market chances showed an OR of 1.64 (95% CI: 0.95 to 2.84) for a decline in health. CONCLUSION: Job insecurity is a predictor for a decline in health in employed women in Denmark. Among men, a suggestive effect of job insecurity was found in employees aged 50 years or younger with poor labour market chances.

Effort-reward imbalance and incidence of low back and neck injuries in San Francisco transit operators.

OBJECTIVES: Effort-reward imbalance (ERI) has been associated with musculoskeletal disorders in cross-sectional and case-control studies, but no longitudinal studies have been published yet. The effect of ERI on the incidence of compensated low back and neck injuries was examined in a 7.5-year follow-up study among 1179 San Francisco transit operators. METHODS: Data from medical examination and a survey on working conditions and health were linked to administrative workers' compensation databases. HRs for first low back and first neck injury were calculated with multivariate Cox regression models. Additional analyses accounted for severity of injury based on medical diagnosis. RESULTS: A 1 SD increase in ERI was associated with compensated low back (HR 1.13, 95% CI 1.02 to 1.26) and neck injuries (HR 1.14, 95% CI 1.02 to 1.27) after adjusting for gender, age, height, weight, years of professional driving, weekly driving hours, vehicle type, ergonomic problems, pain at baseline and job strain. The highest quartile of ERI showed an HR of 1.32 (95% CI 0.94 to 1.86) for low back injuries and an HR of 1.66 (95% CI 1.16 to 2.38) for neck injuries after adjustment for all covariates. The associations between ERI and low back injury were stronger for more severe injuries (HR 1.23, 95% CI 1.03 to 1.46 for a 1 SD increase in ERI) than for less severe injuries (HR 1.11, 95% CI 0.96 to 1.28). For neck injuries, stronger relationships were found for less severe injuries (HR 1.15, 95% CI 1.02 to 1.29) than for more severe injuries (HR 1.10, 95% CI 0.86 to 1.41). CONCLUSIONS: ERI is associated with low back and neck injuries in San Francisco transit operators independently of individual worker characteristics, physical workload, ergonomic problems, baseline pain and job strain. Effect sizes differ by injury severity.

Burnout as a predictor of self-reported sickness absence among human service workers: prospective findings from three year follow up of the PUMA study.

AIM: To investigate whether burnout predicts sickness absence days and sickness absence spells in human service workers. METHOD: A total of 824 participants from an ongoing prospective study in different human service sector organisations were eligible for the three year follow up analysis. Burnout was measured with the work related burnout scale of the Copenhagen Burnout Inventory. Sickness absence was measured with self-reported number of days and spells during the last 12 months before the baseline and the follow up survey. A Poisson regression model with a scale parameter was used to account for over dispersion. A linear regression model was used for analysing changes in burnout and absence between baseline and follow up. RESULTS: Burnout was prospectively associated with both sickness absence days and sickness absence spells per year. Differences in sickness absence days varied from a mean of 5.4 days per year in the lowest quartile of the work related burnout scale to a mean of 13.6 in the highest quartile. An increase of one standard deviation on the work related burnout scale predicted an increase of 21% in sickness absence days per year (rate ratio 1.21, 95% CI 1.11 to 1.32) after adjusting for gender, age, organisation, socioeconomic status, lifestyle factors, family status, having children under 7 years of age, and prevalence of diseases. Regarding sickness absence spells, an increase of one standard deviation on the work related burnout scale predicted an increase of 9% per year (rate ratio 1.09, 95% CI 1.02 to 1.17). Changes in burnout level from baseline to follow up were positively associated with changes in sickness absence days (estimate 1.94 days/year, SE 0.63) and sickness absence spell (estimate 0.34 spells/year, SE 0.08). CONCLUSION: The findings indicate that burnout predicts sickness absence. Reducing burnout is likely to reduce sickness absence.

[Evaluation of physician-accompanied vacation trips for heart patients ("heart vacation trips"). Participants' satisfaction and long term impact on health related quality of life]. / Evaluation ärztlich betreuter Reisen für Herzkranke ("Herzreisen"). Zufriedenheit der Reiseteilnehmer und langfristige Auswirkungen auf die gesundheitsbezogene Lebensqualität.

Physician-accompanied vacation trips for heart patients (so-called "heart vacations trips") have been offered since 1981 and have been regulated by guidelines by the German Society of Prevention and Rehabilitation of Cardiovascular Diseases since 1993. The goal of this evaluation is to assess the satisfaction of the participants and to analyze the long-term impact on health-related quality of life. Between October 1995 and May 1998, 22 vacation trips with 228 participants were evaluated. Satisfaction with the vacation trips was assessed by a questionnaire specifically designed for this study. Health-related quality of life was measured with 5 discrete scales from the standardized and validated instrument "Profile of Quality of Life for the Chronically Ill" ("physical capacity", "ability to enjoy and relax", "positive mood", "absence of negative mood", "sociability"). The proportion of satisfied or very satisfied participants ranged from 81 % (accommodations) to 94 % (physician care). Regarding health-related quality of life, significant or borderline significant improvements were observed on three of the five scales (ability to enjoy and relax: p = 0.02, positive mood: p = 0.001, physical capacity: p = 0.08). Stratified analyses showed improvements for younger participants (< or = 70 years) on all five quality of life scales, whereas no statistically significant improvement was found for older participants. Participants who had a cardiovascular disease other than coronary heart disease showed significant improvements on four scales, whereas participants with coronary heart disease only showed an increase on the scale "positive mood". This evaluation shows that physician-accompanied vacation trips were assessed very positively by the participants and that these trips are associated with long-term improvement in health-related quality of life for specific groups of participants.

[Quality of life in advanced coronary heart disease]. / Lebensqualität bei fortgeschrittener koronarer Herzkrankheit.

The integration of aspects of health-related quality of life (QL) into diagnosis, therapy and rehabilitation of patients with advanced coronary artery disease (CAD), especially with therapy-resistant angina pectoris, is important for at least two reasons. First, restrictions in patients QL often confronts the treating cardiologist with problems which could be overcome by a more comprehensive, psychosocially oriented intervention approach. Secondly, reduced QL was shown to have a negative impact on the course of CAD and on survival. Both aspects are discussed with reference to current scientific evidence, including our own study on effects of a comprehensive lifestyle change on QL in CAD patients.

[Comprehensive life style changes by coronary patients--an intervention study]. / Umfassende Lebensstiländerung bei Koronarkranken--eine Interventionsstudie.

In an intervention trial 31 coronary patients participated in a comprehensive lifestyle change program and 43 control patients received the usual care of the conventional cardiac rehabilitation system. First preliminary findings show that the patients in the intervention group not only improved their health related lifestyle but also increased their exercise capacity and reduced depression, while there was no substantial improvement in the control group. Up to the present, the existing data indicate that German heart patients are able to make comprehensive lifestyle changes and that these changes have positive effects on biomedical and psychosocial variables.