The interplay between emotional exhaustion, common mental disorders, functioning and health care use in the working population
Introduction
In the 1970s, the concept of burnout was introduced as a negative work-related state of mind which occurred in response to high job demands and overload [1]. Currently, the most frequently used definition stems from the Maslach Burnout Inventory (MBI) which identifies three key elements: emotional exhaustion, cynicism and professional inefficacy [1]. As emotional exhaustion has severe health consequences [2] and is often considered to be the core dimension of burnout [3], we focus on exhaustion as a proxy for burnout. A formal exhaustion rate is not available as there are no cross-national validated cut-off points of the MBI [4]; and neither burnout nor exhaustion is defined in the DSM. Yet, exhaustion is estimated to occur in about 14% of the Dutch working population [5]. Burnout, and especially exhaustion, is associated with job-related functioning, such as job performance [1], [6], and increases the risk and duration of sick leave [7], [8]. It is, however, likely that exhaustion has a broader impact, affecting other life dimensions too. In order to better comprehend the extent of the impact of exhaustion, we address two issues: 1) a more complete measurement of the associated impact; this implies not only considering whether an individual with exhaustion is able to continue to work, but also whether social, emotional and physical functioning are impaired and whether health care is sought; and 2) examining this wider impact after adjustment for co-occurring mental disorders.
Regarding the more complete measurement of the impact of exhaustion, the first aspect that we consider is work loss, including both sick leave (absenteeism) and reduced functioning while at work (presenteeism) [9]. A substantial part of work loss related to mental disorders is due to reduced functioning while at work [9], [10], which emphasises the need to examine absenteeism and presenteeism simultaneously. Yet, previous studies associated exhaustion with absent days [7], [8] or the occurrence of presenteeism [11], [12], but not jointly. We expect that severity of exhaustion is associated with work loss, meaning that work loss will mostly consist of shorter periods in people with mild exhaustion and longer periods in those with more severe exhaustion.
Second, due to a spillover effect of work experiences to other life domains [13], exhaustion likely also affects emotional and social functioning, and possibly physical functioning. To our knowledge, such a broad impact of exhaustion has not been examined in the general working population. Studies among specific samples such as surgeons, nurses or home caregivers showed that burnout was related to reduced quality of life in general (for example [14], [15], [16], [17]). We therefore hypothesize that exhaustion is associated with impaired emotional, social and physical functioning in the general working population as well.
Lastly, exhaustion may prompt referral to a company doctor or general practitioner, though, as far as we are aware, it is unknown to what extent general health care is sought by workers with exhaustion. In the Netherlands, there are no financial barriers to receiving general health care and company doctors even have guidelines to identify and treat exhaustion [18]. Yet, a formal DSM diagnosis - which is often leading in a mental health care setting - is lacking and this could limit mental health care use for exhaustion. It is likely that such a threshold predominantly relates to mild exhaustion and less to severe exhaustion, as more specialized care is then thought to be essential [19]. We therefore hypothesize that exhaustion is associated with both general and mental health care [20], but that people with mild exhaustion predominantly receive general health care, whereas those with severe exhaustion more frequently receive mental health care.
To determine the relationship of exhaustion with work loss, functioning and health care use, adjustment for potential confounders (i.e. sociodemographics [21], job characteristics [22], mental health [23] and physical health [24], [25]) is required. The relationship between exhaustion and depression is particularly marked [23] and it has even been suggested that these two constructs represent the same phenomenon [26]. Yet, as not all individuals with exhaustion have a depressive disorder, it seems more likely that exhaustion and depression are related but not identical concepts [1], [27]. A recent study confirmed this assumption and observed a subtype of burnout characterized by high levels of both depression and anxiety without fully coinciding with DSM diagnoses of mood and anxiety disorders (i.e. common mental disorders (CMD)) [28]. Assuming that exhaustion is a unique phenomenon, we hypothesize that the relationship between exhaustion and work loss, functioning and health care used is maintained after adjustment for confounders including CMD. Importantly, if this is true, the following issue arises: namely, the co-occurrence of exhaustion and CMD may point to a subgroup [28] with an especially high burden; i.e. more work loss and poorer functioning. This is supported by findings from a clinical study suggesting that the large majority of people in treatment for exhaustion also have a CMD and that this co-occurrence might result in a more severe course of exhaustion symptoms [29]. Therefore, we hypothesize that the co-occurrence of exhaustion and CMD results in a higher burden than what would be expected from the sum of their separate burdens.
Using cross-sectional data from the third wave (T2) of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative psychiatric epidemiological study, we address the following hypotheses: 1) exhaustion is associated with work loss, impaired emotional, physical and social functioning, and the use of general and mental health care, 2) these associations are maintained after adjustment for confounders including CMD; and 3) the co-occurrence of exhaustion and CMD results in a higher burden than what would be expected from the sum of their separate burdens.
Section snippets
Methods
NEMESIS-2 is based on a multistage, stratified random sampling of households, with one respondent randomly selected in each household. Face-to-face interviews were conducted at the respondent's home. A comprehensive description of the design is provided [30]. Exhaustion was assessed at T2 and therefore data from this wave were used for the present study, resulting in a cross-sectional design.
In the first wave (T0), performed from November 2007 to July 2009, 6646 persons were interviewed
Correlates of exhaustion
Mild and severe exhaustion occurred in 14.9% and 2.3% of the workers, respectively. Mild exhaustion occurred more often in respondents aged 24–34, whereas severe exhaustion occurred more often in respondents aged 55–64 (Table 1). Living without children, future job insecurity, being bullied, and 12-month mood and anxiety disorder were gradually associated with exhaustion; these correlates were more often present in those with mild exhaustion (compared to those without exhaustion) and even more
Key findings
To our knowledge, this is the first study to examine such a broad impact of exhaustion, including work loss (both absenteeism and presenteeism), impaired functioning and health care use, while adjusting for 12-month CMD. Mild exhaustion was associated with short and extended work loss, impaired emotional, physical and social functioning, and use of general and mental health care. Severe exhaustion was not associated with short work loss, but strongly associated with extended work loss, the
COI statement
The authors have no competing interests to report.
Acknowledgements
The Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) is conducted by the Netherlands Institute of Mental Health and Addiction (Trimbos Institute) in Utrecht. Financial support has been received from the Ministry of Health, Welfare and Sport, with supplementary support from the Netherlands Organization for Health Research and Development (ZonMw) and the Genetic Risk and Outcome of Psychosis (GROUP) investigators. The funding sources had no further role in study design; in the
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