The morning salivary cortisol response in burnout

Is the cortisol awakening response truly a response to awakening? Replication and extension using overnight sampling

The cortisol awakening response (CAR) is a discrete component of the circadian cortisol profile. Evidence suggests that the CAR is a deviation from the pre-awakening increase in cortisol concentration, although this has yet to be replicated. Therefore, the purpose of this study was to replicate this finding and to investigate further the extent to which the CAR is distinct from the circadian profile. Twelve participants completed 2 overnight visits in a sleep laboratory. An intravenous catheter was used to sample blood every 15 min. Participants were allowed to sleep ad libitum beginning at 2030 h, and blood sampling continued throughout the night until 1 h post-awakening, generating a total of 802 serum samples. Selected serum samples were assayed for cortisol, and piece-wise linear mixed-effect models tested the extent to which the increase in cortisol concentrations post-awakening deviated from the rise in cortisol concentrations from various pre-awakening periods. Results demonstrated that the CAR only significantly deviates from the pre-awakening rise when the pre-awakening linear rise is considered 4 (β = 1.79, 95% CI = 0.49-3.09, p = 0.007) or 5 (β = 1.79, 95% CI = 0.49-3.09, p = 0.007) h before waking. When including a non-linear change in cortisol during the 4-h pre-awakening period, the deviation from the diurnal profile for the CAR was no longer significant (β = 0.96, 95% CI = - 0.74-2.66, p = 0.266). These results partly agree and replicate previous evidence for the CAR being superimposed on the diurnal profile but continue to extend our teleological understanding of the functional role of the CAR.

Elucidating the relationship between burnout and sleep disturbances among firefighters: a network analysis

BACKGROUND

There exists an intricate relationship between burnout and sleep disturbances, especially among firefighters. Network analysis offers novel perspectives for understanding the interactions of psychopathological variables. This study aims to elucidate the relationship between burnout and sleep disturbances among firefighters through network analysis.

METHODS

A total of 1,486 Chinese firefighters were included in this study. The Maslach Burnout Inventory-General Survey (MBI-GS) (Chinese version) and the Pittsburgh Sleep Quality Index (PSQI) were used to assess burnout and sleep disturbances among firefighters, respectively. Two network construction methodologies, the regularized partial correlation network (RPCN) and the directed acyclic graph (DAG), were employed to perform network analysis.

RESULTS

Within the RPCN, "Subjective sleep quality" emerged as the central domain of firefighters' burnout and sleep disturbances, as well as "Emotional exhaustion" and "Daytime dysfunction" were influential bridge domains connecting the two. From the results pertaining to the DAG, "Subjective sleep quality" was the activation domain that triggered other burnout and sleep disturbance domains, with sleep disturbances serving as the potential cause of burnout.

CONCLUSIONS

Our findings offer some enlightenment into further understanding the relationship between burnout and sleep disturbances in firefighters. Furthermore, the aforementioned central, bridge, and activation domains may be potential targets for prevention and intervention.

Low physical fitness indicates future injury, mental health, menstrual cycle disruptions, and burnout in female emergency service personnel and healthcare providers

Musculoskeletal injury (MSKi), depression, anxiety, and burnout place a considerable burden on emergency services personnel and healthcare providers (HCP). Physical fitness is related to both mental and physical health in these populations, but females in these are hugely underrepresented in this literature. As female representation in first-responder and HCP roles increases, the need for female-specific research is needed. This study examines physical fitness as a short-term indicator of future reproductive health, MSKi, and mental health for females employed as first-responders or HCP. Thirteen first-responders and 29 HCP completed an initial health and demographics questionnaire, a comprehensive physical assessment (e.g., bone mineral density, muscular strength, muscular endurance, muscular power, flexibility, and aerobic capacity), and a health questionnaire 6-7 months after the physical testing. We found that (i) bone mineral density, relative upper body strength, and lower body power were related to sustaining future MSKi, (ii) better lower body endurance and flexibility were related to future menstrual cycle disruptions, and (iii) low bone mineral density was related to future self-reported burnout and Patient Health Questionnaire score ≥ 10. Physical fitness characteristics can be helpful indicators of future MSKi risk, menstrual cycle disruptions, and mental health status in females employed in arduous occupations.

Cortisol Reactivity to Acute Psychosocial Stress in Physician Burnout

BACKGROUND

Physician burnout, characterized by chronic job-related stress leading to emotional exhaustion, depersonalization, and reduced personal accomplishment. This cross-sectional study investigates cortisol reactivity in male physicians with burnout compared to healthy controls during an acute psychosocial stress test.

METHODS

Sixty male physicians (30 burnout, 30 healthy controls) participated between September 2019 and December 2021 to investigate the impact of burnout on cardiovascular health. Salivary cortisol levels were measured before and after a Trier Social Stress Test (TSST). Burnout was assessed with the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Covariates included age, BMI, and physical activity. Data were analyzed using repeated measures analysis and area under the curve analysis.

RESULTS

Male physicians with burnout exhibited significantly greater cortisol reactivity during the TSST, notably post-stress to 15 min post-stress. Emotional exhaustion correlated with reduced cortisol increase from pre-stress and smaller post-stress to 15- and 45-min declines.

DISCUSSION

Findings suggest heightened cortisol reactivity in male physicians with burnout, possibly reflecting initial chronic stress stages. This study highlights the necessity for long-term research on cortisol's influence on cardiovascular health and stress responses across diverse groups.

CONCLUSIONS

The findings contribute to comprehending physiological responses in burnout-afflicted physicians, emphasizing cortisol reactivity's pivotal role in stress-related research and its potential health implications, particularly within the burnout context.

Assessment of self-rated pain perception and whole salivary cortisol levels among adolescents with and without temporomandibular disorders

OBJECTIVE

To assess the self-perceived pain perception (PP) and whole salivary cortisol levels (CL) among adolescents with and without temporomandibular disorders (TMD).

METHODS

Adolescents between 15 and 17 years were included. Participants were categorized into three groups: Group 1: patients with TMD; Group 2: nocturnalbruxers without TMD; and Group 3: controls. Demographic data CL and self-rated PP were assessed. A p-value < 0.05 was proposed as statistically significant.

RESULTS

Fifty-four patients (18 per group) were included. Scores of self-rated PP in the affected TMJ were higher in Group 1 than Group 2 (p < 0.001). Whole salivary CL were higher in groups 1 and 2 (p < 0.01) than in Group 3. Whole salivary CL were higher in Group 2 than Group 3 (p < 0.05).

CONCLUSION

Whole salivary CL are higher in adolescents with TMD, and there is a direct relationship between self-rated PP in the TMJ area and salivary CL.

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 .

Salivary cortisol as a biomarker of stress in surgical patients

Background

Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients.

Methods

A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI - morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA - morphine patient-controlled analgesia) included patients who received morphine via the PCA system - intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes.

The effect of acute exercise on the cortisol awakening response

The effects of acute exercise on the cortisol awakening response (CAR), characterized by the rapid increase in cortisol concentrations within the 30-45 min following sleep offset has yet to be fully elucidated. Thus, our study investigated the effects of late-evening acute exercise on the CAR the following morning. We hypothesized that exercise would have a significant effect on the CAR the following morning. Twelve participants (mean (SD): age = 23 (4) years; mass = 76.8 (8.7) kg; height = 175.6 (5.0) cm; [Formula: see text]O2max = 48.9 (7.5) ml.kg^-1.min^-1) reported to the laboratory in the evening (1800 h) on two occasions and were randomly assigned to either exercise for one hour (70-75% of maximal power output) or rest condition. Blood and saliva samples were assayed for cortisol. Mixed-effects models determined the effect of exercise on the cortisol response post-waking in both blood and saliva. Participants demonstrated an average exercise-induced increase in circulating cortisol of 477.3%, with actual mean (SD) heart rate relative to maximum of 87.04% (6.14%). Model results demonstrated a negative effect for exercise condition when modeling the serum and salivary cortisol responses to awakening via a quadratic growth model (serum, β_Condition = - 42.26 [95% CI - 64.52 to - 20.01], p < 0.001; saliva, β_Condition = - 11.55 [95% CI - 15.52 to - 7.57], p < 0.001). These results suggest that cortisol concentrations in saliva and blood are significantly lower the morning following a prior evening exercise session. Therefore, the CAR may serve as a useful biomarker to monitor responses to exercise training, although the underlying mechanism for these decreases in the CAR should be investigated further.

Effectiveness of mindfulness training on pregnancy stress and the hypothalamic-pituitary-adrenal axis in women in China: A multicenter randomized controlled trial

Introduction

In the past two decades, mindfulness-based intervention programs have gradually become popular.Many studies have confirmed that these programs can effectively alleviate prenatal stress and negative emotion.The mindfulness-based stress-buffering hypothesis suggests that mindfulness training can induce changes in the levels of the cortisol secreted by the HPA axis, thereby reducing stress susceptibility. However, to date, only a few high-quality evidence-based medical studies have analyzed the effect of the mindfulness-based intervention in a maternal population.Thus, this study investigated the effects of a mindfulness-based psychosomatic intervention on pregnancy stress and the HYPERLINK "javascript:;" hypothalamic-pituitary-adrenal (HPA) axis of pregnant Chinese women.

Methods

Women experiencing first-time pregnancy (n = 117) were randomly allocated to the intervention group or parallel active control group, and data were collected at baseline and post-intervention periods. The participants completed questionnaires regarding mindfulness and pregnancy stress. Saliva samples was collected at the time of waking up, and 30, 45, and 60 min after waking up for analyzing the salivary cortisol levels. We analyzed differences between the two groups and changes within the same group before and after the intervention.

Results and discussion

A total of 95 participants completed the trial. Compared with the parallel active control group, the intervention group exhibited lower levels of stress after the intervention (P = 0.047). For HPA-axis-related indicators after the intervention, Delta value (P = 0.01) and AUCM value (P = 0.031) of the intervention group were significantly higher than that of the control group. Mindfulness-based interventions effectively reduced the level of pregnancy stress and adjusted the HPA axis function in pregnant women in China.

Clinical Trial Registration

https://www.chictr.org.cn, identifier ChiCTR 2000033149.

Burnout, stress and resilience of an Australian regional hospital during COVID-19: a longitudinal study

Coronavirus disease 2019 (COVID-19) has placed huge strain on hospital staff around the world. The aim of the current longitudinal study was to investigate the resilience, stress and burnout of hospital staff located at a large, regional hospital in Victoria, Australia during the COVID-19 pandemic over time via cross-sectional surveys. The surveys were disseminated six times from August 2020 to March 2021, with the first three data collection points distributed during a state-wide lockdown. A total of 558 responses from various professional roles within the hospital over the survey period were included in the sample. Analysis of variance indicated significant main effects for the psychological variables across time, age, and workload. Hospital staff reported an increase in burnout levels throughout the eight-months. Significant negative relationships were observed between resilience and burnout, and between resilience and stress. A backward regression highlighted the contribution of resilience, stress, age, and nursing roles on burnout. Hierarchical regression analysis indicated that resilience contributed to the stress-burnout relationship. This study strengthens the evidence between resilience and burnout among healthcare workers and hospital staff and highlights the need for psychological wellbeing programs to be implemented for hospital staff impacted by a prolonged worldwide pandemic.

Residential Greenspace Is Associated with Lower Levels of Depressive and Burnout Symptoms, and Higher Levels of Life Satisfaction: A Nationwide Population-Based Study in Sweden

Population-based studies of individual-level residential greenspace and mental health outcomes are still limited. Thus, the present study investigates greenspace–mental health associations—including depressive symptoms, burnout symptoms, and life satisfaction—in a population-based sample of adults, the Swedish Longitudinal Occupational Survey of Health, in 2016 (n = 14,641). High-resolution land cover of greenspace and green–blue-space was assessed at 50, 100, 300 and 500 m buffers around residential addresses. Higher residential greenspace and green–blue-space were associated with lower levels of depressive and burnout symptoms among non-working individuals and with higher life satisfaction in the whole study population, after controlling for age, sex, individual income, and neighborhood socioeconomics. The immediate residential-surrounding environment (50 m) consistently showed the strongest associations with the outcomes. Having a partner was associated with better mental health outcomes and with having more residential greenspace, and adjusting for this rendered greenspace–health associations mostly statistically non-significant. In conclusion, higher levels of greenspace and green–blue-space in the immediate residential-surrounding environment were associated with better mental health outcomes in the present study, which contributes additional nuances to prior studies. The importance of residential greenspace for public health, urban planning, and development is discussed.

Role of NR3C1 and SLC6A4 methylation in the HPA axis regulation in burnout

BACKGROUND

Work-related stress and burnout have become major occupational health concerns. Dysregulation of HPA axis is considered one of the central mechanisms and is potentially moderated through epigenetics. In the present study, we aim to investigate epigenetic regulation of the HPA axis in burnout, by focusing on salivary cortisol and cortisone and DNA methylation of the glucocorticoid receptor gene (NR3C1) and the serotonin transporter gene (SLC6A4).

METHODS

We conducted a cross-sectional study with 59 subjects with burnout and 70 healthy controls recruited from the general population. All participants underwent a clinical interview and psychological assessment. Saliva samples were collected at 0, 30 and 60 min after awakening and were used to quantify cortisol and cortisone. Pyrosequencing was performed on whole blood-derived DNA to assess DNA methylation.

RESULTS

There were no between-group differences in cortisol levels, whereas burnout participants had higher levels of cortisone. Job stress was associated with increased cortisol and cortisone. We observed both increased and decreased NR3C1 and SLC6A4 methylation in the burnout group compared to the control group. Some of these methylation changes correlated with burnout symptoms dimensionally. Increased methylation in a specific CpG in the SLC6A4 promoter region moderated the association between job stress and burnout. DNA methylation in this CpG was also associated with increased cortisol. In addition, average methylation of NR3C1 was negatively associated with cortisone levels.

LIMITATIONS

This is a cross-sectional study and therefore no conclusions on causality could be made.

CONCLUSIONS

We provide first evidence of changes in DNA methylation of NR3C1 and SLC6A4 in burnout, which were further associated with cortisol and cortisone. Further, increased cortisol and cortisone seemed to reflect job stress rather than burnout itself.

The biology of burnout: Causes and consequences

OBJECTIVES

Burnout is a state of exhaustion resulting from prolonged and excessive workplace stress. We sought to examine biological underpinnings of burnout, focussing on mechanisms and physical consequences.

METHODS

We searched the literature on burnout and evaluated studies examining biological parameters in patient populations (i.e. 'clinical' burnout) as well as in individuals from the general population judged as having some degree of burnout evaluated using a dimensional approach.

RESULTS

Findings suggest that burnout is associated with sustained activation of the autonomic nervous system and dysfunction of the sympathetic adrenal medullary axis, with alterations in cortisol levels. Limited studies have also shown altered immune function and changes in other endocrine systems. Consequences of burnout include increased allostatic load, structural and functional brain changes, excito-toxicity, systemic inflammation, immunosuppression, metabolic syndrome, cardiovascular disease and premature death. Limitations of studies include variability in study populations, low specificity of burnout measures, and mostly cross-sectional studies precluding examination of changes across the course of burnout.

CONCLUSIONS

Further examination of biological mechanisms of burnout would benefit from more homogeneous clinical samples, challenge tests and prospective studies. This would assist in differentiation from conditions such as depression and aid with development of specific treatment targets for burnout.

A Bio-Physio-Psychological Investigation of Athletes' Burnout

Purpose: Changes in biophysiological markers related to perceived burnout and self-comfort were tested in this study. Method: Forty-two student-athletes from middle and high school grades were evaluated for burnout, salivary cortisol levels, measures of arousal-related physiological markers (i.e., blood volume pulse; BVP), galvanic skin response (GSR), and respiratory rate, and self-comfort variables during the last two weeks of the season. Using self-comfort theory as its conceptual framework, we examined burnout through a conceptual model in which feeling of discomfort with the self was related to biophysiological markers affecting perceived burnout. The proposed model was tested by using a partial least squares structural equation modeling (PLS-SEM). Results: The main findings indicate that increased self-discomfort is significantly (p < .001) associated with increased salivary cortisol (β = - 0.189) along with a significant (p = .050) decrease in GSR (β = - 0.259). Increased salivary cortisol is significantly (p < .001) associated with increased burnout (β = 0.242). Conclusion: The findings partially support the model and encourage further effort to capture the burnout syndrome through the integration of biological and psychological markers.

Reduced recognition of facial emotional expressions in global burnout and burnout depersonalization in healthcare providers

The healthcare provider profession strongly relies on the ability to care for others' emotional experiences. To what extent burnout may relate to an actual alteration of this key professional ability has been little investigated. In an experimentally controlled setting, we investigated whether subjective experiences of global burnout or burnout depersonalization (the interpersonal component of burnout) relate to objectively measured alterations in emotion recognition and to what extent such alterations are emotion specific. Healthcare workers (n = 90) completed the Maslach Burnout Inventory and a dynamic emotion recognition task in which faces with neutral emotional expressions gradually changed to display a specific basic emotion (happiness, anger, fear, or sadness). Participants were asked to identify and then classify each displayed emotion. Before the task, a subsample of 46 participants underwent two salivary cortisol assessments. Individuals with global burnout were less accurate at recognizing others' emotional expressions of anger and fear, tending to misclassify these as happiness, compared to individuals without global burnout. Individuals with high burnout depersonalization were more accurate in recognizing happiness and less accurate in recognizing all negative emotions, with a tendency to misclassify the latter as positive ones, compared to healthcare workers with moderate/low depersonalization. Moreover, individuals with high depersonalization-but not participants with global burnout-were characterized by higher cortisol levels. These results suggest that the subjective burnout experience relates to an actual, but selective, reduction in the recognition of facial emotional expressions, characterized by a tendency to misclassify negative emotional expressions as positive ones, perhaps due to an enhanced seeking of positive social cues. This study adds to the understanding of emotional processing in burnout and paves the way for more nuanced studies on the role of altered processing of threat signals in the development and/or persistence of burnout.

Burnout and metabolic syndrome among different departments of medical center nurses in Taiwan-Cross-sectional study and biomarker research

OBJECTIVES

The cross-sectional study aimed to analyze the association between burnout, work-related factors, and metabolic syndrome (Mets) in nurses from several departments of a tertiary hospital in Taiwan. Exploring biomarkers could provide for prevention.

METHODS

Demographic data were obtained through a written questionnaire and include the following information: gender, age, education level, psychosocial and work situations, such as departments, working hours, work shift, depression, and sleep time. Burnout was evaluated according to the Chinese Burnout inventory, Mets was evaluated according to the criteria of the National Cholesterol Education Program of Taiwan-Treatment Panel for Adults III (NCEP-ATP III).

RESULTS

A total of 1758 nurses participated with a median age of 35.2 years. The prevalence of burnout and Mets was 6.4% and 13.84%, respectively. The results showed that burnout induced higher risk of Mets, odds ratio (OR) 1.70 (95% confidence interval, 1.04-3.05). Other factors, such as out-patient nurses, seniority (4-10 and >10 years), working hours (51-59 h/wk), nigh shift, Brief Symptom Rating Scale-5 (score 10-14 and ≧15), poor self-rated health status, and inadequate sleep time, led to higher risk of Mets. Biomarkers research showed that Glycated hemoglobin (Hba1c) was significantly associated with burnout nurses (OR = 24.72, P < .001), but thyroid-stimulating hormone and free thyroxin were not.

CONCLUSIONS

Results suggested positive associations between burnout and Mets in nurses. For nurses with higher seniority, long hours of work, night shifts, poor physical and mental conditions, and poor lifestyle habits in different departments, strategies are needed to prevent burnout and Mets.

The hypothalamo-pituitary-adrenal axis and the autonomic nervous system in burnout

Burnout constitutes a serious health concern in the modern working environment. It is a stress-related condition that has developed as a result of a prolonged psychosocial stress exposure causing a persistent mismatch between demands and resources. The main symptom is emotional exhaustion, but physical fatigue, diminished professional efficacy, cynicism, and cognitive impairments are also associated with this condition. Burnout has been used both as a psychologic term in occupational settings and as a clinical diagnosis in patient populations, and there is currently no universally accepted definition and diagnostic criteria of burnout. It has been hypothesized that the two main stress response systems, the autonomic nervous system (ANS) and the hypothalamus-pituitary-adrenal axis (HPA axis), are involved in the pathogenesis of burnout. A common hypothesis is that in the early stages of chronic stress, the HPA axis and sympathetic ANS activity tend to be higher, while it will decrease with a longer duration of chronic stress to ultimately reach a state of hypoactivity in clinical burnout. The current research in this field shows many contradictory results. Thus there is no compelling evidence of either ANS or HPA dysfunction in burnout. However, there is partial support for the hypothesis of HPA and sympathetic hyperactivity in early stages, and HPA hyporeactivity and low vagal activity in more severe burnout cases, but high-quality studies investigating the causal links are still lacking.

Examination of peripheral basal and reactive cortisol levels in major depressive disorder and the burnout syndrome: A systematic review

It is debated as to whether major depressive disorder (MDD) and the burnout syndrome represent different aspects of the same syndrome or whether they reflect separate entities. A dysregulation of the hypothalamus-pituitary-adrenal-axis has been related to both conditions separately. Dissecting the pathophysiology of the conditions and describing differences and similarities with regard to stress physiological systems might further clarify whether underlying etiological models of these syndromes differ. A systematic literature search including MDD and the burnout syndrome and peripheral cortisol measures was performed and resulted in 190 studies for inclusion in the qualitative synthesis. For MDD, findings suggest a general state of hypercortisolism and glucocorticoid resistance reflected by increased basal cortisol levels, reduced reactivity to psychosocial stress and a reduced cortisol suppression in pharmacological challenge tests. For the burnout syndrome, two central factors limit further conclusions: i) there is not a sufficient amount of studies examining the burnout syndrome and different cortisol secretion patterns to provide an evidence base, ii) the burnout syndrome is assessed heterogeneously reflecting imprecision of the measured constructs. Large prospective cohort studies examining both conditions in parallel rigorously controlling for confounders are required to further elucidate the differences and similarities of the HPA axis in MDD and the burnout syndrome.

Systematic review of posttraumatic stress disorder in police officers following routine work-related critical incident exposure

BACKGROUND

The prevalence of PTSD in police officers has been the subject of a large and highly variable empirical literature. The present systematic review evaluates the extant literature on PTSD in police officers using an international dataset.

METHODS

We employed best-evidence narrative synthesis to evaluate whether PTSD prevalence in police is elevated in comparison to the general population of Canada (8%), which itself has a higher lifetime PTSD prevalence than many other regions and thus serves as a conservative standard of comparison.

RESULTS

PTSD prevalence in police varied considerably across studies from 0% - 44% (M = 14.87%, Median = 9.2%). Despite this variability, strong evidence exists to suggest PTSD prevalence is elevated in police officers. Examination of possible sources of variability in prevalence outcomes highlighted substantial variability in outcomes due to the selection of measurement tool for assessing PTSD (e.g., DSM vs. IES). Examination of commonly-assessed predictive factors for PTSD risk across the literature showed that individual-difference factors (e.g., age, years of service) bear weak-to-nonexistent relationships with PTSD risk, while incident-specific factors (e.g., severity of exposure) are more strongly and consistently associated with PTSD prevalence. Organizational factors (e.g., low support from supervisor) are at present understudied but important possible contributors to PTSD risk.

CONCLUSIONS

PTSD prevalence is elevated in police officers and appears most strongly related to workplace exposure. Measurement variability remains a critical source of inconsistencies across the literature with drastic implications for accurate detection of officers in need of mental health intervention.

Diurnal Cortisol Levels and Subjective Ratings of Effort and Fatigue in Adult Cochlear Implant Users: A Pilot Study

Purpose

There is a growing body of literature that suggests a linkage between impaired auditory function, increased listening effort, and fatigue in children and adults with hearing loss. Research suggests this linkage may be associated with hearing loss–related variations in diurnal cortisol levels. Here, we examine variations in cortisol profiles between young adults with and without severe sensorineural hearing loss and examine associations between cortisol and subjective measures of listening effort and fatigue.

Method

This study used a repeated-measures, matched-pair design. Two groups (n = 8 per group) of adults enrolled in audiology programs participated, 1 group of adults with hearing loss (AHL) and 1 matched control group without hearing loss. Salivary cortisol samples were collected at 7 time points over a 2-week period and used to quantify physiological stress. Subjective measures of listening effort, stress, and fatigue were also collected to investigate relationships between cortisol levels, perceived stress, and fatigue.

Results

Subjective ratings revealed that AHL required significantly more effort and concentration on typical auditory tasks than the control group. Likewise, complaints of listening-related fatigue were more frequent and more of a problem in everyday life for AHL compared to the control group. There was a significant association between subjective ratings of listening effort and listening-related fatigue for our AHL, but not for the control group. In contrast, there was no significant difference in cortisol measures between groups, nor were there significant associations between cortisol and any subjective measure.

Conclusions

Young AHL experience more effortful listening than their normal hearing peers. This increased effort is associated with increased reports of listening-related fatigue. However, diurnal cortisol profiles were not significantly different between groups nor were they associated with these perceived differences.

Psychometric Properties and Convergent Validity of the Shirom-Melamed Burnout Measure in Two German-Speaking Samples of Adult Workers and Police Officers

Burnout is considered an occupation-related psychological syndrome consisting of emotional, physical, and cognitive exhaustion. To assess dimensions of burnout, the Shirom-Melamed Burnout Measure (SMBM) is widely used, but its validity and reliability have rarely been examined in adult samples. The aim of this study is to examine the psychometric properties of the German version of the SMBM in two independent samples of adults. In total, 311 adult workers and 201 police officers completed the SMBM, and questionnaires related to perceived stress and mental well-being. Descriptive statistics, internal consistency, convergent validity, and factorial validity were assessed for both samples, separately for male and female participants. The German SMBM had adequate psychometric properties and sufficient convergent validity. In confirmatory factor analyses, we found a good fit for both the first- and second-order model. Furthermore, measurement invariance across gender was observed in both samples. Although the SMBM is a popular instrument among burnout researchers, this study demonstrates for the first time that the SMBM can be considered a valid and reliable tool to assess burnout symptoms in both male and female adults and across different professional groups. Furthermore, with its 14 items, the SMBM is a succinct and economic self-assessment tool for symptoms of burnout.

Burnout Syndrome and Increased Insulin Resistance

OBJECTIVE

Our aim was to measure the association of burnout syndrome with insulin resistance in the context of a workplace health intervention.

METHODS

One-year intervention program (2015 to 2016) within a university workplace. Participants (n=55) were categorized by the presence or absence of burnout syndrome at baseline using the Maslach Burnout Inventory. Insulin resistance was calculated by the triglyceride glucose index (TyG). The Mediterranean Diet adherence score and several fitness tests were completed by the participants.

RESULTS

Although participants with prevalent burnout syndrome at baseline improved their physical fitness and diet scores more than participants without burnout syndrome, multiple linear regression analyses showed that participants with prevalent burnout syndrome at baseline had increased TyG index compared with participants without burnout syndrome (β=0.18; 95% CI, 0.01 to 0.34).

CONCLUSION

Burnout syndrome may be associated with insulin resistance, despite improvements in diet and fitness.

Burnout Syndrome in Physicians-Psychological Assessment and Biomarker Research

Background and objectives: Burnout is a syndrome typically occurring in work environments with continuous and chronic stress. Physicians are at increased risk for burnout, as a result of 24-h work, delayed work–life balance gratification, and the challenges associated with patient care. The aim of the present study was to evaluate the psychological parameters of burnout symptoms in relation to biomarkers of stress among physicians with different medical specialties. Materials and methods: A total of 303 physicians were contacted as potential participants. A comparison group of 111 individuals working outside medicine was used as a control to verify the results. The physicians were specialists in internal medicine, general surgery, pathology, and primary care. Serum cortisol, salivary cortisol, adrenocorticotropic hormone (ACTH), insulin (IRI), and prolactin levels were analyzed by chemiluminescence enzyme immunoassay (Access 2, Beckman Coulter). Fasting glucose in serum and glycated hemoglobin (HbA1C) in whole blood were measured using the automatic analyzer AU 480 Beckman Coulter system. Symptoms of burnout were measured with the Maslach Burnout Inventory (MBI). Results: The group with burnout presented significantly higher levels of serum and saliva cortisol, ACTH, prolactin, fasting glucose, and HbA1C compared with the control group. The correlation analysis between biomarkers showed a positive correlation with moderate strength between serum and saliva cortisol (r = 0.516, p = 0.01),as well as serum and saliva cortisol with ACTH (r = 0.418; r = 0.412, p = 0.01) and HbA1C (r = 0.382; r = 0.395, p = 0.01). A weak positive correlation was found between serum and saliva cortisol with prolactin (r = 0.236; r = 0.267, p < 0.01) and glucose (r = 0.271; r = 0.297, p < 0.01). In the multiple logistic regression model, saliva cortisol, HbA1C, and age were significantly associated with burnout (chi-square = 16.848, p < 0.032). Conclusion: Our findings demonstrated the interest of exploring biomarkers of stress related to burnout in health professionals.

Psychophysiological concomitants of burnout: Evidence for different subtypes

BACKGROUND

There is evidence that chronic stress and emotional exhaustion are related to physiological dysregulations, which could negatively impact physical and mental health. This study aimed to identify the specific physiological clusters which are most reliable and prominently associated with burnout. Emphasis was placed on variables of the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Burnout was assessed using the Emotional Exhaustion subscale of the German version of the Maslach Burnout Inventory (MBI-GS).

METHODS

A sample of 105 individuals aged between 28 and 60 years (M = 42.7, SD = 7.75) and working under highly demanding conditions participated in this study. 46 participants reported a low risk of burnout, and 58 participants a high risk. They underwent 24 h of ECG monitoring, had cortisol awakening response collected, and had blood pressure measured two times within a week.

RESULTS

Compromised HRV, higher cortisol values, and higher blood pressure were found in individuals with high burnout symptoms. Furthermore, a discriminant function analysis on cardiac and neuroendocrine variables suggested two subgroups within the high burnout individuals, with only one group showing evidence for autonomic dysfunction as indicated by lower vagal efference.

CONCLUSIONS

Results suggest that burnout might not necessarily imply physiological disturbances, thus calling for a more differentiated and individualized view of burnout.

MECHANISMS IN ENDOCRINOLOGY: Endocrine and immunological aspects of burnout: a narrative review

Burnout has several different definitions, and attempts have been made to discriminate between burnout as a psychological construct and burnout as a clinical entity. A large body of research has focused on elucidating the biological link between stress exposure and burnout and/or finding a clinically usable biomarker for burnout. The objective of this narrative review is to summarize the main endocrine and immune findings in relation to burnout. The literature has primarily focused on dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis. However, albeit the large body of studies, it cannot be concluded that clear effects are seen on HPA axis function in people with burnout. The HPA axis and anabolic acute reactivity to stress might be affected in clinical burnout. Plausible, effects of chronic stress might rather be seen when measuring responses to acute stress rather than resting state hormonal levels. Studies on other hormones, including thyroid hormones, prolactin and growth hormone in burnout subjects are inconclusive. It is important to note that this field is faced with many methodological challenges, one being the diurnal and pulsatile nature of many of the hormones of interest, including cortisol, which is not always considered. Another challenge is the heterogeneity regarding definitions and measurements of stress and burnout. Existing studies on burnout and immune function are heterogeneous regarding the results and no firm conclusion can be made if clinically relevant immune changes are present in burnout subjects. An overall conclusion is that existing research cannot confirm any homogenous reliable endocrinological or immunological changes related to burnout.

Inter-correlations Among Clinical, Metabolic, and Biochemical Parameters and Their Predictive Value in Healthy and Overtrained Male Athletes: The EROS-CORRELATIONS Study

Objectives: The Endocrine and Metabolic Responses on Overtraining Syndrome (EROS) study identified multiple hormonal and metabolic conditioning processes in athletes, and underlying mechanisms and biomarkers of overtraining syndrome (OTS). The present study's objective was to reveal independent predictors and linear correlations among the parameters evaluated in the EROS study to predict clinical, metabolic, and biochemical behaviors in healthy and OTS-affected male athletes. Methods: We used multivariate linear regression and linear correlation to analyze possible combinations of the 38 parameters evaluated in the EROS study that revealed significant differences between healthy and OTS-affected athletes. Results: The testosterone-to-estradiol (T:E) ratio predicted the measured-to-predicted basal metabolic rate (BMR) ratio; the T:E ratio and total testosterone level were inversely predicted by fat mass and estradiol was not predicted by any of the non-modifiable parameters. Early and late growth hormone, cortisol, and prolactin responses to an insulin tolerance test (ITT) were strongly correlated. Hormonal responses to the ITT were positively correlated with fat oxidation, predicted-to-measured BMR ratio, muscle mass, and vigor, and inversely correlated with fat mass and fatigue. Salivary cortisol 30 min after awakening and the T:E ratio were inversely correlated with fatigue. Tension was inversely correlated with libido and directly correlated with body fat. The predicted-to-measured BMR ratio was correlated with muscle mass and body water, while fat oxidation was directly correlated with muscle mass and inversely correlated with fat mass. Muscle mass was directly correlated with body water, and extracellular water was directly correlated with body fat and inversely correlated with body water and muscle mass. Conclusions: Hypothalamic-pituitary responses to stimulation were diffuse and indistinguishable between the different axes. A late hormonal response to stimulation, increased cortisol after awakening, and the T:E ratio were correlated with vigor and fatigue. The T:E ratio was also correlated with body metabolism and composition, testosterone was predicted by fat mass, and estradiol predicted anger. Hydration status was inversely correlated with edema, and inter-correlations were found among fat oxidation, hydration, and body fat.

Assessment of work-related stress by using salivary cortisol level examination among early morning shift workers

OBJECTIVE

Early morning shifts have a negative effect on the hypothalamic-pituitary-adrenal axis. The aim of this study was to comprehensively assess the extent of occupational stress in early shift workers of the car industry by using salivary cortisol as an objective marker during a workday and on a day off.

METHODS

For this cross-sectional epidemiological type of study, a survey included 55 suitable volunteers from the car industry. Five saliva samples were collected according to the following schedule: during one work day in the morning, during the morning shift from 6 a.m. - 2 p.m., then after the shift was completed, 3 hours after work and in the evening before going to sleep. Control samples were taken from the same participants on a day off. Radioimmunoanalysis was used as the main analytical method, and the effect of factors and between-factor interactions on the levels of salivary cortisol during the workday were assessed using an ANOVA model.

RESULTS

The cortisol diurnal rhythm was as expected, with the highest values in the morning and declining to the lowest values in the evening hours. Concentrations of salivary cortisol showed higher values during the workday, especially higher concentrations of evening cortisol and attenuated cortisol slope. Based on the results, irregular shift work has a greater increase in cortisol excretion after waking in the morning and a slower progressive recovery of the organism during the workday. In addition, cortisol levels were significantly higher in older women than in older men but did not differ in younger subjects.

CONCLUSIONS

Salivary cortisol levels are a suitable objective marker of stress and can be used as a good predictor of occupational stress by public health services for the purposes of primary prevention.

When Low Leisure-Time Physical Activity Meets Unsatisfied Psychological Needs: Insights From a Stress-Buffer Perspective

Background: Few studies have tested whether the stress-buffering effects of leisure-time physical activity (LTPA) depend on other resources, such as the satisfaction of basic psychological needs. Therefore, the present study examines the interaction between perceived stress, LTPA and psychological need satisfaction (PNS) on occupational burnout symptoms in a sample of Swiss workers.

Methods: The sample consisted of 306 employees (48% women; M_age = 42.9 years, SD = 14.1). Perceived stress was assessed with the Perceived Stress Scale, LTPA with the International Physical Activity Questionnaire, PNS (autonomy, relatedness, and competence) with the Need Satisfaction Scale, and occupational burnout symptoms with the Shirom-Melamed Burnout Measure. A hierarchical regression analysis and single slopes tests were performed to examine two- and three-way interactions.

Results: Stress was positively correlated with burnout, and negatively correlated with LTPA and PNS levels. LTPA was positively associated with PNS, and negatively correlated with burnout. A negative association existed between PNS and burnout. In the hierarchical regression analysis, all main effects, two- and three-way interactions were significant. People who engaged in more LTPA reported fewer burnout symptoms, if they reported high stress. However, the potential of LTPA to buffer stress was particularly evident in participants who reported low PNS.

Conclusion: If adult workers are exposed to elevated stress, they are particularly likely to show increased burnout levels if they report low LTPA in combination with low PNS, specifically a lack of autonomy, competence and relatedness.

The Cortisol Awakening Response: Association With Training Load in Endurance Runners

The cortisol awakening response (CAR) is commonly used as a marker of psychological stress; however, it is unknown whether CAR is affected by regular physical-exercise-induced stress.

PURPOSE

To assess the relationship between training load and CAR.

METHODS

Recreational endurance athletes were recruited from local running clubs. Subjects (n = 15) completed training logs for 2 wk, with various training loads, including psychometric analysis (Recovery-Stress Questionnaire for Athletes). Subjects provided saliva samples each day immediately after waking and 30 min postwaking. Samples were analyzed for cortisol concentration via enzyme-linked immunosorbent assay and subsequently were analyzed for CAR and CAR%. Daily training load was calculated and analyzed as training impulse. Simple linear regression was used to assess the relationship between CAR and training impulse.

RESULTS

CAR (r² = .352, P = .025) and CAR% (r² = .373, P = .012) both showed a significant negative relationship with training load.

CONCLUSIONS

These results suggest that CAR is affected by regular exercise training loads in recreational athletes. It is recommended that future CAR research control for fitness level and exercise training load in physically active populations.

Psychometric properties of the Shirom-Melamed Burnout Measure (SMBM) among adolescents: results from three cross-sectional studies

BACKGROUND

Burnout has long been understood as work-related physical, emotional, and cognitive exhaustion. However, burnout symptoms can also be found among younger people, including school-aged adolescents. While the Shirom-Melamed Burnout Measure (SMBM) is a widely applied instrument, its psychometric properties have not yet been investigated in adolescent populations. We therefore examined the psychometric properties of the SMBM in three independent samples of adolescents.

METHODS

In total, 249 high school students, 144 vocational students, and 257 adolescent elite athletes completed the SMBM, along with questionnaires related to perceived stress, depressive symptoms, and life satisfaction. Descriptive statistics, gender differences, and internal consistency, convergent/discriminant validity, and factorial validity (including measurement invariance across genders) were examined in each sample.

RESULTS

The SMBM had adequate internal consistency. Confirmatory factor analyses showed that both a first- and second-order model achieve good model fit. Moreover, evidence for sufficient convergent and discriminant validity was found. Finally, in two of the three samples, female adolescents reported higher SMBM scores.

CONCLUSIONS

The SMBM has been widely used in international burnout research. However, this is the first study providing empirical evidence that the SMBM has acceptable psychometric properties and satisfactory convergent/discriminant and factorial validity among young people. The SMBM is a concise and economic tool to assess self-rated symptoms of burnout, and presents a valuable alternative to existing school burnout inventories. In particular, the SMBM can facilitate the investigation of the transition of young people from school to working life.

Midday and nadir salivary cortisol appear superior to cortisol awakening response in burnout assessment and monitoring

Burnout and work-related stress symptoms of anxiety disorder and depression cause prolonged work absenteeism and early retirement. Hence, reliable identification of patients under risk and monitoring of treatment success is highly warranted. We aimed to evaluate stress-specific biomarkers in a population-based, “real-world” cohort (burnouts: n = 40, healthy controls: n = 26), recruited at a preventive care ward, at baseline and after a four-month follow up, during which patients received medical and psychological treatment. At baseline, significantly higher levels of salivary cortisol were observed in the burnout group compared to the control group. This was even more pronounced in midday- (p < 0.001) and nadir samples (p < 0.001) than for total morning cortisol secretion (p < 0.01). The treatment program resulted in a significant reduction of stress, anxiety, and depression scores (all p < 0.001), with 60% of patients showing a clinically relevant improvement. This was accompanied by a ~30% drop in midday cortisol levels (p < 0.001), as well as a ~25% decrease in cortisol nadir (p < 0.05), although not directly correlating with score declines. Our data emphasize the potential usefulness of midday and nadir salivary cortisol as markers in the assessment and biomonitoring of burnout.

How to measure glucocorticoid receptor's sensitivity in patients with stress-related psychiatric disorders

Stress is a state of derailed homeostasis and a main environmental risk factor for psychiatric diseases. Chronic or uncontrollable stress may lead to a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which is a common feature of stress-related psychiatric disorders. One of the key mechanisms underlying a disturbed HPA axis is an impaired function of the glucocorticoid receptor (GR) with an enhanced or reduced feedback sensitivity for glucocorticoids and subsequently altered concentrations of peripheral cortisol. GR function is regulated by a multiprotein complex including the different expression of the hsp90 co-chaperone FK 506 binding protein 51 (FKBP5) that may be genetically determined or acquired in response to stressful stimuli. Specific patterns of a dysregulation of the HPA axis and GR function are found in different stress-related psychiatric entities e.g. major depression, job-related exhaustion or posttraumatic stress disorder. GR challenge tests like the dexamethasone-suppression test (DST), the dexamethasone-corticotropin-releasing hormone (dex-CRH) test or most recently the analysis of the dexamethasone-induced gene expression are employed to sensitively measure HPA axis activity in these disorders. They provide information for a stratification of phenotypic similar but neurobiological diverse psychiatric disorders. In this review we present a synopsis of GR challenge tests with a focus on the application of the DST, the CRH test and the dex-CRH test as well as the dexamethasone-induced gene expression in stress-related psychiatric entities.

Mechanisms of Mitochondrial Redox Signaling in Psychosocial Stress-Responsive Systems: New Insights into an Old Story

SIGNIFICANCE

Psychosocial stress is associated with alterations in serum glucocorticoids and cytokines, such as interleukin-6 (IL-6) and IL-1β, which functionally interact. However, the molecular mechanisms and physiological relationship between the two systems within the context of stress exposure are not well characterized. Recent Advances: Extracellular IL-6, which stimulates the release of cortisol from the zona fasciculata of the adrenal cortex, mediates its intracellular effects by tyrosine phosphorylation of the transcription factor signal transducer and activator of transcription 3 (STAT3). Mitochondrial electron transfer reactions are involved in both STAT3-driven ATP production in oxidative respiration and adrenocortical steroid biosynthesis.

CRITICAL ISSUES

The role of STAT3 in oxidative respiration and steroidogenesis suggests that it integrates both nuclear and mitochondrial actions, thereby preserving main steps of glucocorticoid biosynthesis in the adrenal gland under psychosocial stress. This review discusses the notion that these two pathways are together simultaneously involved in protection against chronic stressors.

FUTURE DIRECTIONS

Linking the function of cytokines and main components of the hypothalamic-pituitary-adrenal (HPA) axis to molecular mechanisms of mitochondrial redox signaling will be essential for a better understanding of the relevant stress-responsive systems engaged in stress vulnerability. Antioxid. Redox Signal. 28, 760-772.

Cortisol awakening response in patients with bipolar disorder during acute episodes and partial remission: A pilot study

This exploratory study examined the cortisol awakening response (CAR) in patients with bipolar disorder (BPD) at acute phases and partial remission of manic or depressive episodes. Saliva samples of twenty-seven BPD inpatients and 25 healthy controls were collected to determine the CAR patterns, and 12 patients were sampled again at partial remission. BPD patients exhibited a non-enhanced CAR pattern. Lower cortisol expression and a blunted CAR distinguished bipolar-depressive patients from the controls. The intra-individual follow-up for both patient groups revealed a non-significant improvement in CAR patterns, indicating a trend of a normalized CAR after partial remission for BPD patients.

Subjective Fatigue in Children With Hearing Loss Assessed Using Self- and Parent-Proxy Report

PURPOSE

The primary purposes of this study were to examine the effects of hearing loss and respondent type (self- vs. parent-proxy report) on subjective fatigue in children. We also examined associations between child-specific factors and fatigue ratings.

METHOD

Subjective fatigue was assessed using the Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL-MFS; Varni, Burwinkle, Katz, Meeske, & Dickinson, 2002). We compared self- and parent-proxy ratings from 60 children with hearing loss (CHL) and 43 children with normal hearing (CNH). The children ranged in age from 6 to 12 years.

RESULTS

School-age CHL experienced more overall and cognitive fatigue than CNH, although the differences were smaller than previously reported. Parent-proxy report was not strongly associated with child self-report, and parents tended to underestimate their child's fatigue, particularly sleep/rest fatigue. Language ability was also associated with subjective fatigue. For CHL and CNH, as language abilities increased, cognitive fatigue decreased.

CONCLUSIONS

School-age CHL experience more subjective fatigue than CNH. The poor association between parent-proxy and child reports suggests that the parent-proxy version of the PedsQL-MFS should not be used in isolation when assessing fatigue in school-age children. Future research should examine how language abilities may modulate fatigue and its potential academic consequences in CHL.

Exercise and the Cortisol Awakening Response: A Systematic Review

BACKGROUND

The cortisol awakening response (CAR) has been used as a biomarker of stress response in a multitude of psychological investigations. While a myriad of biochemical responses have been proposed to monitor responses to exercise training, the use of CAR within the exercise and sports sciences is currently limited and is a potentially underutilized variable. Therefore, the purpose of this review was to collate studies that incorporate both exercise and CAR, in an effort to better understand (a) whether CAR is a useful marker for monitoring exercise stress and (b) how CAR may be most appropriately used in future research.

METHODS

A systematic review of the literature was conducted, following PRISMA guidelines. Searches were conducted using PubMed, SportDISCUS, Scopus, and PsychInfo databases, using search terms related toCAR and exercise and physical activity.

RESULTS

10,292 articles were identified in the initial search, with 32 studies included in the final analysis. No studies investigated the effects of laboratory-controlled exercise on CAR. Variable effects were observed, possibly due to inconsistencies in study design, methodology, population, and CAR analysis. The available literature suggests a threshold of exercise may be required to alter the HPA axis and affect CAR. Moreover, CAR may represent a combination of previous exercise load and upcoming stress, making current interpretation of field-based observational research challenging.

CONCLUSIONS

More research is needed to fully elucidate the influence of exercise on CAR and address a number of gaps in the literature, including controlling exercise load, consistent sample collection, and CAR calculation and analysis.

Psychosocial functioning and the cortisol awakening response: Meta-analysis, P-curve analysis, and evaluation of the evidential value in existing studies

Cortisol levels rise immediately after awakening and peak approximately 30-45min thereafter. Psychosocial functioning influences this cortisol awakening response (CAR), but there is considerable heterogeneity in the literature. The current study used p-curve and meta-analysis on 709 findings from 212 studies to test the evidential value and estimate effect sizes of four sets of findings: those associating worse psychosocial functioning with higher or lower cortisol increase relative to the waking period (CARi) and to the output of the waking period (AUCw). All four sets of findings demonstrated evidential value. Psychosocial predictors explained 1%-3.6% of variance in CARi and AUCw responses. Based on these effect sizes, cross-sectional studies assessing CAR would need a minimum sample size of 617-783 to detect true effects with 80% power. Depression was linked to higher AUCw and posttraumatic stress to lower AUCw, whereas inconclusive results were obtained for predictor-specific effects on CARi. Suggestions for future CAR research are discussed.

Association between burnout and cortisol secretion, perceived stress, and psychopathology in palliative care unit health professionals

ABSTRACTObjective:A high incidence of burnout has been reported in health professionals working in palliative care units. Our present study aims to determine whether there are differences in the secretion of salivary cortisol between palliative care unit health professionals with and without burnout, and to elucidate whether there is a relationship between burnout syndrome and perceived stress and psychopathological status in this population.

METHOD

A total of 69 health professionals who met the inclusion criteria participated in our study, including physicians, nurses, and nursing assistants. Some 58 were women (M = 29.65 years, SD = 8.64) and 11 men (M = 35.67 years, SD = 11.90). The level of daily cortisol was registered in six measurements taken over the course of a workday. Burnout syndrome was evaluated with the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), the level of perceived stress was measured using the Perceived Stress Scale, and psychopathological status was gauged using the SCL-90-R Symptoms Inventory.

RESULTS

There were statistically significant differences in secretion of cortisol in professionals with high scores on a single subscale of the MBI-HSS [F(3.5) = 2.48, p < 0.03]. This effect was observed 15-30 minutes after waking up (p < 0.01) and at bedtime (p < 0.06). Moreover, the professionals with burnout showed higher scores on the psychopathology and stress subscales than professionals without it.

SIGNIFICANCE OF RESULTS

A higher score in any dimension of the burnout syndrome in palliative care unit health professionals seems to be related to several physiological and psychological parameters. These findings may be relevant for further development of our understanding of the relationship between levels of burnout and cortisol secretion in the health workers in these units.

Executive Cognitive Functioning and Cardiovascular Autonomic Regulation in a Population-Based Sample of Working Adults

Objective: Executive cognitive functioning is essential in private and working life and is sensitive to stress and aging. Cardiovascular (CV) health factors are related to cognitive decline and dementia, but there is relatively few studies of the role of CV autonomic regulation, a key component in stress responses and risk factor for cardiovascular disease (CVD), and executive processes. An emerging pattern of results from previous studies suggest that different executive processes may be differentially associated with CV autonomic regulation. The aim was thus to study the associations between multiple measures of CV autonomic regulation and measures of different executive cognitive processes. Method: Participants were 119 healthy working adults (79% women), from the Swedish Longitudinal Occupational Survey of Health. Electrocardiogram was sampled for analysis of heart rate variability (HRV) measures, including the Standard Deviation of NN, here heart beats (SDNN), root of the mean squares of successive differences (RMSSD), high frequency (HF) power band from spectral analyses, and QT variability index (QTVI), a measure of myocardial repolarization patterns. Executive cognitive functioning was measured by seven neuropsychological tests. The relationships between CV autonomic regulation measures and executive cognitive measures were tested with bivariate and partial correlational analyses, controlling for demographic variables, and mental health symptoms. Results: Higher SDNN and RMSSD and lower QTVI were significantly associated with better performance on cognitive tests tapping inhibition, updating, shifting, and psychomotor speed. After adjustments for demographic factors however (age being the greatest confounder), only QTVI was clearly associated with these executive tests. No such associations were seen for working memory capacity. Conclusion: Poorer CV autonomic regulation in terms of lower SDNN and RMSSD and higher QTVI was associated with poorer executive cognitive functioning in terms of inhibition, shifting, updating, and speed in healthy working adults. Age could largely explain the associations between the executive measures and SDNN and RMSSD, while associations with QTVI remained. QTVI may be a useful measure of autonomic regulation and promising as an early indicator of risk among otherwise healthy adults, compared to traditional HRV measures, as associations between QTVI and executive functioning was not affected by age.

Patients with burnout in relation to gender and a general population

Aims: The aims of this study were to describe gender differences in patients with burnout and compare these patients with a general population with respect to physical, psychosocial and work variables. Methods: Data were collected from a total of 136 patients (96 women and 40 men, 41,6 ± 7,4 years), diagnosed with stress-related disease and burnout at the Stress Clinic, University Hospital of Umeå. Data on burnout, physical, psychosocial and work characteristics were compared with similar data from a geographical and age-matched population based survey, the 2004 Northern Sweden MONICA study. The survey sample included a total of 573 participants (283 women and 290 men, 40,7 ± 8,5 years). Results: Women with burnout reported a higher rate of impaired awakening, lower job control, greater proportion of unpaid work and worked to a greater extent ``with people'' compared to men. Men with burnout had a more restricted social network and reported working more overtime than women. Patients with burnout reported a higher rate of unemployment, a more restricted social network and higher work demands compared to a general population. Women with burnout reported less emotional support, a more sedentary work situation, high job strain and worked to a greater extent ``with people'' than women from the general population. Conclusions: There are some differences in working conditions and social network between women and men with burnout. Patients with burnout differ from a general population regarding individual and social factors as well as work-related factors.

Adrenal fatigue does not exist: a systematic review

BACKGROUND

The term "adrenal fatigue" ("AF") has been used by some doctors, healthcare providers, and the general media to describe an alleged condition caused by chronic exposure to stressful situations. Despite this, "AF" has not been recognized by any Endocrinology society, who claim there is no hard evidence for the existence. The aim of this systematic review is to verify whether there is substantiation for "AF".

METHODS

A systematic search was performed at PUBMED, MEDLINE (Ebsco) and Cochrane databases, from the beginning of the data until April 22nd, 2016. Searched key words were: "adrenal" + "fatigue", "adrenal" + "burnout", "adrenal" + "exhaustion", "hypoadrenia", "burnout" + "cortisol", "fatigue" + "cortisol", "clinical" + "burnout", "cortisol" + "vitalility", "adrenal" + "vitality", and "cortisol" + "exhaustion". Eligibility criteria were: (1) articles written in English, (2) cortisol profile and fatigue or energy status as the primary outcome, (3) performed tests for evaluating the adrenal axis, (4) absence of influence of corticosteroid therapy, and (5) absence of confounding diseases. Type of questionnaire to distinct fatigued subjects, population studied, tests performed of selected studies were analyzed.

RESULTS

From 3,470 articles found, 58 studies fulfilled the criteria: 33 were carried in healthy individuals, and 25 in symptomatic patients. The most assessed exams were "Direct Awakening Cortisol" (n = 29), "Cortisol Awakening Response" (n = 27) and "Salivary Cortisol Rhythm" (n = 26).

DISCUSSION

We found an almost systematic finding of conflicting results derived from most of the studies methods utilized, regardless of the validation and the quality of performed tests. Some limitations of the review include: (1) heterogeneity of the study design; (2) the descriptive nature of most studies; (3) the poor quality assessment of fatigue; (4) the use of an unsubstantiated methodology in terms of cortisol assessment (not endorsed by endocrinologists); (5) false premises leading to an incorrect sequence of research direction; and, (6) inappropriate/invalid conclusions regarding causality and association between different information.

CONCLUSION

This systematic review proves that there is no substantiation that "adrenal fatigue" is an actual medical condition. Therefore, adrenal fatigue is still a myth.

Salivary Cortisol Profiles of Children with Hearing Loss

OBJECTIVES

It has long been speculated that effortful listening places children with hearing loss at risk for fatigue. School-age children with hearing loss experiencing cumulative stress and listening fatigue on a daily basis might undergo dysregulation of hypothalamic-pituitary-adrenal (HPA) axis activity resulting in elevated or flattened cortisol profiles. The purpose of this study was to examine whether school-age children with hearing loss show different diurnal salivary cortisol patterns than children with normal hearing.

DESIGN

Participants included 32 children with mild to moderate hearing loss (14 males; 18 females) and 28 children with normal hearing (19 males; 9 females) ranging in age from 6 to 12 years. Saliva samples were obtained six times per day on two separate school days. Cortisol levels were measured by mass spectrometric detection after liquid-liquid extraction. Salivary cortisol levels between children with hearing loss and children with no hearing loss over the course of the day were examined with hierarchical linear modeling using mixed model statistical analysis. Between-group comparisons were also computed for the area under the curve, an analytical approach for calculating overall cortisol secretion throughout the day.

RESULTS

Significant differences in the cortisol awakening response (CAR) were observed between children with hearing loss and children with normal hearing; however, no differences were observed between the two groups subsequent to the cortisol awakening response (60-min postawakening, 10:00 A.M., 2:00 P.M., and 8:00 P.M.). Compared with children with normal hearing, children with hearing loss displayed elevated cortisol levels at awakening and a reduced growth in cortisol secretion from awakening to 30-min postawakening. No significant differences in overall cortisol secretion throughout the day were found between groups (area under the curve). Finally, cortisol levels increased with increasing age for children with hearing loss but not for children with normal hearing.

CONCLUSIONS

Results of this preliminary study indicate a possible dysregulation in HPA axis activity in children with hearing loss characterized by elevated salivary cortisol levels at awakening and a diminished increase in cortisol from awakening to 30-min postawakening. The pattern of elevated cortisol levels at awakening is consistent with some studies on adults with burnout, a condition characterized by fatigue, loss of energy, and poor coping skills. These findings support the idea that children with hearing loss may experience increased vigilance and need to mobilize energy promptly in preparation for the new day.

Self-reported sleep lengths ≥ 9 hours among Swedish patients with stress-related exhaustion: Associations with depression, quality of sleep and levels of fatigue

BACKGROUND

Insomnia-type sleep disturbances are frequent among patients suffering from stress-related exhaustion disorder. However, clinical observations indicate that a subgroup suffer from sleep lengths frequently exceeding 9 hours, coupled with great daytime sleepiness.

AIMS

The aim of the present study was to investigate differences in socio-demographic variables, use of medications, sleep parameters, anxiety, depression and fatigue, between individuals with varying sleep lengths, in a sample of 420 Swedish patients (mean age 42 ± 9 years; 77% women) referred to treatment for exhaustion disorder. Patients were allocated to the groups: "never/seldom ≥ 9 hours" (n = 248), "sometimes ≥ 9 hours" (n = 115) and "mostly/always ≥ 9 hours" (n = 57), based on their self-rated frequency of sleep lengths ≥ 9 hours.

METHODS

The design was cross-sectional and data was collected by means of questionnaires at pre-treatment.

RESULTS

Univariate analyses showed that patients in the "mostly/always ≥ 9 hours" group were more often on sick leave, and reported more depression and fatigue, better sleep quality and more daytime sleepiness, than patients in the other groups. Multivariate analyses showed that these patients scored higher on measures of fatigue than the rest of the sample independently of gender, use of antidepressants, sick leave, depression and quality of sleep.

CONCLUSIONS

Patients suffering from exhaustion disorder and reporting excessive sleep seem to have a generally poorer clinical picture but better quality of sleep than their counterparts with shorter sleep lengths. The mechanisms underlying these differences, together with their prognostic value and implications for treatment remain to be elucidated in future studies.