Prevalence and course of somatic symptoms in patients with stress-related exhaustion: does sex or age matter

BACKGROUND: Both mental and somatic symptoms are commonly reported in patients with stress-related problems. We have explored the prevalence of somatic symptoms in patients seeking medical care for stress-related mental health problems and followed the course of illnes alongside with that the patients receive multimodal treatment. METHOD: This study comprises data from 228 patients (69% women, mean age 43 years) who fulfilled the criteria for Exhaustion Disorder (ED). Somatic symptoms were assessed at baseline and after 3, 6, 12 and 18 months using the one-page questionnaire Primary Care Evaluation of Mental Disorders. Prevalence of different symptoms was compared between men and women and patients, over and below 40 years of age, and possible predictors of recovery were explored. RESULTS: Tiredness and low energy are the core symptom reported by the patients. Almost all (98%) reported at least one somatic symptom and 45% reported six symptoms or more, which was similar for men and women. Nausea, gas or indigestion are the most common symptoms (67%) followed by headaches (65%) and dizziness (57%). The number of symptoms reported was significantly related to the severity of mental health problems. The only difference between the sexes was that “chest pain” and “pain or problems during sexual intercourse” were more common among males. Patients over forty more often reported “pain in arms, legs or joints, knees, hips” and this was also the only symptom that did not significantly decline during treatment. Neither sex, age, symptom duration before seeking medical care, education or any other predictor tested was shown to predict recovery in patients reporting six symptoms or more. CONCLUSION: A heavy burden of somatic symptoms was generally seen in most patients with stress-related exhaustion. Somatic symptoms are equally common in males and females and in younger and older patients. The somatic symptoms seem to be mostly stress-related since all symptoms, except musculoskeletal pain, reduce with individualised treatment designed for stress-related mental problems. This study brings to attention the complicated burden of both somatic and mental symptoms in patients with stress-related exhaustion, raising several clinical implications of interest to discuss

Monocyte Chemotactic Protein-1 (MCP-1) and Growth Factors Called into Question as Markers of Prolonged Psychosocial Stress

BACKGROUND:Psychosocial stress is becoming a major contributor to increased mental ill-health and sick leave in many countries. Valid markers of chronic stress would be valuable for diagnostic and prognostic purposes. A recent study suggested monocyte chemotactic protein-1 (MCP-1), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) as markers of chronic stress. We aimed to confirm these potential biomarkers of prolonged psychosocial stress in female patients. METHODOLOGY/PRINCIPAL FINDINGS:Circulating levels of MCP-1, EGF and VEGF, along with several other cytokines, were measured in plasma from 42 female patients suffering from exhaustion due to prolonged psychosocial stress and 42 control subjects, using a protein biochip immunoassay. There were no significant differences between patients and controls in any of the cytokines or growth factors analyzed. Furthermore, when using a different protein bioassay and reanalyzing MCP-1 and VEGF in the same samples, markedly different levels were obtained. To further explore if inflammation is present in patients with exhaustion, the classical inflammatory marker C-reactive protein (CRP) was measured in another group of patients (n=89) and controls (n=88) showing a small but significant increase of CRP levels in the patients. CONCLUSIONS/SIGNIFICANCE:MCP-1, EGF and VEGF may not be suitable markers of prolonged psychosocial stress as previously suggested. Furthermore, significant differences were obtained when using two different protein assays measuring the same samples, indicating that comparing studies where different analytic techniques have been used might be difficult. Increased levels of CRP indicate that low-grade inflammation might be present in patients with exhaustion due to prolonged stress exposure but this inflammation does not seem to be reflected by increase in circulating MCP-1 or other cytokines measured

Utmattningssyndrom, identifikation, karakteristika och förlopp

Aim. The overall aim of the thesis was to study exhaustion disorder (ED) with respect to identification, characterisation and course of illness, as well as some properties of an instrument of self-rated ED (s-ED). Method. The first two studies were based on longitudinal register data of patients referred to a specialist clinic and fulfilling the criteria for ED diagnosis. The burden of mental and somatic symptoms including course of illness were studied, inclusive possible influence of sex and age. The third study was a cross-sectional primary care study of patients seeking for any reason, and completing a stress item and mental health questionnaires including s-ED. Those that indicated mental health problems were invited for clinical examination and assessment for ED. The fourth study was based on data from a longitudinal cohort with the primary aim to investigate how self-rated ED relates to other self-rating scales of mental health and work-ability, and to follow up the predictive validity of s-ED regarding sickness absence. Results. The main finding of the first study was the long duration of mental illness seen in ED patients. Further important findings were the high burden of co-morbid conditions such as depression and anxiety. There were no sex or age group differences. Self-reported symptom duration before seeking care was the only significant predictor of recovery. In the second study the main finding was multiple somatic symptoms reported by patients with ED, without sex or age group differences. The number of somatic symptoms was significantly related to the severity of mental health problems. Nearly half of both female and male patients reported six symptoms or more during the first visit at the clinic and one-fifth of the total at 18-month follow-up. Pain in arms, legs and joints was the only single symptom that persisted at a constant level. The main finding in the third study was that approximately one-third of those invited for clinical examination fulfilled the diagnostic criteria for ED. This corresponded to 9 % of the total primary care study population. Furthermore, co-morbid depression and anxiety were common in ED patients, and the burden of somatic symptoms was high. Those not fulfilling ED (non-ED) showed a similar burden of somatic symptoms, but less mental health symptoms compared to ED patients. In non-ED patients with pronounced s-ED mental health symptoms were similar to ED, except for anxiety being more prevalent in ED. The main finding from the fourth study of a working population was that s-ED corresponded well to other mental health measurements. With increasing severity of s-ED, symptoms of depression, anxiety and burnout rose, and furthermore the rate of poor work-ability and the risk of future sick leave increased. Further results were that one out of six reported self-reported exhaustion. Conclusions. Patients with ED presented long-lasting course of mental health problems. There was extensive co-morbidity including depression, anxiety and multiple somatic symptoms. Similar pattern with regard to both burden of symptoms and course of symptom are seen for all patients irrespective of sex or age. Among patients seeking primary care and reporting elevated stress and mental health problems, one-third was found to fulfil the diagnostic criteria for ED, which is nearly one out of ten of the total group. Patients that did not completely fulfil the criteria but reported pronounced s-ED showed similar burden of mental and somatic health problems. This implies that self-reporting s-ED irrespective of ED diagnosis should be considered an important health problem. The s-ED instrument was found to correlate well with other mental health measures, and the predictive value with regard to future sick leave indicated that this instrument could be considered as a potential tool for early identification of patients risking high burden of stress-related health problems and long sick-leaves

Stressrelaterad psykisk ohälsa – hur ser problemet ut?

Långtidssjukskrivningar på grund av stressrelaterad psykisk ohälsa ökar i Sverige sedan mitten av 1990-talet. Förhållanden på arbetsplatser, den sociala situationen och individuella faktorer är väsentliga för utvecklingen. Vanliga stressymtom är trötthet/utmattning, sömnstörningar, smärtor, koncentrations- och minnesstörningar, ångest och nedstämdhet samt olika kroppsliga problem. Fortsätter stressen kan ett utmattningssyndrom utvecklas. Rätt diagnos är centralt för rätt behandling som innebär hjälp att minska belastningen och öka sina resurser. Möjlighet till återhämtning, stöd till livsstilsåtgärder och arbetsanpassning är också viktigt. Rehabiliteringen kan ta upp till flera år. Förebyggande åtgärder och att fånga upp personer med ökad risk för stressrelaterad ohälsa är viktigt

Involving the employer to enhance return to work among patients with stress-related mental disorders – study protocol of a cluster randomized controlled trial in Swedish primary health care

Abstract Background Work-related stress has become a major challenge for social security and health care systems, employers and employees across Europe. In Sweden, sickness absence particularly due to stress-related disorders has increased excessively in recent years, and the issue of how to improve sustainable return to work in affected employees is high up on the political agenda. The literature on interventions for return to work in patients with common mental disorders is still inconclusive. This randomized controlled trial (RCT) aims to contribute with knowledge about how physicians and rehabilitation coordinators in primary health care can involve the employer in the rehabilitation of patients with stress-related disorders. The objective is to evaluate whether the early involvement of the patient’s employer can reduce the time for return to work compared to treatment as usual. A process study will complete the RCT with information about what prerequisites primary health caregivers need to succeed with this endeavor. Methods Twenty-two primary care centers were randomized to either intervention or control group. At the intervention centers, physicians and rehabilitation coordinators underwent training, providing them with both knowledge and practical tools to involve the employer in rehabilitation. At the patient level, employed patients with an ICD-10 F43 diagnosis were eligible for participation (n=132). Difference in proportion of patients on full- or part-time sick leave at three, six and 12 months after inclusion will be investigated. Register data, logbooks and interviews with coordinators and physicians at both intervention and control centers will be used for process evaluation. Discussion Although the issue of how to tackle work-related stress can be recognized all across Europe, Sweden face an urgent need to curb the disproportional increase of stress-related disorders in the sick-leave statistics. Since physicians are limited by time constraints, the rehabilitation coordinator may be a helpful resource to take this contact. The current study will contribute to knowledge about how this collaboration can be organized to facilitate employer involvement and reduce time to return to work among patients suffering from work related stress. Trial registration Registered on 1 November 2016, ClinicalTrials.gov, NCT03022760

Course of mental symptoms in patients with stress-related exhaustion: does sex or age make a difference?

Abstract Background Long-term sick leave due to mental health problems, especially among women, is a substantial problem in many countries, and a major reason for this is thought to be psychosocial stress. The recovery period of different patient groups with stress-related mental health problems can differ considerably. We have studied the course of mental health symptoms during 18 months of multimodal treatment in relation to sex and age in a group of patients with stress-related exhaustion. Methods The study group includes 232 patients (68% women) referred to a stress clinic and who fulfilled the criteria for Exhaustion Disorder (ED). The majority also fulfilled diagnostic criteria for depression and/or anxiety; this was similar among women and men. Symptoms were assessed at baseline, three, six, 12 and 18 months by the Shirom-Melamed Burnout Questionnaire (SMBQ) and the Hospital Anxiety and Depression scale (HAD). A total SMBQ mean score of ≥ 4 was used to indicate clinical burnout, which correlates well with the clinical diagnosis of ED. Results There were no statistically significant differences between women and men or between young and old patients in the self-reported symptoms at baseline. The proportion that had high burnout scores decreased over time, but one-third still had symptoms of clinical burnout after 18 months. Symptoms indicating probable depression or anxiety (present in 34% and 65% of the patients at baseline, respectively) declined more rapidly, in most cases within the first three months, and were present only in one out of 10 after 18 months. The course of illness was not related to sex or age. The duration of symptoms before seeking health care, but not the level of education or co-morbid depression, was a predictor of recovery from symptoms of burnout after 18 months. Conclusions The course of mental illness in patients seeking specialist care for stress-related exhaustion was not related to sex or age. The burden of mental symptoms is high and similar for men and women, and at the 18 month follow-up, one-third of the study group still showed symptoms of burnout. A long duration of symptoms before consultation was associated with a prolonged time of recovery, which underlines the importance of early detection of stress-related symptoms.</p

Does employer involvement in primary health care enhance return to work for patients with stress-related mental disorders? a cluster randomized controlled trial

Abstract Background Stress-related disorders have become a major challenge for society and are associated with rising levels of sick leave. The provision of support to facilitate the return to work (RTW) for this patient group is of great importance. The aim of the present study was to evaluate whether a new systematic procedure with collaboration between general practitioners (GPs), rehabilitation coordinators (RCs) and employers could reduce sick leave days for this patient group. Method Employed patients with stress-related diagnoses seeking care at primary health care centres (PHCCs) were included in either the intervention group (n = 54), following the systematic intervention procedure, or the control group (n = 58), receiving treatment as usual (TAU). The intervention included a) a training day for participant GPs and RCs, b) a standardised procedure for GPs and RCs to follow after training, c) the opportunity to receive clinical advice from specialist physicians in the research group. Outcome measures for RTW were sick leave days. Results The median number of registered gross sick leave days was lower for the control group at six, 12 and 24 months after inclusion, but the difference was not statistically significant. The control group had significantly fewer net sick leave days at three months (p = 0.03) at six months (p = 0.00) and at 12-months follow-up (p = 0.01). At 24 months, this difference was no longer significant. Conclusions The PRIMA intervention, which applied a standardized procedure for employer involvement in the rehabilitation process for patients with stress-related disorders, actually increased time to RTW compared to TAU. However, at 24 months, the benefit of TAU could no longer be confirmed. The study was registered on 16/01/2017 (ClinicalTrials.gov, NCT03022760)

Additional file 2 of Does employer involvement in primary health care enhance return to work for patients with stress-related mental disorders? a cluster randomized controlled trial

Additional file 2. Questions for employer interviews

Additional file 1 of Does employer involvement in primary health care enhance return to work for patients with stress-related mental disorders? a cluster randomized controlled trial

Additional file 1. A summary of F 43 diagnoses included in the present study