Occupati

Occupational burnout and health
Kirsi Ahola
People and Work

Research Reports 81
Finnish Institute of Occupational Health

Helsinki, Finland
CONTENTS
ACKNOWLEDGEMENTS ...................................................
ABSTRACT
.................................................................
TIIVISTELM ................................................................ 10
LIST OF ORIGINAL PUBLICATIONS ................................... 12
1. INTRODUCTION .........................................................
1.1 Concept of occupational burnout ...........................
1.2 Socio-demographic factors and occupational burnout
1.3 Job strain and occupational burnout .......................
1.4 Occupational burnout and health problems ..............
Mental health problems ................................
Musculoskeletal problems .............................
Cardiovascular diseases ................................
Summary and limitations of previous research..
1.5 Occupational burnout and sickness absence .............
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15
18
20
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24
33
33
35
36
2. PRESENT STUDY ........................................................ 39

2.1 Framework of the study ........................................ 39
2.2 Aims of the study ................................................. 41
3. METHODS .................................................................
3.1 Procedure ..........................................................
3.2 Participants .........................................................
3.3 Measures ............................................................
Occupational burnout ...................................
Mental disorders ..........................................
Depressive symptoms ..................................
Physical illnesses .........................................
Sickness absence ........................................
Job strain ...................................................
Socio-demographic factors ............................
Confounding factors .....................................
3.4 Statistical analyses ...............................................
43
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53
CONTENTS
4. RESULTS ..................................................................
4.1 Association between socio-demographic factors and
occupational burnout ...........................................
Gender, age and burnout ................................
Education, occupational grade and burnout .......
Marital status and burnout ..............................
Brief summary ..............................................
4.2 Job strain in relation to occupational burnout and
depressive disorders .............................................
4.3 Association between occupational burnout and
disorders and illnesses ..........................................
Burnout and mental disorders .........................
Burnout and musculoskeletal disorders.............
Burnout and cardiovascular diseases ................
Co-occurrence of burnout with mental disorders
and physical illnesses .....................................
Brief summary ..............................................
4.4 Contribution of occupational burnout to long sickness
absences ............................................................
5. DISCUSSION ............................................................
5.1 Synopsis of the main findings ................................
5.2 Occupational burnout in the arena of occupational
health psychology ................................................
Burnout and ill health ....................................
Depressive and anxiety disorders ..............
Alcohol dependence ................................
Musculoskeletal disorders ........................
Cardiovascular diseases ...........................
Summary ..............................................
Distinction between burnout and ill health ........
Association with work characteristics .........
Association with work disability.................
Summary ..............................................
Role of individual factors in burnout .................
Gender and the level of burnout ...............
Gender differences in the association
between burnout and ill health .................
Age and the level of burnout ....................
Summary ..............................................
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89
90
CONTENTS
5.3 Evaluation of the study .........................................

Assessment of burnout ..................................
Major strengths.............................................
Study limitations ...........................................
5.4 Conclusions .........................................................
5.5 Policy implications ................................................
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96
REFERENCES ................................................................ 97
ORIGINAL PUBLICATIONS ............................................... 117
ACKNOWLEDGEMENTS
This study was carried out at the Finnish Institute of Occupational Health
(FIOH). I would like to express my sincere gratitude to the Director
General of FIOH, Professor Harri Vainio, for the facilities provided to
me for my work. I also extend my warmest thanks to the Director of
the Centre of Expertise for Work Organisations, Professor Kari Lindstrm, for the opportunity to carry out my research at FIOH. As an
academic dissertation, this work is being presented in the Department
of Psychology at the University of Helsinki, the opportunity for which
I am much obliged.
This project was a part of the Health 2000 Study which was organized
by the National Public Health Institute. I am very grateful to the Chairman of the Health 2000 Study Project Group, Professor Arpo Aromaa,
and the Chairman of the Mental Health Working Group of the Health
2000 Study, Professor Jouko Lnnqvist, for giving me the opportunity
to participate in the Health 2000 Study.
I wish to express my deepest appreciation to the reviewers of this
thesis, Professor Ulla Kinnunen, from the University of Tampere, and
Professor Jyrki Korkeila, from the University of Turku, for their constructive comments, which signicantly improved this thesis.
Most of all, I am immensely indebted to my supervisors, docent Teija
Honkonen, M.D., Ph.D., and Professor Mika Kivimki, for sharing their
expertise with me. I extend my warmest thanks to the co-authors of the
original publications of this thesis, Professor Emerita Raija Kalimo, Professor Jouko Lnnqvist, Professor Erkki Isomets, Professor Jussi Vahtera,
docent Marianna Virtanen, Ph.D., docent Seppo Koskinen, M.D.,
Ph.D., docent Marja Pertovaara, M.D., Ph.D., docent Sami Pirkola,
ACKNOWLEDGEMENTS
M.D., Ph.D., and mathematician Erkki Nykyri, Lic.Sc., for their eort
and valuable comments. It was Raija Kalimo who originally introduced
me to the eld of burnout research, for which I am deeply grateful.
I express my special thanks to my team leader, Sirkku Kivist, M.A,
Lic., for her endless support and encouragement. I have been very privileged in having such stimulating co-workers in the Centre of Expertise
in Work Organisations, and especially in the Work and Mental Health
Team at FIOH. My thanks to you all!
I extend warm thanks to all the participants, eld workers, and project
sta of the Health 2000 Study for their eort and assistance. I warmly
thank Georgianna Oja, E.L.S., for the linguistic editing of the original
publications and this thesis.
Finally, I am so very grateful to my friends and relations, and especially
to my children Jonni and Sanja, for my most valuable resource during
this project: continuous companionship in everyday life.
This study was supported by the Finnish Work Environment Fund
(project no. 106382) and the Academy of Finland (projects no. 105195
and 117604), for which I am deeply indebted.
Helsinki, September 2007
Kirsi Ahola
ABSTRACT
Occupational burnout is assumed to be a negative consequence of chronic
work stress. In this study, it was explored in the framework of occupational health psychology, which focusses on psychologically mediated
processes between work and health. The objectives were to examine the
overlap between burnout and ill health in relation to mental disorders,
musculoskeletal disorders, and cardiovascular diseases, which are the
three commonest disease groups causing work disability in Finland; to
study whether burnout can be distinguished from ill health by its relation to work characteristics and work disability; and to determine the
socio-demographic correlates of burnout at the population level.
A nationally representative sample of the Finnish working population aged 30 to 64 years (n = 31513424) from the multidisciplinary
epidemiological Health 2000 Study was used. Burnout was measured
with the Maslach Burnout Inventory General Survey. The diagnoses
of common mental disorders were based on the standardized mental
health interview (the Composite International Diagnostic Interview),
and physical illnesses were determined in a comprehensive clinical
health examination by a research physician. Medically certied sickness
absences exceeding 9 work days during a 2-year period were extracted
from a register of The Social Insurance Institution of Finland. Work
stress was operationalized according to the job strain model. Gender,
age, education, occupational status, and marital status were recorded as
socio-demographic factors.
Occupational burnout was related to an increased prevalence of depressive and anxiety disorders and alcohol dependence among the men
and women. Burnout was also related to musculoskeletal disorders among
ABSTRACT
the women and cardiovascular diseases among the men independently

of socio-demographic factors, physical strenuousness of work, health
behaviour, and depressive symptoms.
The odds of having at least one long, medically-certied sickness absence were higher for employees with burnout than for their colleagues
without burnout. For severe burnout, this association was independent
of co-occurring common mental disorders and physical illnesses for both
genders, as was also the case for mild burnout among the women. In a
subgroup of the men with absences, severe burnout was related to a greater
number of absence days than among the women with absences.
High job strain was associated with a higher occurrence of burnout
and depressive disorders than low job strain was. Of these, the association
between job strain and burnout was stronger, and it persisted after control for socio-demographic factors, health behaviour, physical illnesses,
and various indicators of mental health. In contrast, job strain was not
related to depressive disorders after burnout was accounted for.
Among the working population over 30 years of age, burnout was
positively associated with age. There was also a tendency towards higher
levels of burnout among the women with low educational attainment
and occupational status and among the unmarried men.
In conclusion, a considerable overlap was found between burnout,
mental disorders, and physical illnesses. Still, burnout did not seem to
be totally redundant with respect to ill health. Burnout may be more
strongly related to stressful work characteristics than depressive disorders
are. In addition, burnout seems to be an independent risk factor for work
disability, and it could possibly be used as a marker of health-impairing
work stress. However, burnout may represent a dierent kind of health
risk for men and women, and this possibility needs to be taken into account in the promotion of occupational health.
TIIVISTELM
Tss vitskirjassa tarkasteltiin tyuupumusta tyterveyspsykologian
nkkulmasta. Tyuupumuksella tarkoitetaan uupumusasteisen vsymyksen, kyynistyneisyyden ja alentuneen ammatillisen itsetunnon muodostamaa oireyhtym, joka voi kehitty pitkn jatkuneen tystressin
seurauksena. Tutkimuksen ptavoitteena oli selvitt tyuupumuksen
samanaikaista esiintymist mielenterveyden hiriiden, tuki- ja liikuntaelinsairauksien ja sydn- ja verenkiertoelinten sairauksien kanssa, koska
nm sairausryhmt ovat Suomessa yleisimmin tykyvyttmyyselkkeen
perusteena. Lisksi tutkittiin, onko tyuupumus yhteydess tykuormitukseen samalla tavalla kuin masennushirit ja onko tyuupumuksella
yhteytt pitkiin sairauspoissaoloihin. Mys sosiodemograsten taustatekijiden yhteyksi tyuupumukseen kartoitettiin tysskyvss
vestss.
Tutkimuksessa kytettiin kansallisesti edustavaa tyikisist (3064vuotiaista) suomalaisista (n = 31513424) muodostettua Terveys 2000
-aineistoa. Tyuupumusta mitattiin Maslachin yleisell tyuupumuksen
arviointimenetelmll (MBI-GS). Mielenterveyden hiriiden diagnoosit
perustuivat standardoituun mielenterveyshaastatteluun (Composite International Diagnostic Interview) ja somaattisten sairauksien diagnoosit
lkrintarkastukseen. Tiedot lkrin mrmist yli 9 piv kestneist sairauspoissaoloista poimittiin Kansanelkelaitoksen rekisterist.
Tykuormitus mriteltiin tyn vaatimusten ja hallintamahdollisuuksien
avulla. Sosiodemograsina taustatekijin kytettiin sukupuolta, ik,
siviilisty, koulutusta ja ammattiasemaa.
Tyuupumus oli yhteydess masennus- ja ahdistushiriihin sek
alkoholiriippuvuuteen miehill ja naisilla. Lisksi se oli yhteydess
tuki- ja liikuntaelinsairauksiin naisilla ja sydn- ja verenkiertoelinten
10
TIIVISTELM
sairauksiin miehill niden sairausryhmien tavallisten riskitekijiden

ohella. Vakava-asteinen tyuupumus oli itsenisesti yhteydess pitkiin
sairauspoissaoloihin, vaikka samanaikaisesti esiintyneet tysskyvill
yleiset mielenterveyden hirit ja somaattiset sairaudet otettiin huomioon. Miehill, joilla oli ollut vhintn yksi pitk sairauspoissaolojakso, vakavaan tyuupumukseen liittyi enemmn poissaolopivi kahden
vuoden aikana kuin vastaavassa tilanteessa olleilla naisilla. Naisilla mys
liev tyuupumus oli yhteydess pitkiin sairauspoissaoloihin.
Kuormittavaa tyt tekevill oli useammin tyuupumusta tai masennushiri kuin vhn kuormittavaa tyt tekevill. Merkitsev yhteys
tykuormituksen ja tyuupumuksen vlill silyi, vaikka tyntekijiden
masennusoireilu ja mielenterveyden hirit otettiin huomioon. Sen sijaan
tykuormituksen ja masennushirin vlill ei ollut suoraa yhteytt, jos
samanaikainen tyuupumus huomioitiin.
Tyuupumus oli 30 vuotta tyttneiden tysskyvien joukossa
yleisemp ikntyneill tyntekijill nuorempiin verrattuna. Lisksi
vaikutti silt, ett tyuupumus olisi muihin verrattuna hieman yleisemp
erityisesti vhn koulutetuilla ja matalassa ammattiasemassa tyskentelevill naisilla sek naimattomilla miehill.
Vaikka tyuupumus oli selvsti yhteydess mielenterveyden hiriihin
ja somaattisiin sairauksiin, se ei ollut aivan samalla tavalla yhteydess
tykuormitukseen eik tykyvyttmyyteen kuin nm sairaudet. Tyuupumus nytt liittyvn vahvemmin tykuormitukseen kuin masennushirit ja vaikuttaa olevan samanaikaisista yleisist sairauksista huolimatta itseninen riskitekij pitkille sairauspoissaoloille. Tyuupumusta
voitaisiinkin pit terveytt vaarantavan tystressin hlytysmerkkin. Se
nytt muodostavan osin erilaisen riskin miesten ja naisten terveydelle,
mik on tarpeen ottaa huomioon tyterveytt edistettess.
11
LIST OF ORIGINAL PUBLICATIONS

This review is based on the following original publications, which are
referred to with Roman numerals IVI. The original articles have been
re-published in this report with the permission of Springer-Verlag Germany (I), Lippincott, Williams & Wilkins (II), Elsevier (III, V, VI), and
Blackwell Publishing (IV).
I.
Ahola, K., Honkonen, T., Isomets, E., Kalimo, R., Nykyri, E.,
Koskinen, S., Aromaa, A. & Lnnqvist, J. (2006) Burnout in the
general population. Results from the Finnish Health 2000 Study.
Social Psychiatry and Psychiatric Epidemiology 41, 1117.
II.
Ahola, K., Honkonen, T., Kivimki, M., Virtanen, M., Isomets,

E., Aromaa, A. & Lnnqvist, J. (2006) Contribution of burnout
to the association between job strain and depression: the Health
2000 Study. Journal of Occupational and Environmental Medicine
48, 10231030.
III. Ahola, K., Honkonen, T., Isomets, E., Kalimo, R., Nykyri, E.,
Aromaa, A. & Lnnqvist, J. (2005) The relationship between jobrelated burnout and depressive disorders results from the Finnish
Health 2000 Study. Journal of Aective Disorders 88, 5562.
IV. Ahola, K., Honkonen, T., Pirkola, S., Isomets, E., Kalimo, R.,
Nykyri, E., Aromaa, A. & Lnnqvist, J. (2006) Alcohol dependence in relation to burnout among the Finnish working population.
Addiction 101, 14381443.
12
LIST OF ORIGINAL PUBLICATIONS
V.
Honkonen, T., Ahola, K., Pertovaara, M., Isomets, E., Kalimo,

R., Nykyri, E., Aromaa, A. & Lnnqvist, J. (2006) The association
between burnout and physical illness in the general population
results from the Finnish Health 2000 Study. Journal of Psychosomatic Research 61, 5966.
VI. Ahola, K., Kivimki, M., Honkonen, T., Virtanen, M., Koskinen,
S., Vahtera, J. & Lnnqvist, J. (in press) Occupational burnout and
medically certied sickness absence: the population-based sample
of Finnish employees. Journal of Psychosomatic Research.
In addition, some unpublished data have been included in this thesis.
13
1. INTRODUCTION
The psychosocial characteristics of work have changed during the past
few decades in response to trends in the global economy and increasing
demands in worklife (Maslach & Leiter 1997, Allvin & Aronson 2001,
Landbergis 2003, Allvin et al. 2006, Sennett 2006). Although both positive and negative changes have occurred in the quality of work (Lehto
& Sutela 2005, Green 2006), concerns have been raised. For example,
it has been argued that competitive pressure in the manufacturing industry, growing demands of consumers in the service industry, and the
fast development of the high technology industry increasingly tax employees' resources via demands for excessive work hours and exibility,
the responsibility for work processes, the need for continuous learning
and re-orientation, job insecurity, and the blurring of the line separating work and private life (Allvin & Aronson 2001, Sparks et al. 2001,
Shirom 2003).
In the context of occupational health, the problems of individual
employees related to work stress are often encountered as burnout. One
of the Oxford English language dictionaries (Hornby 1982) denes
burnout as "to ruin one's health by overwork". Scientic interest in
occupational burnout started approximately three decades ago, after
Herbert Freudenberger (1974), a psychiatrist, described a negative phenomenon among dedicated volunteers working in a clinic for drug addicts. "Burn-out" meant that a sta member became gradually exhausted
from excessive demands on energy, strength, or resources about a year
after he or she began work and showed various physical, behavioural,
and mental symptoms. At the same time, Christina Maslach (1976), a
researcher in social psychology, reported how professionals in health and
social services can lose all their emotional feelings and concern for their
14
1. INTRODUCTION
clients after months of listening to their problems and how this change
correlates with other damaging indices of stress, for example, alcoholism,
mental illness, and suicide. These observations on burnout were made
in human service work in which contacts with other people constitute
the major part of the task and can become a source of stress (Maslach &
Jackson 1981, Zapf 2002, Schaufeli 2006). Later it was discovered that
burnout can evolve in a wide range of occupations (Leiter & Schaufeli
1996, Demerouti et al. 2001, Toppinen-Tanner et al. 2002) and can
be conceptualized generally as a crisis in one's relationship with work
instead of with clients (Schaufeli et al. 1996).
The fact that occupational burnout tends to show considerable stability over time indicates the chronic nature of the problem (McKnight
& Glass 1995, Bakker et al. 2000b, Taris et al. 2005). The estimated
prevalence of severe burnout has been around 67% in Finnish and
Swedish working populations (Kalimo & Toppinen 1997, Hallsten et
al. 2002). However, because burnout has mainly been studied in nonrandom vocational and organizational samples, population-based evidence
on the distribution of burnout by socio-demographic factors is scarce.
Compared with the large quantity of research on the developmental
process of burnout, much less is known of the consequences of burnout
for individuals and society. Observed correlations between burnout and
depressive symptoms have raised questions about the conceptual redundancy of burnout and depression, but it is unclear to what extent burnout
is related to mental disorders and physical illnesses and whether it has any
independent status in relation to ill health.
1.1 Concept of occupational burnout

Occupational burnout refers to a negative consequence of chronic work
stress (Shirom 1989, Schaufeli & Enzmann 1998, Maslach et al. 2001).
There are several theoretical models on the origins of burnout, ranging
from individual and interpersonal explanations to organizational and
societal approaches. Many of these models share a basic assumption of
some kind of a chronic discrepancy between the expectations of a motivated employee and the reality in unfavourable work conditions, which
develops towards burnout via dysfunctional ways of coping (Schaufeli &
15
1. INTRODUCTION
Enzmann 1998). Regarding unfavourable work conditions, occupational

burnout has been presented to result especially from a combination
of high demands and low resources at work (Demerouti et al. 2001,
Schaufeli & Bakker 2004). Job demands refer to the physical, psychological, social, and organizational aspects of the job that require sustained
eort and are therefore associated with physiological and psychological
costs for the individual. Job resources refer to those corresponding aspects
of the job that are functional in achieving work goals, reducing the associated costs, and stimulating learning and professional development.
It has been proposed that individual factors concerning personality, for
example, alexithymia, low sense of coherence, un-hardiness, and neuroticism, inuence vulnerability to burnout (Nowack 1986, McCranie
& Brandsma 1988, Zellars et al. 2000, Kalimo et al. 2003, Mattila et
al. 2007), which may then interact with the situational factors that are
conductive to the development of burnout (Maslach & Leiter 1997,
Schaufeli & Enzmann 1998, Shirom 2003, Hakanen 2004).
Based on the utilization of the concept in peer-reviewed publications, burnout is generally (e.g. Schaufeli & Enzmann 1998) dened as
a three-dimensional psychological syndrome of emotional exhaustion,
depersonalization, and diminished personal accomplishment that may
occur in human service work (Maslach & Jackson 1996). In a general
form, not restricted to any particular kind of work, the dimensions of
burnout are labelled exhaustion, cynicism, and diminished professional
ecacy (Schaufeli et al. 1996). Exhaustion is generic and refers to feelings
of overstrain, tiredness, and fatigue. Cynicism (depersonalization) reects
an indierent and distant attitude towards work (clients), disengagement
from it, and a lack of enthusiasm. Professional ecacy (personal accomplishment) consists of feelings of competence, successful achievement,
and accomplishment in one's work, which are assumed to diminish as
burnout develops.
Exhaustion is considered to result from long-term involvement in
an over-demanding work situation (Shirom 1989, Maslach & Jackson
1996, Schaufeli et al. 1996) and to lead to changes in attitudes towards
work and oneself as a worker. Cynicism develops as a dysfunctional way
of coping in exhausting situations, which further reduce the possibilities
to nd creative solutions at work and build professional ecacy (Leiter
& Schaufeli 1996, Schaufeli et al. 1996). This developmental sequence
16
1. INTRODUCTION
between the dimensions of burnout has gained the most consistent support (Leiter & Maslach 1988, Bakker et al. 2000b, Toppinen-Tanner et
al. 2002, Taris et al. 2005), although other sequences have also been presented (Golembiewski et al. 1983, 1996, Lee & Ashforth 1993, Bakker
et al. 2000b, Demerouti et al. 2001, van Dierendonck et al. 2001).
Some researchers have proposed that exhaustion and cynicism would
be the primary dimensions of burnout, while diminished professional efcacy would be a separate but related entity (Leiter 1993, Lee & Ashforth
1993, Halbesleben & Demerouti 2005). Supporting this suggestion,
professional ecacy has loaded on a dierent factor than exhaustion and
cynicism in structural equation modelling (Schaufeli & Bakker 2004).
However, this occurrence could also reect a statistical artefact because,
in contrast to the positively worded items of the exhaustion and cynicism dimensions, the items of professional ecacy are worded negatively
(Schaufeli & Taris 2005).
Because the associations between the three burnout dimensions and
between the dimensions and the characteristics of employees and work
have been found to be complex, the Maslach Burnout Inventory Manual
recommends the use of separate scores for the dimensions rather than
the construction of a single burnout score (Maslach & Jackson 1996),
a recommendation also supported by statistical arguments (Taris et al.
1999). On the other hand, because burnout is, by denition, a single
construct, a specic work-related syndrome, the use of a single score has
been considered appropriate when the main interest is in the burnout
syndrome and when the study design is complex (Taris et al. 1999, Brenninkmeijer & van Yperen 2003). Single scores for burnout have been
constructed relative to the distribution of the dimensional scores in a
population (Schaufeli et al. 2001, Brenninkmeijer & van Yperen 2003,
Roelofs et al. 2005) or as a sum score of the dimensional scores (Buunk
et al. 2001, Kalimo et al. 2006). The phase model for burnout (Golembiewski et al. 1983, 1996) can also be regarded as means of forming a
single burnout score. In this model, the burnout process is divided into
eight phases that are dened in terms of the dierent combinations of
the dimensional scores above or below the median.
The dimensional denition of burnout, which is based on observations on burnt out employees, has been criticized especially for lacking
theoretical arguments for grouping dierent concepts together in a
17
1. INTRODUCTION
cluster of heterogeneous symptoms (Shirom 2003, Kristensen et al.

2005). Therefore, in the alternative denitions of burnout, the exhaustion dimension alone is considered to constitute the burnout syndrome
(Shirom 1989, Hallsten 1993, Pines 1993, Kristensen et al. 2005).
Burnout is dened as a state of physical fatigue and mental exhaustion
(Pines 1993, Kristensen et al. 2005), and of cognitive weariness (Shirom
1989). Exhaustion has also been complemented with performance-based
self-esteem to take into account another line of criticism concerning
the inclusion of persons without high initial motivation (Hallsten et al.
2005). In these alternative denitions, exhaustion is either considered
generic or is attributed to specic domains, for example, the work context.
At present, there is no universal consensus on the denition of burnout
(Cox et al. 2005). In this dissertation, the term burnout is used to refer
to the dimensional burnout concept, and the term exhaustion refers
to the exhaustion-based burnout concept.
1.2 Socio-demographic factors and

occupational burnout
Socio-demographic associations can be the most reliably studied in
representative population-based samples that are free from any selection
in the sample formation. However, population studies on burnout are
scarce. One Swedish study (Lindblom et al. 2006) and one Finnish study
(Kalimo & Toppinen 1997, Kalimo 2000) have examined burnout, and
another Swedish study has examined exhaustion (Hallsten et al. 2002).
The main ndings from these studies are summarized in Table 1.
Burnout and exhaustion were commoner among women in all three
population studies than among men (Kalimo & Toppinen 1997, Hallsten
et al. 2002, Lindblom et al. 2006). Among the working population of one
Swedish county, employees with a high level of burnout were older, more
often over 50 years of age, than those with a moderate level of burnout
but not older than those with a low level of burnout (Lindblom et al.
2006). Among the Finnish working population, the level of burnout was
higher among employees over 55 years of age than among the younger
employees (Kalimo & Toppinen 1997, Kalimo 2000). However, in an
earlier study among the Swedish working population, an opposite trend
18
19
Cross-sectional
survey (61%)
Working
population of
one county
Working
population
Working
population
Sample
1812
3502
2300
Three-dimensional
syndrome (MBI-GS)
Exhaustion with
achievement-based
self-esteem (BM
and a self-construed scale)
Three-dimensional
syndrome (MBI-GS)
Burnout
measure
not peer-reviewed, MBI-GS = Maslach Burnout Inventory - General Survey, BM = Burnout Measure
Sweden
Cross-sectional
survey (71%)
Sweden
Hallsten et al.
2002a
Lindblom et al.
2006
Cross-sectional
survey (66%)
Finland
Kalimo &
Toppinen 1997a,
Kalimo 2000
Study design
(response rate)
Country
Authors
and date
A high level of burnout

was commoner among the
women and the over-50year-old employees than
among the other groups.
Marital status and education were not related to
burnout.
Exhaustion was commoner

among the women, employees younger than 50
years of age, upper grade
non-manual workers, and
the married versus other
groups.
Burnout was commoner

among the women and
those over 55 years of age.
Severe burnout was commonest among those with
little vocational education.
Main results
Table 1. Review of the population-based studies on socio-demographic factors and burnout
1. INTRODUCTION
1. INTRODUCTION
was detected for exhaustion when it was combined with performancebased self-esteem; it was lower among employees older than 50 years of
age than among those younger (Hallsten et al. 2002).
The level of exhaustion has been found to be higher among upper-grade
non-manual workers (Hallsten et al. 2002), while the results regarding
the association between burnout and education were mixed (Kalimo
& Toppinen 1997, Lindblom et al. 2006). Results on the relationship
between burnout and marital status are not consistent either. A recent
Swedish population-based study failed to establish an association between
marital status and burnout (Lindblom et al. 2006), although, in a previous
study, exhaustion was found to be higher among those not married than
among those married when it was combined with performance-based
self-esteem (Hallsten et al. 2002).
Most of the knowledge concerning the relative prevalence of burnout
in various population subgroups is based on indirect evidence, because
very few studies have been primarily set up to study the relationship
between socio-demographic factors and burnout. Usually these associations have been reported as a part of the sample description and then
adjusted for. In the few published representative studies, burnout was
related to gender, age, education, and occupational and marital status
(Table 1), but the dierences according to these factors were small and,
to some extent, inconsistent. The only peer-reviewed population study
(Lindblom et al. 2006) was not nationally representative and did not
include gender-stratied analyses on the associations of burnout.
1.3 Job strain and occupational burnout

The job strain model is probably the most widely used conceptualization
of health-impairing work stress. It has successfully predicted cardiovascular diseases, mental disorders, and musculoskeletal problems among
employees (Karasek 1979, Karasek & Theorell 1990, Bongers et al.
1993, Theorell & Karasek 1996, van der Doef & Maes 1999, Arins et
al. 2001, Feveile et al. 2002, de Lange et al. 2003, Belkic et al. 2004,
Kivimki et al. 2006b, Standsfeld & Candy 2006).
The job strain model characterizes jobs according to two main aspects, the psychological demands of the work situation and the control
20
1. INTRODUCTION
available to the worker facing these demands in making decisions on

his or her work activity and to use his or her skills (Karasek 1979). The
combination of high demands and low control, referred to as high job
strain, is hypothesized to produce the highest risk of health impairment,
while active work involving high demands and high control is proposed
to promote learning, growth, and satisfaction and to predict only an average amount of psychological strain (Karasek & Theorell 1990). The job
strain model of work stress resembles the work demands and resources
model of burnout (Schaufeli & Bakker 2004), which includes a general
representation of demands and resources at work.
Job strain has been found to be associated with burnout and exhaustion (Table 2). High job demands and low control showed a positive
interaction eect on burnout among German software professionals
(Sonnentag et al. 1994) and on exhaustion among Dutch human service
workers (de Jonge et al. 2000). In these studies, job control moderated
the associations between job demands and burnout or exhaustion, as
originally proposed by Karasek (1979). High job strain compared with
low job strain was positively associated with exhaustion in a cross-sectional population-based study among Finnish wage earners (KauppinenToropainen et al. 1983) and in several human service samples (Raerty
1987, Landsbergis 1988, Melamed et al. 1991, Bourbonnais et al. 1998,
1999). Active and passive work has also to some extent been shown to be
associated with an increased level of exhaustion (Kauppinen-Toropainen
et al. 1983, Landsbergis 1988, Bourbonnais et al. 1998, 1999). In addition, most studies that have explored the correlates of burnout have
supported independent positive associations between high work load and
low autonomy at work on one hand and a high level of burnout (Lee &
Ashforth 1996, Schreurs & Taris 1998, Kalimo et al. 2003, Schaufeli &
Bakker 2004, Lindblom et al. 2006) or exhaustion (Borritz et al. 2005)
on the other.
Similar associations of job strain with burnout and exhaustion and
with problems of mental health have raised the question of whether
burnout is conceptually redundant with respect to low mental health
and especially to depression. As a dierence between the two, it has
been proposed that burnout would be work-related, whereas depression is expected to be context-free or multi-factorial in origin (Warr
1987, Maslach et al. 2001). This assumption has not, however, been
21
22
Canada
Canada
Netherlands
Bourbonnais
et al. 1998
Bourbonnais
et al. 1999
de Jonge et al.
2000
Crosssectional survey
Crosssectional
survey (79%)
Crosssectional
survey (62%)
Crosssectional
survey (90%)
Crosssectional
survey (76%)
Crosssectional
survey (38%)
Crosssectional survey
Crosssectional
survey (93%)
Study design
(response rate)
Human service
workers in five
sectors
Nurses in one
district
Nurses in one
district
Software
professionals
in several organizations
Female social
workers in one
organization
Nursing staff in
several units
Human service
workers
Wage earning
population
Sample
2485
1378
1891
180
267
289
188
5471
not peer-reviewed; MBI = Maslach Burnout Inventory; BM = Burnout Measure
Germany
USA
Landsbergis
1988
Sonnentag et
al. 1994
USA
Rafferty 1987a
Israel
Finland
Kauppinen-Toropainen et al.
1983
Melamed et al.
1991
Country
Authors
and date
Table 2. Review of the literature on job strain and burnout
Emotional exhaustion
(MBI)
(MBI)
(MBI)
Two-dimensional
syndrome
(self-construed scale)
Exhaustion (BM)
Tthree-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Work-related
exhaustion
(self-construed scale)
Burnout
measure
Focussed job demands and job

control showed an interaction
effect on exhaustion in specific
occupational groups.
High job strain, active work, and

passive work were positively associated with emotional exhaustion.
High job strain, active work, and

passive work were positively associated with emotional exhaustion.
The effect of stressors at work on

burnout was modified by control
at work.
The lowest level of exhaustion

was found under conditions of
low demands, high perceived
control, and high social support.
Emotional exhaustion was higher

in high strain work and passive
work than in low strain work.
High job strain compared with

low job strain was positively associated with emotional exhaustion.
The joint effect of time pressure

and low self-determination was
related to increased work-related
exhaustion. Passive jobs were
related to exhaustion among
women.
Main results
1. INTRODUCTION
1. INTRODUCTION
denitely conrmed. Only one study has explored burnout and depressive symptoms in relation to dierent contexts (Bakker et al. 2000a). In
this cross-sectional study among Dutch teachers, a lack of reciprocity in
work context was associated with a high level of burnout, whereas a lack
of reciprocity in private life was associated with depressive symptoms
indicating support for the work-relatedness of burnout and the absence
of such relatedness concerning depression. However, the evidence was
based on a rather small sample of one vocational group, and it covered
only a single aspect of the psychosocial work environment, which is not
included in the leading model of work-related health (Karasek & Theorell 1990). The associations between job strain, burnout, and depression
have not been previously analysed in the same study.
1.4 Occupational burnout and health

problems
There is strong evidence indicating that continuous work stress, when
operationalized by demanding psychosocial work characteristics and especially by job strain, is detrimental to health (Leino & Hnninen 1995,
National Research Council and the Institute of Medicine 2001, Hagen et
al. 2002, Kivimki et al. 2006b, Stansfeldt & Candy 2006). Therefore, it
is highly plausible that occupational burnout, dened as a consequence
of chronic work stress, would also be associated with ill health.
There are several conceivable mechanisms to account for the adverse
health eects of long-term work stress (McEwen & Stellar 1993, Maier &
Watkins 1998, Kiecolt-Glaser et al. 2002, Siegrist 2002, Epel et al. 2004,
2006, Chandola et al. 2006). The autonomic nervous system and the
hypothalamus-pituitary-adrenal cortex axis, which are partly responsible
for an individual's potential to adapt to stressful challenges, can, if overly
activated, also result in harmful allostatic load (Frankenhauser 1989,
Brunner 1997, McEwen 1998b). Adverse stress processes may become
pronounced in some persons because innate temperamental aspects of
personality (Cloninger et al. 1993) have been shown to aect a person's
emotional experiences and physiological activation in challenging situations (Keltikangas-Jrvinen & Heponiemi 2004, Ravaja et al. 2006,
Puttonen et al. 2005, Tyrka et al. 2006). These kinds of mechanisms
23
1. INTRODUCTION
may also account for the possible associations between burnout and ill
health (Shirom et al. 2005, Toker et al. 2005, Melamed et al. 2006).
In addition to direct eects, work stress, as well as burnout, may also
inuence health through health behaviour (i.e., health-related habits and
behavioural decisions of employees) (Siegrist & Rdel 2006, Kouvonen
et al. 2007). However, the connection between burnout and health could
also operate in a reverse direction. If suering from a disease results in the
lowering of work ability, it could also hinder the attainment of the work
goals, which, in turn, could activate the process of burnout (Hallman et
al. 2003, de Lange et al. 2005, Donders et al. 2007).
Among the Finnish work force, the three most prominent disease
groups related to work disability are mental disorders, musculoskeletal
disorders, and cardiovascular diseases (The Social Insurance Institution
of Finland 2005). In 2000, these diseases accounted for 75% of all
causes of disability pensions and for 62% of the causes of compensated
sickness absences (The Social Insurance Institution of Finland 2000).
Together these diseases cover 43% of the global disease burden in European countries, indicated by disability-adjusted life years (World Health
Organization 2002).
Mental health problems
Psychiatric classications are categorical systems that divide mental disorders into types based on sets of descriptive criteria. The classications
currently in use are the International Statistical Classication of Diseases
and Related Health Problems (ICD-10) (World Health Organization
1992) and the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) (American Psychiatric Association 1994). Among the work
force, depressive disorders, alcohol use disorders, and anxiety disorders
are common mental disorders and relevant in terms of work disability
(Raitasalo & Maaniemi 2006, Sanderson & Andrews 2006, Honkonen
et al. 2007, Raitasalo & Maaniemi 2007). In the classication systems,
burnout can be coded as a factor that inuences health status (Z73.0
burnout) (World Health Organization 1992) or as a condition that
may require clinical attention (V62.2 occupational problem) (American
Psychiatric Association 1994).
24
1. INTRODUCTION
Summaries of the existing publications on burnout and mental health

problems are presented in Table 3 (depression), Table 4 (anxiety), and
Table 5 (alcohol problems) in chronological order. Most of the research
conducted on the relationship between burnout and mental health
problems concerns depression. Only two studies have investigated
depressive disorders, but they did not use structured psychiatric diagnostic methods. Among Finnish participants in occupational rehabilitation,
a depressive disorder, based on a medical examination in the beginning
of the rehabilitation programme, was almost always (90%) present
among those who suered from severe burnout (Kinnunen et al. 2004).
Self-reported physician-diagnosed depression was more prevalent also
among burnt out teachers than among their colleagues without burnout
in a cross-sectional North American survey (Belcastro & Hayes 1984).
Most of these teachers with depression reported that they had developed
depression after becoming a teacher.
Four studies have investigated burnout and depressive symptoms
in a longitudinal design. In a 1-year follow-up among Canadian teachers, high scores on the exhaustion and depersonalization dimensions
of burnout predicted depressive symptoms among women, while high
scores on exhaustion and diminished personal accomplishment predicted
depressive symptoms among men (Greenglass & Burke 1990). Among
North American medical residents, patient-related but not job-related
exhaustion predicted mood disturbance during 1-year of follow-up
(Hillhouse et al. 2000). On the other hand, depressive symptoms at
baseline correlated positively with exhaustion 20 years later among North
American physicians (McCranie & Brandsma 1988). However, a 2-year
longitudinal study among North American nurses failed to provide support for a temporal relation between burnout and depression (McKnight
& Glass 1995).
In cross-sectional designs, burnout and depressive symptoms have
been found to correlate positively in various study samples: among the
Swedish working population (Lindblom et al. 2006), in human service
work (Meier 1984, Firth et al. 1986, Landsbergis 1988, Seidman &
Zager 1991, Glass et al. 1993, McKnight & Glass 1995, Baba et al.
1999, Sears et al. 2000, Korkeila et al. 2003), and among patients (Roelofs et al. 2005). Corresponding correlations were found also between
exhaustion and depressive symptoms in human service work (Firth et
25
1. INTRODUCTION
al. 1987, Jayaratne et al. 1986, Lemkau et al. 1988, Martin et al. 1997,
Tselebnis et al. 2001) and heterogeneous occupations (Toker et al. 2005,
Middeldorp et al. 2006). Among Greek hospital sta, the lower the
scores on personal accomplishment, the closer the relationship between
the attitudes towards work and the emotional tone of the participants
(Iacovides et al. 1999).
Despite a signicant positive association between burnout and depressive symptoms, burnout and depression have been statistically dierentiated from each other. Conrmatory factor analyses on cross-sectional
data from four dierent studies on human service work showed that the
items of a burnout inventory and a depression scale did not load on the
same factor. Instead, a model with two second-order factors of burnout
and depression was preferred over one second-order factor of negative
aectivity (Glass et al. 1993, Leiter & Durup 1994, Iacovides et al. 1999,
Bakker et al. 2000a). When the measures of burnout and depression were
completed with a self-constructed scale of professional depression, many
items of the work-related scales (emotional exhaustion and professional
depression) loaded on the same factor in contrast to the non-contextual
scale of depressive symptoms (Firth et al. 1987).
Dierences have also have been noted in the associations between
burnout and depression. In a cross-sectional study among Dutch teachers, a reduced sense of superiority was more characteristic of depression
than of burnout (Brenninkmeijer et al. 2001); depressive symptoms were
related to burnout when the teachers experienced low superiority. In another cross-sectional Dutch study among teachers, burnout was related
to a lack of reciprocity with students, while depression was related to
a lack of reciprocity with one's spouse (Bakker et al. 2000a). In addition,
burnout and depression were related dierently to some demographic
and work characteristics in a random sample of French health care
professionals (Martin et al. 1997). Burnout was commoner among
women with unconventional work hours and employees who were young
or had instrumental work motivation, while depression was positively
related to seniority at work and a lack of social support. Dierences were
also found between exhaustion and depression at the neurobiological
level; they related dierently to inammation biomarkers among Israeli
employees and the relationships were dependent on gender (Toker et al.
2005). Among women, a high level of exhaustion, unlike depression,
26
27
USA
USA
Lemkau et
al. 1988
McCranie &
Brandsma
1988
Table 3. continues...
USA
Landsbergis
1988
USA
Jayaratne
et al. 1986
UK
USA
Firth et al.
1986
Firth et al.
1987
USA
USA
Country
Meier 1984
Authors
and date
Belcatsro &
Hays 1984
20-year longitudinal survey (72%

at time 2)
Cross-sectional
survey (94%)
Cross-sectional
survey (38%)
Cross-sectional
survey (40%)
Cross-sectional
survey (85%)
Cross-sectional
survey (41%)
Cross-sectional
survey (61%)
Study design
(response rate)
Cross-sectional
survey (58%)
Physicians from
eight classes
in one medical
college
Medical residents
Nursing staff in
several units
Nursing staff in
several hospitals
Female welfare
workers
Nurses in one
district
Teaching faculty
members of one
university
Teachers in one
district
Sample
440
67
289
200
75
200
320
265
Table 3. Review of the literature on burnout and depression
Syndrome of
exhaustion (Tedium
scale)
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Emotional exhaustion (MBI)
Three-dimensional
syndrome (modified MBI)
Three-dimensional
syndrome (MBI)
Three dimensional
syndrome (MBI)
Burnout
measure
Three-dimensional
syndrome (MBI)
Teachers with burnout more
often reported physician-diagnosed depression than teachers
with no burnout.
Burnout correlated positively
with depression (Costello-Comrey Depression Scale, MMPI,
self-rating).
The burnout dimensions correlated positively with depression
(BDI).
Employees high on emotional
exhaustion and low on personal
accomplishment had higher
levels of depression (6 items).
Several items of exhaustion and
professional depression scales
(modified Beck Depression
Inventory) loaded on the same
factor. Exhaustion correlated
positively with professional
depression.
(Job Content Survey).
Emotional exhaustion correlated
positively with psychotic depression (Millon Clinical Multiaxial
Inventory).
Depression (MMPI at time
1) correlated positively with
exhaustion (time 2) over two
decades.
Main results
1. INTRODUCTION
28
USA
USA
Canada
USA
France
Caribbean
Seidman &
Zager 1991
Glass et al.
1993
Leiter &
Durup
1994
McKnight
& Glass
1995
Martin
et al. 1997
Baba et al.
1999
Canada
Greenglass
& Burke
1990
Cross-sectional
survey (48%)
Cross-sectional
survey (86%)

at time 1, attrition
20%)
Cross-sectional
survey
Cross-sectional
survey (28%)
Cross-sectional
survey

at time 2)
Nurses from
several units
Random sample
of health care
professionals in
one hospital
Nurses
Health care
workers in one
hospital
Random sample
of nurses in one
hospital
Teachers in one
district
Teachers and
principals on
one school
board
119
536
100
307
162
365
361
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Pattern of responding (Teacher

Burnout Scale)
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI)
Emotional exhaustion and

depersonalization predicted
depression (Hopkins Symptom
Checklist) among women. Emotional exhaustion and diminished personal accomplishment
predicted depression among
men.
Burnout subscales correlated
positively with depression (selfreport).
(BDI). The items of the burnout
and depression scales loaded on
different factors.
A model with two primary factors (burnout and depression;
BDI) was preferred over a model
with one primary factor (negative affectivity).
(BDI) at time 1 and at time 2.
The exhaustion and depression
scores changed concurrently.
Emotional exhaustion and depersonalization were related to
depression (CES-D). Burnout and
depression related differently to
the demographic factors and
work characteristics.
with and was related to depression (CES-D).
1. INTRODUCTION
29
Greece
Tselebis
et al. 2001
Netherlands
Brenninkmeijer
et al. 2001
USA
Hillhouse
et al. 2000
USA
Netherlands
Bakker
et al.
2000a
Sears et al.
2000
Greece
Iacovides
et al. 1999
Cross-sectional
survey
Cross-sectional
survey
Cross-sectional
survey (88%)
1-year longitudinal survey (85%)
Cross-sectional
survey (83%)
Cross-sectional
survey (100%)
Nurses in one
hospital
Extension
agents in one
organization
Teachers
Medical residents
Teachers in several schools
Nursing staff in
one hospital
79
190
264
46
154
368
Three-dimensional
syndrome (MBI)
Three-dimensional
syndrome (MBI-ES)
Three-dimensional
syndrome (MBI)
Syndrome of exhaustion (SBS-HP)
Three-dimensional
syndrome (MBI)
Modified three-dimensional syndrome

(MBI)
Not all of the employees with
the burnout syndrome had
depression (Zung Self-Rating
Depression Scale). Items of
the burnout and depression
scales clustered separately. The
lower the personal accomplishment, the more the symptoms
resembled depression.
A lack of reciprocity in the
relationship with students was
related to burnout but not
to depression (CES-D). A lack
of reciprocity in the relationship with one's spouse was
related to depression but not to
burnout.
Patient-related exhaustion
at time 3 predicted mood
disturbance (POMS) at time 4.
Job-related exhaustion was not
related to mood disturbance in
time.
(CES-D).
A reduced sense of superiority
was more characteristic for depression (CES-D) than for burnout. Depression was related to
burnout when low superiority
was experienced.
Emotional exhaustion and diminished personal accomplishment correlated positively with
depression (BDI).
1. INTRODUCTION
30
Cross-sectional
survey
Cross-sectional
survey (61%)
Cross-sectional
medical examination (91%)
Twins and their

siblings
Working population of one

county
Consecutive patients with clinical burnout and

with another
diagnosis
Employed
clients of one
medical centre
Participants in
occupational
rehabilitation
Random sample
of physicians in
psychiatry
4309
+1008
1812
1563
95+73
154
218
Exhaustion (MBIGS)
Three-dimensional
syndrome (MBI-GS)
Syndrome of exhaustion (SMBM)
Three-dimensional
syndrome (MBI-GS)
Three-dimensional
syndrome (MBI-GS)
Three-dimensional
syndrome (MBI)
Depressive disorder was commoner among the rehabilitants
with severe burnout than
among the others.
(Symptom Checklist SCL-90)
among those with burnout and
among those with no burnout.
Exhaustion correlated with
depression (Personal Health
Questionnaire). Exhaustion and
depression were differently associated with the inflammation
biomarkers (C-reactive protein,
fibrinogen).
The burnout dimensions correlated positively with depression (the Hospital Anxiety and
Depression Scale). A high level
of burnout was related to depression.
Exhaustion correlated positively
with anxious depression (Young
Adult Self Report). The association between exhaustion and
depression was explained by
shared genetic and individualspecific environmental factors.

with self-reported depression.
not peer-reviewed; MBI = Maslach Burnout Inventory; MBI-GS = Maslach Burnout Inventory - General Survey; MBI-ES = Maslach Burnout Inventory
- Educators Survey, MMPI= Minnesota Multiphasic Personality Inventory, BDI = Beck Depression Inventory, CES-D = Center for Epidemiologic Studies
Depression Scale, SBS-HP = Staff Burnout Scale for Health Professionals, POMS = Profile of Mood States, SMBM = Shirom-Melamed Burnout Measure
Netherlands
Middeldorp et al.
2006
Israel
Toker et al.
2005
Sweden
Netherlands
Roelofs et
al. 2005
Lindblom
et al. 2006
Cross-sectional
Finland
Kinnunen
et al.
2004a
Cross-sectional
survey (100%)
Cross-sectional
survey (74%)
Finland
Korkeila et
al. 2003
1. INTRODUCTION
31
Sweden
Lindblom
et al. 2006
Cross-sectional
Cross-sectional
survey (61%)
Cross-sectional
survey (100%)
Cross-sectional
survey (85%)
Cross-sectional
survey (83%)
Cross-sectional
survey (28%)
Cross-sectional
survey (94%)
Cross-sectional
survey (85%)
Study design
(response rate)
Working population of
one county
Employed clients of one

medical centre
Consecutive patients
with clinical burnout and
with another diagnosis
Female nurses in one

hospital
Nursing staff in one

hospital
Health care workers in

one hospital
Medical residents
Female welfare workers
Sample
1812
1563
95+73
117
47
212
67
75
Three-dimensional syndrome
(MBI-GS)
Syndrome of exhaustion (SMBM)
(MBI-GS)
(MBI)
(MBI)
(MBI)
(MBI)
(modified MBI)
Burnout
measure
Employees high on emotional exhaustion and low
on personal accomplishment had a higher level of
anxiety (4 items).
correlated positively with
anxiety (Millon Clinical
Multiaxial Inventory).
The burnout dimensions
were positively related to
trait anxiety (STAI).
Burnout correlated
positively with trait anxiety
(STAI).
trait and state anxiety
(STAI).
anxiety (Symptom Checklist-90) among patients
with and without burnout.
Exhaustion correlated
positively with anxiety
(adapted questionnaire).
anxiety (the Hospital Anxiety and Depression Scale).
Main results
MBI=Maslach Burnout Inventory; MBI-GS=Maslach Burnout Inventory-General Survey; STAI=State-Trait Anxiety Inventory; SMBM=Shirom-Melamed
Burnout Measure
Israel
Toker
et al. 2005
USA
Corrigan
et al. 1995
Netherlands
Norway
Richardsen
et al. 1992
Roelofs
et al. 2005
USA
Lemkau
et al. 1988
USA
USA
Jayaratne
et al. 1986
Turnipseed
1998
Country
Authors
and date
Table 4. Review of the literature on burnout and anxiety
1. INTRODUCTION
Cross-sectional survey
(64%)
Australia
USA
Study design
(response rate)
Cross-sectional medical examination (78%)
Country
Random sample of
dentists
Transit operators in
one organization
Sample
312
993
work-related exhaustion (CBI)
Burnout
measure
emotional
exhaustion
(MBI)
Exhaustion was associated with an elevated risk
for alcohol dependence
(CAGE).
Work-related exhaustion correlated positively
with the risk for alcohol
dependence (AUDIT).
Main results
32
Finland
Sweden
Country
Cross-sectional medical examination (69%)
Study design
(response rate)
Cross-sectional survey
(85% and 68%)
MBI-GS = Maslach Burnout Inventory-General Survey
Miranda et al.
2005
Authors
and date
Soares &
Jablonska
2004
30 to 64-year-old
working population
Patients with physician-diagnosed pain

and without selfreported pain
Sample
3378
838+135
Table 6. Review of the literature on burnout and musculoskeletal problems

Burnout
measure
Syndrome
of tension,
anxiety,
withdrawal
and isolation (selfconstrued
scale)
Three-dimensional
syndrome
(MBI-GS)
Burnout was the

strongest correlate for
non-specific shoulder
pain.
Patients with pain

had a higher level of
burnout than patients
without pain.
Main results
MBI = Maslach Burnout Inventory, CBI = Copenhagen Burnout Inventory, CAGE = A screening instrument to identify those with a high risk for
alcohol dependence (Cut-down, Annoyed, Guilty, Eye-opener), AUDIT = Alcohol Use Disorder Indicator Test
Winwood
et al. 2003
Authors
and date
Cunradi
et al. 2003
Table 5. Review of the literature on burnout and alcohol problems
1. INTRODUCTION
1. INTRODUCTION
was associated with increased concentrations of C-reactive protein and

brinogen.
Compared with depression, anxiety and alcohol problems have been
studied much less in relation to burnout. In cross-sectional designs,
signicant positive correlations were found between burnout and state
and trait anxiety among a working population (Lindblom et al. 2006),
human service workers (Richardsen et al. 1992, Corrigan et al. 1995,
Turnipseed 1998), and patients (Roelofs et al. 2005), and also between
exhaustion and anxiety in human service work (Jayaratne et al. 1986,
Lemkau et al. 1988) and heterogeneous occupations (Toker et al. 2005).
There was also cross-sectional evidence of a positive association between
exhaustion and a risk for alcohol dependence in a random sample of
Australian dentists (Winwood et al. 2003) and among North American
transit operators (Cunradi et al. 2003).
Musculoskeletal problems
Compared with mental health, physical health has been studied to a

much less degree in relation to burnout. Two studies have explored the
relationship between burnout and musculoskeletal pain (Table 6). In the
cross-sectional population-based Finnish Health 2000 Study, a positive
association was found between burnout and non-specic shoulder pain
(Miranda et al. 2005). Among Swedish pain patients, a positive association emerged between burnout and heterogeneous musculoskeletal pain
(Soares & Jablonska 2004).
Cardiovascular diseases
The three research publications on burnout and cardiovascular diseases

are reviewed in Table 7. In a longitudinal setting among male employees
who took part in a medical examination, self-reported burnout predicted
physician-diagnosed myocardial infarctions in a 4-year follow-up (Appels
& Shouten 1991). In a cross-sectional study among North American
teachers, burnout was associated with self-reported physician-diagnosed
cardiovascular disease (Belcastro 1982). None of the teachers reported
having a cardiovascular disease before they had begun teaching. In another cross-sectional study, women with coronary heart disease reported
33
34
Sweden
Netherlands
USA
Country
4-year longitudinal medical

examination
Cross-sectional
survey (100%)
Study design
(response rate)
Cross-sectional
survey (79%)
Male employees
aged 39-45 years or
54-65 years
Consecutive female
patients with CHD
and healthy controls
Teachers
Sample
MBI = Maslach Burnout Inventory, CHD = cardiovascular disease
Appels &
Shouten
1991
Hallman
et al. 2003
Authors
and date
Belcastro
1982
97+97
3877
181
Uni-dimensional
(self-report, singleitem)
Exhaustion (selfconstrued index)
Burnout
measure
Three-dimensional
syndrome (MBI)
Table 7. Review of the literature on burnout and cardiovascular diseases
High scores on the

burnout dimensions were
related to self-reported
physician-diagnosed cardiovascular disorders.
Burnout was related to
an increased risk of myocardial infarction.
Women with CHD
reported higher level of
exhaustion than matched
healthy controls.
Main results
1. INTRODUCTION
1. INTRODUCTION
higher levels of exhaustion than their matched healthy controls (Hallman

et al. 2003).
Summary and limitations of previous research
All studies published on burnout and mental health problems support

a positive association between burnout or exhaustion on one hand and
depression, anxiety, or alcohol problems on the other. In addition to
signicant positive correlations, qualitative dierences have been found
between burnout and depression. Burnout and depressive symptoms
have diered according to statistical considerations, on a neurobiological
level, and to their associations with other factors.
The studies on burnout and mental health problems have relied
on self-reports or screening instruments in the assessment of mental
health. For assessing mental health, this approach may be inadequate
because the duration and clinical validity of the symptoms remain unknown. Self-report measures, especially in cross-sectional designs, may
also exaggerate the observed relationships between burnout and mental
health problems due to common method variance (i.e., shared variance
in measurement that is attributed to instrumentation rather than to the
association between the constructs) (Lindell & Whitney 2001). There are
no studies on burnout and mental health in which validated diagnostic
methods have been used. Therefore, it is not known how occupational
burnout is related to depressive and other mental disorders fullling the
standardized diagnostic criteria.
The few studies conducted on burnout and musculoskeletal problems
or cardiovascular diseases support a positive association also between
burnout and physical ill health. However, some of the studies concerning
cardiovascular diseases were conducted only among men or women. Very
few of the studies on burnout and health have analysed this relationship
according to gender. Because the work-related correlates of health have been
found to vary to some degree between the genders due to, for example,
gender segregation in worklife, dierences in work conditions, dierential
vulnerability to stressors, and dierent help-seeking behaviour among men
and women (Punnet & Herbert 2000, Taylor et al. 2000, Vnnen et al.
2003, Oliver et al. 2005, Rugulies et al. 2006), a gender perspective may be
justied when the associations between burnout and health are studied.
35
1. INTRODUCTION
From an epidemiological point of view, there are serious limitations

in the studies on burnout and health problems. Most studies have used
vocational or organizational samples, primarily of human service work,
which were rarely randomly sampled. The scarcity of population-based
studies is problematic regarding health, because employed samples generally include persons with a good level of functioning. This so-called
"healthy worker eect" (i.e., those employed are healthier than those
who are not employed) may dilute any association with health in occupational samples. Furthermore, most studies have had a modest sample
size, and some of the surveys have been vulnerable to self-selection bias
due to a rather low response rate. Therefore, currently it is not reliably
known to what extent people suering from burnout full the diagnostic
criteria for mental disorders, musculoskeletal disorders, or cardiovascular
diseases, and whether the associations between burnout and health are
similar for men and women.
1.5 Occupational burnout and sickness

absence
Medically certied sickness absences are hypothesized to serve as a global
measure of health that is tuned to the requirements in each employee's
occupational setting (Marmot et al. 1995, Kivimki et al. 2003). They
are often distinguished from short and self-certied absences that can also
be viewed as a coping strategy in a dicult situation or as an indicator
of low motivation (Marmot et al. 1995, Borritz et al. 2006). Especially
long sickness absences have been found to predict future disability pensioning (Kivimki et al. 2004, Lund et al. 2007). Therefore, they can
also be used as a proxy measure for work disability.
A summary of the research publications on the relationship between
burnout and sickness absence is presented in Table 8. Burnout predicted
sickness absences in two longitudinal studies. A higher level of burnout
was related to a greater number of medically certied spells of absence
during a 3-year follow-up in a multi-national forest industry organization (Toppinen-Tanner et al. 2005) and to longer company-registered
absence duration during a 1-year follow-up in a nutrition production
organization (Bakker et al. 2003). In the former study, burnout increased
36
37
Denmark
Borritz et al.
2006
3-year longitudinal survey

(64%) linked
to absence
registers
at time 1, 75%
at time 2).
Cross-sectional
Study design
(response rate)
1-year longitudinal survey
(65%) linked
to absence
registers
Cross-sectional
survey (71%)
Human service
workers in several organizations
Employees in
one multinational organization
Transit operators in one

organization
Working population
Production employees in one

organization
Sample
1561 (time 1),

824 (time 2)
3895
1446
3502
214
Work-related exhaustion (CBI)
Three-dimensional
syndrome (MBI-GS)
Emotional exhaustion (MBI)
Exhaustion with
achievement-based
self-esteem (BM
and a self-construed
scale)
Burnout
measure
Three-dimensional
syndrome (MBI-GS)
Work-related exhaustion
was positively associated with self-reported
sickness absence days
and spells in a cross-sectional and a prospective
setting.
Burnout was positively

related to the amount
of self-reported long
stress-related sickness
absences during the
past year.
Exhaustion was positively related to selfreported short-term
absences among male
employees.
associated with future
medically certified
absences.

related to the duration
of company-registered
sickness absences.
Main results
not peer-reviewed; MBI-GS = Maslach Burnout Inventory-General Survey, BM = Burnout Measure, MBI = Maslach Burnout Inventory;
CBI = Copenhagen Burnout Inventory
Finland
USA
Cunradi
et al. 2005
ToppinenTanner et al.
2005
Sweden
Netherlands
Country
Hallsten
et al. 2002a
Author
and date
Bakker et al.
2003
Table 8. Review of the literature on burnout and sickness absence
1. INTRODUCTION
1. INTRODUCTION
future absences granted for mental disorders and diseases of the musculoskeletal and circulatory systems (Toppinen-Tanner et al. 2005). A
prospective association was also registered between a high level of workrelated exhaustion and the number of self-certied sickness absences and
days during a 3-year follow-up among Danish human service workers
(Borriz et al. 2006).
In a cross-sectional setting, long self-reported stress-related absences
were commoner among those who had high levels of exhaustion combined with performance-based self-esteem in the Swedish working
population (Hallsten et al. 2002). A cross-sectional association between
work-related exhaustion and self-reported absences was also found among
Danish human service workers (Borritz et al. 2006) and North American
transit operators (Cunradi et al. 2005).
Population-based evidence on the association between burnout
and sickness absence is based on exhaustion and self-reported absence
(Hallsten et al. 2002). Prospective evidence concerning the relationship
between burnout and medically certied sickness absence covers only
one occupational branch (Toppinen-Tanner et al. 2005). On the basis
of this evidence, it can be concluded that burnout is related to sickness
absence, and this relationship further supports the association between
burnout and health problems.
However, because burnout and exhaustion are associated with health
problems (Shirom et al. 2005), the observed relationship between burnout and sickness absence could be fully explained by the co-existing
disorders and illnesses. None of the previous studies on burnout and
sickness absence have controlled for co-occurring mental disorders or
physical illnesses. Therefore, it is not known whether burnout has any
independent contribution to sickness absence or whether the observed
associations mainly reect the relationship between burnout and ill
health.
38
2. PRESENT STUDY
2.1 Framework of the study
This study was conducted in the framework of occupational health
psychology, a specialty in psychology that aims at promoting healthy
workplaces (Quick 1999). A workplace is assumed to be healthy when
it supports ecient and high-quality work production as well as the
motivation, job satisfaction, and well-being of the employees. Research
in occupational health psychology focusses on psychologically mediated
processes between the psychosocial work environment and health (Sauter
et al. 1999). Although health is widely understood as complete physical,
mental, and social well-being (World Health Organization 1946), a
traditional medical disease model of ill-health has mostly been applied
in research to date (Schaufeli 2004).
A discrepancy of some kind between the individual and his or her
environment is a common moderator of outcomes in psychology (Tinsley 2000). Relevant external or internal demands that are estimated to
exceed the resources available to cope with them are assumed to activate
the stress process in an individual (Lazarus & Folkman 1986, Lazarus
1991). Work-related and social aspects of the perceived environment
are related to employees' physiological, psychological, and behavioural
processes (Caplan et al. 1975). The perception of the environment is
thought to always include individual appraisal (Lazarus 1991).
Individual processes may, when prolonged or extremely strong, accumulate as strain and aect the health status of an employee. The interactions between the environment and health are complex (see Figure
1). Every association can be interpreted in both directions, from the
environment to health and from health to the environment. In addition
39
2. PRESENT STUDY
to the characteristics of the work environment, also individual factors

aect the stress process (Caplan et al. 1975, Lindstrm et al. 2005).
The theoretical stress process can be viewed as resembling the generalized adaptation syndrome (GAS) which is presented in psychophysical
terms (Selye 1956). In GAS, excessive demands rst induce an alarm
reaction and the mobilization of energetic resources, then resistance,
and nally exhaustion as the capacity for adjustment is depleted, if
resistance fails.
The core elements in the theories of psychosocial stress (i.e., the personal meaning of the demands, the discrepancy between the individual
and his or her environment, and the coping strategies used) are included
also in the meta-theory of occupational burnout (Schaufeli & Enzmann
1998), but the status of burnout in the arena of occupational health
psychology is not clearly dened. Even though burnout is more or less
unanimously dened as a consequence of chronic work-related stress, it
has sometimes been considered a process causing illnesses and sometimes
more of an illness or adverse outcome of stress in itself (Maslach 2001,
Maslach et al. 2001).
Due to the variability of theoretical models and practical operationalizations in psychology, the empirical results are always to some extent
dependent on the chosen definitions and measures. In the present
study, burnout has been regarded as a three-dimensional work-related
syndrome of exhaustion, cynicism, and diminished professional ecacy
(Schaufeli et al. 1996, Maslach et al. 2001). This psychological denition
encompasses the process of energy depletion at work instead of reducing
burnout to a state of fatigue (Schaufeli & Taris 2005), and it therefore
suits the purposes of the present study in the occupational health psychology framework. Due to its wide usage, the qualities and shortcomings
of the dimensional burnout concept are well-known, and the results are
also comparable with many other national and international burnout
studies. Because the exhaustion dimension of burnout is regarded as the
core of the syndrome in the dimensional models (Brenninkmeijer & van
Yperen 2003, Roelofs et al. 2005, Schaufeli & Taris 2005), it is unlikely
that exhaustion-based and dimensional operationalizations of burnout
would yield essentially dierent results.
40
2. PRESENT STUDY
2.2 Aims of the study

The principal aim of the present study was to clarify the status of burnout in the arena of occupational health psychology. With the use of a
nationally representative sample, it is possible to avoid the shortcomings of previous studies in which non-random samples were used. More
specically, the objective was to determine the extent to which burnout
co-occurs with common health problems, that is mental disorders, musculoskeletal disorders, and cardiovascular diseases. The examination of
health in this study was restricted to these diseases due to their vast impact
on work disability. Furthermore, whether burnout has any independent
status in relation to ill health was explored with respect to its associations
with work characteristics and work disability. An additional aim was to
establish the role of some individual factors in the level and prevalence
of burnout in an adult working population aged 30 years or over. Most
of the analyses were stratied by gender because many health-related
Individual factors
gender
age
education
occupational status
marital status
Perceived psychosocial
work environment
job strain
Physiological, psychological,
and behavioural processes:
transient and accumulated
occupational burnout
Health and illnesses

depressive disorders
anxiety disorders
alcohol dependence
musculoskeletal disorders
cardiovascular diseases
sickness absence
Figure 1. The stress process (modified from Caplan et al. 1975 and
Lindstrm et al. 2005). Factors examined in the present study are printed in
italics (the arrows indicate an associative relationship).
41
2. PRESENT STUDY
aspects of work have been recently found to be gender-related. The

variables examined in this study are presented in the framework of the
hypothesized associations between the psychosocial work environment
and health in occupational health psychology in Figure 1.
The specic study questions were:
1. How is burnout related to gender, age, education, occupational
grade, and marital status in a working population (I, II)?
2. How is job strain related to burnout and depressive disorders
(II)?
3. How is burnout related to depressive disorders, anxiety disorders,
alcohol dependence, musculoskeletal disorders, and cardiovascular
diseases among men and women, and what is the overall co-occurrence of burnout with mental disorders and physical illnesses ( III,
IV, V)?
4. How does burnout contribute to long medically certied sickness
absence among men and women (VI)?
42
3. METHODS
3.1 Procedure
A multidisciplinary epidemiological health study, the Health 2000 Study,
was carried out in Finland during August 2000 and June 2001 to obtain
up-to-date information on the most important national public health
problems, including their causes and treatment, as well as the functional
capacity and work ability of the population (Aromaa & Koskinen 2004).
Due to a nancial imperative to set priorities, this health-oriented study
focussed on persons over 30 years of age, among whom illnesses are, on
average, commoner.
The two-stage stratied cluster sample represented the population
living on the Finnish mainland and included 8028 persons aged 30
years or over. The ve Finnish university hospital districts were used for
stratication and sampling, each serving about one million inhabitants
and diering in geography, economic structure, health services, and the
socio-demographic characteristics of the population. From each of the ve
strata, 16 health care districts were sampled as clusters, adding up to 80
districts in the whole country. Firstly, the 15 largest health care districts
were included with a probability of one. Next, the other 65 health care
districts were included in the sample with a probability proportional
to the population size. Finally, from each of these 80 areas, a random
sample was drawn from the National Population Register so that the
total number of persons drawn from each stratum was proportional to
the population size. (Aromaa & Koskinen 2004)
The participants were rst interviewed at home by trained interviewers of Statistics Finland, the Finnish National Bureau for Statistics.
The structured interview lasted about 90 minutes and covered information
43
3. METHODS
on socio-demographic factors, health and illnesses, use of medication

and health services, living habits including smoking, type of work, work
capacity, and the need for health services. Then the participants were
given a questionnaire that covered information on their functional capacity, leisure-time activities, physical activity, alcohol consumption, job
strain, burnout, and depressive symptoms. The questionnaire was to be
returned at the time of the clinical health examination, which included
a structured interview on mental health, approximately 4 weeks later.
Information on sickness absence was extracted from a register of The
Social Insurance Institute of Finland. It was linked to the other data by
means of each participant's personal identication number, which is
given to all Finns at birth and used for all contacts in health care.
During the rst interview, the respondents received an information
leaet on the study and gave their written consent to participate. The
Health 2000 Study was approved in 2000 by the ethics committee for
epidemiology and public health in the hospital district of Helsinki and
Uusimaa in Finland.
3.2 Participants
Of the total sample (n=8028), 7419 persons participated in at least one
phase of the study. The participants accounted for 93% of the 7977
persons alive on the day the study began. Of the 558 non-participants,
416 refused, 110 were not located, and 32 were abroad. Of the total
sample, 5871 persons were of working age (30 to 64 years). Of this
base population for studies IV, 88% was interviewed, 84% returned
the questionnaire, 82% participated in the clinical health examination,
and 80% participated in the mental health interview. At the time of the
rst interview, 95 participants were on sick leave, and 34 were on leave
of absence. In study VI, the 30- to 60-year-olds were used as the base
population (n=5380).
The participants were excluded if they were not currently employed
according to their main activity, were on maternity or parental leave, had
more than one missing value per dimension on the burnout inventory,
or had missing data on the relevant health variables. A maximum of
one missing value per dimension in the burnout inventory was replaced
44
45
Multivariate
analyses of
variance and
covariance
Yes
Statistical analysis
Results by gender
No
Logistic
regression
analysis
30 - 64 years
Sum score,
as dichotomized
Partly
Cross-tabulations, risk
ratiosa
30 - 64 years
Sum score,
as categorized
Depressive
disorders
3387
3270
88
84
80
-
Study III
5871
3387
3251
88
84
80
-
Study IV
5871
Yes
Logistic regression analysis
30 - 64 years
Sum score,
as continuous
Alcohol dependence
In the summary of the results, logistic regression analysis was used to calculate the odds ratios
30 - 64 years
Dimensional
scores, as continuous
Job strain
3387
3270
3637
3424
Socio-demographic factors
88
84
80
-
Study II
5871
88
84
-
Study I
5871
Age of the participants

Burnout variable
Characteristic
Base population (n)
Participation (%):
Interview
Questionnaire
Health examination
Mental health interview
Sickness absence register
Study population (n):
Working participants
Final study sample
Study design:
Burnout in relation to
Table 9. Descriptive characteristics of the studies I-VI
Partly
30 - 64 years
Sum score, as
categorized
and continuous
Cross-tabulations, logistic
regression
analysis
Physical illnesses
3473
3368
88
84
82
-
Study V
5871
Logistic
regression
analysis,
analysis of
variance
Yes
Medically
certified sickness absence
30 - 60 years
Sum score,
as categorized
3307
3151
87
84
83
80
100
Study VI
5380
3. METHODS
3. METHODS
by the mean of the existing values of the respondent on the particular

dimension. The size of the nal study population ranged from 3151 to
3424 persons in the studies IVI (Table 9).
The weighted gender and age distribution of the participants was
crudely similar to the corresponding distribution of the total Finnish
work force (Statistics Finland 2000). The weighted percentage of women
was 48%, and the mean age of the participants was 44 years. Of the
participants, 78% was married or cohabiting, and 30% was manual
workers. The participants represented dierent occupational branches
(Ahola et al. 2004).
Table 10 contains a detailed description of the participants by gender.
The men and women diered statistically signicantly with respect to
most of the socio-demographic and clinical characteristics examined.
Compared with the men, the women were a little older, had a higher
level of education, were more often unmarried, worked more often part
time, and were more often in lower-level non-manual work, in passive or
high-strain work, and in physically non-strenuous work. Furthermore,
the women had less risky health behaviour than men. However, there
was no gender dierence in the level of burnout. Instead, the women
had a higher prevalence of depressive and anxiety disorders and depressive symptoms, but a lower prevalence of alcohol dependence, and more
long sickness absences than the men.
3.3 Measures
Occupational burnout
Occupational burnout was measured with the Maslach Burnout Inventory General Survey (MBI-GS) (Schaufeli et al. 1996, Kalimo et al.
2006). The MBI-GS consists of the following three subscales: exhaustion (ve items, Cronbach's = 0.91), cynicism (ve items, = 0.79),
and (diminished) professional ecacy (six items, = 0.82). The items
were scored on a 7-point frequency rating scale ranging from 0 (never)
to 6 (daily). High scores on exhaustion and cynicism and low scores on
professional ecacy were indicative of burnout. The items of professional
ecacy were reversed (diminished professional ecacy).
46
47
Burnout (N=3424)
No
Mild
Severe
Socio-demographic
characteristics (N=3424)
Age
30-34 years
35-44 years
45-54 years
55-64 years
Basic education
< 9 years
9-11 years
12 years
Vocational education
None or a course
School
Institute
Higher education
Occupational status
Upper non-manual
Lower non-manual
Manual
Self-employed
Married
688 (40.2)
576 (33.6)
452 (26.2)
445 (26.0)
709 (41.4)
321 (18.7)
241 (14.0)
458 (26.6)
267 (15.6)
655 (38.3)
333 (19.5)
1379 (80.3)
851 (25.2)
1202 (35.3)
854 (24.5)
517 (15.0)
943 (27.4)
940 (26.9)
1018 (30.2)
519 (15.4)
2670 (78.0)
287 (16.6)
601 (34.9)
626 (36.8)
202 (11.7)
546 (15.6)
1165 (33.5)
1288 (38.3)
425 (12.7)
1206 (35.9)
1108 (32.3)
1108 (31.8)
1249 (72.8)
434 (25.3)
33 ( 1.9)
Men
n (weighted %)
2475 (72.2)
867 (25.4)
82 ( 2.4)
All
n (weighted %)
485 (28.2)
673 (39.4)
363 (21.4)
186 (11.0)
1291 (75.5)
406 (24.3)
493 (28.7)
533 (30.9)
276 (16.1)
518 (31.2)
532 (30.9)
656 (37.9)
259 (14.4)
564 (31.8)
662 (39.9)
223 (13.9)
1226 (71.6)
433 (25.5)
49 ( 2.9)
Women
n (weighted %)
Difference
(1)= 12.91, p< 0.001
(3)= 261.2, p< 0.001
(3)= 92.12, p< 0.001
(2)= 56.26, p< 0.001
(3)= 10.88, p= 0.013
(2)= 3.60, p= 0.166
Table 10. Socio-demographic and clinical characteristics of the study population by gender
3. METHODS
48
Data missing for 1 person;

Data missing for 90 persons;
Clinical characteristics,
mental-related (N=3270)
Depressive disorder
Anxiety disorder
Alcohol dependence
Lifetime mental disorder
Depressive symptoms
Job strain
Low-strain work
Active work
Passive work
High-strain work
Full-time work
Clinical characteristics,
physical-related (N=3368)
Musculoskeletal disorder
Cardiovascular disease
Physical strenuousness of work
Sedentary work
Some walking
A lot of walking
Very strenuous
Daily smoking
Physical activity
< 2 times a week
2-3 times a week
> 3 times a week
Body mass indexa,
kg/m2: mean; SE
Alcohol consumptionb,
drinks/month: mean; SE
Sickness absence (N=3211)
503 (30.1)
275 (16.5)
660 (39.6)
382 (22.9)
378 (22.8)
245 (14.8)
481 (28.7)
784 (46.7)
590 (35.0)
308 (18.3)
26.9; 0.10
38.2; 1.17
263 (16.4)
1336 (40.0)
882 (26.2)
782 (23.5)
332 (10.2)
846 (25.3)
1474 (44.1)
1181 (35.1)
706 (20.9)
26.4; 0.07
26.3; 0.73
654 (20.3)
472 (29.5)
389 (24.3)
409 (25.5)
331 (20.6)
1577 (96.3)
838 (26.5)
700 (22.1)
910 (28.4)
732 (23.0)
3034 (92.9)
1003 (30.2)
525 (15.9)
64 ( 3.9)
46 ( 2.8)
112 ( 6.9)
122 ( 7.4)
229 (14.0)
204 ( 6.1)
125 ( 3.8)
136 ( 4.3)
306 ( 9.3)
616 (18.7)
13.0; 0.57
391 (24.6)
25.9; 0.11
690 (41.2)
591 (35.1)
398 (23.7)
676 (40.6)
500 (29.9)
404 (24.3)
87 ( 5.2)
365 (21.5)
500 (30.2)
250 (15.4)
366 (23.1)
311 (19.7)
501 (31.6)
401 (25.6)
1457 (89.2)
140 ( 8.5)
79 ( 4.9)
24 ( 1.5)
184 (11.4)
387 (23.9)
(1)= 36.90, p< 0.001
F(1,3276)= 403.3, p<0.001
F(1,3365)= 45.79, p< 0.001
(1)= 19.46, p< 0.001

(2)= 20.23, p< 0.001
(1)= 0.004, p= 0.947

(1)= 0.64, p= 0.423
(3)= 87.29, p< 0.001
(1)= 64.25, p< 0.001
(1)= 23.52, p< 0.001

(1)= 11.00, p< 0.001
(1)= 56.22, p< 0.001
(1)= 15.03, p< 0.001
(1)= 53.17, p< 0.001
(3)= 36.08, p< 0.001
3. METHODS
3. METHODS
For the assessment of the level of burnout, a weighted sum score of

the dimensional sum scores was calculated (IIVI) (Kalimo et al. 2006).
Exhaustion, cynicism, and diminished professional ecacy had dierent
weights in the syndrome (Kalimo et al. 2003). This syndrome indicator
had been constructed with the help of a discriminant function analysis, in
which various health-related indicators were used as dependent variables
(Kalimo & Toppinen 1997). The coecients were formed by weighting
each dimension so that the scores corresponded to the original response
scale (0.4 x exhaustion + 0.3 x cynicism + 0.3 x diminished professional
ecacy). Burnout and the dimensional scores were categorized as follows (Kalimo et al. 2003, 2006): no symptoms (sum score 01.49),
mild symptoms (sum score 1.53.49), and severe symptoms (sum score
3.56). According to this categorization, symptoms that were experienced
approximately daily or weekly were severe, they occurred monthly when
mild, and they were experienced only a few times a year or never in cases
of no burnout (III, VI). In study II, burnout was dichotomized as no
burnout versus burnout (mild or severe).
Mental disorders
The assessment of the 12-month prevalence of mental disorders was

based on the Composite International Diagnostic Interview (CIDI,
version 2.1) (Andrews & Peters 1998, Wittchen et al. 1998), which is
a fully standardized diagnostic interview for the assessment of mental
disorders for research purposes. A Finnish translation of the German,
computerized version of the CIDI was used (M-CIDI). The CIDI questions were designed to elucidate symptoms and behaviour that map on
each diagnostic criterion for mental disorders according to the Diagnostic
and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV)
(American Psychiatric Association 1994) in addition to information
about their onset, recency, and associated impairments (Andrews & Peters
1998). In approximately 75 minutes, the CIDI allows the estimation of
DSM-IV diagnoses for major mental disorders (i.e., mental disorders
due to general medical conditions, substance-related, psychotic, mood,
anxiety, somatoform and dissociative, and eating disorders), while the
assessment of personality disorders was not included (Wittchen et al.
1998). However, in the CIDI interview in the Health 2000 Study,
49
3. METHODS
mental disorders due to general medical conditions, special phobias,

obsessive-compulsive and post-traumatic stress disorders, somatoform
and dissociative disorders, and eating disorders were not assessed because
the time allocated for the mental health interview was set at 30 minutes
(Aromaa & Koskinen 2004).
The 21 interviewers were health care professionals trained for 34
days in the use of CIDI interview by physicians who had themselves
been trained by an authorized trainer of the World Health Organization.
In a separate analysis, the CIDI interviewers examined, pairwise and
independently, a consecutive series of 49 visitors to occupational health
services to test the test-retest reliability of the CIDI depressive disorders
section. The Kappa values for the two interviews were 0.88 (95% CI
0.641.00, observer agreement 94%) for major depressive disorder and
0.88 (95% CI 0.641.00, observer agreement 98%) for dysthymic disorder (Pirkola et al. 2005).
Depressive disorders included major depressive disorder and dysthymic disorder in studies II and VI. In study III, also minor depressive
disorder was included in the depressive disorders. Minor depressive
disorder comprises current sub-clinical depression (i.e., 24 symptoms
of depression). The anxiety disorders (unpublished data) included panic
disorder with or without agoraphobia, generalized anxiety disorder, social
phobia, phobia not otherwise specied, and agoraphobia without panic
disorder. The alcohol use disorders included alcohol dependence and
alcohol abuse. A participant was identied as having a mental disorder
(VI) if he or she fullled the criteria for a depressive (major depressive
and dysthymic disorder), anxiety, or alcohol use disorder. Lifetime mental disorders (II) were assessed with a single-item question in the home
interview asking whether a physician had ever conrmed a psychiatric
illness or a mental disorder for the participant.
Depressive symptoms
The original Beck Depression Inventory (Beck et al. 1961, 1988) was
used to assess depressive symptoms as an indicator of mental health (II,
V). The inventory consisted of 21 items scored from 0 to 3. An acceptable
answer was expected for at least 14 items. Missing values (7 at the most)
were replaced by the mean of the existing values of the respondent. A sum
50
3. METHODS
score was then calculated for the depressive symptoms (II, V). Depressive symptoms were dichotomized (II) as no depressive symptoms (09
points) or depressive symptoms (1063 points) (Beck et al. 1988).
Physical illnesses
The clinical health examination began with a symptom interview covering

musculoskeletal, cardiovascular and respiratory symptoms, atopy, and
allergies. Then the participants were given an additional questionnaire
about infections and vaccinations to be lled out during the health
examination. Next, the research physician took a medical history and
performed a standard 30-minute clinical examination including tests
related to the functioning and movements of the joints. The health examination also included the measurement of height and weight, body
circumference, electrocardiogram, blood pressure, spirometry, bioimpedance, heel bone density, and orthopantomography.
The diagnostic criteria of the physical illnesses were based on current
clinical practice. The separate diagnoses were divided into the following
four main groups: musculoskeletal disorders (V), cardiovascular diseases
(V), respiratory diseases, and other physical illnesses including, for example, diabetes, metabolic disorders, skin disorders, and allergies. The
participant was identied as having a physical illness (VI) if he or she
fullled any diagnostic criteria of a musculoskeletal disorder, cardiovascular disease, respiratory disease, or other physical illness.
Sickness absence
In Finland, the national sickness insurance scheme covers the entire

population and reimburses the loss of income due to a sickness absence
on the basis of a medical certicate and a period of more than 9 consecutive work days. The number of compensated sickness absence days in
2000 and 2001 was extracted from the register of The Social Insurance
Institution of Finland. Variables of at least one long sickness absence
(no/yes) and the number of compensated days were formed for those
with at least one absence during the 2-year period (VI).
51
3. METHODS
Job strain
Job strain (II) was measured with the Job Content Questionnaire
(Karasek et al. 1998). The scale of job demands comprised ve items
(Cronbach's = 0.79), and the scale for job control comprised nine
items ( = 0.85). Responses were given on a 5-point scale ranging from
1 (strongly disagree) to 5 (strongly agree). To create an indicator of job
strain, the job demand and job control scales were dichotomized at their
median (Landbergis et al. 1994), and the following four subgroups were
formed for work (Karasek 1979, Karasek & Theorell 1990): low-strain
work (low demands with high control), active work (high demands with
high control), passive work (low demands with low control), and highstrain work (high demands with low control).
Socio-demographic factors
Information on the socio-demographic factors was collected during the

rst interview at home. Age was categorized in dierent ways in studies
IVI. Marital status was dichotomized as married or co-habiting (married) and the rest (unmarried). Basic education was categorized as less
than comprehensive schooling (< 9 years), comprehensive schooling
(911 years), and secondary schooling (12 years). Vocational education
was categorized as a course or less, school level, institute level, or higher
vocational education. Occupational status was formed on the basis of
occupation and the type of business: upper grade non-manual, lower
grade non-manual, manual, and self-employment (Statistics Finland
1999). In study VI, the groups of upper and lower grade non-manual
work were combined as non-manual work.
Confounding factors
In addition to socio-demographic factors, health behaviour and the

physical strenuousness of the work were used as confounding factors in
the analyses concerning physical illnesses, and work hours and health
behaviour were used in the analyses for job strain. The physical strenuousness of work was assessed with a questionnaire using a single question
with a following 4-point scale: mostly sedentary work, work including a
52
3. METHODS
fair amount of walking, work including a lot of walking, climbing stairs

or carrying heavy loads, or very strenuous work. Daily smoking (no/yes)
was inquired about in the home interview. Habitual alcohol consumption and health-enhancing physical activity were assessed with the
questionnaire. The participant's report of the frequency and amount of
consumed beer, wine, and spirits was transformed into drinks per month.
Health-enhancing physical activity included exercise causing at least slight
shortness of breath and sweating for a minimum of 30 minutes at a time.
It was classied as once a week or less, two to three times a week, and
at least four times a week. Body mass index (kg/m2) was calculated on
the basis of the participants' height and weight, which were measured
in the clinical health examination. Work hours were inquired about in
the home interview and classied as full-time or part-time.
3.4 Statistical analyses

Cross-tabulations and chi-square tests were used to describe the participants according to gender and to analyse the association between
burnout and depressive disorders (III), musculoskeletal disorders (V),
and cardiovascular diseases (V). In addition, cross-tabulations were used
to summarize the overall co-occurrence of burnout, mental disorders,
and physical illnesses (unpublished data).
A 2x5 multivariate analysis of variance was used to analyse the relation
of gender and age to burnout using continuous variables of exhaustion,
cynicism, and lack of professional ecacy as dependent variables at the
same time to take into account the multi-dimensional nature of burnout
(I). When the multivariate eect was signicant, univariate analyses of
variance were conducted for each burnout dimension separately. The
focus was on the variables that had a statistically signicant eect on
every burnout dimension. The dierences between the categories of the
independent variables were analysed with 95% condence intervals of
the means. The relation of basic and vocational education, occupational
grade, and marital status to the continuous burnout variable was analysed with multivariate analyses of covariance separately for the men and
women using the categorical factors as independent variables one at a
time and age as a continuous variable as a covariate.
53
3. METHODS
Logistic regression analysis was used to investigate the relationship

between the socio-demographic factors and burnout (II), between job
strain and burnout and depressive disorders (II), and between burnout
and depressive disorders (III), alcohol dependence (IV), anxiety disorders (unpublished data), musculoskeletal disorders (V), cardiovascular
diseases (V), and sickness absence (VI). The models, except in study
III, were adjusted for potential confounding factors. In the models of
job strain, an interaction term was applied to test whether the association was dependent on gender (II). In studies IIIVI, the analyses were
conducted according to gender. The analyses of sickness absence were
repeated for the employees with mental or physical disorders to examine whether burnout increased the odds for sickness absence also in an
unhealthy population.
A univariate analysis of variance was used for the employees with
sickness absences to calculate the mean dierence and its signicance
in the logarithmically transformed number of sickness absence days
separately according to burnout, mental disorders, and physical illness
(VI). These analyses were adjusted for socio-demographic factors, and
the analyses for burnout were adjusted further for mental disorders and
physical illnesses.
Sampling parameters and weighting adjustment were used in all of
the analyses to account for the survey design complexities, including
clustering in a stratied sample, and the loss of participants (Lehtonen
et al. 2003, Aromaa & Koskinen 2004). The data were analysed using
the SAS (I) and SUDAAN (IIVI) statistical program packages. The
SUDAAN has been specically designed to analyse cluster-correlated
data in complex sample surveys.
54
4. RESULTS
The results are presented in accordance with study questions 14. Firstly,
the associations between socio-demographic factors (i.e., gender, age,
marital status, basic and vocational education, and occupational grade)
and burnout are presented (I, II). Secondly, the relationship of job
strain to burnout and to depressive disorders is compared (II). Thirdly,
the associations between burnout and mental disorders (i.e., depressive
disorders, anxiety disorders, and alcohol dependence), musculoskeletal
disorders, and cardiovascular diseases are shown (IIIV, and unpublished
data). Finally, the contribution of burnout to long medically certied
sickness absences is investigated (VI).
4.1 Association between socio-demographic

factors and occupational burnout
Gender, age and burnout
The odds of having burnout did not dier by gender when burnout
comprised both mild and severe symptoms (Table 11) (II). When burnout was analysed as a continuous variable, gender did have a signicant
multivariate main eect on burnout (F=24.7, df=3, p< 0.001). However,
the univariate eects of gender were signicant only for the dimensions
of exhaustion and cynicism. The level of exhaustion was higher among
the women than among the men. The dierence in the means of cynicism for the men and women was in the opposite direction, but it was
not statistically signicant (Table 12) (I).
Having burnout was more probable among the 55- to 64-year-old
employees than in the younger age groups (Table 11) (II). Age had a
55
4. RESULTS
Table 11. Odds ratios for burnout by gender and age, and genderand age-adjusted odds ratios for burnout by occupational grade and
marital status
Factor
Gender
Men
Women
Age (years)
30-34
35-44
45-54
55-64
Factor
Occupational grade
Upper non-manual
Lower non-manual
Manual
Self-employed
Marital status
Married
Unmarried
a
b
Cases
Burnout
Odds ratio (95% CIa)
1637
1633
441
459
1.00
1.07 (0.92-1.25)
517
1116
1236
401
130
265
347
158
Cases
1.00
0.91 (0.73-1.14)
1.15 (0.92-1.45)
1.89 (1.44-2.49)
Burnout
Adjustedb odds ratio (95% CIa)
922
896
958
490
230
200
335
135
1.00
0.84 (0.68-1.04)
1.69 (1.36-2.10)
1.14 (0.89-1.46)
2558
712
670
230
1.00
1.33 (1.10-1.61)
CI indicates confidence interval

Adjusted for gender and age
signicant multivariate main eect on burnout when it was treated as

a continuous variable (F=6.4, df=12, p< 0.001), and this eect was
signicant for all of the burnout dimensions. The level of exhaustion
was higher in the age group of 5364 years than among the 30- to 41year-olds, and the level of cynicism was higher in the age group of 5364
years than among the 36- to 52-year-olds. In addition, professional efcacy was lower among the 53- to 64-year-olds than among the 42- to
47-year-olds, among whom it was lower than among the 30- to 35-yearolds. Furthermore, professional ecacy was lower in the age group of
4852 years than in the age group of 3641 years. The interaction eect
between gender and age was not statistically signicant.
56
57
1.01 (0.91-1.12)
1.13 (1.00-1.25)
1.20 (1.10-1.31)
1.22 (1.10-1.34)
1.49 (1.35-1.64)
0.99 (0.91-1.08)
1.17 (1.05-1.30)
1.52 (1.42-1.62)
1.15 (1.01-1.29)
1.49 (1.36-1.62)
1.30 (1.20-1.39)
0.99 (0.89-1.09)
1.04 (0.93-1.15)
1379 0.97 (0.91-1.03) 1.07 (1.01-1.13) 1.22 (1.16-1.28)

337 1.12 (0.99-1.25) 1.35 (1.20-1.50) 1.39 (1.25-1.52)
1.09 (0.98-1.19)
1.04 (0.90-1.18)
1.22 (1.12-1.31)
1.07 (0.95-1.19)
1.21 (1.10-1.33)
1.10 (1.02-1.19)
1.06 (0.93-1.19)
1.11 (0.96-1.25)
1.25 (1.15-1.35)
1.08 (0.99-1.16)
1.43 (1.28-1.57)
1.11 (0.96-1.27)
0.99 (0.90-1.08)
0.97 (0.89-1.05)
1.22 (1.09-1.36)
1.01 (0.84-1.17)
1.19 (1.06-1.31)
0.92 (0.82-1.01)
0.97 (0.88-1.07)
1.13 (0.99-1.27)
1.08 (0.99-1.16)
1.13 (1.04-1.21)
1.57 (1.41-1.72)
1.29 (1.07-1.50)
1.55 (1.41-1.70)
1.23 (1.12-1.33)
1.01 (0.92-1.10)
1.13 (1.02-1.25)
1291 1.19 (1.12-1.26) 0.99 (0.93-1.05) 1.20 (1.13-1.26)

417 1.25 (1.13-1.37) 1.16 (1.05-1.28) 1.31 (1.19-1.43)
485
673
363
186
1.35 (1.21-1.50)
1.11 (1.02-1.20)
1.11 (1.01-1.20)
1.34 (1.20-1.48)
1.00 (0.91-1.09)
0.87 (0.76-0.97)
1.03 (0.94-1.13)
1.05 (0.94-1.17)
0.96 (0.84-1.08)
0.90 (0.79-1.01)
0.96 (0.86-1.06)
1.02 (0.90-1.13)
1.29 (1.17-1.42)
458
267
655
333
1.02 (0.91-1.13)
1.08 (0.97-1.20)
1.15 (1.03-1.26)
1.21 (1.09-1.34)
1.50 (1.35-1.65)
406
493
533
276
300
340
373
344
352
1.03 (0.92-1.15)
1.01 (0.93-1.09)
0.96 (0.84-1.08)
0.95 (0.84-1.07)
1.10 (1.00-1.21)
1.10 (0.98-1.21)
1.29 (1.18-1.40)
1.38 (1.25-1.50)
1.42 (1.27-1.56)
445
709
321
241
1.19 (1.06-1.33)
1.00 (0.88-1.13)
1.15 (1.02-1.28)
1.05 (0.91-1.18)
1.24 (1.11-1.36)
518 1.35 (1.23-1.47) 1.14 (1.04-1.24) 1.48 (1.36-1.60)

532 1.03 (0.95-1.12) 0.92 (0.84-1.00) 1.14 (1.04-1.23)
656 1.22 (1.13-1.31) 1.04 (0.96-1.12) 1.09 (1.01-1.17)
0.98 (0.88-1.08)
0.90 (0.78-1.02)
1.05 (0.94-1.16)
1.00 (0.87-1.14)
1.07 (0.95-1.20)
Women
N
Exhaustion
Cynicism
Lack of PEa
1708 1.20 (1.15-1.26) 1.03 (0.98-1.09) 1.22 (1.17-1.28)
688 1.02 (0.93-1.11) 1.14 (1.06-1.22) 1.45 (1.35-1.56)

576 0.99 (0.91-1.07) 1.09 (1.00-1.19) 1.18 (1.09-1.27)
452 0.98 (0.89-1.07) 1.14 (1.03-1.24) 1.03 (0.95-1.11)
343
350
373
332
318
Men
N
Exhaustion
Cynicism
Lack of PEa
1716 1.00 (0.95-1.05) 1.12 (1.07-1.18) 1.25 (1.20-1.31)
PE indicates professional efficacy
Factor
All
Age (years)
30-35
36-41
42-47
48-52
53-64
Basic education
< 9 years
911 years
12 years
Vocational education
None or a course
School
Institute
Higher education
Occupational grade
Upper non-manual
Lower non-manual
Manual
Self-employed
Marital status
Married
Unmarried
Table 12. Level of the burnout dimensions according to the socio-demographic factors among the men and
women: weighted means and their 95% confidence intervals
4. RESULTS
4. RESULTS
Education, occupational grade and burnout
Both basic and vocational education had a signicant multivariate main

eect on burnout when age was adjusted for (F=3.5, df=9, p< 0.001,
and F=4.5, df=11, p< 0.001 for the women; F=3.9, df=9, p< 0.001, and
F=4.0, df=11, p< 0.001 for the men), but the univariate eects of these
variables were statistically signicant only for the women. The level of
burnout was a little higher among the women who had not nished
comprehensive school than among those who had (Table 12) (I). The
women who had little vocational education scored somewhat higher on
exhaustion and diminished professional ecacy than the women with
school- and institute-level education and higher on cynicism than the
women with a school-level education. Among the men, education had a
statistically signicant univariate eect only on diminished professional
ecacy (Table 12) (I).
Mild-to-severe burnout was more prevalent among the manual workers
than among the non-manual workers or the self-employed when gender and age were adjusted for (Table 11) (II). Occupational grade also
had a signicant multivariate eect on burnout when age was adjusted
for (F=5.1, df=11, p< 0.001 for the women; F=7.1, df=11, p< 0.001
for the men), but the univariate eects of occupational grade were signicant only for the women. The female manual workers scored higher
on exhaustion than the self-employed and the lower-level non-manual
female workers and higher on cynicism and diminished professional
ecacy than the non-manual female workers (Table 12) (I). As for the
men, occupational grade had a statistically signicant univariate eect
on exhaustion and lack of professional ecacy.
Marital status and burnout
As a dichotomy, burnout was more prevalent among those unmarried

than among those married when gender and age were adjusted for (Table
11) (II). When the analyses for the continuous burnout variable were
stratied by gender, marital status had a signicant multivariate main
eect on burnout only for the men, when age was adjusted for (F=5.0,
df=5, p< 0.001). The univariate eect of marital status among the men
was signicant for every burnout dimension. The level of burnout was
58
4. RESULTS
higher among the unmarried men, but the dierence was statistically
signicant only for the cynicism dimension of burnout (Table 12) (I).
The eect of marital status on burnout was not signicant among the
women.
Brief summary
As a summary of the results concerning the rst study question on the

associations between socio-demographic factors and burnout, it can be
concluded that the level of burnout was unrelated to gender. Instead,
burnout was more likely among employees who were over 55 years of
age, in manual work or unmarried. The associations of burnout partly
diered between the genders. The results indicated a negative relationship between burnout and the level of education and occupational status
especially among the women and an association between burnout and
being unmarried especially among the men.
4.2 Job strain in relation to occupational

burnout and depressive disorders
The odds ratios of job strain for burnout are presented in Table 13 (II).
The employees with high-strain work, passive work, and active work had
higher odds ratios for burnout than their counterparts with low-strain
work. The association was the strongest for high-strain work. The associations persisted after adjustment for socio-demographic factors, health
behaviour, physical illnesses, and the indicators of mental health. There
was no signicant attenuation in the strength of the association between
job strain and burnout after adjustment for depressive symptoms and
depressive disorders.
The odds ratios for depressive disorders in relation to job strain are
presented in Table 14 (II). High-strain work and active work were associated with depressive disorders before, but not after, adjustment for
burnout. No statistically signicant interaction between job strain and
gender was evident in the models for burnout and depressive disorders
(p> 0.07).
59
4. RESULTS
Table 13. Odds ratios for burnout in relation to job strain
Work
Low strain
Active
Passive
High strain
N Cases
820
95
688
161
880
240
702
342
Adjusteda
odds ratio
(95% CId)
1.00
2.34 (1.75-3.12)
2.94 (2.24-3.86)
7.36 (5.62-9.65)
Burnout
Adjustedb
odds ratio
(95% CId)
1.00
2.31 (1.72-3.11)
3.16 (2.38-4.19)
7.86 (5.99-10.3)
Adjustedcodds
ratio
(95% CId)
1.00
1.90 (1.39-2.60)
3.05 (2.25-4.13)
6.69 (5.06-8.82)

Adjusted for gender, age, marital status, occupational grade, work hours, daily smoking,
alcohol consumption, health-enhancing physical activity, body mass index, physical illnesses,
and lifetime mental disorders
c
lifetime mental disorders, depressive symptoms, and depressive disorders
d
b
Table 14. Odds ratios for depressive disorders in relation to job strain
Work
Low strain
Active
Passive
High strain
N
820
688
880
702
Depressive disorders
Adjusteda
Adjustedb
odds ratio
odds ratio
Cases (95% CId)
(95% CId)
37
1.00 (ref.)
1.00 (ref.)
49
1.57 (1.03-2.38) 1.58 (1.01-2.49)
45
1.06 (0.69-1.63) 1.03 (0.63-1.66)
55
1.69 (1.11-2.58) 1.66 (1.03-2.66)
Adjustedc
odds ratio
(95% CId)
1.00 (ref.)
1.20 (0.76-1.91)
0.68 (0.41-1.13)
0.83 (0.52-1.34)

and lifetime mental disorders
c
lifetime mental disorders, and burnout
d
b
60
4. RESULTS
In conclusion, high job strain was related to burnout and to depressive disorders, but the association was stronger for burnout.
4.3 Association between occupational

burnout and disorders and illnesses
Burnout and mental disorders
Of the employees with severe burnout, 45% had major depressive disorder or dysthymic disorder. The gender- and age-adjusted odds of having major depressive disorder or dysthymic disorder accompanied with
mild-to-severe burnout was 5.0-fold (95% CI 3.96.6; II). When the
depressive disorders also included minor depressive disorder, a depressive
disorder was present in 53% of the participants with severe burnout, in
20% of the participants with mild burnout, and in 7% of the participants
with no burnout. The weighted prevalence and odds ratios for depressive
disorders are presented according to the level of burnout in Table 15 (III).
Compared with the persons without burnout, those with a depressive
disorder had a crude odds ratio that was 14-fold when severe burnout
was present and 3.2-fold when mild burnout was present.
Burnout was related to major depressive disorder among both the
men and the women, as was also severe burnout to dysthymic disorder.
Mild but not severe burnout was related to minor depressive disorder
among the men and women. Severe burnout was related to a substantial probability for major depressive disorder when compared with the
situation with no burnout. For the men, the odds of severe burnout in
relation to major depressive disorder were 44-fold, and for the women
they were 18-fold. However, the gender dierence was not statistically
signicant. Moreover among the men, mild burnout was also related to
dysthymic disorder. Also the odds of mild burnout versus the situation
of no burnout in relation to any depressive disorder were higher among
the men than among the women (Table 15) (III).
The weighted prevalence and odds ratios for depressive disorders in
relation to the separate dimensions of burnout are presented in Table
16 (III). A depressive disorder was diagnosed for 35% of those who had
severe exhaustion, for 33% of those who had severe cynicism, and for
61
62
1.00
4.83 (3.34-6.98)
19.0 (9.03-40.1)
1.00
2.46 (1.86-3.26)
11.4 (6.21-20.9)
10.8
23.0
58.0
1.00
3.20 (2.55-4.03)
14.1 (9.22-21.7)
7.4
20.3
52.9
4.3
17.9
46.1
OR (95% CI)c
prevalence
4.4
11.2
44.8
1.2
6.9
34.1
2.7
9.0
40.2
prevalence
1.00
2.74 (1.87-4.01)
17.6 (9.29-33.3)
1.00
6.34 (3.29-12.2)
44.2 (18.9-104)
1.00
3.57 (2.59-4.92)
24.3 (15.2-39.1)
OR (95% CI)c
Major DDa (173 cases)
1.2
2.2
6.1
0.2
1.9
12.6
0.6
2.1
8.9
1.00
1.89 (0.82-4.33)
5.62 (1.58-20.1)
1.00
12.4 (3.05-50.2)
90.3 (15.6-522)
1.00
3.28 (1.68-6.42)
15.4 (6.04-39.3)
Dysthymic disorderb
(40 cases)
prevalence OR (95% CI)c
5.6
9.8
9.0
3.0
9.3
5.8
4.2
9.5
7.6
prevalence
1.00
1.84 (1.28-2.65)
1.67 (0.58-4.84)
1.00
3.32 (2.08-5.29)
2.00 (0.47-8.47)
1.00
2.39 (1.79-3.21)
1.88 (0.82-4.32)
OR (95% CI)c
Minor DDa (187 cases)
DD indicates depressive disorder

Of the participants with dysthymic disorder, 9 had a concurrent major depressive disorder and 10 had a concurrent minor depressive disorder
c
OR indicates odds ratio; CI indicates confidence interval; in the original publication (study III), risk ratios were used
Gender
N
Men and Women
No burnout
2370
Mild burnout
822
Severe burnout
78
Men
No burnout
1196
Mild burnout
409
Severe burnout
32
Women
No burnout
1174
Mild burnout
413
Severe burnout
46
Any DDa (391 cases)
Table 15. Weighted prevalence (%) and odds ratios for depressive disorders in relation to the level of burnout
according to gender
4. RESULTS
63
2150
922
204
No lack of PEd
Mild lack of PEd
Severe lack of PEd
8.5
16.7
23.6
8.3
18.4
32.9
1.00
2.17 (1.75-2.69)
3.35 (2.33-4.80)
1.00
2.48 (1.94-3.17)
5.42 (3.86-7.62)
3.6
6.9
13.4
3.2
8.0
21.1
Prevalence
2.8
9.9
22.8
1.00
1.97 (1.41-2.76)
4.08 (2.60-6.41)
1.00
2.61 (1.90-3.59)
8.07 (5.33-12.2
OR (95% CI)c
1.00
3.82 (2.71-5.40)
10.3 (6.84-15.4)
Major DDa
(173 cases)
0.9
1.7
2.4
0.9
1.3
5.3
Prevalence
0.7
2.3
5.3
1.00
2.08 (1.13-3.83)
2.85 (1.06-7.70)
1.00
1.45 (0.63-3.34)
6.38 (2.76-14.5)
OR (95% CI)c
1.00
3.50 (1.72-7.13)
8.54 (3.69-19.7)
Dysthymic disorderb
(40 cases)
4.2
8.2
8.8
4.4
9.2
8.1
1.00
2.04 (1.51-2.77)
2.21 (1.36-3.59)
1.00
2.20 (1.60-3.05)
1.93 (1.08-3.45)
OR (95% CI)c
1.00
1.95 (1.43-2.65)
1.79 (1.01-3.16)
Minor DDa
(187 cases)
Prevalence
4.7
8.8
8.1
DD indicates depressive disorder

Of participants with dysthymic disorder, 9 had a concurrent major depressive disorder and 10 a concurrent minor depressive disorder
c
OR indicates odds ratio; CI indicates confidence interval; in the original publication, risk ratios were used
d
2414
692
170
No cynicism
Mild cynicism
Severe cynicism
Level of
dimension
N
Prevalence OR (95% CI)c
No exhaustion
2500
8.0
1.00
Mild exhaustion
602
20.5
2.96 (2.32-3.78)
Severe exhaustion 174
35.1
6.21 (4.43-8.70)
Any DDa
(391 cases)
Table 16. Weighted prevalence (%) and odds ratios for depressive disorders in relation to the level of burnout
dimensions
4. RESULTS
4. RESULTS
24% of those who had severly diminished professional ecacy. All of the
dimensions of burnout, at both severe and mild levels, were signicantly
related to the occurrence of a depressive disorder. Concerning dierent
depressive disorders, only the association between mild cynicism and
dysthymic disorder was not statistically signicant.
An anxiety disorder was present among 21% of the employees with
severe burnout, among 8% with mild burnout, and among 2% with no
burnout. The odds ratios for burnout in relation to anxiety disorders according to gender are presented in Table 17 (unpublished data). Burnout
was a signicant correlate of anxiety disorders for both genders. For the
anxiety disorders, each 1-point increase in the burnout sum score was
associated with a 129% increase in the odds for anxiety disorders among
the men and a 105% increase among the women. These associations did
not attenuate after adjustment for socio-demographic factors.
Table 17. Odds ratios of burnout for anxiety disorders according to

gender
Gender
Men
Women
a
b
N
1608
1601
Cases
46
79
Anxiety disorders
Adjusteda odds ratio
Odds ratio
(95% CIb)
(95% CIb)
2.29 (1.83-2.85)
2.30 (1.81-2.93)
2.05 (1.71-2.47)
2.08 (1.72-2.51)
Adjusted for age, marital status, and basic education

Table 18. Odds ratios of burnout for alcohol dependence according

to gender
Gender
Men
Women
a
b
N
1622
1629
Cases
112
25
Alcohol dependence
Adjusteda odds ratio
Odds ratio
b
(95% CI )
(95% CIb)
1.51 (1.27-1.78)
1.51 (1.28-1.79)
1.80 (1.35-2.40)
2.06 (1.52-2.81)
Adjusted for age, marital status, and basic education

64
4. RESULTS
Alcohol dependence was present among 10% of all the employees

with severe burnout, among 7% of those with mild burnout, and among
3% of those with no burnout. Burnout was a signicant correlate of
alcohol dependence for both genders. The odds ratios for burnout in
relation to alcohol dependence are presented in Table 18 (IV) according to gender. For alcohol dependence, each 1-point increase in the
burnout sum score was associated with an 80% increase in the odds for
alcohol dependence among the women and a 51% increase among the
men. The associations remained signicant after adjustment for sociodemographic factors.
Burnout and musculoskeletal disorders
Of the persons with severe burnout, 47% had a musculoskeletal disorder

compared with 36% of those with mild burnout and with 28% of those
with no burnout. The weighted prevalence of musculoskeletal disorders
increased with the level of burnout for both genders (Table 19) (V). The
prevalence of musculoskeletal disorders increased also with the level of
all three dimensions of burnout in the whole study population (Table
20) (V).
The odds ratios for musculoskeletal disorders in relation to burnout
are presented in Table 21 (V) according to gender. Among the women,
burnout was signicantly related to musculoskeletal disorders even when
socio-demographic factors, the physical strenuousness of work, health
behaviour, and depressive symptoms were adjusted for. After these ad-
Table 19. Weighted prevalence (%) of musculoskeletal disorders

according to the level of burnout
Burnout
No
Mild
Severe
(df), p
All
Prevalence
Men
Prevalence
2438
849
81
27.6
36.1
46.7
1228
422
33
28.3
33.9
51.1
32.5 (2), <.001
11.3 (2), <.01
65
Women
Prevalence
1210
26.7
427
38.4
48
45.1
N
24.5 (2), <.001
4. RESULTS
Table 20. Weighted prevalence (%) of musculoskeletal disorders

according to the level of the burnout dimensions
Level
No
Mild
Severe
(df), p
a
Exhaustion
N
Prevalence
2571
27.3
617
38.6
180
43.2
Cynicism
N
Prevalence
2481
28.1
714
34.3
173
42.1
42.7 (2), <.001
22.6 (2), <.001
Lack of PEa
N
Prevalence
2209
28.1
948
33.9
211
34.9
16.4 (2), <.01
Table 21. Odds ratios of burnout for musculoskeletal disorders

according to gender
Odds
Adjusteda
Adjustedb
Adjustedc
odds ratio
odds ratio
odds ratio
ratio
Gender
N
(95% CId)
(95% CId)
(95% CId)
(95% CId)
Men
1628 1.25 (1.11-1.40) 1.21 (1.08-1.36) 1.20 (1.06-1.35) 1.08 (0.93-1.25)
Women 1596 1.39 (1.25-1.56) 1.29 (1.16-1.45) 1.31 (1.17-1.47) 1.22 (1.07-1.38)
a
Adjusted for age, marital status, basic education, occupational grade, and physical strenuousness
of work
Adjusted for age, marital status, basic education, occupational grade, physical strenuousness of
work, daily smoking, alcohol consumption, health-enhancing physical activity, and body mass
index
Adjusted for age, marital status, basic education, occupational grade, physical strenuousness of
work, daily smoking, alcohol consumption, health-enhancing physical activity, body mass index,
and depressive symptoms
justments, each 1-point increase in burnout score was related to a 22%

increase in the odds for musculoskeletal disorders. Among the men,
the association between burnout and musculoskeletal disorders was not
signicant after depressive symptoms were adjusted for.
66
4. RESULTS
Burnout and cardiovascular diseases
Of the persons with severe burnout, 28% had a cardiovascular disease

compared with 20% of those with mild burnout and with 14% of those
without burnout. The weighted prevalence of cardiovascular diseases
increased statistically signicantly with the level of burnout among the
men (Table 22) (V). The prevalence of cardiovascular diseases increased
with the severity of all three dimensions of burnout in the whole study
population (Table 23) (V).
The odds ratios for cardiovascular diseases in relation to burnout are
presented in Table 24 (V). Among the men, burnout was signicantly
Table 22. Weighted prevalence (%) of cardiovascular diseases

Burnout
No
Mild
Severe
(df), p
N
2438
849
81
All
Prevalence
14.3
19.5
27.6
23.1 (2), <.001
N
1228
422
33
Men
Prevalence
14.3
21.2
36.4
24.0 (2), <.001
N
1210
427
48
Women
Prevalence
14.3
17.7
21.1
4.00 (2), n.s.
Table 23. Weighted prevalence (%) of cardiovascular diseases

according to the level of the burnout dimensions
Level
No
Mild
Severe
(df), p
a
Exhaustion
N
Prevalence
2571
14.5
617
19.7
180
23.3
20.3 (2), <.001
Cynicism
N
Prevalence
2481
14.8
714
17.1
173
27.8
21.6 (2), <.001
67
Lack of PEa
N
Prevalence
2209
14.1
948
18.8
211
22.8
18.7 (2), <.001
4. RESULTS
Table 24. Odds ratios of burnout for cardiovascular diseases

according to gender
Adjusted
Adjusted
Adjusted
Odds
odds ratioa
odds ratiob
odds ratioc
ratio
Gender N
(95% CI)d
(95% CI)d
(95% CI)d
(95% CI)d
Men
1628 1.38 (1.22-1.56) 1.35 (1.17-1.54) 1.34 (1.16-1.54) 1.35 (1.13-1.61)
Women 1598 1.23 (1.07-1.41) 1.03 (0.88-1.21) 1.05 (0.90-1.23) 0.96 (0.81-1.13)
a
Adjusted for age, marital status, basic education, occupational grade, and physical strenuousness of work
b
Adjusted for age, marital status, basic education, occupational grade, physical strenuousness
of work, daily smoking, alcohol consumption, health-enhancing physical activity, and body
mass index
c
Adjusted for age, marital status, basic education, occupational grade, physical strenuousness
of work, daily smoking, alcohol consumption, health-enhancing physical activity, body mass
index, and depressive symptoms
d
related to cardiovascular diseases, even when socio-demographic factors,

the physical strenuousness of work, health behaviour, and depressive
symptoms were adjusted for. After these adjustments, each 1-point
increase in the burnout score was related to a 35% increase in the odds
for cardiovascular disease among the men. Among the women, the association between burnout and cardiovascular diseases was not signicant
after the socio-demographic factors and the physical strenuousness of
work were adjusted for.
Co-occurrence of burnout with mental disorders and
physical illnesses
With the dichotomy of no burnout versus mild-to-severe burnout,

27.2% of the participants had burnout in this study. The co-occurrence
of mild-to-severe burnout with mental disorders and physical illness in
the total sample is presented in Figure 2 (unpublished data). Mental
disorders included depressive disorders (i.e., major depressive disorder
and dyshymic disorder), anxiety disorders, and alcohol use disorders,
and physical illnesses included cardiovascular diseases, musculoskeletal
disorders, respiratory illnesses, and a group of other physical illnesses.
Participants were included in every combination of burnout and dis-
68
4. RESULTS
Mental disorders
Mild-to-severe burnout
3.1%
6.8%
3.6%
4.6%
12.7%
4.6%
34.2%
Physical illnesses
30.4%
No burnout or disorders
Figure 2. Co-occurrence of mild-to-severe burnout with mental disorders

and physical illnesses in the total sample (weighted prevalences, adding up
to 100% of N = 3211)
Mental disorders
Severe burnout
0.5%
0.2%
6.2%
0.9%
0.7%
8.3%
46.2%
Physical illnesses
36.9%
No severe burnout or
disorders
Figure 3. Co-occurrence of severe burnout with mental disorders and physical illnesses in the total sample (weighted prevalences, adding up to 100%
of N = 3211)
orders. Mild-to-severe burnout co-occurred with physical illnesses in

17.3% of the cases and with mental disorders in 7.7% of the cases in
the total sample.
A severe level of burnout was present in 2.3% of the participants.
The co-occurrence of severe burnout with mental disorders and physical
69
4. RESULTS
Table 25. Summary of the weighted prevalence (%) of common mental disorders, musculoskeletal disorders, and cardiovascular diseases
Level of
burnout
No
Mild
Severe
Depressive
disorders
3.2
10.8
45.3
Anxiety
disorders
2.0
7.6
21.0
Alcohol
dependence
3.3
6.7
10.0
Level of
burnout
No
Mild
Severe
Musculoskeletal
disorders
27.6
36.1
46.7
Cardiovascular
diseases
14.3
19.5
27.6
No disorder
or illness
41.2
25.8
9.6
illness among all the participants is presented in Figure 3 (unpublished

data). Again, participants were included in every combination of burnout and disorders. Severe burnout co-occurred with physical illnesses in
1.6% of all the cases and with mental disorders in 1.4% of all the cases
in this study.
The weighted prevalence of depressive disorders, anxiety disorders,
alcohol dependence, musculoskeletal disorders, and cardiovascular diseases is summarized in Table 25 according to the level of burnout. Of
those with severe burnout, 47% had a musculoskeletal disorder, and 45%
had a depressive disorder. Ten per cent of those with severe burnout did
not have any co-occurring disorder or illness.
Brief summary
Burnout co-occurred to a high extent with mental disorders and physical illnesses. There was a signicant association between burnout and
depressive disorders, anxiety disorders, and alcohol dependence for
both genders, between burnout and musculoskeletal disorders among
the women, and between burnout and cardiovascular diseases among
the men.
70
4. RESULTS
4.4 Contribution of occupational burnout to

long sickness absences
The association between burnout and the existence of at least one long
sickness absence during a 2-year period is presented in Table 26 (VI).
Burnout was positively associated with sickness absence for both genders
after adjustment for the socio-demographic factors and mental disorders.
After additional adjustment for physical illnesses, severe burnout was
still positively related to sickness absence for both genders. The adjusted
odds of having a long absence with severe burnout were 6.9-fold for the
men and 2.1-fold for the women when compared with the situation
with no burnout. However, the gender dierence was not statistically
signicant. In contrast to mens results, the womens association between
mild burnout and sickness absence was also statistically signicant after
adjustment for physical illnesses.
Table 26. Odds ratios for having a long medically certified sickness
absence during 2 years in relation to the level of burnout according
to gender
Sickness absence
Gender
Men
No burnout
Mild burnout
Severe burnout
Adjusteda
odds ratio
(95% CId)
Adjustedb
odds ratio
(95% CId)
Adjustedc
odds ratio
(95% CId)
Number
of
absences
1154
162
393
79
1.42 (1.05 - 1.92) 1.37 (1.00 - 1.86) 1.26 (0.93 - 1.71)
29
18
8.00 (3.09 - 20.7) 7.21 (2.69 - 19.4) 6.87 (2.65 - 17.8)
1138
239
1.00
389
127
1.71 (1.31 - 2.22) 1.60 (1.23 - 2.09) 1.55 (1.18 - 2.03)
44
21
2.82 (1.49 - 5.37) 2.15 (1.12 - 4.11) 2.10 (1.10 - 4.01)
1.00
1.00
1.00
Women
No burnout
Mild burnout
Severe burnout
1.00
1.00
Adjusted for age, marital status, and occupational status

Adjusted for age, marital status, occupational status, and mental disorders
c
Adjusted for age, marital status, occupational status, mental disorders, and physical
illnesses
d
b
71
72
33.8
47.7
93.2
40.8
46.2
22.5
49.1
162
79
18
196
63
68
191
0.00
22.6
0.00
7.97
0.00
12.3
55.2
Adjusted for age, marital status, and occupational status

Number of days was log-transformed before the analyses
Burnout
No
Mild
Severe
Mental disorder
No
Yes
Physical illness
No
Yes
Men with absence

Mean number
of absence
days
Differencea
0.007
0.105
0.407
<0.001
p-valueb
116
271
309
78
239
127
21
27.5
41.2
34.5
47.3
33.2
38.2
83.0
0.00
11.4
0.00
11.7
0.00
0.32
41.4
Women with absence

Mean number
of absence
days
Differencea
0.001
0.094
0.661
0.135
p-valueb
Table 27. Difference in the mean number of compensated sickness absence days during a 2-year period
among employees with at least one long absence according to burnout, mental disorders, and physical illness
4. RESULTS
4. RESULTS
Among the men with co-occurring disorders, severe burnout was related to 7.7-fold odds (95% CI 3.218.4) for sickness absence compared
with the situation of no burnout (OR for mild burnout 1.3, 95% CI
0.91.8). Among the women with co-occurring disorders, the respective
probability of severe burnout for sickness absence was 2.6-fold (95% CI
1.35.1), and that for mild burnout was 1.5-fold (95% CI 1.12.0).
The number of compensated sickness absence days in relation to
burnout among those who had at least one long absence is presented in
Table 27 (VI). Among the participants with absences, the number of
sickness absence days was signicantly associated with burnout among
the men but not among the women. The men with severe burnout had
55 excess sickness absence days over the 2-year period when compared
with the men without burnout after socio-demographic factors were
adjusted for. In comparison, having a physical illness was related to 23
excess days among the men. The association between sickness absence
days and severe burnout remained statistically signicant among the men
even after adjustment for co-occurring common mental disorders and
physical illnesses. In this adjusted model, the men with severe burnout
had 52 excess sickness absence days (p=0.002) over the 2-year period.
The women with severe burnout had 41 excess sickness absence days
after adjustment for socio-demographic factors, but this association did
not reach statistical signicance.
Concerning the results for the fourth study question, the contribution of burnout to work disability, it can be concluded that burnout was
related to long medically certied sickness absences for both genders. The
association between severe burnout and sickness absence was independent
of co-occurring common mental disorders and physical illnesses.
73
5. DISCUSSION
5.1. Synopsis of the main findings
In this representative sample of the Finnish working population aged
30 years or over, the prevalence of severe burnout was 2.3%, while some
symptoms of burnout, from mild to severe, were present in 27% of the
cases. Employees aged 55 years or over had higher odds of having symptoms of burnout than the younger ones did. Manual workers and those
unmarried had higher odds of mild-to-severe burnout than the other
groups of participants. Especially among the women, those who had
not nished comprehensive school had a higher level of burnout than
the women who had comprehensive schooling. Moreover, the women
in manual work scored higher on the exhaustion dimension of burnout
than the women in lower-level non-manual work or self-employment
did. They also scored higher on cynicism and lower on the professional
ecacy dimension than the women in non-manual work did. Especially
among the men, the level of cynicism was higher among those unmarried
than among those married.
High job strain was associated with higher odds of having mild-tosevere burnout and a depressive disorder than low job strain was. Of
these, the association with burnout was stronger, and it remained after
adjustment for the indicators of mental health. In contrast, the associations between job strain and depressive disorders disappeared after
adjustment for burnout. Unlike depressive disorders, burnout was also
related to active and passive work after adjustments.
Burnout and all of its three sub-dimensions were associated with
depressive disorders for both genders. Forty-ve per cent of the employees with severe burnout also had a depressive disorder; when minor
depressive disorder was also included among the depressive disorders, the
74
5. DISCUSSION
corresponding percentage was 53%. Both severe and mild burnout was
related to major depressive disorder and dysthymic disorder, while mild
burnout was also related to minor depressive disorder. The odds for any
depressive disorder among the employees with mild burnout were higher
among the men than among the women. Of the employees with severe
burnout, 21% suered from an anxiety disorder, and 10% had alcohol
dependence. The associations between burnout and anxiety disorders
and alcohol dependence remained for both genders after adjustment for
socio-demographic factors.
Burnout and all of its three sub-dimensions were related to musculoskeletal disorders and cardiovascular diseases in the total sample. Among the
participants with severe burnout, a musculoskeletal disorder was present
in 47% of the cases, and a cardiovascular disease occurred in 28% of the
cases. After adjustment for socio-demographic factors, the physical strenuousness of work, health behaviour, and depressive symptoms, burnout
was associated with cardiovascular diseases only among the men and with
musculoskeletal disorders only among the women. Ten per cent of those
with severe burnout had no co-occurring disorder or illness.
The odds of having at least one long medically certied sickness
absence during a 2-year period were higher for the employees with
burnout than for their colleagues free of burnout. For the men who had
at least one long absence in 2 years, severe burnout was associated with
55 compensated sickness absence days in addition to 9 days' qualifying
period. For the women, the corresponding number was 41 days, but it
did not reach statistical signicance. For both genders, severe burnout was
associated with sickness absence even after adjustment for co-occurring
common mental disorders and physical illnesses. Among the women,
mild burnout was also independently associated with sickness absence.
5.2 Occupational burnout in the arena of

occupational health psychology
Burnout and ill health
Depressive and anxiety disorders
The observed positive association between burnout and depressive disorders in this population-based sample supports the concept that burnout
75
5. DISCUSSION
and depression are associated; they seem to co-occur at a high rate. This
nding is in agreement with the numerous positive associations found
earlier between burnout and depressive symptoms in dierent kinds of
samples (Meier 1984, Firth et al. 1986, Landsbergis 1988, Seidman &
Zager 1991, Glass et al. 1993, McKnight & Glass 1995, Baba et al. 1999,
Sears et al. 2000, Roelofs et al. 2005, Lindblom et al. 2006). Furthermore,
the present results are in line with the ndings of two earlier studies that
explored the associations between burnout and depressive disorders in
selected samples (Belcastro & Hayes 1984, Kinnunen et al. 2004).
Mild and severe levels of the three dimensions of burnout (i.e., exhaustion, cynicism, and diminished professional ecacy) were all associated
with an increased probability of depressive disorders and, therefore, supported the syndrome quality of burnout. These associations are in line
with the results of six earlier studies (Firth et al. 1986, Landsbergis 1988,
McKnight & Glass 1995, Sears et al. 2000, Roelofs et al. 2005, Lindblom
et al. 2006), but are contrary to the results of four studies concerning
human service work in which only some of the burnout dimensions were
related to depressive symptoms. Two small-scale studies found only the
exhaustion dimension, which has usually shown the strongest associations with depression (Firth et al. 1986, Landbergis 1988, McKnight
& Glass 1995, Sears et al. 2000, Lindblom et al. 2006), to be related to
depressive symptoms (Lemkau et al. 1988, Tselenis et al. 2001). Another
study, which used a modied version of the Maslach Burnout Inventory
and a mean split of the dimensional burnout scores, found high levels
of exhaustion and diminished professional ecacy to be associated with
depressive symptoms (Jayaratne et al. 1986). Furthermore, in logistic
regression analyses, only exhaustion and depersonalization, categorized
with tertiles, showed a signicant association with depressive symptoms,
as assessed with the Depression Scale by the Center for Epidemiologic
Studies (Martin et al. 1997). Therefore, at least when considered in
relation to depressive disorders, burnout could be considered a single
work-related construct, even though consisting of three dimensions.
The present study conrmed a positive association also between burnout and anxiety disorders. Such an association has been suggested earlier
by ve studies showing a relationship between high levels of burnout
syndrome or the three dimensions of burnout and a high level of state
and trait anxiety among the Swedish working population (Lindblom et
76
5. DISCUSSION
al. 2006), in samples of human service work (Richardsen et al. 1992,

Corrigan et al. 1995, Turnipseed 1998), and among patients with workrelated problems (Roelofs et al. 2005).
Depressive and anxiety disorders are assumed to result from complex
interlinked genetic, temperamental, and past and present environmental
inuences (Kendler et al. 1993, 2002 & 2006, Merikangas 2005, Caspi
& Mott 2006). In the psychiatric literature, common risk factors for
these disorders have included, for example, female gender, low socioeconomic position and security, the presence of physical illnesses, previous
mental disorders, and a low level of social support (Salokangas & Poutanen 1998, Gruenberg & Goldstein 2003, Merikangas 2005, Rihmer
& Angst 2005). Stressors, such as work-related life events, have also been
found to precede the onset of depressive and anxiety disorders (Kessler
1997, Tennant 2001, Standsfeld 2002, Leskel et al. 2004, Wilhelm et
al. 2004, Standfeld & Candy 2006).
It is possible that burnout is a part of the process leading to the development of depression or anxiety in situations in which the predisposing
stressor is work-related (Greenglass & Burke 1990, Golembiewski et al.
1992, Leiter & Durup 1994, Iacovides et al. 1999, Bakker et al. 2000a,
Hillhouse et al. 2000, Standsfeld 2002, Iacovides et al. 2003). According to a recent hypothesis, adverse psychosocial work characteristics may
aect mental health through a psychological pathway of injured self-esteem via erosion in the feelings of mastery in an adverse work situation
(Standsfeld & Candy 2006). Burnout could partly indicate this erosion
of mastery and therefore be associated with depressive or anxiety disorders. Erosion in the feelings of mastery over the work situation closely
resembles the dimension of diminished professional ecacy in the threedimensional denition of burnout (Maslach & Jackson 1996).
However, the relationship between burnout and depressive or anxiety
disorders could also be reversed. Employees with mental health problems
may face diculties in meeting their job demands or drift into jobs with
low resources, or they may articially perceive their work situation more
negatively (de Lange et al. 2005) and thus show higher levels of burnout.
Employees with various chronic illnesses, including depressive and anxiety disorders, reported higher levels of exhaustion in a cross-sectional
study among university employees (Donders et al. 2007). Support for
bi-directional associations between low mental health and negatively
77
5. DISCUSSION
perceived work characteristics have been found in prospective studies

(de Jonge et al. 2001, de Lange et al. 2004). However, the pathway from
health to work was less prominent than the one from work to health in
these studies.
Previous ndings on the temporal order between burnout and depressive symptoms are mixed. One longitudinal study supported prospective associations from the burnout dimensions to depressive symptoms
(Greenglass & Burke 1990), another from depressive symptoms to
exhaustion (McCranie & Bransma 1988), while a third failed to nd
support for either of these sequences. In the last study (McKnight & Glass
1995), burnout and depression were suggested to develop "in tandem".
In a recent prospective study, in which well-being at baseline was taken
into account, both of the sequences, from burnout to depression and from
depression to burnout, emerged (Ahola & Hakanen 2007), supporting
a bi-directional association also between burnout and mental health.
Alcohol dependence
The present results on mental disorders supported a positive association

between burnout and alcohol dependence. This association is in agreement with two previous cross-sectional studies that found evidence
indicating that work-related exhaustion is related to the screened risk
for alcohol dependence (Cunradi et al. 2003, Winwood et al. 2003).
Alcohol dependence is a mental disorder, which is assumed to develop
as a consequence of a complex interplay between individual vulnerability, environmental risk factors, and pathological neural learning during
repetitive use (Kaprio et al. 1987, Heath & Nelson 2002, Hyman 2005,
Schuckit 2005). Individual vulnerability for alcohol problems is thought
to include a familiar risk of the sensitized eects of alcohol use, the positive expectancy of the eects of alcohol, and the low personal and social
resources for responding adaptively to stressors (Cooper et al. 1990 &
1992, Zimmermann et al. 2004).
Could a stressful work environment be an underlying factor for the
observed association between burnout and alcohol dependence? Prospective associations have been found between adverse psychosocial work
characteristics and an elevated risk for alcohol dependence, and these
associations indicate that work stress is one possible environmental risk
78
5. DISCUSSION
factor for this disorder. In the North American Epidemiologic Catchment

Area Program, high job strain was found to be a signicant predictor of
alcohol use disorders among men (Crum et al. 1995). The Whitehall II
study among British civil servants showed that psychosocial work characteristics predisposed both men and women to a risk of alcohol dependence;
eort-reward imbalance was a crucial factor for the men and low decision
latitude was important for the women (Head et al. 2004). These results on
work stress as an environmental risk factor for alcohol dependence are in accordance with the present result of a positive association between burnout,
a possible consequence of chronic work stress, and alcohol dependence.
However, as the development of burnout is related to a self-perpetuating
process due to inadequate coping strategies (Schaufeli & Enzmann 1998),
it is also possible that employees with low personal and social resources are
vulnerable to both burnout and addictive behaviour in demanding work
situations. Indeed, inadequate coping strategies have been suggested to be
an essential element behind both burnout (Schaufeli & Enzmann 1998)
and serious alcohol problems (Cooper et al. 1992).
The association between burnout and alcohol dependence can also
derive from a connection between stress, craving for stress relief, and
addictive behaviour on a neurobiological level (Brady & Sonne 1999).
It has been theoretically proposed that stressful experiences and addictive behaviour may share common neural pathways involving dopamine
receptors in the limbic system. Stress from disappointed reward expectancies due to unfavourable social exchange has been suggested to
trigger neuro-regulatory dysfunction in reward-sensitive brain areas
and further mitigate compensatory addictive behaviour (Siegrist 2000
& 2002, Hyman 2005). This process may be especially pronounced
among persons with a familiar vulnerability for stronger dampening
eects of alcohol in stress situations (Zimmermann et al. 2004). In this
way, socio-environmental and personal factors can interact in shaping
the complex patterns behind alcohol dependence at the neural level
(Heath & Nelson 2002).
Musculoskeletal disorders
The robust positive association in the present study between burnout and
musculoskeletal disorders independently of socio-demographic factors,
79
5. DISCUSSION
the physical strenuousness of work, and health behaviour is in line with

the associations between burnout and musculoskeletal pain reported
in two earlier studies (Soares & Jablonska 2004, Miranda et al. 2005).
Musculoskeletal disorders are multi-factorial in nature; individual, environmental, and psychosocial factors aect their development (Hagberg
et al. 1995). Exposure to work-related biomechanical and psychosocial
factors has been found to be associated with musculoskeletal disorders
(Bongers et al. 1993, Hagberg et al. 1995, Punnet & Herbert 2000,
National Research Council and the Institute of Medicine 2001). In addition to direct pathways between work characteristics and musculoskeletal
disorders, including repetitive work aecting muscles and joints and
work stress increasing muscle tension, experienced strain has also been
shown to mediate between work characteristics and the interpretation
and reporting of musculoskeletal problems (Bongers et al. 1993, 2002,
Ari ns et al. 2001, National Research Council and the Institute of Medicine 2001, Lundberg et al. 2002, Larsman et al. 2006).
The direct and indirect links between work characteristics and musculoskeletal disorders may also explain the observed association between
burnout and these disorders. On the other hand, the association may
also be reversed so that a musculoskeletal disorder and a related decrease
in one's work ability may have a negative eect on the capability of a
worker to cope with his or her previous job demands and thus increase
the risk of burnout (Hallman et al. 2003, Donders et al. 2007).
Cardiovascular diseases
The positive unadjusted association between burnout and clinically

determined cardiovascular diseases is in agreement with similar results
on burnout and self-reported cardiovascular disease in previous studies
(Belcastro 1982, Hallman et al. 2003). In addition, it is consistent with
earlier studies reporting associations between exhaustion and coronary
risk factors (Melamed et al. 2006), such as increased levels of total
cholesterol, low-density lipoprotein cholesterol, triglycerides, and uric
acid, as well as elevated diastolic blood pressure (Melamed et al. 1992)
and inammatory biomarkers (Grossi et al. 2003). Although chronic
stress has also been associated with an increased secretion of the stress
hormone cortisol at awakening, the results on burnout or exhaustion
80
5. DISCUSSION
and the levels of cortisol are mixed (Melamed et al. 1999, Pruessner et
al. 1999, De Vente et al. 2003, Moch et al. 2003, Grossi et al. 2003 &
2005, Langelaan et al. 2006, Mommersteeg et al. 2006a, 2006b, 2006c).
The associations between exhaustion and coronary risk factors indicate
that burnout probably precedes cardiovascular disease rather than being
a consequence of it.
The observed association between burnout and cardiovascular diseases
is in line with the preveious ndings showing a prospective association
between work stress and cardiovascular disease. (For a meta-analysis of
prospective cohort studies see Kivimki et al. 2006b.) The adverse effect of sustained work stress on cardiovascular disease may be accounted
for by several mechanisms (McEwen & Stellar 1993, Maier & Watkins
1998, Kiecolt-Glaser et al. 2002, Siegrist 2002, Epel et al. 2004, 2006,
Chandola et al. 2006). The prolonged hyperactivity of the physiological stress mechanisms (i.e., the sympathetic-adrenergic-medullar system and the hypothalamic-pituitary-adrenal system), which slow the
organism's basic reparatory functions in order to reallocate energy and
prepare the body to meet the increased demands of the perceived situation (Frankenhauser 1989, Brunner 1997), may predispose a person to
cardiovascular disease through the wear and tear of the organism (i.e.,
accumulation of the so-called allostatic load) (McEwen & Stellar 1993,
McEwen 1998a & 1998b). Psychosocial work characteristics can also
aect cardiovascular disease through negative emotions (Musselman et
al. 1998, Kiecolt-Glaser et al. 2002, Belkic et al. 2004, Everson-Rose
& Lewis 2005, Suls & Bunde 2005). In addition, chronic work stress
may inuence cardiovascular disease indirectly through an unhealthy
life style, often associated with chronic strain, in particular low leisuretime physical activity, overweight, cigarette smoking, and heavy alcohol
consumption, or their co-manifestation (Kouvonen et al. 2005, Siegrist
& Rdel 2006, Kouvonen et al. 2007).
Summary
It has previously been suggested that burnout is related to ill health.

The present results from a representative sample of the Finnish working
population over 30 years of age strongly support this hypothesis. Burnout
showed a marked overlap with mental disorders and physical illnesses.
81
5. DISCUSSION
Because work stress has previously been shown to predispose people to

depressive and anxiety disorders, alcohol dependence, musculoskeletal
problems, and cardiovascular disease, it is plausible that burnout, as a
consequence of chronic work stress, is related to these disorders. On the
other hand, ill health has been shown to be related to exhaustion and a
negative evaluation of work characteristics. Therefore, it is also possible
that health problems predispose a person to burnout.
Distinction between burnout and ill health
Association with work characteristics
The consistent correlations between burnout and depressive symptoms

(Meier 1984, Firth et al. 1986, Landsbergis 1988, Seidman & Zager
1991, Glass et al. 1993, McKnight & Glass 1995, Baba et al. 1999,
Sears et al. 2000, Roelofs et al. 2005, Lindblom et al. 2006) have raised
the question of whether burnout is conceptually redundant to depression. This study provided an opportunity to compare the work-related
associations between burnout and depression and to evaluate the possible
redundancy of these concepts in relation to one health-related aspect of
the psychosocial work environment, the job strain.
In this study, work stress was operationalized according to the
job strain model, which has previously successfully predicted various
manifestations of ill health (van der Doef & Maes 1999, de Lange et
al. 2003, Kivimki et al. 2006b, Standsfeld & Candy 2006). High job
strain, when compared with low job strain, was related to burnout. This
nding strengthens the previous evidence on the association between job
strain and burnout, which has, to date, mainly been based on ndings
concerning exhaustion (Raerty 1987, Landsbergis 1988, Melamed et al.
1991, Bourbonnais et al. 1998, 1999). The association between high job
strain and burnout was independent of the indicators of mental health.
As a new contribution of the present study, the association between high
job strain and depressive disorders was found to be fully dependent on
burnout. In other words, after burnout was taken into account, there was
no direct relationship between job strain and depressive disorders.
Causal chains such as mediated eects cannot be inferred from crosssectional observational epidemiological data. However, such data can be
82
5. DISCUSSION
used to test whether the observed associations are consistent with what
one would expect if the path from job strain to burnout to depression
were causal.
In the present study, both of the operational criteria that would demonstrate a mediated eect of burnout between job strain and depressive
disorders were met (Kenny 2005). Firstly, an association between burnout
and depression was documented. Secondly, job strain was shown to be
associated with depression, but only when burnout was not accounted
for; the association between job strain and depressive disorders disappeared after adjustment for burnout. This kind of mediational eect
of burnout between job strain and depressive symptoms was recently
demonstrated also in a 3-year prospective study among dentists (Ahola
& Hakanen 2007). Burnout has further been shown to mediate between
work characteristics and health in studies in which health was indicated
by sickness absence (Bakker et al. 2003) or psychosomatic complaints
(Schaufeli & Bakker 2004). However, these elaborations need to be
veried with longitudinal data on depressive disorders among various
occupations to establish the direction of the associations and true causality between work, burnout, and depression.
The job strain model postulates that high job strain is a risk factor for
mental strain and health problems, while active work with high demands
and control is hypothesized to lead to average strain but also to favourable consequences, for example, work motivation and the development
of new behaviour patterns (Karasel & Theorell 1990). When compared
with low job strain in the present study, active work and passive work
were related to an increased probablity for burnout after adjustment for
mental health. These associations are in accordance with the ndings of
previous studies on burnout (Landbergis 1988) and exhaustion (Kauppinen-Toropainen et al. 1983, Bourbonnais et al. 1998, 1999). The
observed probablities related to active and passive work in the present
study were smaller than the one related to high-strain work. Corresponding associations were not found between active and passive work and
depressive disorders. These results strengthen the proposed dierential
associations with work characteristics for burnout and depression (Warr
1987, Maslach et al. 2001).
83
5. DISCUSSION
Association with work disability
The observed positive association between burnout and long medically

certied sickness absence is in line with earlier results that have shown
high work-related exhaustion to be associated with an increased prevalence of self-reported sickness absence in a Swedish working population
(Hallsten et al. 2002), human service work (Borritz et al. 2006), and
transportation work (Cunradi et al. 2005) and burnout to predict increased company-registered (Bakker et al. 2003) and medically certied
absences (Toppinen-Tanner et al. 2005).
As an original contribution of the present study, it was shown that
severe burnout had a positive association with long medically certied
sickness absence independently of co-existing common mental disorders
and physical illnesses in a nationally representative sample. The controlled disorders and illnesses included depressive, anxiety, and alcohol use
disorders, and musculoskeletal disorders, cardiovascular and respiratory
diseases, and a heterogeneous group of other physical illnesses, among
which are the leading causes of compensated sickness absences in Finland
(The Social Insurance Institution of Finland 2005). Because long sickness absences have been found to predict future disability pensioning
(Kivimki et al. 2004, Lund et al. 2007), this result suggests that burnout
may make a distinctive contribution to work disability when compared
with ill health and therefore further supports the independent status of
burnout in the arena of occupational health psychology.
Summary
Despite the strong associations between burnout and mental disorders

and physical illnesses, several ndings suggest that burnout may be
partly distinct from depressive disorders and from ill health in general.
Compared with depressive disorders, burnout was more strongly related
to high job strain, and it was related to active and passive work after
adjustments. The results were also consistent with the possibility that
burnout would mediate the eects of job strain on depressive disorders.
Furthermore, burnout had an independent contribution to work disability even when the eects of the co-occurring common mental disorders
and physical illnesses were taken into account.
84
5. DISCUSSION
Role of individual factors in burnout

Gender and the level of burnout
No gender dierences were found for the level of burnout syndrome.

This nding runs contrary to earlier results from population-based
studies showing women to experience a slightly higher level of burnout
than men (Kalimo & Toppinen 1997) or to be over-represented among
employees with a high level of burnout (Lindblom et al. 2006). However, women experienced a slightly higher level of exhaustion, and this
nding replicated the results of previous studies in human service work
(Maslach & Jackson 1981, Tyry 2005).
It has been suggested that the possible gender dierence in burnout
may reect dierences in roles and occupations (Schaufeli & Greenglass 2001). However, dierential exposure has generally accounted only
minimally for women's higher distress or lower health (Roxburgh 1996,
Denton et al. 2004). In addition to having generally less control at work,
women have been found to be more vulnerable to low job control than
men (Rugulies et al. 2006); this nding supports the dierential vulnerability to adverse conditions (Denton et al. 2004) and, especially, to low
job control. In the present study, the women tended to show a slightly
higher level of burnout when they had a low level of education or were
in manual work than other women did. Parallel results of women with a
low level of education showing worse health, indicated by self-reported
general and mental health, fatigue, and musculoskeletal symptoms, than
highly educated women was reported in a recent Swedish study (Dahlberg
2005). Vulnerability to low control may explain the association between
a low level of education or occupational status and a higher level of
burnout among women, because these socio-demographic factors are
strong correlates of job control.
An alternative explanation for the slightly higher level of burnout
among women in manual work is a gender dierence in the process of
worklife exit among men and women. In Finland, women have reached
the statutory retirement age more probably than men, who have retired
more often earlier on disability or unemployment pensions (Hakola
2000a & 2000 b). The healthy worker eect has been shown to operate
strongly among men in manual occupations (Bartley & Owen 1996). It
85
5. DISCUSSION
seems that men have to be healthy to remain employed in manual jobs.

This assumption may apply to a less extent to women, who can continue
to work with less selection and therefore be an unhealthier sub-population in their senior years than men are (Hakola 2000a).
The present result that those married had less burnout than those not
married recognizes social support as a general health resource (Broadhead et al. 1983, House et al. 1988). Signs of the protective eect of
marital status have earlier been reported for exhaustion (Hallsten et
al. 2002). However, when the analyses were segregated by gender, the
positive eect of marital status on burnout applied only to the men; the
married or co-habiting men showed less cynicism than the men who
were single, divorced, or widowed. Compared with women, men have
been reported to seek less social support when coping with job loss or
depression (Bebbington 1987, Salokangas et al. 1988, Leana & Feldman
1991). As being married has been found to be benecial especially to
men's health (House et al. 1988), it is possible that the family provides
men an important source of social support and therefore protects them
against burnout.
In light of the present dierent results among men and women, the
earlier mixed results on socio-demographic factors and burnout may be
due to unsegregated analyses by gender.
Gender differences in the associations between burnout and ill
health
The men with mild burnout in the present study had higher odds of
having a depressive disorder than the women with a similar level of burnout. At least two issues may explain this nding. Firstly, the importance
of work-related problems in the aetiology of mental disorders may be
greater among men than women. Work may be a more dominant arena
for men, whereas, for women, the aetiological factors of mental health
may be distributed across several spheres of life, including domestic
factors and social relations. Supporting this assumption, the relationship between work stress and the use of antidepressant medication was
found only among men in a Finnish population study (Virtanen et al.
2007). This assumption is also in line with studies showing unemployment to be a greater health risk for men than for women (Artazcoz et
86
5. DISCUSSION
al. 2004, Cooper et al. 2006). Furthermore, it was shown in a crosssectional study among white-collar workers that men's general distress
was mostly related to work conditions, while women's level of distress was
determined by the interaction between conditions at work and at home
(Krantz et al. 2005). Family structure and social relations were found to
be more important determinants of women's than men's health in the
large Canadian National Population Health Survey (Denton et al. 2004).
Secondly, as elaborated by Hensing et al. (1996), the stigma and social
consequences of having a psychiatric disorder may be worse at work for
men than for women due to cultural role expectations. Because men are
not supposed to show weakness, the consequences for the men suering
from mild burnout may be more severe than for the women.
In general, men have been found to use more alcohol and suer more
often from alcohol dependence than women (Grant et al. 2004, Pirkola
et al. 2005). This nding has been explained by a gender dierence in
social and cultural behaviour regarding alcohol use (Holmila & Raitasalo
2005). In the present study, the association between burnout and alcohol
dependence was similar and of about the same magnitude for both genders. This result may partly reect the changes in drinking habits among
women during the past several years, including an increase in alcohol
use (Grant et al. 2004, Raitasalo & Maaniemi 2007). Similar results for
men and women in this study may also indicate that, in the relationship
between burnout and serious alcohol problems, the signicance of individual factors outweigh the social and cultural behavioural models.
As a new contribution of this study, burnout was found to be related
to musculoskeletal disorders only among women when depression was
taken into account. Musculoskeletal disorders and many of their risk
factors have generally been more prevalent among women, and the
prevalence suggests dierential exposure (Punnet & Herbert 2000, de
Zwart et al. 2001). Women may also have a special vulnerability to
physical strain (Punnet & Herbert 2000, de Zwart et al. 2001). In spite
of possible gender dierences, previous analyses on work characteristics
and musculoskeletal problems have seldom been stratied by gender.
The relationship between burnout and musculoskeletal disorders needs
to be explored further in order to increase the understanding of why
the association between burnout and musculoskeletal disorders may be
mood-related only among men.
87
5. DISCUSSION
This study revealed that the association between burnout and cardiovascular diseases among women may depend on standard health risk
factors such as older age, a low level of education, a low occupational
grade, unmarried status (Hemingway & Marmot 1999, Kivimki et
al. 2002, Everson-Rose & Lewis 2005), and physical strain at work. In
contrast, the association between burnout and cardiovascular diseases
was independent of these factors among the men. Although the formal
test of gender dierence in the association between job strain and cardiovascular diseases failed to reach signicance in a meta-analysis (Kivimki
et al. 2006b), the evidence on the associations between job strain and
cardiovascular diseases have generally been stronger and more consistent
among men and more sparse and less consistent among women (Belkic
et al. 2004). Further supporting the gender dierence, the association
between burnout and cardiovascular biomarkers has also diered to some
extent between the genders (Shirom et al. 1997, Toker et al. 2005).
To understand how stress aects the development of cardiovascular
diseases among women, it may also be necessary to take into account
domestic strain, because women may still be more responsible for
domestic duties than men (Vnnen et al. 2004). The combined exposure to a high amount of both paid work hours and household work
hours was signicantly related to a high level of distress among women,
whereas men's distress was related to high paid work hours and not to
household work hours in a cross-sectional study among white-collar
workers (Krantz et al. 2005). Indeed, a double exposure to stress from
work and from marriage was associated with the highest risk for coronary
disease among women in the Stockholm Female Coronary Risk Study
(Orth-Gomr & Leineweber 2005). Furthermore, low control at home
predicted cardiovascular diseases among women but not among men in
the prospective Whitehall II study among British civil servants (Chandola
et al. 2004). Therefore, uncontrolled domestic strain may have imputed
the association between burnout and cardiovascular diseases among the
women in the present study.
Among the women, mild burnout was also independently related to
sickness absence in contrast to the situation among the men. Instead,
only for the men was severe burnout related to delayed return to work.
Similar results showing that women have more absences and men have
longer absences have been obtained previously concerning psychiatric
88
5. DISCUSSION
disorders and sickness absence in a Swedish population-based register

study (Hensing et al. 1996). In the NEMESIS study, mental disorders
were more important predictors of sickness absence among men than
among women (Laitinen-Krispijn & Bijl 2000).
A study with a large random British sample indicated that men tend
to seek any form of help for stress or strain to a less degree than women
(Oliver et al. 2005). A similar trend emerged concerning seeking professional help for psychiatric problems in four large-scale North American
surveys (Kessler et al. 1981) and in a random Canadian sample (Bland
et al. 1997). It seems that women interpret feelings of distress as signs
of problems needing help more likely than men (Kessler et al. 1981).
Therefore, women seek help more probably in distress and may get it in
an earlier phase of the problematic situation than men do. If men miss
professional advice and also obtain less social support, which among
women can buer mental health problems during work stress (Stansfeld
et al. 1997, Vnnen et al. 2003), the problems may accumulate and a
longer absence would then be needed for men to recover.
Age and the level of burnout
In contrast to what has been presented in two previous burnout reviews

(Schaufeli & Enzmann 1998, Maslach et al. 2001), the level of burnout
was not lower in the older age groups in the present sample of the Finnish working population aged 30 years or over. Instead, the prevalence
of burnout seemed to slightly increase with age, although the absolute
dierences between the age groups were small. Corresponding ndings
have been obtained from Swedish and previous Finnish population-based
samples (Kalimo & Toppinen 1997, Lindblom et al. 2006). Population
studies catch all workers in dierent age groups and also those who
might have changed jobs or occupations because of burnout. Therefore,
population studies may provide a more reliable view on the relationship
between age and burnout than studies using non-random occupational
or organizational samples.
There are at least two conceivable explanations for an age-related
increase in burnout. Firstly, the exposure time models of stress state
that the incidence of ill health increases with the duration of the stressor exposure (Zapf et al. 1996). In line with these models, it has been
89
5. DISCUSSION
shown that prolonged exposure to poor psychosocial factors increases the

probability of reduced well-being and the risk of disease (Kivimki et al.
2002, Kalimo et al. 2003, Kivimki et al. 2006a, Rugulies et al. 2006). It
has also been emphasized that burnout takes time to develop (Schaufeli &
Enzmann 1998, Maslach et al. 2001) and that the symptoms are persistent
over time (McKnight & Glass 1995, Bakker et al. 2000b, Taris et al. 2005).
Secondly, the change in worklife in Western countries has been rapid during
the past decade. Earlier, age with accumulating work experience usually
benetted the worker, raising his or her status and prociency. In today's
continuously changing worklife, the growing demands for learning and
exibility may become a burden particularly for ageing workers who, on
average, have less education than younger workers. However, the situation
of young employees needs to be investigated in more detail in future studies
because employees under 30 years of age were not included in the medical
examination of the Health 2000 Study, which determined the inclusion
criteria in the present study. In a previous Finnish population study on
burnout, which included employees from 24 years of age on, no dierence in the prevalence of burnout was detected between the age groups of
2434 years and 3544 years (Kalimo & Toppinen 1997).
However, it is also possible that age and accompanying work experience are benecial in some sectors of the labour market. The negative association between age and burnout reported in burnout reviews (Schaufeli
& Enzmann 1998, Maslach et al. 2001) is based on research done in
human service work (Maslach & Jackson 1981, Mor & Laliberte 1984,
Birch et al. 1986, Huberty & Huebner 1988, Rogers & Dodson 1988,
Poulin & Walter 1993, Vredenburgh et al. 1999) and was also found for
a nationally representative sample of Finnish physicians (Tyry 2005).
The experienced human service workers may have learned special professional and coping skills that protected them especially against burnout
in demanding non-reciprocal interactions. This issue should be explored
further in the future by comparing human service workers with employees
in non-human service professions in population-based samples.
Summary
Gender was not related to the level of burnout, but the associations
between burnout and other socio-demographic factors and ill health
90
5. DISCUSSION
diered to some extent for the men and women. Especially among the
men, burnout was related to being unmarried, having a cardiovascular
disease, and being longer on sick leave. Especially among the women,
burnout was related to low-quality jobs and having a musculoskeletal
disorder. These gender dierences may partly explain earlier mixed results
concerning burnout and these factors in samples combining men and
women. The positive association between age and the level of burnout in
a working population may reect the accumulated eects of prolonged
work stress over time.
5.3 Evaluation of the study

Assessment of burnout
The general version, the MBI-GS (Schaufeli et al. 1996), of the most
widely used and most extensively validated burnout instrument, the MBI
(Maslach & Jackson 1996), was chosen for the assessment of burnout in
the Health 2000 Study because it is widely regarded as a gold standard
for measuring burnout (Schaufeli & Enzmann 1998, Schaufeli & Taris
2005). Satisfactory reliability and validity has been conrmed for the
MBI-GS in dierent occupations (Leiter & Schaufeli 1996, Taris et al.
1999, Schutte et al. 2000, Bakker et al. 2002). The nationally established
procedure used in the present study to form a weighted sum score for
the burnout syndrome and to categorize the burnout sum score in three
levels on the basis of the frequency of the symptoms (Kalimo et al. 2006)
has been published in a peer-reviewed scientic journal (Kalimo et al.
2003), but its clinical validity has not been conrmed.
The results of the present study are dependent on the three-dimensional conceptualization of burnout, which has been criticized for its
vague theoretical basis and a circular argument between the denition of
burnout and the related measure of burnout (Shirom 2003, Kristensen
et al. 2005). The associations between the three-dimensional operationalization of burnout and health may be stronger than the ones obtained
between exhaustion and health, because the three-dimensional burnout
syndrome has been proposed to be a possible consequence of prolonged
exhaustion in the stress process. The available alternatives for assessing
91
5. DISCUSSION
burnout are not free of deciencies (Schaufeli & Taris 2005) and are
much less evaluated and known. In the future, burnout research would
benet from reaching a shared consensus denition for burnout and from
validated multi-method practice guidelines for its assessment.
Major strengths
This study employed a large population-based sample that represented

the 30- to 64-year-old working population of Finland, including also
employees who were on sick leave or leave of absence. This sample gives
a unique quality to the present study as, to our knowledge, no previous
ndings on burnout and its correlates from nationally representative
samples have been published in international peer-reviewed journals.
The participation rate in the data collection of the present study was
high; at least 80% of the working-age participants were covered. The
use of weighting adjustment and sampling parameters in the analyses
enabled the complex sample survey design and dierences in sample attrition between subgroups to be accounted for. Therefore, the acquired
results concerning burnout can be generalized to worklife, including all
occupational branches in the age range of the participants.
Another major strength of the present study was its assessment of the
health and work disability of the participants. The assessment of mental
disorders was based on a fully standardized diagnostic interview, the CIDI,
which provided the estimates for the diagnoses of DSM-IV mental disorders (Andrews & Peters 1998, Wittchen et al. 1998). The CIDI has been
shown to be a valid method for assessing common mental non-psychotic
disorders among primary care attendees (Jordanova et al. 2004) but it has
not been validated in general populations. In a community setting, the
depression module of the CIDI has been found to over-estimate prevalence
rates slightly (Kurdyak & Gnam 2005). This over-estimation may have
led to a slight ination of the associations between burnout and depressive disorders and over-adjustment in the observed relationship between
burnout and work disability. The assessment of physical illnesses was based
on a comprehensive clinical health examination including a symptom
interview, a history, and a medical examination by a research physician.
Work disability was indicated by medically certied sickness absences for
over 9 consecutive work days (Kivimki et al. 2004, Lund et al. 2007),
92
5. DISCUSSION
which were extracted from a register of The Social Insurance Institution

of Finland covering all Finnish citizens. In the present study, the CIDI
interview, the clinical health examination, and the use of absence records
reduced the risks of common method bias, confounding by negative affectivity, selective record bias, and other problems characterizing research
with only self-reported data.
Study limitations
The main limitation of the present study was its cross-sectional design,
which does not allow for the ascertainment of temporal order in the associations between burnout and ill health. These associations are open
to reversed causality (i.e., the direction of the associations remains unknown). In addition, due to the cross-sectional design, it was not possible
to dierentiate between the actual development of burnout during the
work career and a cohort eect.
The cross-sectional design was especially problematic in the examination of the associations between job strain and burnout, both of which
were self-assessed and therefore had an association open to the eects of
common method variance (Lindell & Whitney 2001). In a meta-analytic
review, burnout has been shown to be related to negative aectivity (i.e.,
a predisposition to experience negative emotions) (Watson & Clark 1984,
Thorensen et al. 2003). Negative aectivity can colour all perceptions
(Brief et al. 1988) and therefore may have articially strengthened the
observed relationship between job strain and burnout in the present
study. However, the relationships between work stressors and experienced
strain have tended to remain signicant after adjustment for negative
aectivity (Parkes 1990, Chen & Spector 1991, Moyle 1995, de Jonge
et al. 2001). Job strain was more strongly related to burnout than to
depression even when depression was also self-assessed in a longitudinal
design (Ahola & Hakanen 2007); this nding suggests that the stronger
association between job strain and burnout than the one between job
strain and depression would not solely be an articial result of common
method variance. However, longitudinal studies on work, burnout, and
health are called for to clarify the complex temporal associations in the
process of stress in the work context.
93
5. DISCUSSION
The sampling excluded those 18 to 29 years of age from the health

examination for nancial reasons; too, chronic illnesses are usually less
common among the young. It is possibile that this exclusion may have
slightly aected the observed association between burnout and illnesses.
Therefore, the results can be most reliably generalized to employees over
30 years of age.
Of the mental disorders, the three prevalent and relevant groups
of disorders regarding working populations (i.e., depressive disorders,
anxiety disorders, and alcohol dependence) (Sanderson & Andrews
2006, Honkonen et al. 2007) were analysed in relation to burnout. Of
the physical illnesses, musculoskeletal and cardiovascular disorders were
investigated in detail because they are among the leading causes for work
disability in Finland (The Social Insurance Institution of Finland 2005).
These disorders and illnesses belonged also to those that have been shown
previously to be related to exhaustion (Shirom et al. 2005). When sickness absence was explored, also alcohol abuse was included in the mental
disorders, and respiratory diseases and a mixed group of physical illnesses
were added to the physical illnesses used as confounding factors.
Not all of the possible disorders and illnesses that the subjects might
have had were recorded. They include adjustment disorders and neurasthenia, which may be used as a diagnosis in cases of burnout (Schaufeli
et al. 2001, Glass et al. 2004), and personality disorders. Therefore, the
present study may present an underestimation in the overall prevalence
of ill health in relation to burnout, as well as regarding the adjustment
for sickness absence. In addition, personality, temperament, and other
individual factors, including recent life events, were not controlled for,
and it is not known whether these variables would have modied the
relationships between burnout and ill health. These possible associations
remain as an important subject to be examined in future studies.
5.4 Conclusions
The present ndings concerning the Finnish working population suggest that occupational burnout is strongly related to ill health. Burnout
and common mental disorders seem to co-occur among both men and
women; the most substantial overlap was observed with depressive dis-
94
5. DISCUSSION
orders. There is also common co-existence with burnout and physical

illnesses. After possible confounders were taken into account, burnout
was related to musculoskeletal disorders among the women and to cardiovascular diseases among the men. Because the design of this study
was cross-sectional, no inferences can be drawn about the true temporal
order between burnout and the manifestations of ill health.
Burnout was also related to long medically certied sickness absences.
Severe burnout has an independent contribution to sickness absence,
which was not totally accounted for by common mental disorders
and physical illnesses. Especially among the men, the absences due to
severe burnout were lengthy, lasting twice as long as those for physical
illnesses.
The association between burnout and depressive disorders, musculoskeletal disorders, and cardiovascular diseases was evident for all three
dimensions of burnout; this nding suggests that the associations between
burnout and ill health are not explained solely by the exhaustion dimension of burnout. Signicant associations concerning all three dimensions
of burnout may justify the use of the three-dimensional burnout concept
and a total burnout score.
Despite the strong associations between burnout and disorders and
illnesses, burnout does not seem to be totally redundant to ill health.
Burnout was more strongly work-related than depressive disorders and
severe burnout was related to work disability independently of common
disorders and illnesses.
The present data suggest that there are no substantial dierences in
the level of burnout between subgroups of socio-demographic factors.
However, the associations between burnout and other socio-demographic
factors diered to some extent between the genders. Burnout is also partly
a dierent kind of health risk for men and women. Among the men, mild
burnout was a higher risk in relation to depressive disorders, and severe
burnout was associated with delayed return to work, while, among the
women, mild burnout was more probably related to absence from work.
Although cohort eects cannot be excluded, the possible positive association between age and burnout suggests that conditions increasing
the risk of burnout either accumulate over time or are more prevalent
among older employees. The present ndings suggest that burnout may
capture accumulating psychological work-related strain.
95
5. DISCUSSION
5.5 Policy implications

In order to promote health and prevent an early exit from the labour
market, the work situation of clients should always be assessed in health
care when working-age persons are being delt with. Burnout can be directly screened when work-related problems are encountered in medical
check-ups and in occupational health services. Severe burnout can be
regarded as a proxy for health-impairing work stress, and therefore can
serve as a risk marker for work disability.
Many of the work-related variables associated with a high level of
psychological ill health are potentially amenable to change (Michie &
Williams 2003, Bourbonnais et al. 2006). Continuous improvement
of psychosocial work characteristics could probably help prevent some
burnout, and it could be facilitated by regular workplace surveys. In
order to elicit the need for individual and occupational interventions,
it may be benecial to use coding for burnout in addition to making a
diagnosis, as a factor that aects health status (World Health Organization 1992) or a condition that may require clinical attention (American Psychiatric Association 1994), in all health care contacts. Besides
tailored individual interventions, a change in the work conditions in
which burnout has evolved may promote long-lasting recovery from
this stress-related condition (Bernier 1998, Weber & Jaekel-Reinhard
2000, Glass et al. 2004).
A higher probability of burnout among ageing workers is challenging
when contrasted with the national aims to lengthen the approximate
work career of the population set in face of the ageing work force and
the tendency towards early retirement in Finland and other European
countries (Jrvisalo et al. 2005, Ilmarinen 2006a & 2006b). In addition to ageing workers, special attention should be paid to women with
low-quality jobs and men with work-related problems, since some associations with burnout were highlighted in these groups. It is likely that,
to be eective, interventions need to be tailored according to the special
characteristics of the target group.
96
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Occupational burnout and health

People and Work

Finnish Institute of Occupational Health

2. PRESENT STUDY ........................................................ 39

5.3 Evaluation of the study .........................................

the women and cardiovascular diseases among the men independently

sairauksiin miehill niden sairausryhmien tavallisten riskitekijiden

LIST OF ORIGINAL PUBLICATIONS

Ahola, K., Honkonen, T., Kivimki, M., Virtanen, M., Isomets,

LIST OF ORIGINAL PUBLICATIONS

Honkonen, T., Ahola, K., Pertovaara, M., Isomets, E., Kalimo,

1.1 Concept of occupational burnout

Enzmann 1998). Regarding unfavourable work conditions, occupational

cluster of heterogeneous symptoms (Shirom 2003, Kristensen et al.

1.2 Socio-demographic factors and

A high level of burnout

Exhaustion was commoner

Burnout was commoner

Table 1. Review of the population-based studies on socio-demographic factors and burnout

1.3 Job strain and occupational burnout

available to the worker facing these demands in making decisions on

not peer-reviewed; MBI = Maslach Burnout Inventory; BM = Burnout Measure

Table 2. Review of the literature on job strain and burnout

Focussed job demands and job

High job strain, active work, and

High job strain, active work, and

The effect of stressors at work on

The lowest level of exhaustion

Emotional exhaustion was higher

High job strain compared with

The joint effect of time pressure

1.4 Occupational burnout and health

Summaries of the existing publications on burnout and mental health

20-year longitudinal survey (72%

Table 3. Review of the literature on burnout and depression

Emotional exhaustion (MBI)

2-year longitudinal survey (85%

1-year longitudinal survey (57%

Pattern of responding (Teacher

Emotional exhaustion and

1-year longitudinal survey (85%)

Teachers in several schools

Syndrome of exhaustion (SBS-HP)

Modified three-dimensional syndrome

Twins and their

Working population of one

Consecutive patients with clinical burnout and

Syndrome of exhaustion (SMBM)

Burnout correlated positively

Employed clients of one

Female nurses in one

Nursing staff in one

Health care workers in

Female welfare workers

Syndrome of exhaustion (SMBM)

Table 4. Review of the literature on burnout and anxiety

work-related exhaustion (CBI)

Cross-sectional medical examination (69%)

MBI-GS = Maslach Burnout Inventory-General Survey

Patients with physician-diagnosed pain

Table 6. Review of the literature on burnout and musculoskeletal problems

Burnout was the

Patients with pain