Burnout as a predictor of all-cause mortality among industrial employees: a 10-year prospective register-linkage study
Journal of Psychosomatic Research 69 (2010) 51 – 57
Burnout as a predictor of all-cause mortality among industrial employees:
A 10-year prospective register-linkage study☆
Kirsi Aholaa,⁎, Ari Väänänena, Aki Koskinena, Anne Kouvonenb, Arie Shiromc
aFinnish Institute of Occupational Health, Helsinki, Finland
bInstitute of Work, Health, and Organizations, University of Nottingham, Nottingham, United Kingdom
Received 3 August 2009; received in revised form 17 December 2009; accepted 5 January 2010
Objective: Burnout, a psychological consequence of pro-
graphic factors and register-based health status according to
longed work stress, has been shown to coexist with physical and
entitled medical reimbursement and prescribed medication for
mental disorders. The aim of this study was to investigate
mental health problems, cardiac risk factors, and pain problems.
whether burnout is related to all-cause mortality among employ-
Results: During the 10-year 10-month follow-up, a total of 199
ees. Methods: In 1996, of 15,466 Finnish forest industry
employees had died. The risk of mortality per one-unit increase
employees, 9705 participated in the ‘Still Working’ study and
in burnout was 35% higher (95% CI 1.07–1.71) for total score
8371 were subsequently identified from the National Population
and 26% higher (0.99–1.60) for exhaustion, 29% higher for
Register. Those who had been treated in a hospital for the most
cynicism (1.03–1.62), and 22% higher for diminished profes-
common causes of death prior to the assessment of burnout were
sional efficacy (0.96–1.55) in participants who had been under
excluded on the basis of the Hospital Discharge Register,
45 at baseline. After adjustments, only the associations regarding
resulting in a final study population of 7396 people. Burnout was
burnout and exhaustion were statistically significant. Burnout
measured using the Maslach Burnout Inventory–General Survey.
was not related to mortality among the older employees.
Dates of death from 1996 to 2006 were extracted from the
Conclusion: Burnout, especially work-related exhaustion, may
National Mortality Register. Mortality was predicted with Cox
hazard regression models, controlling for baseline sociodemo-
2010 Elsevier Inc. All rights reserved.
Keywords: Burnout; Exhaustion; Forest industry; Mortality; Prospective; Work
have been found to contribute to the risk of early death.
Furthermore, high experienced justice at work has been
Extensive overwork is acknowledged as a serious health
shown to buffer against premature death .
risk In Japan, the phenomenon of Karoshi—death from
Burnout is a psychological reaction to chronic work stress
overwork—has recently been recognized as a social concern
with the core content of gradual depletion of employ-
. Also, other psychosocial work conditions, such as low
ees' intrinsic energetic resources over time The
job control high job strain, and effort–reward
most widely used conceptualization (e.g., Ref. ) views
imbalance , and major downsizing in the organization
burnout as consisting of three major components: exhaus-tion, cynicism, and diminished professional efficacy
☆ This work was supported by the Academy of Finland (grant number
The estimated prevalence of severe burnout has ranged from
128089) and the Finnish Work Environment Fund (grant number 109395,
3% to 7% in representative working populations
Several work characteristics, such as high workload, role
⁎ Corresponding author. Finnish Institute of Occupational Health,
conflict and ambiguity, low predictability, lack of participa-
Topeliuksenkatu 41 a A, FI-00250 Helsinki, Finland. Tel.: +358 30 474
tion and support, and experienced unfairness, have also been
0022-3999/10/$ – see front matter 2010 Elsevier Inc. All rights reserved.
K. Ahola et al. / Journal of Psychosomatic Research 69 (2010) 51–57
In some European countries, burnout has entitled
disease was emphasized in the group of workers less than 50
financial compensation and the use of rehabilitation services
years of age Since burnout develops as a consequence
for employees. In Sweden, for example, burnout has been a
of prolonged work stress , it is possible also that the
legitimate diagnosis for medical certificates , and in
association between burnout and mortality might differ
the Netherlands, burnout has been considered an occupa-
according to the age of the workers.
tional disease justifying work disability benefits . In
The aim of the present study was to investigate whether
Finland, burnout does not justify compensation, but it has
burnout predicts all-cause mortality among forest industry
been shown to independently associate with physician-
employees. We took the baseline health status of the
diagnosed sickness absences and to predict disability
participants into account by excluding those with major
pensions . Burnout-related absences tend to last for
health problems and by adjusting for minor health
relatively long periods , the excess risk being approx-
problems. Following the above rationale, we examined
imately 50–65 working days However, to our
age group as a potential moderator of the relationship
knowledge, there are no prospective studies linking burnout
Burnout has been shown to often coexist with depressive,
anxiety, and alcohol use disorders and musculoskel-
etal disorders and cardiovascular diseases . In addition,in a 4-year prospective study of initially healthy men,
burnout was associated with a twofold risk of developing amyocardial infarction Burnout has also been found to
This study is a part of the ongoing ‘Still Working’ cohort
predict diabetes , the common cold and sick leaves
study examining work-related antecedents of health, mor-
due to musculoskeletal disorders and diseases of the
bidity, and mortality in a multinational private sector forest
respiratory system . Furthermore, burnout has been
industry corporation . The researchers gave each
found to predict depressive symptoms , new cases of
employee in the corporation an identification code, which
insomnia and sickness absences due to mental and
was marked in the questionnaire. The link between this
identification code and the national personal identification
The process between stress and health problems can be
number given to all Finns at birth was known only to the
direct (i.e., stress predisposing to illness or accelerating the
researchers and used later to merge the questionnaire data
disease process in its subclinical phase), indirect (i.e., stress
collected in 1996 to data from several national Finnish
increasing unfavorable health behavior), or even reversed
registers till the end of 2006. During spring 1996, the
(i.e., coping with illnesses at work further increasing stress)
questionnaires which at that point did not contain any
. As burnout reflects past accumulated exposure to a
personal information were sent to the work units, distributed
variety of stressful conditions at work , it may be a phase
to employees by their supervisors, and, once completed,
in the process between adverse psychosocial factors at work
mailed directly to the Finnish Institute of Occupational
and ill health. However, it is equally possible that the early
Health. Participation was voluntary, and confidentiality was
phases of illnesses reduce the possibilities to reach one's
assured to all employees. Approval of the Ethics Committee
goals at work, eventually leading to burnout .
of the Finnish Institute of Occupational Health was obtained
For example, in a prospective study among Finnish dentists,
a reciprocal relationship between burnout and depressionwas established. However, the relationship between job
strain and depression was totally mediated by burnout, whilethe relationship between job strain and burnout was only
Of the eligible Finnish employees aged 16–65 years
partially mediated by depression The mechanisms
(n=15,466) who returned the questionnaire (n=9705, re-
linking chronic stress and strain with mortality are
sponse rate 63%), 8371 could later be identified from the
relevant in explaining the biological plausibility of the work
database of the National Population Register Centre contain-
ing the personal information. Of this base population, the
In a long-term cohort study, the association between
542 people who before baseline, according to the Finnish
burnout and diseases may differ between workers of
Hospital Discharge Register, had already been treated as an
separate age groups. Older workers are more likely to
in-patient for the most common causes of death in Finland,
leave the work force or retire during the follow-up period.
i.e., alcohol problems, heart disease, cancer, and suicide
Therefore, those who continue working until the official
attempt were excluded. Furthermore, 433 persons were
retirement age may be characterized by especially high
excluded due to missing values in the relevant items in the
resiliency and effective health-enhancing coping strategies.
questionnaire leaving 7396 employees in the final study
Supporting this line of reasoning, recent longitudinal
population. Women (24% vs. 21%, Pb.001), nonmanual
evidence showed that the association between chronic
workers (38% vs. 19%, Pb.001), and married participants
work-related stress and an increased risk of cardiovascular
(65% vs. 60%, Pb.001) were overrepresented in the final
K. Ahola et al. / Journal of Psychosomatic Research 69 (2010) 51–57
study sample compared to the original population, whereas
age, gender, and marital status were obtained from the
no difference emerged regarding age group, formed by
National Population Register Centre. Marital status was
dichotomizing the age distribution at its medium, i.e., 44
dichotomized as married vs. unmarried based on the register
years (P=.146). In addition, mortality was higher among
information. Occupational status was collected from
those excluded compared to those in the final study
employer's records. It was dichotomized as manual (i.e.,
production and maintenance) vs. nonmanual worker (i.e.,supervisory, research, developmental, and office work).
Burnout was measured using the Maslach Burnout
Inventory–General Survey (MBI-GS) The MBI-
The associations between the burnout and the subscales
GS consists of the following three subscales: exhaustion
and mortality were analyzed using Cox proportional hazard
(five items, Cronbach's α=0.87), cynicism (five items,
regression models. For each participant, person-days of
α=0.76), and (diminished) professional efficacy (six items,
follow-up were calculated from 1 March 1996 to either the
α=0.83). Satisfactory reliability and validity of the MBI-
event of death or 31 December 2006, whichever came first.
GS have been confirmed In the present study, one of
Hazard ratios (HR) and their 95% confidence intervals (95%
the cynicism items was left out due to its low correlation with
CI) provided risk estimates associated with the 1-S.D.
the other items intended to measure cynicism (α=0.83
increase in the standardized burnout and subscale sum scores
afterwards). The items were scored on a seven-point
for overall mortality. The time-dependent interaction terms
frequency rating scale ranging from 0 (never) to six (daily).
between the burnout and the subscales and logarithm of the
High scores for exhaustion and cynicism and low scores for
follow-up period were examined to confirm that
professional efficacy are indicative of burnout. The items of
the proportional hazards assumptions were justified. The
professional efficacy were reversed (diminished professional
analyses were adjusted stepwise for sociodemographic
efficacy). One missing value per burnout subscale was
factors and health problems at baseline. The significance of
allowed. A sum score, in which exhaustion, cynicism, and
interaction effects on mortality between total burnout and its
lack of professional efficacy have different weights (0.4×ex-
three subscales, and age group or gender of the respondents
haustion+0.3×cynicism+0.3×lack of professional efficacy),
was systematically tested by including interaction terms in
the models. In case of a significant interaction, the analyses
The date of dying from the death certificate was extracted
were stratified. Two-tailed P values below .05 were
from the National Mortality Register maintained by Statistics
considered to indicate statistical significance. The analyses
Finland from 1 March 1996 to 31 December 2006.
were performed using the SAS statistical program package,
Registered medication use was taken as an indicator of
version 9.1 (SAS Institute, Cary, NC, USA).
minor health problems affecting the coping resources of theworkers. All Finns are entitled to drug reimbursement as partof the national public health insurance . Firstly, approved
drugs qualify for partial reimbursement under the basicrefund category. All outpatient drug purchases are contained
The majority of the study participants were men (76%),
in the Prescription Register according to the Anatomical
manual workers (62%), and married (65%) employees. The
Therapeutic Chemical classification code . Secondly,
mean age of the participants was 43 (S.D. 9 years, median 44
drugs used to treat certain chronic illnesses are fully
years, range 16–65 years). The detailed characteristics of the
reimbursed under the special refund category. These
study population are presented in according to the
entitlements are contained in the Special Refund Entitlement
Register. The totally reimbursed medication (for example,
All of the time-dependent interaction terms between
diabetes mellitus, chronic hypertension, chronic coronary
burnout and the subscales and the logarithm of the follow-up
artery disease, and hyperlipidemia) until 1996 and the
period were nonsignificant (PN.20), indicating that the
partially reimbursed medication for mental health problems
association between burnout and mortality was not moder-
(psycholeptics and antidepressants), cardiac risk factors
ated by the time elapsed between survey and death, therefore
(cardiac therapy, antihypertensive, and lipid-modifying
justifying the use of proportional hazard models. Significant
agents), and pain problems (anti-inflammatory and antirheu-
interaction effects between burnout and the exhaustion
matic products) during 1994 and 1995, as the most common
component and age group (P=.02 and .04, respectively) were
causes for work disability in Finland, were adjusted for in
found. Therefore, the analyses were stratified by age group.
A total of 199 (3%) of the employees died during the
Sociodemographic factors, i.e., age, gender, marital
follow-up. The results showed that a one-unit increase in the
status, and occupational status, were used as covariates in
standardized burnout sum score was related to a 35%
the analyses because they have been shown to relate to the
increase in the risk of all-cause mortality among workers
level of burnout as well as to mortality Data on
younger than 45. The association attenuated (HR=1.31) but
K. Ahola et al. / Journal of Psychosomatic Research 69 (2010) 51–57
predicted mortality among the younger workers. Each one-
Characteristics of the study population by age group
unit increase in the sum score was related to a 29% increase
in the risk of mortality. However, this association attenuated
after adjustment for sociodemographic factors and was nolonger statistically significant. The younger workers who
reported diminished professional efficacy were at a 22%
excess risk of mortality, but this association did not reach
statistical significance before or after adjustments. The
burnout subscales did not predict mortality among the
older workers, i.e., those who had been at least 45 years old
In this prospective cohort study linking various indepen-
dent health-related national registers, overall burnout and the
exhaustion component were related to all-cause mortality
during the 10-year 10-month follow-up period among those
forest industry workers who at baseline were under 45 years
of age, after the sociodemographic factors and health
problems of the participants at baseline had been taken
into account. The cynicism component of burnout predicted
mortality before but not after adjustments, suggesting thatthis association was affected by sociodemographic factors.
remained significant after all adjustments ().
The association between the third subscale of burnout, i.e.,
Exhaustion sum score was related to a 26% increase in the
diminished professional efficacy, and mortality was weak
risk of mortality among younger workers, but the association
and did not reach statistical significance. Among employees
failed to reach significance. However, when adjusted for
aged 45 or over, burnout was not associated with mortality.
sociodemographic factors, this association was statistically
Burnout is a result of chronic work stress . The
significant. After further adjustment for health problems at
present results concerning the association between burnout
baseline, the excess risk of mortality related to a 1-S.D.
and subsequent mortality are in accordance with Japanese
findings that working too much can lead to death, i.e., the
Table 2Hazard ratios of one-unit increase in the standardized burnout subscales for overall mortality among Finnish forest industry workers between 1996 and 2006 byage group
HR, Hazard ratio; CI, confidence interval; PE, professional efficacy.
a Model 1 is unadjusted.
b Model 2 is adjusted for baseline gender, marital status, and socioeconomic status.
c Model 3 is adjusted for baseline gender, marital status, socioeconomic status, and common risk factors for health and work ability (by register-based
medication, for example, for coronary artery disease, depression, diabetes, hyperlipidemia, hypertension, and pain).
K. Ahola et al. / Journal of Psychosomatic Research 69 (2010) 51–57
Karoshi phenomena—death by overwork Also, other
, is the core of burnout and especially related to
aspects of overload have in prospective studies shown lethal
the process of deteriorating health .
consequences for workers, for example, high job strain and
The association between burnout and exhaustion and
effort–reward imbalance , low job control ,
mortality was observed only among younger workers, a
experienced injustice and major downsizing in the
group formed by dichotomizing the baseline age distribution
at its medium, i.e., 44 years. In the WOLF Stockholm Study,
The most common specific causes of death among
it was suggested that the inclusion of older employees may
working-age Finns are alcohol-related causes, coronary
dilute the association between job strain and cardiovascular
artery disease, accidents, suicide, and specific cancers (breast
disease as a result of the healthy worker survivor bias
cancer in women and lung cancer in men) . The possible
Because work disability increases with age, it has been found
pathways linking burnout to mortality should be further
that men in manual jobs in particular are healthier than those
explored in future research. There may be several plausible
who drift outside the work force . Therefore, the level of
mechanisms to account for the observed associations. For
job strain may decrease in the group still working and its
example, there is a body of evidence supporting the
effects may be weaker among the remaining participants
association between burnout and the risk factors for
leading to a lower risk of burnout-related mortality in the
cardiovascular disease: at least several components of the
group of workers who were older at baseline. The association
metabolic syndrome, i.e., change in stress hormone levels,
between exhaustion and mortality was not statistically
low-grade inflammation, impairment of the immune system,
significant until adjusted for gender, marital status, and
blood coagulation, and fibrinolysis, have been found to be
occupational status. This indicates that there may be other
associated with burnout . The evidence on burnout and
factors, in addition to age, which affect the exhaustion-
health-risk behaviors is scarce and inconsistent , but
the results that have linked work stress to a higher likelihood
There are several limitations to be taken into consider-
of adverse health behaviors support the possibility of
ation in this study. First, we used a nonrandom sample in
an additional, indirect path between burnout and cardiovas-
only one occupational branch, the forest industry. Although
our target organization, a large private sector company,
Furthermore, burnout is related to an increase in the level
employs heterogeneous personnel ranging from production
of depressive symptoms and it often coexists with
to managerial work, the majority of the study sample
depressive disorders . Depression may in turn predispose
comprised manual workers. However, it has been shown that
to suicide and hazardous behavior leading to accidents
burnout can evolve in all types of work and that the
as well as to cardiovascular diseases It also
process of burning out is similar among blue- and white-
has high comorbidity with alcohol problems These
collar workers In the final study sample, women were
observations support the mental health-related link between
overrepresented compared to the original, male-dominated
burnout and mortality as another possible mechanism.
personnel. However, the risk of burnout was shown not to
To our knowledge, there is no specific evidence on the
differ by gender in the Finnish working population
mechanism linking burnout to cancer or other kinds of
Furthermore, there was no statistically significant interaction
neoplasm. It is possible that, in addition to the cause-specific
between gender and burnout on mortality.
links between burnout and mortality, part of the burnout-
Second, even though the original response rate (63%) was
related mortality risk is general in nature, i.e., associated with
of a satisfactory level in relation to observational studies in
the depletion of total health resources. A previous study on
general the final identified sample with no missing
the current cohort showed that, in addition to associating
information at baseline covered only 48% of all employees.
with disability pensions due to mental disorders, exhaustion-
Fortunately, the mortality data were complete, i.e., covered
related chronic work disability was related to the combined
all employees, and were therefore not influenced by the
group of miscellaneous disorders as the diagnosed cause of
degree of burnout. The final study sample suffered from the
healthy worker effect, i.e., that the participants were healthier
In previous population-based studies, all three burnout
according to mortality than those missing. This observation
components have been shown to relate to health when
suggests increased pathology among those excluded.
indicated by coexisting illnesses , while the exhaus-
Therefore, the most likely consequence, if any, is a possible
tion and cynicism subscales have mediated the association
underestimation of the association between burnout and
with work disability . However, in the present
mortality. However, caution is warranted regarding gener-
prospective study in an industrial sample, in addition to
alization of these results to other, dissimilar populations.
burnout syndrome, only the exhaustion subscale predicted
Thirdly, even though the sample was large, mortality was
mortality after adjustments. The components of burnout have
quite rare during the approximately 10-year follow-up period
been shown to relate differently to various aspects of the
which may have caused diminished statistical power in the
work environment and individual well-being It has
stratified analyses. All in all, these findings need to be
previously been suggested that the exhaustion subscale,
replicated in representative samples with a larger number
closely resembling vital exhaustion and chronic fatigue
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Depletion of Mitochondrial DNA in Liver UnderAntiretroviral Therapy With Didanosine, Stavudine,Ulrich A. Walker,1 Jochen B¨auerle,1 Montse Laguno,2 Javier Murillas,2 Stefan Mauss,3 G ¨unther Schmutz,3Bernhard Setzer,1 Rosa Miquel,2 Jos´e M. Gatell,2 and Josep Mallolas2 The “D drug” HIV reverse-transcriptase inhibitors zalcitabine, didanosine, and stavudine are relatively strong inhibito
European Journal of Neurology 2004, 11: 483–488Pergolide mesylate can improve sexual dysfunction in patientswith Parkinson’s disease: the results of an open,prospective, 6-month follow-upM. Pohankaa, P. Kanˇovsky´b, M. Baresˇb, J. Pulkra´bekb and I. RektorbaDepartment of Sexology, Teaching Hospital, Brno Bohunice; and bFirst Department of Neurology, Masaryk University, St Anne Hospital,