The main finding of this study was that the majority, around 60%, of patients with previous exhaustion disorder reported that they had made some kind of change in their work situation as a consequence of the exhaustion, including either changing their workplace, changing their work tasks, and/or changing their working hours. Almost half of the patients had changed their workplace, more than 40% had changed their work tasks, and almost 25% had reduced their working hours. One important finding was that sex was the sole predictor for changes at work, with women being more likely to reduce their working hours and a trend for men being more likely to change work tasks.
Thus, around half of the population included in this study reported that they had changed workplace due to their illness. Putting these results into perspective, between 1994 and 2008 the general Swedish labour market mobility in the form of change of workplace within 1 year varied between 13 and 19%. A general population study performed in the same region, as our study found that over a 5-year period 25.5% of participants changed their workplace . Individuals with and without sick leave experience seemed to change their workplace to a similar degree . The general mobility on the labour market in Sweden is relatively low compared to other countries, due to historical commitment to full employment and the so-called Swedish ‘work line’ which aims at protecting employment as such rather than particular jobs . Mobility close to 50% found in this study could therefore be considered relatively high, particularly since sick leave in general is not related to change of workplace .
A 5-year follow-up study of production workers with sickness absence due to mental disorders reported that 18% left their employment during this period . Similar job mobility was found in a study on patients with mild traumatic brain injury, showing that 17.3% of the patients had exited their employment and 15.5% needed to make changes at work to enable to continue their employment 4 years post-injury . Patients with common mental disorders and mild traumatic brain injury have similar symptoms to patients with ED, in terms of cognitive deficits and mental fatigue. Thus, we can cautiously speculate that the burden of symptoms does not seem to be the main driving force behind changes at work, even though it is most probably part of the reason. Furthermore, patients with common mental disorders and patients with ED are likely to relate differently to their work environment compared to, for example, patients with stroke; this includes the process of RTW, since work-related factors are often strongly related to these mental conditions [11, 31].
Thus, given the above, it is likely that patients with ED were forced to make changes at work partly due to remaining symptoms but also due to poor psychosocial work environment [32, 33]. Indeed, the group that did make changes in their work situation reported a somewhat poorer work situation than those who made no such changes, regarding conflicts at work, reorganization, deficient leadership, and general discontent with their work situation. These types of work-related stressors are known to contribute to burnout, and it could be speculated that they might also contribute to a decision to make changes at work . It can thus be hypothesized that one contributing factor to making changes in the work situation was the psychosocial work environment, including high job demands, which thus plausible have not changed during the time that the patients were off work. The group who made changes reported a higher degree of conflict at the workplace; and regardless of the reason for this conflict, it might have been difficult for these individuals to return to the same workplace. Other plausible reasons for changes in the work situation could include feelings of shame about becoming ill and/or private related situations.
Another important finding was that patients who had made some kind of change at work reported significantly more stressors at baseline related to conflicts at work, reorganization, deficient leadership, and discontent compared to the group who had not made any such changes. To the best of our knowledge, no previous study has explored changes in work situation among individuals who have been on sick leave due to stress-related exhaustion.
Thus, those who have made changes describe a psychosocial work situation at baseline that is clearly linked to higher psychological strain including situation such as conflicts and reorganisations as well as factors such as deficient leadership suggesting lack of support. According to the JDCR model, high demands and lack of resources are factors that have contributed to the exhaustion resulting in sickness absence. The job resource part of the model has on the other hand been shown to be related to work engagement and intention to stay at the workplace . We can thus speculate that the individuals that choose to make changes at work still experiences the work situation to be unsatisfying, particular with regard to resources which affects their work engagement and motivation to stay at the same workplace . If changes to avoid stress at work are made, this would plausibly lead to gain resources at work and reduce stress exposure and thus also the risk for stress-related exhaustion.
This is in line with the results showing that the group that had made no changes at work reported significantly more work-related stress after 7 years due to quantitative demands and poor working environment, indicating that changes in the psychosocial work environment are needed in these workplaces. Private related stress was not clearly associated with changes at work except from relational conflicts, indicating that changes at work is mainly associated with work-related stressors. Surprisingly, no difference was seen with regard to remaining symptoms between patients who still experienced work-related stress and those who did not. It could be expected that productivity was affected in patients who were still experiencing a poor psychosocial work environment, but this was not measured in the current study.
Changes in work tasks are plausibly related to difficulties stemming from remaining symptoms. It has previously been shown that as many as one third of patients with ED still fulfil the clinical criteria after 7 years, and many still report problems with cognitive function, fatigue, and reduced stress tolerance . This could also be the primary reason for reducing working hours, though other reasons such as making different priorities in life and gaining a balance between work and leisure are also plausible.
The social insurance system in Sweden might also be of importance to discuss as a possible explanation for changes at work, since many patients with ED are on sick leave at some point. In the present system, a workplace transfer to another job with the same employer but with lesser demands must take place after 3 months. Furthermore, according to the regulations, a discussion regarding work ability and plausible return to the same workplace should be conducted after 6 months . Several aspects related to the regulations on sick-leave benefits, such as time pressure, uncertainty regarding work ability, position at work, and financial situation, could also plausibly contribute to pressure on both the employer and the individual to make changes that otherwise would not have been made.
Gender predicts changes at work
In this study, we found that women were more likely to reduce their working hours while men tend to be more likely to change their work tasks when analysed in the regression model. This difference in changes at work raises several questions. Previous studies found that there was no difference in burden of symptoms between women and men with ED , and thus it is not likely that women and men make different changes at work due to their burden of symptoms. A more plausible explanation could be gender segregation on the labour market; women and men generally work in different sectors, and gender segregation is also seen even within the same sector . In general, women more frequently work part time, use most of the insurance system for parental leave, and spend more time on domestic work . Thus, one explanation for why women in this study tended to reduce their working hours to a larger extent than men could be that they performed more domestic work and had less time for recovery in their private life. In a societal perspective men historically have been considered to be the breadwinners and in many countries women still are more likely to work part-time than men .
The gender difference regarding working hours is somewhat problematic, since women already have a less favourable situation when it comes to income, with lower lifetime income and pension than men [38, 39]. Women are more commonly employed in the educational and healthcare sectors, where it might be more difficult to change or adjust work tasks. Men, on the other hand, have professions such as technician and craftsman, where it might be easier to change or adjust work tasks . A previous study found gender differences in rehabilitation, with men being more likely than women to demand actions and to strive for full-time waged work . It might also be easier to make adjustments at work in sectors which mainly employ men than in sectors which mainly employ women.
Limitations and strengths
There are several limitations in this study that need to be considered. The patients included were admitted to a specialist tertiary clinic, and might thus have had a higher burden of symptoms compared to what might be expected within primary care . Most of them had higher education, which might have affected their ability to make changes at work. Relatively few men were included in the study, and so conclusions regarding differences between men and women need to be confirmed in larger studies. It was not possible to make direct comparisons with a working population in this study, and so we cannot draw conclusions regarding whether changes in work situation are more common among patients with ED compared to the general working population.
All data on changes at work were retrospective self-reports, using register data on employment status would have given more accurate information. The questions about changes of workplace and work tasks specifically asked if changes were made because of their illness or if the patients were forced to make changes due to other reasons. Working hours were reported at baseline and at the 7-year follow-up, but we did not ask specifically if participants had changed their working hours due to their illness; this is an important limitation of this study, and so these results must be interpreted with caution. Another limitation of this study is that we did not ask for details of when they made the changes at work during the 7-year period. Changes at work could have been done at different points during the past 7 years and the symptoms of ED, depression and anxiety might have fluctuated over the past 7 years and possible affected changes at work.
Another methodological consideration that should be mentioned is that work-related stressors were measured as self-reports at 7-year follow up and thus plausible recall bias must be considered as a limitation.
Clinical implications and further perspectives
A majority of patients with exhaustion disorder made considerable changes regarding their work situation, and it is plausible to believe that their psychosocial work environment has been a major trigger for these changes. The role of the workplace in the RTW process is of utmost importance, and good collaboration between the healthcare provider and the workplace needs to be established. However, most sick-leave notes for stress-related mental health problems are dispensed by general practitioners within the primary health care system. Thus, it is important to increase the knowledge of the importance of involving the workplace in the rehabilitation process. Adjustments at the workplace are in many cases both necessary and favourable and might avoid personal turnover and recurrent sick leave. Nevertheless, forced changes due to deficient support in the RTW process or due to regulations in the insurance system can also drive competent people to change to workplaces where they are unable to use their education and/or knowledge, resulting in a great loss of competence in the workforce. Further research is needed to understand why people with ED make changes at work.
Our study also illustrates gender differences in the rehabilitation process for patients with ED; awareness of this is particularly important in order to avoid further marginalization of women on the labour market.