Role of rehabilitation in chronic stress-induced exhaustion disorder
van der Klink by including an additional decade of
studies, both published and unpublished sources, but
including only those interventions evaluated by a true
experimental design including randomization of par-
ticipants and control groups. The systematic review
included 36 studies representing 55 interventions co-
ded into multimodal, CBI, relaxation, organizational,
or alternative interventions. The mean length of the
interventions was 7.4 weeks. The populations inclu-
ded were working populations not diagnosed with a
major psychiatric disorder or a stress-related somatic
disorder. CBI was the intervention that produced the
largest effect on psychological outcome variables, such
as stress, anxiety and mental health. No intervention
had an effect on absenteeism (29).
In an RCT from Denmark, 163 patients referred to
the regional department of occupational medicine were
randomized into 3 groups: (i) an intervention group
receiving individual cognitive behavioural therapy
(CBT) and an offer of a minor workplace intervention;
(ii) a control group receiving a clinical examination;
or (iii) a control group receiving no treatment at the
department. The patients had a diagnosis of adjustment
disorder, reaction to severe stress or mild depressive
episode, and were on sick leave due to work-related
stress complaints. In all groups psychological com-
plaints improved, but there were no treatment effects
on the outcomes perceived stress, general mental
health, sleep quality and cognitive failures. At follow-
up at 16 weeks there was no significant difference
in RTW, but at 44 weeks the intervention group had
significantly faster lasting RTW compared with the
control group receiving clinical examination (31, 32).
Even though traditional CBT and other forms of psy-
chotherapy can be effective on symptom reduction in
stress-related conditions they do not seem to influence
RTW or sickness absence (33, 34). A Cochrane review
from 2012 evaluated interventions facilitating RTW in
patients with adjustment disorders (33). Patients with
SED may be sorted under the diagnosis adjustment
disorder, which makes this review interesting. Inter-
ventions were RCT including pharmacological, psy-
chological, such as CBT and problem-solving therapy
(PST), relaxation, physical and employee assistance
or combinations. The interventions were effective on
symptom reduction, but no intervention achieved a
statistically significant reduced time to full-time RTW.
The only treatment that significantly shortened time to
partial RTW at 1 year follow-up was PST, according to
a study of patients from primary healthcare with emo-
tional symptoms, not necessarily reflecting SED (35).
Few studies report long-term follow-up. In a study
by Stenlund et al. (55) the long-term effects of 2 dif-
ferent rehabilitation programmes were evaluated in
335
patients with burnout (n = 107). The group receiving a
cognitively oriented behavioural rehabilitation in com-
bination with qigong showed positive effects 3 years
after the end of intervention compared with controls
receiving qigong alone. Patients reported significantly
reduced symptoms of burnout, larger recovery and used
significantly more tools learned from the intervention.
This may indicate that, for patients with SED, establi
shing new behaviours may take time.
A more recently published systematic review
from 2018 investigated the effect of psychological
interventions in individuals on sick leave due to com-
mon mental disorders. The effect size was small, but
psychological interventions were found to be more
effective than treatment as usual (TAU) for reducing
sick leave and symptoms. There was no significant
difference between work-focused interventions, PST
or CBT (36).
In summary, psychological interventions, CBI and
MMI seem to reduce symptoms in individuals on sick
leave due to common mental disorders. There seem
to be small effect size for CBI and PST on RTW. The
interpretation of MMI studies is complicated by the fact
that MMI is not a uniform concept. Different clinics
include different treatment modalities and furthermore,
the selection of treatment modalities used for an in-
dividual patient is often based on local traditions and
patients’ preferences.
Stress-reducing techniques
In order to recover from SED and to prevent relapse
many patients use different stress-reducing techniques.
The most commonly used stress-reducing techniques
are discussed below.
Physical activity. Physical exercise can be seen as a
buffer against stress through its physiological impact.
In healthy people there seems to be almost a dose
response effect between leisure-time physical activity
and psychosocial well-being, including stress-level and
life dissatisfaction (37). Physical activity also appears
to lower the risk of burnout (38) and improve cognitive
function (39).
Eskilsson et al. (40) published, in 2017, an RCT
exploring the effect of aerobic training in patients with
SED. Patients participating in a 24-week multimodal
rehabilitation (MMR) programme including group-ba-
sed CBT, vocational measures and individual physical
activity on prescription, were randomized to either a
12-week aerobic training intervention (n = 24) or no ad-
ditional training (n = 32). Primary outcome was cogni-
tive function. The patients in the aerobic training group
(51% completed intervention) significantly improved
their episodic memory performance after the aerobic
J Rehabil Med 51, 2019