Role of rehabilitation in chronic stress-induced exhaustion disorder
to depression, anxiety and stress-related disorders. In
all treatment groups sickness absence decreased and
work ability increased after 9 months, there was no
difference between the interventions groups. However,
when diagnostic group was included as a moderator,
participants with stress-related disorders had fewer sick
leave days in the WDI group compared with TAU. In
addition, self-reported symptoms of depression, anx-
iety and exhaustion decreased, but with no significant
difference between the groups (83). In another RCT
by Blonk et al. (84) the effect of 2 different CBT-based
interventions and a control group were compared in
patients on sick leave due to work-related psycholo-
gical complaints (i.e. adjustment disorders, such as
burnout and job stress). Significant effects were found
in the group of patients that received a combined in-
tervention including workplace and individual-focused
techniques delivered by a labour expert. The patients
in the combined intervention group returned to full
work almost 7 months before the other groups. There
was no difference in RTW between the CBT group
and the control group. In addition, partial RTW was
found significant in favour of the combined interven-
tion. However, the dropout level was high (84 out of
122 subjects fulfilled the study) (84). Interestingly, like
the RCT by Finnes et al., psychological complaints
generally diminished over time, with no differences
between the groups (83, 84). Increased RTW, but no
significant difference in perceived stress, was also
found in a comparative study by Eklund et al. (85)
in women rehabilitated in a 16-week group-based
Redesigning Daily Occupations programme (ReDO)
(n = 42) compared with women who received TAU.
However, in an RCT by Salomonsson et al. (86),
patients with common metal disorders (n = 211) were
randomized into 3 groups; CBT (n = 64), an RTW
intervention (n = 67) or a combination (n = 80). There
was no significant difference between the groups re-
garding sick leave and all groups effectively reduced
symptoms, although CBI a little faster than the others,
at least until the 1-year follow-up (86).
Instead of focusing on symptom recovery, the main
aim of WI is to prevent disability and promote manage-
ment to enable RTW. According to a Cochrane review
(87) of 14 RCTs there is moderate-quality evidence
that WI help workers with musculoskeletal disorders
to RTW. However, there was only low-quality evidence
on the effectiveness for WI in patients with mental
health problems, including stress-related disorders
(87). In a systematic review and meta-analysis, from
2016, of interventions for enhancing RTW in individu-
als with common mental disorders, the available inter-
ventions did not improve the percentage of employees
who returned to work; however, they seemed to reduce
the number of days of sick leave (88). A review from
339
Kärkkäinen et al. (68) exploring work-related factors
associated with RTW found that enhanced communi-
cation had a positive association and low control at
work a negative association with RTW. Another recent
systematic review and meta-analysis from Perski et al.
(89) found that interventions focusing on treatment
and facilitation of RTW, including advice from labour
experts and enablement of a workplace dialogue, may
be effective in facilitating RTW. However, no signi-
ficant effect was found on full RTW or psychological
symptoms (89).
The result of an RCT for sick-listed employees with
distress, by van Oostrom et al., pinpointed that the in-
tention to RTW at baseline is important for the result.
The WI included a stepwise process involving the
patient and their supervisor, aiming to reduce obstacles
for RTW, significantly reduced time until lasting RTW
only for employees who at baseline intended to RTW,
despite symptoms (90).
In summary, WI, either by work-focused CBT or
workplace dialogue intervention, seem to improve
RTW.
PROGNOSIS
Patients with SED have experienced high levels of
stress without sufficient recovery for a long time, in
SED by definition for more than 6 months. Patients
are initially often markedly mentally and physically
exhausted and in need of full- or part-time sick leave.
Several studies show decreasing symptoms over time
in both intervention and control groups, and early re-
habilitation does not necessarily shorten the period of
sick leave (91). However, although patients with SED
initially need to rest, long-term sickness in itself could
be a risk factor for reduced probability of RTW (68).
This, in turn, means economic and social deprivation
(92). Graded RTW seems to be effective for successful
work participation in patients with chronic mental di-
sorders (93). In order to avoid relapses the workplace
often needs to take necessary measures, and good
cooperation with the employer might facilitate this.
Patients with SED referred to a stress clinic still
describe symptoms of exhaustion after 18 months (26),
indicating that RTW often has to start, even though the
patient still experiences some symptoms. In a study by
Glise et al. (26) the only predictor of recovery from
symptoms of burnout after 18 months was the duration
of symptoms before the patient sought healthcare. This
underlines the importance of finding these patients at an
early stage, but also of not waiting for an asymptomatic
state before starting rehabilitation and RTW. Long-
term sick leave before rehabilitation is significantly
related to future sick leave for patients with burnout
(34). Rehabilitation of severe SED takes time, and it is
J Rehabil Med 51, 2019