Original articlesOn the nature of burnout–insomnia relationships: A prospective study of employed adults
Introduction
In recent years, there has been growing interest in the long-term consequences of burnout. Burnout represents a negative affective state that comprises feelings of emotional exhaustion, physical fatigue, and cognitive weariness, and denotes depletion of energetic resources resulting from cumulative exposure to chronic work and life stresses [1]. Burnout has been shown to be relatively stable over time [1]. Accumulating evidence suggests that, in addition to its negative impact on quality of life and mental health [2], it is implicated in several disease states [1], including increased risk of cardiovascular disease (CVD) [1], diabetes [3], musculoskeletal disorders [4], and impaired fertility [5].
There is compelling evidence, based on both questionnaire data and objective polysomnographic recordings, pointing to an association between burnout and sleep disturbances, particularly chronic insomnia [6], [7], [8], [9]. Insomnia is defined as difficulty in initiating sleep and/or maintaining sleep, prolonged awakening during the night, or waking up too early in the morning for more than a 1-month period [10], [11]. Like burnout, insomnia has been described as a chronic disturbance [12], [13] and has been shown to be associated with similar disease end points, mainly CVD [14], [15], [16].
The consistent finding of an association between burnout and insomnia, and the recurrent finding that both are related to the same disease end points suggest that they may influence each other across time. In order to understand the nature of the relationships between burnout and sleep disturbances, and for the clinical purpose of designing suitable interventions to alleviate them, it is desirable to determine whether burnout recursively predicts insomnia, whether insomnia recursively predicts burnout, or whether the relationship between them is bidirectional across time. However, past studies on burnout–insomnia relations were based on cross-sectional design, thus precluding elucidation of the contribution of each to the development of the other. Moreover, most previous studies were conducted on small (and sometimes clinical) samples. Such studies do not permit making causal inferences concerning the directionality of influence.
There is considerable evidence that both burnout and insomnia may be closely associated with chronic stress (for a review of the stress–insomnia linkage, see Jansson and Linton [17]; for a recent review of the stress–burnout linkage, see Melamed et al. [1]). Several longitudinal studies supported the effects of burnout on subsequent levels of worry and anxiety [18], [19], [20], and a heightened level of affective arousal could induce insomnia [13]. Indeed, the possibility that chronic burnout may bring about subsequent insomnia has been suggested by Schaufeli and Enzmann [2] and other researchers. Therefore, we have hypothesized that burnout would predict the development of insomnia across time or would intensify insomnia symptoms over time for those with insomnia symptoms at baseline. To our knowledge, this hypothesis has not been tested prospectively.
Based on the Conservation of Resources (COR) theory [21], [22], we may also hypothesize that insomnia will predict the development of burnout across time. The COR theory postulates that stress at work occurs when individuals are threatened with resource loss, lose resources, or fail to regain resources following resource investment. Following the COR theory, we argue [23] that people feel burned out when they perceive a continuous net loss of energetic coping resources that cannot be replenished. Burned-out individuals may further exacerbate their losses by entering an escalating spiral of losses [24]. We expect the linkages between burnout and insomnia to represent a variant of an escalating spiral of losses, with insomniacs' sleep deprivation depleting their coping resources and intensifying the feeling of being burned out. Thus, we further hypothesized that insomnia would predict the onset of new cases of burnout with time or would intensify burnout symptoms over time in those with burnout symptoms at baseline. Again, this hypothesis has not been tested prospectively. The present study is the first attempt to examine the directionality of the linkage of burnout and insomnia in a follow-up study of apparently healthy employed adults.
Section snippets
Sample
Study participants (N=1937) were all apparently healthy employees attending the Center for Periodic Health Examinations of the Tel-Aviv Sourasky Medical Center for routine health examination at Time 1 (T1) and Time 2 (T2), 18 months apart on average. At T1, they represented 92% of the center's examinees during this period who voluntarily agreed to participate in the study. We systematically checked for nonresponse bias at T1 and found that nonparticipants did not differ from participants on any
Results
The prevalence of burnout and insomnia at T1, based on the dichotomous definitions of these two criteria, was 20.7% and 10.0%, respectively; the prevalence of burnout and insomnia at T2 was 18.6% and 13.1%, respectively. Using the same dichotomous definitions, the rates of comorbidity were 4.5% and 5.5% at T1 and T2, respectively, suggesting that only a minority of those afflicted suffered from both burnout and insomnia. In agreement with past research (e.g., Voderholzer et al. [34] and Toker
Discussion
To the best of our knowledge, our study pioneered in investigating the directionality of the across-time relations of burnout and insomnia. We tested our hypothesis on a fairly large and representative sample of apparently healthy men and women; the major findings were that, at baseline (T1), burnout and insomnia were only moderately related (r=.31). Yet, in support of our hypotheses, we found that burnout predicts subsequent cases of insomnia (OR=1.93) and changes in levels of insomnia (β
Acknowledgments
We would like to acknowledge the financial support provided to the study by the Israel Science Foundation (grant 962/02-1). Ms. Yasmin Alkaly helped with the data analyses.
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