Original articles
On the nature of burnout–insomnia relationships: A prospective study of employed adults

https://doi.org/10.1016/j.jpsychores.2008.01.012Get rights and content

Abstract

Objective

This prospective study was designed to test the hypothesis that burnout and insomnia predict each other's incidence and intensification across time. Burnout is conceptualized as representing individuals' unique affective response to their exposure to chronic stressors.

Method

Apparently healthy respondents (1356) completed questionnaires during periodic health examinations undergone at two time points T1 and T2, about 18 months apart. Burnout was assessed by the Shirom–Melamed Burnout Measure, while insomnia was assessed by the Brief Athens Insomnia Scale. Depressive symptomatology, neuroticism, body mass index, age, gender, follow-up duration, and T1 levels of the criterion were controlled.

Results

Burnout and insomnia were found to be only moderately associated at T1. However, logistic regression results indicated that burnout significantly predicted the development of new cases of insomnia at 18-month follow-up [odds ratio (OR)=1.93; 95% confidence interval (95% CI)=1.45–2.58], even after adjusting for depression and other potent confounders. Likewise, insomnia significantly predicted the onset of new cases of burnout at 18-month follow-up (OR=1.64; 95% CI=1.30–2.08). Hierarchical regression results indicted that T1 burnout significantly predicted an increase in T2 insomnia (β=.05, P<.05), and that T1 insomnia significantly predicted an increase in T2 burnout (β=.07, P<.05).

Discussion

The results indicate that burnout and insomnia recursively predict each other's development and intensification over time, thus suggesting that either might be a risk factor for the other across time. Possible mechanisms of link between burnout and insomnia, as well as the clinical implications of the findings, were suggested.

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.

References (71)

  • AD Krystal

    Insomnia in women

    Clin Cornerstone

    (2003)
  • AN Vgontzas et al.

    Chronic insomnia and activity of the stress system: a preliminary study

    J Psychosom Res

    (1998)
  • M LeBlanc et al.

    Psychological and health-related quality of life associated with insomnia in a population based sample

    J Psychosom Res

    (2007)
  • JM Cortina

    Interaction, nonlinearity, and multicollinearity: implications for multiple regression

    J Manag

    (1993)
  • A Rodenbeck et al.

    Interactions between evening and nocturnal cortisol secretion and sleep parameters in patients with severe chronic primary insomnia

    Neurosci Lett

    (2002)
  • C Heim et al.

    The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders

    Psychoneuroendocrin

    (2000)
  • PH Black et al.

    Stress, inflammation and cardiovascular disease

    J Psychosom Res

    (2002)
  • C Tsigos et al.

    Hypothalamic–pituitary–adrenal axis, neuroendocrine factors and stress

    J Psychosom Res

    (2002)
  • S Melamed et al.

    Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

    Psychol Bull

    (2006)
  • WB Schaufeli et al.

    The burnout companion to study and practice: a critical analysis

    (1998)
  • S Melamed et al.

    Burnout and risk of type 2 diabetes: a prospective study of apparently healthy employed persons

    Psychosom Med

    (2006)
  • E Sheiner et al.

    Potential association between male infertility and occupational psychological stress

    J Occup Environ Med

    (2002)
  • M Ekstedt et al.

    Disturbed sleep and fatigue in occupational burnout

    Scand J Work Environ Health

    (2006)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • American Sleep Disorder Association

    The International Classification of Sleep Disorders, Revised: diagnostic and coding manual

    (1997)
  • JA Costa e Silva et al.

    Special report from a symposium held by the World Health Organization and the World Federation of Sleep Research Societies: an overview of insomnias and related disorders—recognition, epidemiology, and rational management

    Sleep

    (1996)
  • R Carney et al.

    Insomnia and depression prior to myocardial infarction

    Psychosom Med

    (1990)
  • S Schwartz et al.

    Insomnia and heart disease: a review of epidemiological studies

    J Psychosom Res

    (1999)
  • M Jansson et al.

    Psychosocial work stressors in the development and maintenance of insomnia: a prospective study

    J Occup Health Psychol

    (2006)
  • PW Corrigan et al.

    Staff burnout in a psychiatric hospital: a cross-lagged panel design

    J Organ Behav

    (1994)
  • J de Jonge et al.

    Testing reciprocal relationships between job characteristics and psychological well-being: a cross-lagged structural equation model

    J Occup Organ Psychol

    (2001)
  • T Kushnir et al.

    The Gulf War and its impact on burnout and well-being of working civilians

    Psychol Med

    (1992)
  • SE Hobfoll

    The ecology of stress

    (1988)
  • SE Hobfoll

    Conservation of Resources: a new attempt at conceptualizing stress

    Am Psychol

    (1989)
  • A Shirom et al.

    Burnout and health review: current knowledge and future research directions

  • Cited by (140)

    • Australian and EASA based pilots’ duty schedules, stress, sleep difficulties, fatigue, wellbeing, symptoms of depression and anxiety

      2022, Transportation Research Interdisciplinary Perspectives
      Citation Excerpt :

      Recent, still unpublished research reported that stress, sleep problems, fatigue-levels, wellbeing, depression and anxiety symptoms were significantly intercorrelated (Venus and grosse Holtforth, n.d.). Considerable evidence has shown, that chronic stress promotes burnout and insomnia (Armon et al., 2008; Demerouti et al., 2019; Ekstedt et al., 2006; Jansson and Linton, 2006; McEwen, 2006; McEwen and Karatsoreos, 2015; Sapolsky, 2004). Australian pilots’ wellbeing was significantly more impaired, while both groups were on average above the WHO5 cut-off value 50 (Krieger et al., 2014).

    View all citing articles on Scopus
    View full text