Psychological treatment of exhaustion disorder

Exhaustion disorder is characterized by mental and physical symptoms of exhaustion that have developed as a result of stress over an extended period of time. Since the diagnostic criteria were developed in Sweden, it has become one of the most common diagnoses for long-term sick leave.

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SBU Enquiry Service

Responds to queries received from Swedish healthcare and social service providers, or governmental organisations. Queries have a limited scope and the process is designed to enable a more rapid response, typically within two to three months. Reports are based on systematic reviews, that are identified through structured searches and critically appraised for risk of bias.

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Published: Report no: ut202316 Registration no: SBU 2022/938

Question

What scientific studies and systematic reviews have been published regarding psychological treatment of exhaustion disorder?

Method

A systematic literature search was performed using the following databases: Medline and Scopus.
Two authors independently assessed the abstracts of all identified studies.

Identified literature

No relevant systematic review was identified but 21 primary studies were identified.

Table 1 Relevant primary studies (not assessed for risk of bias).
* Secondary analysis with sick-leave data and cost-effectiveness calculations for diagnostic groups
** Follow up study with additional participants and 1-year data
*** Secondary analysis of study population with stress-related disorders (ED+AD)
ACT = acceptance and commitment therapy; AD = adjustment disorder; CBT = cognitive behavioral therapy; CT = cognitive therapy; ED = exhaustion disorder; MMR = multimodal rehabilitation
Author
Year
Reference 		Population
(n) 		Intervention Comparison Outcome measures
Finnes et al
2019
[1]
Finnes et al
2022*
[2] 		Individuals with ED (67%), anxiety disorder or depression, and at least 25% sick leave
(352)		 a) ACT
b) Workplace dialogue
c) ACT+ workplace dialogue		 Standard care Primary: sick-leave and work ability
Secondary: work and social adjustment, satisfaction with life, symptoms of exhaustion, anxiety and depression, satisfaction with treatment
Grensman et al
2018
[3] 		Individuals with ED on sick leave
(94)		 a) Traditional yoga
b) Mindfulness-based CT		 CBT Health-related quality of life
Malmberg Gavelin et al
2015
[4]
Malmberg Gavelin et al
2018**
[5] 		Individuals with ED on sick leave
(161)		 a) MMR+cognitive training
b) MMR+physical training		 MMR Primary: Global cognitive performance
Secondary: domain-specific cognition, symptoms of burnout, fatigue, depression, anxiety, aerobic capacity, work ability and sick leave
Lindegård et al
2022
[6] 		Individuals with ED and at least 25% sick leave
(142)		 Individually tailored interventions (physical activity,
CBT for insomnia, computerized memory training, CBT for self-esteem) + standard care		 Standard care Primary: sick leave
Secondary: Symptoms of burnout, physical activity, sleep disturbance, self-esteem, cognitive function
Lindsäter et al
2018
[7] 		Individuals suffering from chronic stress, operationalized as AD and ED
(100)		 Internet-based CBT Waitlist control Primary: perceived stress Secondary: symptoms of burnout, depression, sleep disturbance, anxiety, sickness behavior, self-rated health, somatoform complaints, quality of life, functional impairment, work ability
Salomonsson et al
2017
[8]
Salomonsson et al
2020***
[9] 		Individuals with common mental disorders (ED 59%), and sick leave
(211)		 a) CBT
b) Return to work intervention
c) CBT+Return to work intervention		 Control group not specified Primary: sick leave and psychiatric symptoms Secondary: depression, anxiety, perceived stress, quality of life work ability, satisfaction with treatment

 

Table 2 Relevant primary studies with a study population that is similar to the population with exhaustion disorder (not assessed for risk of bias).
* Two separate publications reporting different outcomes from the same study
AD =adjustment disorder; CBT = cognitive behavioral therapy
Author
Year
Reference
Population
(n)
Intervention
Comparison
Outcome measures
Ben-Itzhak et al
2021
[10]
Individuals with AD
(66)		 Brief (12 sessions) focused psychodynamic
psychotherapy		 Intermediate (48 sessions) psychodynamic psychotherapy Primary: psychological distress and well-being, psychiatric symptoms, illness severity, Secondary: psychological resiliency, working alliance, patient-therapist bond, global functioning
Corazon et al
2018*
[11]
Stigsdotter et al
2018*
[12]
Individuals with AD and/or reaction to severe stress
(84)		 Nature-based therapy with individual and group-based stress reduction exercises CBT (STreSS manual) Psychological well-being, symptoms of burnout, sick leave, health care consumption
Dalgaard et al
2014*
[13]
Glasscock et al
2018*
[14]
Individuals with sick leave due to work-related stress complaints and a diagnosis of AD, reactions to stress or mild depression
(137)		 Individual CBT and an optional brief workplace intervention Standard care Sleep quality, cognitive failure, self-perceived stress, general mental health, return to work
Dalgaard et al
2017
[15]
Individuals with sick leave due to work-related stress complaints and a diagnosis of AD, reactions to stress or mild depression
(163)		 Individual CBT and an optional brief workplace intervention a) Standard care with clinical assessment
b) Standard care without clinical assessment		 Primary: self-perceived stress and general mental health
Secondary: Sleep quality and cognitive failure
De Vente et al
2008
[16]
Individuals with work-related stress on sick leave
(82)		 a) CBT-based stress management training, individual
b) CBT-based stress management training in group		 Standard care Complaints of burnout and distress, sick leave
Heiden et al
2007
[17]
Individuals on sick leave at least 50% due to stress-related diagnoses
(75)		 a) Cognitive behavioral training
b) Physical activity		 Standard care Autonomic activity, pressure-pain thresholds, general mental and physical health, symptoms of burnout, coping with stress, behavioral patterns, sleep quality
Leterme et al
2020
[18]
Individuals with AD and anxiety, most common cause stress at work
(120)		 a) Face-to-face CBT
b) Blended CBT, online and face-to-face		 Waitlist control Symptoms of anxiety, stress, worry and depression
Netterström et al
2013
[19]
Individuals on sick leave with symptoms of persistent work-related stress
(198)		 Multidisciplinary program (workplace-focused psychotherapy and mindfulness-based stress reduction therapy) a) Standard care
b) Waitlist control		 Return to work, psychological symptoms, work ability, degree of stress
Rachyla et al
2021
[20]
Individuals with AD
(68)		 Internet-delivered CBT Waitlist control Primary: symptoms of depression and anxiety
Secondary: symptoms of AD, post-traumatic growth, positive and negative affect, quality of life
Sandahl et al
2011
[21]
White collar workers on long-term (>90 days) sick leave and a diagnosis of work-related depression, dysthymia or maladaptive stress
(117)		 a) Cognitive group therapy
b) Focused psychodynamic therapy		 Standard care Symptoms of depression, anxiety, general psychological function, symptoms of burnout, return to work

References

  1. Finnes A, Ghaderi A, Dahl J, Nager A, Enebrink P. Randomized controlled trial of acceptance and commitment therapy and a workplace intervention for sickness absence due to mental disorders. J Occup Health Psychol. 2019;24(1):198-212. Available from: https://doi.org/https://dx.doi.org/10.1037/ocp0000097.
  2. Finnes A, Hoch JS, Enebrink P, Dahl J, Ghaderi A, Nager A, et al. Economic evaluation of return-to-work interventions for mental disorder-related sickness absence: two years follow-up of a randomized clinical trial. Scand J Work Environ Health. 2022;48(4):264-72. Available from: https://doi.org/https://dx.doi.org/10.5271/sjweh.4012.
  3. Grensman A, Acharya BD, Wandell P, Nilsson GH, Falkenberg T, Sundin O, et al. Effect of traditional yoga, mindfulness-based cognitive therapy, and cognitive behavioral therapy, on health related quality of life: a randomized controlled trial on patients on sick leave because of burnout. BMC Altern Med. 2018;18(1):80. Available from: https://doi.org/https://dx.doi.org/10.1186/s12906-018-2141-9.
  4. Gavelin HM, Boraxbekk CJ, Stenlund T, Jarvholm LS, Neely AS. Effects of a process-based cognitive training intervention for patients with stress-related exhaustion. Stress. 2015:1-11.
  5. Malmberg Gavelin H, Eskilsson T, Boraxbekk CJ, Josefsson M, Stigsdotter Neely A, Slunga Jarvholm L. Rehabilitation for improved cognition in patients with stress-related exhaustion disorder: RECO - a randomized clinical trial. Stress. 2018;21(4):279-91. Available from: https://doi.org/https://dx.doi.org/10.1080/10253890.2018.1461833.
  6. Lindegard A, Glise K, Wiegner L, Reinhardt P, Ellbin S, Pettersson S, et al. Effects of Additional Individually Tailored Interventions on Sick-Leave and Symptoms in Patients with Exhaustion Disorder: A Randomized Controlled Trial. J Rehabil Med. 2022;54:jrm00321. Available from: https://doi.org/https://dx.doi.org/10.2340/jrm.v54.2941.
  7. Lindsater E, Axelsson E, Salomonsson S, Santoft F, Ejeby K, Ljotsson B, et al. Internet-Based Cognitive Behavioral Therapy for Chronic Stress: A Randomized Controlled Trial. Psychother Psychosom. 2018;87(5):296-305. Available from: https://doi.org/https://dx.doi.org/10.1159/000490742.
  8. Salomonsson S, Santoft F, Lindsater E, Ejeby K, Ljotsson B, Ost LG, et al. Cognitive-behavioural therapy and return-to-work intervention for patients on sick leave due to common mental disorders: a randomised controlled trial. Occup Environ Med. 2017;74(12):905-12. Available from: https://doi.org/https://dx.doi.org/10.1136/oemed-2017-104342.
  9. Salomonsson S, Santoft F, Lindsater E, Ejeby K, Ingvar M, Ljotsson B, et al. Effects of cognitive behavioural therapy and return-to-work intervention for patients on sick leave due to stress-related disorders: Results from a randomized trial. Scand J Psychol. 2020;61(2):281-9. Available from: https://doi.org/https://dx.doi.org/10.1111/sjop.12590.
  10. Ben-Itzhak S, Bluvstein I, Schreiber S, Aharonov-Zaig I, Maor M, Lipnik R, et al. The effectiveness of brief versus intermediate duration psychodynamic psychotherapy in the treatment of adjustment disorder. J Contemp Psychother. 2012;42(4):249-56. Available from: https://doi.org/10.1007/s10879-012-9208-6.
  11. Corazon SS, Nyed PK, Sidenius U, Poulsen DV, Stigsdotter UK. A Long-Term Follow-Up of the Efficacy of Nature-Based Therapy for Adults Suffering from Stress-Related Illnesses on Levels of Healthcare Consumption and Sick-Leave Absence: A Randomized Controlled Trial. Int J Environ Res Public Health. 2018;15(1):15. Available from: https://doi.org/https://dx.doi.org/10.3390/ijerph15010137.
  12. Stigsdotter UK, Corazon SS, Sidenius U, Nyed PK, Larsen HB, Fjorback LO. Efficacy of nature-based therapy for individuals with stress-related illnesses: randomised controlled trial. Br J Psychiatry. 2018;213(1):404-11. Available from: https://doi.org/https://dx.doi.org/10.1192/bjp.2018.2.
  13. Dalgaard L, Eskildsen A, Carstensen O, Willert MV, Andersen JH, Glasscock DJ. Changes in self-reported sleep and cognitive failures: a randomized controlled trial of a stress management intervention. Scand J Work Environ Health. 2014;40(6):569-81. Available from: https://doi.org/https://dx.doi.org/10.5271/sjweh.3460.
  14. Glasscock DJ, Carstensen O, Dalgaard VL. Recovery from work-related stress: a randomized controlled trial of a stress management intervention in a clinical sample. Int Arch Occup Environ Health. 2018;91(6):675-87. Available from: https://doi.org/https://dx.doi.org/10.1007/s00420-018-1314-7.
  15. Dalgaard VL, Aschbacher K, Andersen JH, Glasscock DJ, Willert MV, Carstensen O, et al. Return to work after work-related stress: a randomized controlled trial of a work-focused cognitive behavioral intervention. Scand J Work Environ Health. 2017;43(5):436-46. Available from: https://doi.org/https://dx.doi.org/10.5271/sjweh.3655.
  16. de Vente W, Kamphuis JH, Emmelkamp PM, Blonk RW. Individual and group cognitive-behavioral treatment for work-related stress complaints and sickness absence: a randomized controlled trial. J Occup Health Psychol. 2008;13(3):214-31. Available from: https://doi.org/https://dx.doi.org/10.1037/1076-8998.13.3.214.
  17. Heiden M, Lyskov E, Nakata M, Sahlin K, Sahlin T, Barnekow-Bergkvist M. Evaluation of cognitive behavioural training and physical activity for patients with stress-related illnesses: a randomized controlled study. J Rehabil Med. 2007;39(5):366-73.
  18. Leterme AC, Behal H, Demarty AL, Barasino O, Rougegrez L, Labreuche J, et al. A blended cognitive behavioral intervention for patients with adjustment disorder with anxiety: A randomized controlled trial. Internet Interv. 2020;21:100329. Available from: https://doi.org/https://dx.doi.org/10.1016/j.invent.2020.100329.
  19. Netterstrom B, Friebel L, Ladegaard Y. Effects of a multidisciplinary stress treatment programme on patient return to work rate and symptom reduction: results from a randomised, wait-list controlled trial. Psychother Psychosom. 2013;82(3):177-86. Available from: https://doi.org/https://dx.doi.org/10.1159/000346369.
  20. Rachyla I, Mor S, Cuijpers P, Botella C, Castilla D, Quero S. A guided Internet-delivered intervention for adjustment disorders: A randomized controlled trial. Clin. 2021;28(2):313-24. Available from: https://doi.org/https://dx.doi.org/10.1002/cpp.2518.
  21. Sandahl C, Lundberg U, Lindgren A, Rylander G, Herlofson J, Nygren A, et al. Two forms of group therapy and individual treatment of work-related depression: a one-year follow-up study. Int J Group Psychother. 2011;61(4):539-55. Available from: https://doi.org/https://dx.doi.org/10.1521/ijgp.2011.61.4.538.

Search strategies

Medline via OvidSP 16 February 2023

Title: Exhaustion disorder - psychotherapy
Search terms Items found
Population: Exhaustion disorder
1. mental fatigue/ or compassion fatigue/ 2720
2. exp Burnout, Psychological/ 17037
3. exp Adjustment Disorders/ 4305
4. ("common mental disorders" or exhaustion or (stress* adj ill-health) or "adjustment disorder*" or "maladaptive stress" or burnout or "burn out" or "chronic stress*" or (reactive adj (depr* or disord*))).ab,ti. 57601
5 1 OR 2 OR 3 OR 4 68524
6. exp Stress, Psychological/ 150973
7. stress*.ab,ti. 1031633
8. Sick Leave/ 6683
9. (sick* adj (leav* or absen*) or sicklisted or sick listed).ab,ti. 8819
10. (7 OR 8) AND (9 OR 10) 1385
11. 5 OR 10 69526
Intervention: Psychotherapy
12. exp psychotherapy/ 216132
13. (psychotherap* or psychodynam* or "psycho dynam*" or (accept* adj commit*) or cbt or ((cognitiv* or interpersonal) adj2 (behav* or therap* or train* or treat* or method* or approach*)) or (behav* adj (therap* or train* or treat* or method* or approach*)) or mindfulness).ab,ti. 138912
14. 12 OR 13 290012
Study types: systematic reviews and meta-analysis / randomized controlled trials1
15. Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or meta analys* or metaanalys*).ti,bt,ab. 435529
16. (randomized controlled trial.pt. OR controlled clinical trial.pt. OR clinical trial, phase iii.pt. OR ((randomized or randomised).ab.) OR placebo.ab. OR clinical trials as topic.sh. OR randomly.ab. OR trial.ti. OR (("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.)) NOT (exp animals/ not humans.sh.) 1467944
Final result
  11 AND 14 AND 15 limit 17 to danish or english or norwegian or swedish 261
  11 AND 14 AND 16 limit 18 to danish or english or norwegian or swedish 815
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp= Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf; .pt = Publication type .ja = Journal abbreviation .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other. * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase

1.Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity- and precision-maximizing version (2008 revision); Ovid format. The Cochrane Collaboration; 2008. Available from: https://training.cochrane.org/handbook/current/chapter-04-technical-supplement-searching-and-selecting-studies#section-3-6-1. with modifications: the following terms are added: clinical trial, phase iii.pt. ; randomised.ab. ; ("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.

Scopus via scopus.com 16 February 2023

Title: Exhaustion disorder - psychotherapy
Search terms Items found
Population: Exhaustion disorder
1. TITLE ( "common mental disorders" OR exhaustion OR "adjustment disorder*" OR "maladaptive stress" OR burnout OR "burn out" OR "chronic stress*" ) OR TITLE ( stress* W/2 ill-health ) OR TITLE ( ( reactive ) W/2 ( depr* OR disord* ) ) 27,673
Intervention: Psychotherpy
2. ( ( TITLE ( ( psychotherap* OR psychodynam* OR "psycho dynam*" OR cbt OR mindfulness ) ) OR KEY ( ( psychotherap* OR psychodynam* OR "psycho dynam*" OR cbt OR mindfulness ) ) OR TITLE ( ( accept* W/2 commit* ) ) OR KEY ( ( accept* W/2 commit* ) ) ) ) OR ( ( TITLE ( ( cognitiv* OR interpersonal ) W/2 ( behav* OR therap* OR train* OR treat* OR method* OR approach* ) ) OR KEY ( ( cognitiv* OR interpersonal ) W/2 ( behav* OR therap* OR train* OR treat* OR method* OR approach* ) ) ) ) OR ( ( TITLE ( behav* W/2 ( therap* OR train* OR treat* OR method* OR approach* ) ) OR KEY ( behav* W/2 ( therap* OR train* OR treat* OR method* OR approach* ) ) ) ) 303,838
Study types: systematic reviews and meta-analysis / randomized controlled trials
3. ( INDEXTERMS ( "systematic review" OR "meta analysis" ) ) OR ( TITLE-ABS ( ( systematic W/3 review ) OR meta-analys* OR metaanalys* ) ) 648,195
4. INDEXTERMS ( "clinical trials" OR "clinical trials as a topic" OR "randomized controlled trial" OR "randomized controlled trials as topic" OR "controlled clinical trial" OR "controlled clinical trials" OR "random allocation" OR "double-blind method" OR "single-blind method" OR "cross-over studies" OR "placebos" OR "multicenter study" OR "double blind procedure" OR "single blind procedure" OR "crossover procedure" OR "clinical trial" OR "controlled study" OR "randomization" OR "placebo" ) OR TITLE-ABS-KEY ( "clinical trials" OR "randomized controlled trial" OR "randomized controlled trials" OR "controlled clinical trial" OR "controlled clinical trials" OR "random allocation" OR "randomly allocated" OR "allocated randomly" OR "double-blind method" OR "single-blind method" OR "cross-over studies" OR placebo* OR "cross-over trial" OR "single blind" OR "double blind" OR "factorial design" OR "factorial trial" ) OR TITLE ( trial* OR rct OR randomised* OR randomized* ) 8,984,439
Final result
  1 AND 2 AND 3 82
  1 AND 2 AND 4 356
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings * = Truncation; “ “ = Citation Marks; searches for an exact phrase
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