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R E S E A R C H A R T I C L E Open Access
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
Astrid Grensman
1*
, Bikash Dev Acharya
1
, Per Wändell
1
, Gunnar H. Nilsson
1
, Torkel Falkenberg
2,3
, Örjan Sundin
4
and Sigbritt Werner
5
Abstract
Background: To explore if health related quality of life(HRQoL) increased after traditional yoga(TY), mindfulness
based cognitive therapy(MBCT), or cognitive behavioral therapy(CBT), in patients on sick leave because of burnout.
Methods: Randomized controlled trial, blinded, in ninety-four primary health care patients, block randomized to TY,
MBCT or CBT (active control) between September 2007 and November 2009. Patients were living in the Stockholm
metropolitan area, Sweden, were aged 18–65 years and were on 50%–100% sick leave. A group treatment for 20 weeks,
three hours per week, with homework four hours per week. HRQoL was measured by the SWED-QUAL questionnaire,
comprising 67 items grouped into 13 subscales, each with a separate index, and scores from 0 (worse) to 100
(best). SWED-QUAL covers aspects of physical and emotional well-being, cognitive function, sleep, general health
and social and sexual functioning. Statistics: Wilcoxon’s rank sum and Wilcoxon’s sign rank tests, Bonett-Price for
medians and confidence intervals, and Cohen’sD.
Results: Twenty-six patients in the TY (21 women), and 27 patients in both the MBCT (24 women) and in the CBT
(25 women), were analyzed. Ten subscales in TY and seven subscales in MBCT and CBT showed improvements,
p< 0.05, in several of the main domains affected in burnout, e.g. emotional well-being, physical well-being, cognitive
function and sleep. The median improvement ranged from 0 to 27 points in TY, from 4 to 25 points in CBT and
from 0 to 25 points in MBCT. The effect size was mainly medium or large. Comparison of treatments showed no
statistical differences, but better effect (small) of both TY and MBCT compared to CBT. When comparing the effect of
TY and MBCT, both showed a better effect (small) in two subscales each.
Conclusions: A 20 week group treatment with TY, CBT or MBCT had equal effects on HRQoL, and particularly on main
domains affected in burnout. This indicates that TY, MBCT and CBT can be used as both treatment and prevention, to
improve HRQoL in patients on sick leave because of burnout, reducing the risk of future morbidity.
(Continued on next page)
* Correspondence: astrid.grensman@ki.se
1
Department of Neurobiology, Care Sciences and Society, Division of Family
Medicine and Primary Care, Karolinska Institutet, Alfred Nobels allé 23, 141 83
Stockholm, Sweden
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Grensman et al. BMC Complementary and Alternative Medicine (2018) 18:80
https://doi.org/10.1186/s12906-018-2141-9
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(Continued from previous page)
Trial registration: July 22, 2012, retrospectively registered. ClinicalTrails.gov NCT01168661. Funding: Stockholm County
Council, grant 2003–5.
Keywords: Stress-related disorder, Burnout, Exhaustion syndrome, Work-related stress, Randomized controlled trial,
Traditional yoga, Mindfulness-based cognitive therapy, Cognitive behavioral therapy, Mind-body therapies, Integrative
medicine
Background
Burnout and other mental health problems related to
stress have increased in prevalence in recent decades
and currently constitute a substantial problem world-
wide with escalating costs [1,2]. The cause of burnout is
thought to be related to work and, to some extent, the
individual’s personal situation [3,4]. It is characterized
by emotional and physical exhaustion [3–5]. No com-
mon definition of burnout exists, but the Maslach defin-
ition and the Maslach Burnout Inventory are often used
in research [3,6]. Emotional and physical exhaustion are
the core symptoms of Exhaustion Syndrome, which has
been used in Sweden since 2005 to diagnose burnout in
a medical context, with the diagnostic code F43.8A in
the ICD-10 [7]. The diagnostic criteria are listed in
Table 1. The majority of patients diagnosed with burn-
out are women aged 18–49 years, although the number
of men affected is increasing [8,9]. Though mainly work
related, patients are diagnosed and rehabilitated not only
in occupational medicine, but also in primary care [10]
and other health care settings, such as psychiatry. Depres-
sion and anxiety may follow or coexist [9,11,12]. Long-
term sick leave is common, especially if the condition has
lasted for a long time and severe symptoms are present
[9]. A long-standing sensitivity to stress often occurs in
burnout patients and may postpone full recovery [13]. Re-
lapse is common and there is a risk for cronocity [14,15].
Considered together, the morbidity and costs are enor-
mous at all levels of society—on the personal level, in the
health care system and at companies [2,16]. At companies
the costs may arise from higher levels of absenteeism and
sick leave, employee turnover, presenteeism with deterior-
ation of productivity and an increased risk of mistakes and
accidents [2,16].
Persons with burnout have a lowered quality of life,
especially in the emotional sphere [17]. In severe
cases such as in our study group, the decrease is glo-
bal, with low scores also in subscales reflecting sexual
function and social interaction [18]andwithequalor
lower scores than those in chronic somatic diseases
and severe psychiatric disorders surveyed in previous
research [19–21]. Health related quality of life
(HRQoL) has become an increasingly popular meas-
urement in research as it provides us with the pa-
tient’s perspective of his or her HRQoL and aids in
designing better treatment and prevention [22].
HRQoL also predicts future health and mortality [23],
and patients with burnout have been shown to have
an increased risk for somatic and psychiatric disease
as well as for long-term sick leave [24,25].
Table 1 Diagnostic criteria for Exhaustion syndrome, ICD-10 code F43.8A
A Physical and mental symptoms of exhaustion with minimum 2 weeks duration. The symptoms have developed in response to one or more
identifiable stressors which have been present for at least 6 months
B Markedly reduced mental energy which is manifested by reduced initiative, lack of endurance, or increase of time needed for recovery after
mental efforts
C At least four of the following symptoms have been present most of the day, nearly every day, during the same 2 week period:
1 Persistent complaints of impaired memory
2 Markedly reduced capacity to tolerate demands or to work under time pressure
3 Emotional instability or irritability
4 Insomnia or hypersomnia
5 Persistent complaints of physical weakness or fatigue
6 Physical symptoms such as muscular pain, chest pain, palpitations, gastrointestinal problems, vertigo or increased sensitivity to sounds
D The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
E The symptoms are not due to the direct physiological effects of a substance (e.g. abuse of a drug, a medication) or a general medical condition
(e.g. hypothyroidism, diabetes, infectious disease)
F The stress-related disorder does not meet the criteria for major depressive disorder, dysthymic disorder or generalized anxiety disorder
Translation from Glise et al., [9]
Grensman et al. BMC Complementary and Alternative Medicine (2018) 18:80 Page 2 of 16
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Rehabilitation for burnout
The rehabilitation recommended is often multimodal
with psychological support, usually cognitive behavioral
therapy (CBT) in a group or individually as the main
component [11,26], although so far CBT alone has not
been shown to have an effect on the length of sick leave,
and evidence-based treatment for burnout is not estab-
lished [27]. Today the length of the treatment in research is
usually 8–16 weeks, and the amount of sick leave allowed
before inclusion usually does not exceed six months [28].
Wedonotknowwhattheoptimallengthoftreatmentwill
be for this group of patients, and relapse is a common
problem. Other rehabilitation components include support
to return to work [14], physical activity and stress manage-
ment, provided not only in occupational medicine but also
in primary care [10]. Few randomized controlled studies
have been performed on patients on sick leave with burn-
out. To find more effective prevention and rehabilitation/
treatment, and to decrease the incidence of relapse, a dee-
per understanding of efficacious treatment components is
needed that includes the patient perspective. Methods that
can be used in different health care settings are urgently
needed. Early intervention and prevention are fairly easily
administered, can be less complicated and reduce costs
[15]. Both yoga and MBCT are two different methods
that have emerged recently in medicine and many pa-
tients and health care personnel are interested in these
methods and what they can contribute with. Especially
when evidence based methods are lacking. CBT is a well
documented method which is in this study served as con-
trol group. Therapy in group is an advantage as it may
lower the costs for therapy, and as there is generally a
shortage of therapists. Furthermore, Yoga may be prac-
ticed at home with weekly feedback delivered by a yoga in-
structor under supervision. Also, more optional therapies
will increase the availability of therapy and the possibility
to find a suitable and individualized therapy.
Yoga in health care
In recent decades yoga, both traditional and the numerous
variations, has become increasingly popular in the West
as a means of increasing and maintaining physical, mental
and emotional well-being [29]. When reporting on yoga as
treatment in RCTs the most common is not to report any
specific style. When yoga style is reported, the most com-
monly used yoga styles in research are Hatha yoga (HY),
Iyengar yoga (IY) and Pranayama (breathing exercises)
[30]. Yoga has recently been introduced in health care,
with programs for stress reduction using for example
mindfulness based stress reduction which comprises
asanas (physical postures) [31], and yoga has been sug-
gested for rehabilitation after acute myocardial infarction
[32]. Surdarshan Kriya Yoga (SKY), has been shown to be
effective as a treatment for moderate stress-related
disorders,and for depression [33]. Asanas (physical pos-
tures), breathing exercises and meditation have all shown
an effect in different patient groups, as stand alone or more
often in a combination. In a meta-analysis of yoga as treat-
ment for major depression SKY and HY for example, were
effective [34]. In another meta-analysis HRQoL and mental
health in women diagnosed with breast cancer, showed im-
provement after HY and IY among others [35]. Also, IY has
shown an effect in depression [36], to some extent shown
an effect in anxiety [37,38], and as stress-management in
healthy [39]. A recent systematic review showed that most
yoga styles have the same proportion of positive conclu-
sions, indicating that different yoga styles might have simi-
lar effects [40]. The majority of studies in that review had a
combination of exercises, such as asanas, breathing exer-
cises and meditation [40]. Traditional Yoga (TY), usually
with a combination of these three types of exercises, has an
effect both on a physical and an emotional level [41], and
could be an interesting treatment alternative in this group
of severely sick patients with a global decrease in HRQoL
and with diverse symptoms. Few studies have compared
HRQoL before and after treatment with TY in severely sick
patients with burnout.
Mindfulness–based cognitive therapy
Mindfulness–based cognitive therapy (MBCT) was de-
veloped from translational research to cope with de-
pressive relapse/recurrence [42]. MBCTs theoretical
premise is that depressive relapse is associated with
the reinstatement of negative modes of thinking and
feeling that contribute to recurrence and relapse.
MBCT targets cognitive reactivation [42], and the
mindfulness component helps the patient to accept
aversive thoughts and emotions and adapt an
intentionally open, receptive, and flexible disposition
with respect to moment-to-moment experience. The
effect of MBCT in treating burnout is yet to be
established, and, to the best of our knowledge, there
is no study addressing this issue.
Aims
The objectives were to assess the effects of long
(20 weeks) treatment with TY, MBCT and CBT (active
control) on HRQoL in patients on sick leave because of
burnout. The specific aims were: 1) to evaluate the
group treatment effect by comparing the scores before
and after treatment within each group; and 2) to com-
pare the treatment effects in TY and in MBCT with
those of CBT. Finally, also to compare the treatment ef-
fects in TY with those of MBCT. The hypothesis was
that all three groups, TY, MBCT and CBT would have
similar effects on HRQoL with a possible advantage of
TY and MBCT.
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Methods
Settings and participants
This study was part of a randomized controlled trial inves-
tigating the effect of TY, MBCT and CBT, in patients on
sick leave because of burnout caused mainly by difficulties
at the workplace [18]. The intention with the larger study
was to investigate how therapy in group with TY, MBCT
and CBT worked for this kind of patients, from different
aspects. The study was conducted at the Department of
Neurobiology, Care Sciences and Society, Division of
Family Medicine and Primary Care, at Karolinska Institutet,
Stockholm, Sweden, from September 2007 until November
2009.Seven hundred and two people were assessed for
eligibility. They came from different occupations and were
recruited foremost from primary health care centres in the
Stockholm County Council, as most patients with work-
related disorders are found in primary care [10]. The trial
ended due to time limitation.
Before inclusion, they underwent psychological exam-
ination by a physician (first author) and a licensed psy-
chotherapist (second author) to confirm the diagnosis of
Exhaustion Syndrome, and they were assessed for psychi-
atric co morbidity. The inclusion and exclusion criteria are
listed in Table 2. All patients were on sick leave; 50%, 75%
or 100%, prescribed by their ordinary physician and all re-
ceived sickness benefits, that is, they received financial
compensation for medically certified illness. After a baseline
clinical examination and assessments (results presented
elsewhere) by a physician, the participants were allotted to
oneofthethreetreatments.TheHRQoLquestionnairewas
self-completed directly into the database before and after
treatment, either at the time of the interview (before treat-
ment)orlateronviaacomputerlink,usingapersonal
code. Allocation to the treatment groups was done by block
randomization, separately for women and for men, using
sealed nontransparent envelopes, before the start of each
treatment round. Generation of the random allocation
sequence was prepared by an independent person and
randomization was performed by the first author. One
hundred and seven patients, 94 women and 13 men,
fulfilled the inclusion criteria and were invited to par-
ticipate. Thirteen of these one hundred seven patients
declined to participate because they thought too great a
commitment was involved or due to other personal rea-
sons. Finally, 94 patients were included in the study, 84
women and 10 men. Please see flow chart, (Fig. 1). The
assignment to interventions was blinded to those asses-
sing outcomes by using a different code for each par-
ticipant at the assessment.
Dropouts
A total of 14 patients dropped out during the treatment
(Fig. 1). Their subscale scores at baseline as well as age
and gender did not differ significantly from those of the
remaining participants.
Interventions
All three groups, TY, MBCT and CBT received three
hours of supervised group training per week and the
participants practiced on their own for 1–1½ hours, 3–4
times a week, including homework, for a total of at least
7 h per week over five days. All participants followed
this schedule, including the specific practices for each
treatment arm stated below, for 20 weeks. All three groups
practiced various practical skills, such as formulating a self-
motivated day-to-day activity chart and planning and exe-
cuting a micro-pause as homework, see below, which was
assessed during the following week’sgroupsession.Theac-
tivity chart was used to help the patients create a realistic
planning system. The preceding night they planned the
next day’s activities, and then during the day they tried to
follow their planned activities. In the evening they evaluated
their work and rated how manageable their day had been
and how they had felt emotionally during the day, thus
gradually coming to understand their limitations; i.e. valid-
ation [43]. During the micro-pause they tried for several
minutes to be present with their bodily sensations and
emotions while doing some sort of brief practical task. The
micro pause aims at helping the patients to come into
closer contact with how they feel and how things are affect-
ing them. The groups consisted of 9–11 participants and
three rounds of groups went through the program. The
instructor for all of the TY groups was a physician (first
author), a trained TY teacher with many years of personal
practice and of teaching TY. In the CBT groups a licensed
psychotherapist (second author) with extensive clinical ex-
perience in the field conducted the treatment.
Traditional yoga
The participants in this arm practiced TY, a variation
of Ashtanga yoga, which is a form of yoga with gentle
Table 2 Inclusion and exclusion criteria
Inclusion critera:
•Aged 18 through 65 years
•Being on at least 50% sick-leave at the interview. Sick-leave for
a maximum of one year if on full-time sick leave at the interview,
or for a maximum of three years if on part-time sick leave at the
interview
•Body mass index (BMI) of between 18 and 26
•Meets the diagnostic criteria for Exhaustion Syndrome from the
Swedish National Board of Health and Welfare, ICD 10 code; F43.8A
Exclusion criteria:
•Having other diseases that could give similar symptoms or hamper
recovery
•Not speaking Swedish well enough and not being well enough to
participate in the study interventions
•Using medication, including medication containing glucocorticoids.
Exceptions: antidepressants, sedatives, contraceptives and hormone
replacement therapy. The patients were asked to take the same
prescribed doses at both assessment times.
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movements and postures (asanas), breathing exercises
and meditation (Table 3). The TY which was used in
this study is mild and does not demand too much ef-
fort, considering the physical and mental condition of
the patients. The program was designed specifically
forthisgroupofpatients,andtheprogramwasintro-
duced in two steps due to their condition and be-
cause they did not have much pervious yoga
experience (Table 3).TheoverallpurposeoftheTY
intervention was to help participants attain increased
awareness of their own bodily sensations and emo-
tional feelings.
The components of TY were
1. Physical movements and postures (asanas); about 70%
2. Breathing exercises; active and passive, about 20%
3. Awareness: During all exercises, focus on feelings
and bodily sensation was encouraged in order to
understand and experience what was going on
physiologically and emotionally; and,
Fig. 1 Flow diagram
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4. Processing feelings by exercising the previous three
components, so the individual gradually comes in
contact with and becomes more aware of his or her
feelings and emotions [33], and learns how to be
present with and to experience difficult feelings and
emotions instead of avoiding them.
Mindfulness–based cognitive therapy
The MBCT intervention was designed with the aim
to teach mindfulness and cognitive skills as a means
to note distressing thoughts and feelings. They in-
clude: Be aware of and recognize one’sownbodily
sensations, attending to distressing thoughts and
feelings by holding them in the presence, and culti-
vating acceptance and self-awareness. These exercises
possibly contributed to a kind of awareness of
present-moment experience together with a compas-
sionate, non-judgmental state. Additional skills, such
as how to plan a satisfactory day by their own defin-
ition (by the help of a self-motivated day-to-day ac-
tivity chart), plan and execute micro-pauses, and
accept negative feelings without being overwhelmed
by them, were also on the agenda. Participants were
taught to focus more on the emotional part of their
feelings and less on their thoughts when they were
practising mindfulness. Homework consisted of a
protocol for measuring/observing negative feelings,
body-mind awareness exercises, a day-to-day moti-
vated chart, and instructions to follow a special
theme for the week. All assignments and homework
were assessed and analyzed during the following
week’sgroupsession.
Cognitive behavioral therapy
In addition to the day-to-day activity chart and the micro
pause, the CBT program comprised different working com-
ponents such as cognitive restructuring, applied relaxation
technique, identifying the stressors, coping with stress, and
how to reduce the experience of daily stress. The home-
work included a protocol for negative thoughts, relaxation,
and a special theme for the week. Each session had a
specific theme based on different cognitive and behav-
ioral concepts and the theory behind the practical ex-
ercises, working material, and the specific homework
assignment. Reports on the daily working chart were
used for self–monitoring of day-to-day behavior and
reactions. The structure of a therapeutic session included:
formulating a commonly agreed upon work agenda for
the group, a brief period of relaxation, reflections on the
previous session, follow-up of the homework assignment,
introduction of new themes, and preparation for the next
homework assignment.
Assessment
The outcome variable HRQoL was measured using the
full version of a generic instrument, the Swedish health-
related quality of life survey, 1.0 (SWED-QUAL) [44],
which is well validated in the Swedish general population
[45]. SWED-QUAL is developed from the American med-
ical outcome study, as is the SF-36 [46]. SWED-QUAL is
more extensive than SF-36, with several questions about
social, cognitive and sexual functioning, aspects of life
whichareoftenaffectedinpatientswithburnout[18].
SWED-QUAL has been used in a wide range of research
concerning both somatic and psychiatric conditions [19,47].
It comprises 67 self-assessed questions about the present
situation (now or the past week) grouped into 13 subscales,
each with a separate index, from 0 (worst) to 100 (best pos-
sible). The subscales and descriptions are listed in Table 4.
The questions are formulated negatively or positively, with
four alternative answers such as No, not at all = 1, Yes,
slightly = 2, Yes, fairly much = 3 or Yes, very much = 4.
For some of the questions a Likert scale format is used
with answers ranging from completely agree = 4 to com-
pletely disagree = 1. In addition, six questions about gen-
der, age, having a partner or not, marital status, cohabiting
and education level are included.
Statistical methods
The sample size needed was estimated to be approxi-
mately 20–25 participants per group. The calculation was
based on estimation, as when the study was designed
there were no relevant studies in this field, and power ana-
lysis to determine the (effective) sample size was not pos-
sible. In a population (a cohort study) with diabetes type I
and II [48], the sample size was 40 persons per group with
a power of 80% and α= 0.05 based on a difference of 8
Table 3 Exercises in the Traditional Yoga treatment
Exercises
Name in Sanskrit (Name in English)
Weeks 1–5 Weeks 6–20
Padahastasana (Standing forward bend) X X
Supta pawanmuktasana (Knee-lock pose) X X
Bhujangasana (Cobra pose) X X
Ardha Salambhasana (Half grasshopper pose) X X
Digapranam (Salutation) X X
Vajrasana (Diamond pose) X
Breathing exercise X X
Vipareet Karan Mudra (Inverted pose) X
Matsyasana (Fish) X
Yoga Mudra (Sitting, forward bend) X
Tadasana (Mountain pose) X
Kapal Bati (Bellow breathing) X
Chakki Chalanasana (Grind grain) X
Meditation X X
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points on the SWED-QUAL subscale “general health per-
ceptions,”which is often used for comparison between
groups and for sample size calculations. Since the partici-
pants in our study had a condition that was far worse than
in the diabetic group (data not shown), we assumed that
the sample size could be smaller.
Wilcoxon’s rank sum test [49] was used for comparison
of the treatment groups’subscale scores at baseline and
for comparison of the between-group treatment effect.
Wilcoxon’s sign rank was used for comparison of treat-
ment effects [49]. Effect size was calculated using Cohen’s
D[50]. Effect size is the ratio of the mean change in scores
to the weighted SD and measures the relative effect of the
treatment, that is, whether the results are clinically rele-
vant or not. Cohen’s D < 0.2 is considered without import-
ance, 0.2–< 0.5 is a small effect, 0.5–<0.8 is a moderate
effect and ≥0.8isalargeeffect.WhenCohen’s D is 1.0
the mean effect corresponds to the SD. The median
and the confidence interval were determined using the
Bonett-Price calculation [51]. The significance level was
set to < 0.05. Because there were multiple comparisons,
the Holm-Bonferroni correction was used in the statistical
calculations for the outcome variables [52]. Missing data
were found, with few exceptions, in the subscales sexual
function and partner functioning. This is in accordance
with previous studies [53]. Those who did not answer these
items lived almost exclusively alone and had reported that
they did not have a partner.
The analyses were carried out according to the protocol.
Data analyses were conducted using the statistical program
STATA 11.2 StataCorp. (2009). Stata Statistical Software:
Release 11. College Station, TX: StataCorp LP.
Results
We have previously shown that these patients on sick leave
because of burnout, mainly due to work-related causes,
have markedly lower HRQoL in general [18], but random-
ized control studies measuring HRQoL after treating these
severely sick patients are scarce. In this study, HRQoL was
measured in the above-mentioned group of patients after a
20-week group treatment with TY (26 patients), MBCT (27
patients), or CBT (27 patients). The results are presented in
Tabl e s 6and 7,andFig.2.
The majority of the patients were women, 81% in
the TY group, 82% in the MBCT group, and 93% in
the CBT group. All three groups had a high level of
education (Table 5). Eighty percent of the participants
in the study reported that they were on sick -leave
with work-related causes. The occupations were white
collar (47%), school and nursery (17%), blue collar
(17%), health care (14%) and other (6%). All patients
fulfilled the diagnostic criteria for anxiety and depres-
sion. There were no baseline differences between the
treatment groups regarding sociodemographic vari-
ables (Table 5) or baseline scores in the 13 subscales
constituting SWED-QUAL (Table 6). At baseline all
subscales scores, except “physical functioning”was
markedly low and were significantly lower compared
to a healthy group who were working full time [18].
Table 4 Characteristics of subscales in SWED-QUAL 1.0
Subscale No. of items Description
Physical wellbeing
Physical functioning 7 Extent to which health interferes with ability to perform physical activities (e.g., heavy
manual work, sports, climbing stairs, dressing)
Satisfaction with physical functioning 1 Satisfaction with physical ability to do what wanted
Pain, frequency and intensity 6 Pain frequency, intensity and interference with activities of daily life (ADL), sleep and mood
Role limitation due to physical health 3 Extent to which physical problems interfere with ADL
Emotional wellbeing
Role limitation due to emotional
health
3 Extent to which emotional problems interfere with ADL
Positive affect 6 Is a happy person, felt liked, emotionally in harmony, much to look forward to
Negative affect 6 Felt nervous, tense, down, sad, impatient, annoyed
Cognitive function 6 Concentration, memory, capacity to take decisions, confusion
Sleep 7 Problems with sleep initiation and maintenance, sleep adequacy and somnolence
General Health perceptions 8 Health: prior and current, overall rating of health, immune defense, health worries
Satisfaction with family functioning 4 Satisfaction with family life in terms of cohesiveness, amount of support and understanding,
amount of talking things over, overall happiness with family life
Satisfaction with partner functioning 6 Relation to spouse (or person felt closest to) in terms of saying anything wanted, sharing
feelings, feeling close, being supportive
Sexual functioning 5 Interest in sex, capability to enjoy sex, having orgasm(w), getting and keeping erection(m)
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Effects of treatment
All three groups had a good effect on HRQoL in general
as measured by SWED-QUAL, with the highest numerical
increase (Fig. 2) in subscales related to the main domains
affected in burnout [54]. These include emotional well-
being, cognitive function, sleep and, to a lesser degree,
physical well-being (Tables 4and 6), with a median in-
crease of 15%–167% in most of the significant subscales.
The effect size in these subscales was, with one exception,
medium or large (Table 6). When an overall analysis was
made, comprising all three groups together, n= 80, twelve
out of thirteen subscales showed a significant change after
Fig. 2 Test of treatment effect (post-pre)
a
in SWED-QUAL
b
median, subscales scores, ranging from 0 (worst) to 100 (best) possible, after 20 weeks
treatment with Traditional Yoga (TY), Cognitive Behavioral Therapy (CBT) (control) or Mindfulness-based Cognitive Therapy (MBCT). Significant
p-values, P< 0.05, and after Holm-Bonferroni correction are indicated by (*).Legend:
a
Wilcoxon’s sign-rank test was used for comparisons in
each group
b
Swedish Health related Quality of Life Questionnaire
Table 5 Socio-demographic data among the study groups compared to the Swedish population
Treatment group Swedish population
a
TY MBCT CBT
Sociodemografic data, n All [men]
n= 26[5]
All [men]
n= 27[3]
All [men]
n= 27[2]
All
Age, years, means ± SEM 43.4 ± 1.7 [43.6 ± 4.6] 41.3 ± 1.7 [45 ± 6.7] 47.2 ± 1.5 [44.0 ± 3.0]
Sick-leave % ± SD 88.3 ± 21.0 [83.3 ± 25.8] 85.5 ± 19.1 [75.0 ± 25.0] 78.2 ± 23.9 [50.0 ± 0.0]
Body mass index (BMI) ± SD 22.6 ± 2.4 [23.9 ± 3.0] 22.4 ± 2.0 [23.2 ± 2.9] 22.9 ± 1.9 [24.4 ± 1.4]
Education, years, n (%) (%)
≤9 years 0(0) 1(4) 1(4) (17)
>9–12 years 9(35) 9(33) 5(18) (46)
> 12 years 17(65) 17(63) 21(78) (36)
Having a partner, n (%) 17(65) 16(59) 16(59)
Medication
b
, psychotropic drugs prescribed, n 7 11 12 ~ (10)
a
The official Swedish population statistics for 2003–2008 from The National Board of Health and Welfare, The National Social Insurance Board and
Statistics Sweden are included for comparison in this table.
b
ATC code NO6, antidepressants; ATC code N05, sleep medication and tranquillizers and ATC code
NO2, pain killers
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Holm-Bonferroni correction (P<0.05)andCohen’s D was
medium or large in the subscales related to the main do-
mains affected in burnout, as mentioned above (Table 6).
Traditional yoga
Yoga has previously not been used as a treatment in this
group of patients, but might have a good effect, as TY
employs exercises involving the main domains affected
in burnout. The group treatment effect measured as pre/
post scores showed an improvement in HRQoL in general
with high median numerical differences in most of the 10
statistically significant subscales (Fig. 2). The largest im-
provements were seen in the subscales concerning emo-
tional well-being (Tables 4and 6), with subscales such as
“role limitation due to emotional health”,P= 0.0006; “posi-
tive affect”,P= 0.0009; and “negative affect”,P= 0.0000;
physical well-being (Tables 4and 6), with the subscales “sat-
isfaction with physical functioning”,P= 0.0031; and role
limitation due to physical health”,P= 0.0105; together with
the subscales “cognitive function,”P=0.0001 “sleep”,P=
0.0008 and “general health.”P=0.0041 (Tables 4and 6).
Median differences ranged from 13 to 27 points, with a per-
cent increase ranging from 34% to 138%, in these subscales.
The largest percentage increases were, as expected, found
in subscales concerning emotional well-being, with an
increase of 138% in the subscale “role limitation due to
emotional health”and an increase of 100% in the sub-
scale “negative affect.”There was a discrepancy in the
effect of the treatment between the subscales in physical
wellbeing; on the one hand “physical functioning,”2
points (3% increase) and “pain,”6 points (12%increase),
both non-significant and, on the other hand “role limita-
tion due to physical health”—a 17-point median difference
(55% increase), and “satisfaction with physical function”,0
points (0% increase) but both significant, which was a sur-
prise. Another discrepancy was seen in TY. While there
was a significant effect in both “satisfaction with family
function,”P= 0.0010, 9 points (27% increase), and “sexual
function;”P= 0.0019,8 points (18% increase), the “satisfac-
tion with partner functioning was non-significant.The
clinical effect, measured by Cohen’s D, was seen in all of
the 13 subscales in TY, and there was a medium or a large
effect size in all 10 statistically significant subscales for the
TY group, which was quite expected, as the TY treatment
covers many different aspects.
Mindfulness–based cognitive therapy
In the MBCT group the effect of the intervention measured
by SWED-QUAL, showed an increase in seven of the 13
SWED-QUAL subscales, with high significant median
differences P<0.05 (Fig. 2) after Holm-Bonferroni cor-
rection. The largest increase in scores was found in the
subscales “sleep”,P= 0.0002, “cognitive function”,P=
0.0000 (Tables 4and 6) and in emotional wellbeing
with the subscales “negative and positive affect”,P=
0.0001 and P= 0.0011 (Tables 4and 6). All which are
Table 6 SWED-QUAL baseline median subscale scores ranging from 0(worst) to 100(best possible)
a
, and test of treatment effect
b
per
group and for all. Main results marked
c
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important factors in burnout, and possible indicators of
positive change in a patients’quality of life. Calculation
of the median numerical difference of each subscale pre
and post treatment showed median differences between
10 and 25 points (Fig. 2)withanincreaseinsubscale
scores ranging from 25% to 167% in all seven of the signifi-
cant subscales, except for “physical functioning.”The lar-
gest percent increase was found in the subscales “cognitive
function”167%, “negative affect”120% and “positive affect”
64%. The effect size was medium (≥0.5) or a large (≥0.8)
in all of the subscales which showed a statistical improve-
ment P<0.05 (Table 6). Also in MBCT the subscales in
the domain physical wellbeing were not consistent. The
subscale “physical functioning”had, a significant increase
in median scores, P= 0.0009, 0 points (0% increase).
Additionally, “role limitation due to physical health”
and the subscale “pain”had an 11 point difference in
scores (21%increase) in both. Although they are not sta-
tistically significant according to Holm-Bonferroni correc-
tion, they showed a medium and small treatment effect
respectively. In MBCT “sexual functioning”was signifi-
cant, P= 0.0009, with a medium effect size, while the sub-
scales “satisfaction with family function”and “satisfaction
with partner functioning”were non-significant, both with
a small effect size.
Cognitive behavioral therapy
The results here show a similar pattern that was seen in
theMCBTgroup,withhighmedian numerical differences
in most of the 7 statistically significant subscales (Fig. 2).
The largest increases in scores were found in subscales con-
cerning important domains in burnout such as emotional
well-being (Tables 4and 6) with the subscales “role limita-
tion due to emotional health”,P= 0.0036, “positive affect”,
P= 0.0005 and “negative affect”,P= 0.0002; physical well-
being (Table 4) with the subscale “role limitation due to
physical health”,P= 0.0043; and the subscales “cognitive
function”,P= 0.0001 and “sleep”,P= 0.0010. Median differ-
ences ranged from 7 to 25 points in these subscales (Fig. 2),
and with an increase of 15% to 100%. The largest percent
increase was found in the subscales “positive affect”(100%)
and “cognitive function”(80%), both important domains af-
fected in burnout. The clinical effect, measured by Cohen’s
D, was medium or large in six of these seven subscales,
which indicates a good clinical effect (Table 6). Despite an
overall large effect on HRQoL and effect on “role limitation
due to physical health,”11 points (34% increase) no effect
was seen in the subscale “physical function,”0 points (0%
increase) or in “pain”, 11 points (18% increase), which was
quite surprising (Table 6). In CBT “satisfaction with partner
functioning”was significant, P= 0.0048, but without effect
size. In “satisfaction with family functioning”and “sexual
functioning”a non-significant effect was found with a small
effect size for both.
In all the treatments, some subscales showed a low, or
no numerical median difference, but the p-value showed
that the difference was significant, and/or a Cohen’sD
indicated a clinical effect (Table 6). This was because both
parametric and nonparametric methods for analyzing the
treatment effects were used.
Comparison of the treatments
The overall effect from TY and MBCT were slightly better
than that from CBT measured by Cohen’sD(Table6).
When calculating effect size for the treatment effects, a
small difference was found in favor of TY in five of the sub-
scales, with a Cohen’s D of 0.22–0.43 (Table 7), and in favor
of MBCT in seven of the subscales, with a Cohen’sDof
0.32–0.44 (Table 7). This indicates a slightly better effect
from TY and MBCT than from CBT in certain domains.
Both TY and MBCT had a larger increase in “negative
affect,”compared to CBT, P=0.09andP=0.19, which, we
assume, in turn helped to increase “role limitation due to
emotional health”more in TY and MBCT compared to
CBT, P=0.25andP= 0.36. Also, measured numerically (12
subscales) (Fig. 2), and measured by percentage increase (6
subscales), (data not shown), TY showed a larger increase
(14%–69%) than did CBT, although not a statistically sig-
nificant one. In five subscales the CBT group improved
more than the TY group did, but to a lesser degree (4%–
49%), (data not shown). When measured by percent in-
crease (7 subscales), (data not shown), MBCT showed a
larger increase (2%–87%) than did CBT. In four subscales
theCBTgroupimprovedmorethantheMBCTgroupdid,
butalsotoalowerextent(5%–36%), (data not shown).
Finally, when comparing the effects of TY and MBCT, the
overall effect from TY was slightly better but not significant
when comparing median, numerical increase (Fig. 2). The
effect from TY and MCBT were similar regarding effect
size, with a better effect for both treatments in two sub-
scales each, with a small effect size. When measured by
percent the increases were similar (data not shown). Six
subscales in TY showed a larger increase (3%–88%) than
did MBCT, and MBCT showed a larger increase in five
subscales (2%–121%), (data not shown), than did TY.
Satisfaction with the treatment
All patients reported good effect from, and satisfaction
with, the received treatment. This was despite the fact
that they were assigned the treatments and had, in the
interview, in many cases reported that they preferred an-
other of the treatments.
Attendance, adherence and adverse events
Attendance at all three groups’sessions was recorded by
the yoga teacher or the therapist. Homework was reported
via the activity chart executed every day, indicating what
exercises they had performed. Homework including activity
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chart was turned in to the yoga teacher or therapist
each week.
The average attendance for the participants was not
significantly different between TY mean 69%, MBCT
mean 75%, and CBT mean 70%. Adherence: Homework
was practiced in the TY mean 89.4 h, in the MBCT
group 90.4 h, and 83 h in the CBT group. The majority
of the absences were due to tiredness or unexpected
events. The therapist in the MBCT and CBT groups
reviewed the content of the missed session and homework
at the next session. If absent more than one session the
therapist or the yoga teacher contacted the participant to
keep the participant engaged and to maintain program
continuity.
Adverse events: The yoga teacher or therapist queried
participants regarding potential problems and adverse
events at each session, and these were recorded. The
participants were also encouraged to contact the therapist/
yoga teacher regarding any potential concerns. No serious
treatment-related adverse events were reported.
Discussion
In this randomized controlled trial we have shown that a
20-week group treatment with two new treatments; TY
and MCBT, or CBT (control), improved HRQoL in se-
verely sick patients on sick leave because of burnout,
which supports our hypothesis. The patients were sicker
than most patients in earlier studies and they had in
most cases been sick for a longer time at inclusion, than
patients in previous studies. The treatments had a good
effect in general on HRQoL as measured by SWED-QUAL
and the effects were larger than we had expected. Effect
sizes were medium or large in all the significant subscales
in all three groups, except for one in CBT. Comparison
between the treatments showed a slightly larger effect sizes
forTYandMBCT,incomparisontoCBT,inseveralofthe
subscales.
Emotional wellbeing
The large impact on emotional well-being, one of the
main components in burnout, was seen in all three sub-
scales, “positive affect,”“negative affect”and “role limitation
due to emotional health”(Tables 4and 6). The improve-
ment in TY may be caused by the mild physical move-
ments, the rhythmic, regular breathing and the constant
awareness training during the exercises [33,55,56]. These
are known to have an effect on both the parasympathetic
and the sympathetic nervous systems, as well as on positive
and negative affect (emotions) [57,58]. Also, the results in
the TY group might have benefitted from employing
exercises in the physical, emotional and cognitive do-
mains simultaneously. The MBCT treatment targets
mostly the cognitive and emotional part of the individuals’
experience (Segal et al., 2002).. It is found that patients who
suffer from stress, anxiety and depression often use the
strategy of ‘experiential avoidance’.Thisstrategyisthe
alteration of frequency of thoughts, feelings, bodily sensa-
tions, or memories. Although these alterations may not
bring any real comfort or lessen the severity of suffering,
those practices end up being even more costly, ineffective
and damaging to the patients habitually using it. One of the
ways to encourage patients to replace experiential avoid-
ance is with mindfulness acceptance. This is to accept real
experiences, emotions and thoughts as they are. It is an
intentional behavior that alters the function of inner experi-
ences from events to be avoided, to a focus on interest,
Table 7 Comparison between the groups’treatment effects, measured by SWED-QUAL subscale scores, as p-values
a
and effect size
b
Subscale TY - CBT MBCT - CBT TY - MBCT
P-value ES P-value ES P-value ES
Physical functioning 0.28 0.09 0.13 0.44 M 0.70 0.29 M
Satisfaction with physical functioning 0.82 0.06 0.89 −0.08 0.71 0.06
Pain 0.39 0.18 0.38 −0.07 0.66 0.13
Role limitation due to physical health 0.76 −0.02 0.47 0.33 M 0.75 0.04
Role limitation due to emotional health 0.25 0.39 Y 0.36 0.32 M 0.95 0.1
Positive affect 0.94 0.07 0.52 −0.17 0.70 0.23 Y
Negative affect 0.09 0.43 Y 0.19 0.37 M 0.65 0.09
Cognitive function 1.0 0.01 0.38 0.32 M 0.35 0.28 M
Sleep 0.40 0.16 0.16 0.36 M 0.66 0.16
General health 0.41 0.26 Y 0.88 0.04 0.69 0.20 Y
Satisfaction with family functioning 0.14 0.22 Y 0.32 0.15 0.46 0.07
Satisfaction with partner functioning 0.60 0.05 0.47 0.01 0.87 0.04
Sexual functioning 0.39 0.31 Y 0.48 0.30 M 0.91 0.09
a
Wilcoxon rank-sum test.
b
Effect size (ES), Cohen’s D < 0.2 is considered as no effect, ≥0.2 < 0.5 a small effect,
≥0.5 < 0.8 = a medium effect and ≥0.8 = a large effect. Signific ant ES and p-values after Holm-Bonferroni correction in bold
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curiosity, and observation as part of living a valued life.
MBCT has previously show good effect on burnout in a
group of primary care physicians [59]andmindfulnesshas
shown to be effective in primary care patients suffering
from stress related disorders [60]. In CBT treatment the
improvement might be due to cognitive changes caused by
the use of different kinds of methods to detect negative
thoughts and to replace them with more positive ones. This
mayinturnhaveaneffecton“positive”and “negative
affect.”Previous studies have shown that CBT has a good
effect on positive and negative affect [61].
Cognitive function
Emotion is also known to be closely connected to cognitive
function [62,63], and may affect emotional wellbeing, and
vice versa. Cognitive function, which signifies concentration
ability, understanding capacity, memory and the capacity to
focus on day-to-day life, is an important component of
burnout. The improvement in scores in “cognitive function”
is similar, although TY treatment uses different methods of
cognitive training, from MBCT and CBT. This indicates
that TY might be helpful for people who, for various rea-
sons, find it difficult to participate in CBT or MBCT. Cog-
nitive function has previously been shown to increase after
six weeks of Yoga training in breast cancer patients [64],
and in menopausal women after a Yoga program [65]. Also,
in a group of elderly participants cognitive function in-
creased together with emotional wellbeing after following a
mindfulness program [66]. Numerous studies have shown a
good effect on different aspects of cognition [73,76], which
supports our findings.
Physical wellbeing
The subscale score at baseline for “physical functioning”
was comparatively high in all three groups; probably due
to their relatively young age and that they were previously
healthy. The results are in accordance with earlier findings
in a group of persons experiencing emotional ill-being and
attending a mind-body-medicine course [67]. Further-
more, previous findings have shown that emotional and
cognitive functions are much more readily affected than
physical function in a stressful situation [68].
The subscales concerning physical wellbeing showed
inconsistent patterns in the three groups with betterment
in some subscales but not in others, despite the increase in
emotional wellbeing. Burnout patients are generally in-
clined to negative affect and consistently report declining
health symptoms, such as mental health and somatic com-
plaints [69] Furthermore, negative affect has a weak and
inconsistent association to objectivity in regards to assessed
health status [70]. Suner-Soler et al. (2013) finds that high
levels of burnout especially in the “emotional exhaustion”
component, leads to deterioration in the health-related
quality of life both physically and mentally [71]. And recent
evidence suggests that burnout also has a negative impact
on physical health [72]. Thus, we expected that along with
the improvement in emotional wellbeing there should be a
simultaneous improvement in physical wellbeing. In TY
treatment, bodywork in the form of mild yoga postures and
movements might give the participants a more accurate
idea about their level of functioning. Here, in TY, the sub-
scale “physical functioning”was non-significant while “role
limitation due to physical health”showed a significant in-
crease. A possible explanation might be that while “physical
functioning”also contains questions on heavy work and
strenuous exercises, the subscale “role limitation due to
physical health”concerns day-to-day activities that a person
usually performs anyway and an improvement here may
probably be experienced earlier. In a previous study exam-
ining the effects of mild yoga it was found that 83% of the
yoga practitioners improved in overall physical function
and capacity [73], but these patients were older and at risk
for cardiovascular disease. The MBCT group showed the
opposite pattern, with a significant increase in the subscale
“physical functioning”but a non-significant increase in the
subscale “role limitation due to physical health”.Thisdiffer-
ence we assume exist because of the already higher, baseline
median score, and therefore the subscale “role limitation
due to physical health”do not show a significant increase.
The significant increase of “physical functioning”could be
counted as a positive sign for the burnout patients. In the
CBT treatment group the median subscale score for “phys-
ical functioning”was high at baseline, but despite the in-
crease in “role limitation due to physical health,”emotional
well-being, cognition and sleep the subscale score for
“physical functioning”actually did not change. CBT treat-
ment comprised relaxation as a means of increasing body
awareness in addition to the cognitive exercises and strat-
egies, but this was apparently not enough to counteract the
influence of burnout over time. Also, the scores were high
from the beginning, which might have made further
improvement in the scores less likely. These findings
contradict previous research showing that CBT improved
physical function in patients on sick leave for stress-related
disorders as measured by SF-36, a HRQoL questionnaire
similar to SWED-QUAL. However, in that study the partic-
ipants’baseline scores were not reported [74]. The low,
non-significant improvement of the subscale “pain”,inall
three groups was a surprise. Also, there was only a low ef-
fect size in TY and no effect size at all in CBT, while MBCT
had a medium effect size. Pain is often one of the first
symptoms experienced in stress related disorders, and we
expected somehow that there should be an improvement
after treatment. But, as pain is an unspecific symptom, it
might be the other way around; pain may be the last symp-
tom that disappears. Here, MBCT had a significant increase
in “physical functioning”which might have influenced the
improvement in the subscale “pain”, while in TY the low
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increase might be caused by the bodywork which made
them more in contact with their body. This might have
made them experience, and assess their pain to a larger
extent.
Sleep
The subscale sleep showed good results in the all three
groups group. In TY this impact on sleep may be ex-
plained by a combination of the relaxing and overall
stress-reducing effect together with increased calmness,
lowered negative affect and improved body awareness,
which TY is reported to have [75]. In previous studies
yoga has also been shown to have a good effect on sleep
disturbances [73], which is in line with our results. The
subscale “sleep”was the one most improved for the
MBCT group, and that improvement would have helped re-
duce the severity of burnout, as previous studies showed
that insufficient sleep predicts burnout [76]. An eight
week treatment containing mindfulness meditation has
previously shown an effect on chronic Insomnia in a
group of adults [77],andMBCTimprovedpolysomno-
graphic and subjective sleep profiles in antidepressant
users with sleep complaints [78], which support our
findings.InCBT,whichisacommontherapyusedfor
sleeping problems, showed good effect on insomnia in
a group of depressed patients ([79,80].
The differences between the groups regarding the sub-
scales “satisfaction”.
The improvement in sexual function seen in the TY
group was probably because of the increase in both emo-
tional and physical well-being. The result is in accordance
with studies by Dhikav et al. [81,82]. In MBCT the
non-significant improvements in “satisfaction with partner
functioning”and “satisfaction with family functioning”
contrasted to “sexual functioning”which had a significant
effect in MBCT. This result evoke an interesting question,
how can sexual functioning score significantly higher for
MBCT when satisfaction with family functioning and
partner functioning scored low? Wändell et al. found psy-
chiatric conditions would have been the second most im-
portant predictor, next to age of sexual dysfunction in
diabetic patients [53]. Fernros et al., also found that phys-
ical functioning had a strong correlation with sexual func-
tioning [67]. In this study, physical functioning, emotional
health and cognitive functioning are all significantly high
for participants in MBCT, and thereby concluding that, a
low score in partner and family functioning may not ne-
cessarily affect sexual functioning.
The trend for TY and to some extent the trend for
MBCT over CBT in the subscale “negative affect”might
indicate that these two treatments have an additional ef-
fect compared to CBT. This is in line with our quest but
more studies are needed to explore this.
Although a general increase in HRQoL is not necessarily
followed by an increase in work ability, an improvement in
the scores of subscales “role limitation due to emotional
health”and “role limitation due to physical health”may in-
dicate an increased capacity to work. These two subscales
deal with how our role functions in various professions are
affected by how one feels emotionally and physically. All
three treatment groups, TY, MCBT and CBT had large
improvements in these subscales. Previous research has not
been able to show an increased work ability with CBT as a
stand-alone treatment, but usually these treatments are
shorter (8–16 weeks) [28].
When the scores in the TY, MBCT and CBT treatment
were compared with those of a healthy group working
full time [18], all three groups showed decreased median
differences in scores after treatment compared to the
healthy group. In ten subscales in the TY group, in seven
subscales in the MBCT group and in five subscales in
the CBT group, the difference in subscale score between
the treatment groups and the healthy group were no
longer significant after median regression (data not
shown), which indicates a good effect of the treatment.
Asthedataareordinal,group-wise and between-group
analyses of scores were done using nonparametric methods.
For the sake of comparison with previous studies, percent
increase and Cohen’s D were calculated. An analysis with
parametric methods was also carried out, and it yielded the
same results concerning P-values. The results pre- and post
treatment differ slightly when presented as means instead
of medians, but the general picture remains. Another
phenomenon, “regression towards the mean,”might have
influenced the scores. For example, if SWED-QUAL is
filled in a second time in close approximation to the first
occasion, the scores tend to be closer to the mean. This
might have influenced the scores to some extent in our
group, but it is unlikely to have changed the results.
Strengths and limitations
One of the strengths of this study is that it is a RCT, and
that the study group was a clinical sample of patients
with different occupations, reflecting the situation of these
patients on sick leave in occupational medicine and in pri-
mary care. Also, they were diagnosed with Exhaustion
Syndrome beside self-assessment. Furthermore, HRQoL
was measured by SWED-QUAL, which comprises ques-
tions covering most components known to be affected in
burnout. Also, SWED-QUAL has been shown to be stable
over time, so that a change in scores reflects a real change
[45]. The interventions were group treatments, which may
facilitate implementation in the health care system and as
prevention at work sites and companies. The limitations
were the small group size and that there were few men, al-
though it reflects the actual situation. All the patients had
actively applied to participate in the study, which reflects
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initiative and a certain level of strength, and thus patients
with less motivation and strength are not represented.
Also, all participants were receiving sickness benefits, and
therefore persons outside the labor market were not in-
cluded in the study. In addition, many of the partici-
pants increased their level of activity during the study.
This in turn resulted in reported increased symptoms
and less self-reported improvement, which may have
negatively influenced the SWED-QUAL subscale scores
and thus underestimating the effects of the treatment.
The therapies in the study were provided by the first
and second authors, which may have influenced results.
Another limitation is that the restricted sample size did
not allow sub analyses based on factors such as gender,
age, different professions or level of sick leave. Although
some individuals reported that the stressor inducing the
symptoms leading to exhaustion syndrome was their per-
sonal situation, we do not know if the situation at work also
contributed to the symptoms developing, as we did not ask
for this information specifically. Despite the improvement
in HRQoL, we do not actually know whether the partici-
pants’levels of burnout decreased or not. In summary, this
studydidnothavethebasicfoundationtojudgewhether
TY, MBCT and CBT treatments certainly decreased the
suffering of the burnout patients. Nevertheless, it showed
that TY, MBCT and CBT as group treatments positively in-
fluenced several subscales of SWED-QUAL for patients
with burnout who were on sick leave.
Implications for health care and research
We assume that the results are generalizable to patients
undergoing rehabilitation in occupational medicine and
primary care settings, where most of these patients are
found, despite the limitations of inclusion and exclusion
criteria such as age, gender, whether working or not, under-
or overweight and having other diseases. Also, we believe
that the results are generalizable to burnout patients on sick
leave in other health care settings such as psychiatric,
internal or emergency medicine, as patients initially might
seek care outside of occupational medicine and primary
care due to the wide variety of symptoms. More therapies,
with different working components, could help patients im-
prove their HRQoL and decrease the risk of future morbid-
ity, both as early intervention and in severe cases, as in this
study. All three group treatments can be used as health
promotion and burnout prevention in occupational health
care management in companies and, after the active treat-
ment phase is over, to prevent relapse. This is an advantage,
as these can help patients handle stress at work and in their
day-to-day lives.
Future research with larger groups, effective sample size
determination, and with equal representation of both gen-
ders is needed to confirm the results from this study and
to further explore the efficacious components in each of
the treatments. Also, studies to explore whether increased
HRQoL decreases burnout and improves return-to-work
rates after longer treatment with TY, MCBT and CBT
would be beneficial, as well as studies which combine TY,
MCBT and CBT with workplace intervention methods. A
follow-up study is planned to evaluate the long-term ef-
fects together with the relapse ratio and cost-effectiveness
calculations.
Conclusions
Group treatment with TY, MBCT or CBT had large equal
effects on HRQoL, specifically on several main compo-
nents such as emotional well-being, cognitive function
and sleep, in severely sick patients on sick leave because of
burnout. Also, but to a lesser extent, a treatment effect on
the physical component was seen in TY. Comparisons
between groups showed no significant differences in
scores, but a small difference in effect size in favor of TY
in five subscales and in MBCT in seven subscales when
compared with CBT. Our results indicate that all three
group treatments could be used in rehabilitation in differ-
ent parts of the health care system to increase HRQoL
and, as such, lower the risk of future morbidity in patients
on sick leave because of burnout. The results can also be
used for power calculations in future research.
Acknowledgments
We would like to thank Professor Emeritus in Statistics, Sven-Erik Johansson,
and Statistician Robert Szulkin of Karolinska Institutet (KI) for statistical support;
Research Nurse Kirsti Westerlund of the NVS, Division of Family Medicine and
Primary Care, KI, for support with administration and laboratory work; the staff
at Liljeholmen Primary Health Care Center, and colleagues at NVS, Division of
Family Medicine and Primary Care, KI.
Funding
This research was supported by a Stockholm County Council research grant
(Pick-up), 2003–7555, (AG). AG was partially supported by the Stockholm
County Council. The funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Authors’contributions
AG and BA conceived the study, and were responsible for the treatment. BA
designed the treatments and AG, PW and SW participated in the design. AG
and BA conducted the interviews at inclusion. All authors, AG, BA, PW, GN,
TF, ÖS and SW, participated in the analyses, drafted the manuscript, and read
and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Research Ethics Committee South at KI,
Stockholm, Sweden. All procedures performed in studies involving human
patients were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declaration
and its later amendments or comparable ethical standards. Written informed
consent was obtained from all individual patients included in the study. Trial
registration: July 22, 2012, retrospectively registered. ClinicalTrails.gov
NCT01168661.
Consent for publication
“Not applicable”
Grensman et al. BMC Complementary and Alternative Medicine (2018) 18:80 Page 14 of 16
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Neurobiology, Care Sciences and Society, Division of Family
Medicine and Primary Care, Karolinska Institutet, Alfred Nobels allé 23, 141 83
Stockholm, Sweden.
2
Department of Neurobiology Care Sciences and
Society, Division of Nursing, Research Group Integrative Care, Karolinska
Institutet, Stockholm, Sweden.
3
Centre for Social Sustainability, Karolinska
Institutet, Stockholm, Sweden.
4
Faculty of Human Sciences, Department of
Social Sciences, Mid Sweden University, Östersund, Sweden.
5
Department of
Medicine, Karolinska Institutet, Stockholm, Sweden.
Received: 20 March 2017 Accepted: 22 February 2018
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