Traditional yoga and clinical burnout : quality of life and biomarkers before and after treatment

Abstract: Background. Stress-related disorders including clinical burnout (CB) are one of the main causes of sickness absenteeism in many Western countries. Little is known about the situation of CB patients, and objective markers are not used as an aid in clinical work with these patients. Moreover, evidence-based treatments are scarce to date. Yoga has shown an effect on stress, depression and anxiety, and might be an interesting treatment alternative. Aims. To understand the situation of patients with CB on sick leave (CBG), to investigate the effect of traditional yoga (TY) on patients with CB, and whether there are subjective and objective measures that can be used for screening, to diagnose CB, to follow the course and evaluate treatment effects. Subjective measures: 1. To describe health-related quality of life (HRQoL) in the CBG at baseline and compare to a healthy control group experiencing stress (HCG). 2. To explore the effect of psychological treatment with TY, mindfulness-based cognitive therapy (MBCT) and cognitive behavioural therapy (CBT) on HRQoL in the CBG. Objective measures: 1. To evaluate potential biomarkers for screening, diagnosis, to follow the course and to evaluate treatment effects in patients with CB on sick leave. 2. To compare the concentration of biomarkers in the CBG at baseline with that of biomarkers in the HCG at baseline. 3. To evaluate whether the 1 μg ACTH test can be used as a stress test. Material and methods. This thesis comprises 4 publications, derived from two randomized clinical trials (RCTs). Study population 1: The CBG, primary care patients (n=94, 12 men). Randomized to TY, MBCT or CBT. They received 20 weeks of group treatment, three hours per week, with additional homework for a minimum 4.5 hours per week. HRQoL was measured using SWED-QUAL questionnaire (S-Q). S-Q and biomarkers in blood and urine were sampled before and after treatment. Study population 2: The HCG, health care personnel (n = 88, 16 men). The HRQoL and biomarker baseline measurements for the HCG were used for comparison. HCG also provided data from the ACTH stimulation test. Article I presented a descriptive and comparative study of HRQoL at baseline. In Article II we explored the treatment effect of TY, CBT and MBCT measuring HRQoL pre- and posttreatment. Article III presented a hypothesis-generating and comparative study exploring biological markers in blood and urine for potential use as tools for screening, diagnosis, to follow the course and evaluate the treatment effects. Article IV presented a methodological study in which we explored whether the 1 μg ACTH stimulation test could be used as a tool to assess the capacity to respond to stress. Results. Subjective measures: (I) HRQoL in the CBG was low in general, and significantly lower in most subscales compared to the HCG. (II) Several S-Q subscale scores were normalized after treatment in all groups. Differences between the treatment groups were found in favour of TY and MBCT with a small effect size (ES). Objective measures: (III) All 6 biomarker concentrations were within the normal range at baseline in CBG. Compared to the biomarker concentrations in the HCG, the concentrations of the urinary hormones epinephrine, norepinephrine, dopamine, 5-hydroxyindoleacetic acid were significantly higher, while urinary cortisol concentrations were significantly lower. When comparing preand post-treatment concentrations for each treatment and for all treatments calculated together, testosterone and urinary epinephrine showed a significant decrease, while, estradiol showed a significant increase. (IV) The intravenous 1 μg ACTH stimulation test showed that the highest cortisol concentrations after injection were found at 30 and 40 min, and that the concentration curves for cortisol in serum and saliva were parallel at 30 and 40 min. Conclusions. In severely ill patients on sick leave and diagnosed with CB, ICD-10 code F43.8, subjective measures (HRQoL) showed a global decrease. After treatment small differences in effect size between groups were seen in several subscales, in favour of TY over MBCT and CBT, indicating differences in treatment effects. All groups showed large, significant improvements after treatment in HRQoL, presumably at least partly due to the treatments. Objective measures (biomarkers) showed potential biomarkers for screening and diagnosis (urinary catecholamines, urinary cortisol and 5-hydroxyindoleacetic), to follow the course and evaluate treatment effects (testosterone, estradiol and urinary epinephrine), and these warrant further investigation. The ACTH test could be a potential stress test, measuring the maximum concentration of cortisol in saliva after 1μg IV ACTH after 30 and 40 minutes solely. TY seems to be of interest to explore further for treatment and prevention. HRQoL and biomarkers can be used for screening and to follow the course, and warrant further investigation for the purpose of diagnosis and to evaluate treatment effects.