Sara Lindeberg | Lund University (original) (raw)

Papers by Sara Lindeberg

Research paper thumbnail of Region Skånes sociala investeringsfond

Socialmedicinsk Tidskrift, Sep 3, 2014

Research paper thumbnail of Synergistic interaction eVect between job control and social support at work on general psychological distress

Int Arch Occup Envir Health, 2011

Research paper thumbnail of Exhaustion is differentiable from depression and anxiety: Evidence provided by the SF-36 vitality scale

Stress, 2006

Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet ... more Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet fully conceptualised. This is perhaps partly due to the fact that the distinction between exhaustion and other already established concepts, such as depression, is not clear. This study explores whether exhaustion can be differentiated from depression and anxiety, by means of introducing the SF-36 vitality scale as a strategy for the measurement of exhaustion. The Malmö Shoulder and Neck Study cohort, in this study including 12,607 middle-aged men and women, was utilized. Depression and anxiety were assessed by the general health questionnaire (GHQ). Factor analysis was performed in order to potentially discriminate between the included measures. Factor analysis showed that all four exhaustion items of the (inverted) SF-36 vitality scale loaded on a single factor, separate from the GHQ depression and anxiety factors. These results support the notion that exhaustion can be distinguished from depression and anxiety, providing an empirical foundation for defining exhaustion as a unique concept. Furthermore, since SF-36 has been widely used in clinical and epidemiological studies, the benefits of using the SF-36 vitality scale in the assessment of exhaustion could be substantial.

Research paper thumbnail of Conflict between the work and family domains and exhaustion among vocationally active men and women

Social Science & Medicine, 2010

Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job... more Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job strain more often, which may constitute a partial explanation for this phenomenon, but experienced shortcomings in combining work and family demands may also contribute to ill health. The aim of this study was to investigate, and analyse by gender, how work-related and family-related factors, as well as the interface between them, i.e. work-to-family conflict (WFC) and family-to-work conflict (FWC), are related to exhaustion. The study was crosssectional with self-administered questionnaires assessing exposures and outcome with previously well validated instruments. The participants were 2,726 men and 2,735 women, aged 45 to 64, vocationally active, and residing in Malmö, Sweden. Sixteen percent of the women and 8% of the men considered themselves exhausted. WFC, FWC, job strain, and low job support were all strongly correlated to exhaustion in both genders. In the multivariate analyses, adjusting for other work and family risk factors, WFC and FWC remained statistically significant risk factors for exhaustion in both men and women. Job strain, low job support, and having a somatic disorder were also independently associated with exhaustion. While WFC was more prevalent among men, it was more strongly associated with exhaustion in women than in men. In women, WFC and FWC contributed to a larger part of the explanatory power of the model, which amounted to 22% of the variance in women and 14% in men. The results imply that the concept of 'work stress' should be regarded in a wider context in order to understand gender related issues of exhaustion among vocationally active individuals.

Research paper thumbnail of Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: A longitudinal, register-based study

Journal of Psychosomatic Research, 2014

Insomnia and short and long sleep durations have all been linked to cardiovascular disease. Male ... more Insomnia and short and long sleep durations have all been linked to cardiovascular disease. Male gender and low socioeconomic status are also related to cardiovascular disease, but it is unclear whether these two factors modify the impact of poor sleep on cardiovascular disease incidence. Participants (5875 men and 7742 women ages 45 to 64 with no history of cardiovascular disease from the general population of Malmö, Sweden; participation rate 41%) were enrolled from 1992 to 1994 and followed until 2005 or until the first cardiovascular event (defined as myocardial infarction, stroke, or death due to ischemic heart disease), as recorded by official registers. Baseline blood pressure, BMI, and inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with hazard ratios (HRs) of cardiovascular events. Affirming 'moderate' or 'considerable' problems with at least one out of the four insomnia symptoms was associated with cardiovascular event in women (fully-adjusted HR 1.4 [95% CI 1.2-1.6] and population attributable fraction 17.3%). The same was true of men with past or present manual occupation (HR 1.3 [95% CI 1.1-1.6] and population attributable fraction 11.8%). The HRs increased further in women where insomnia symptoms were combined with short or long sleep duration. Insomnia is a significant public health problem with implications for cardiovascular disease incidence. Taking gender and socioeconomic status into account is a worthwhile approach in research on sleep and cardiovascular disease outcomes.

Research paper thumbnail of Insomnia Symptoms, Sleep Duration, and Disability Pensions: a Prospective Study of Swedish Workers

International Journal of Behavioral Medicine, 2013

Background Previous studies have found insomnia and long sleep duration to be independently assoc... more Background Previous studies have found insomnia and long sleep duration to be independently associated with subsequent disability pension (DP). However, the issue of a possible gender-based pattern in this context has received little attention. Purpose To assess the impact of insomnia symptoms and sleep duration on the DP rates among Swedish women and men during a 12-year follow-up period. Methods The participants, from the general population of Malmö, Sweden, were enrolled from 1992 to 1994 (n = 4,319; participation rate 41%), aged 45-64, healthy and employed ≥ 30 hours per week. Baseline inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with official register-based DP rates. Results Five-hundred-and-nine persons were granted a DP. Insomnia symptoms, affirmed by 33% of the men and 41% of the women, was associated with receiving a DP; the hazard ratios in the fully-adjusted model were 1.4 for both men (95% CI: 1.1, 1.9) and women (95% CI: 1.1, 1.7). The fully-adjusted hazard ratio for women sleeping ≥ 9 hours was 7.8 (95% CI: 3.7, 16.6) for DP due to a mental disorder. In the age-adjusted analyses, the sub-domain 'difficulties falling asleep' was related to DP due to mental disorders in men and DP due to cardiovascular diseases in women. Conclusions The findings suggest that preventing and treating insomnia symptoms could reduce DP, and that disease mechanisms linking sleep disturbances to DP may differ by gender. Table 1. Baseline sociodemographic characteristics and new cases of disability pension awards, in a cohort of healthy men (n = 2254) and women (n = 2065). Mamö Shoulder and Neck Study Men Women No. Cases % HR 95% CI No. Cases % HR 95% CI

Research paper thumbnail of Synergistic interaction effect between job control and social support at work on general psychological distress

International Archives of Occupational and Environmental Health, 2010

Research paper thumbnail of An epidemiological study of exhaustion in the context of chronic stress – concept, cortisol, causes and consequences

Socialmedicinsk Tidskrift, Jan 10, 2012

The interest in exhaustion has increased rapidly during the last few decades in many developed co... more The interest in exhaustion has increased rapidly during the last few decades in many developed countries. In Sweden, prevalence of exhaustion increased by 50 percent on average between 1989 and 2005, and recent data reveals that exhaustion still remains at this higher level. Scientifically, exhaustion is not clearly defined. Chronic stress is acknowledged to give rise to exhaustion, but specific mechanisms involved have generally been overlooked in stress research. The relatively new concept of "hypocortisolism" in this context, referring to low levels of circulating cortisol, and observed in disorders featuring exhaustion, should be of interest. Hypocortisolism has also been suggested to comprise a mechanism for development of stress-related disease that challenges the previous general view of stress pathophysiology. The main objective of this thesis was to evaluate whether exhaustion as concept may be helpful in elucidating stress mechanisms. The four included Papers explored the discriminant validity of exhaustion in relation to depression and anxiety; HPA activity in exhaustion; associations with psychosocial work stressors; and significance for onset of a "stress-related disease", i.e. cardiac disease. Two study populations were used. For Papers I, III, and IV, analyses were performed on data from the Malmö Shoulder and Neck Study (N = 12,607); prospective data on coronary heart disease for Paper IV was obtained through data linkage. For Paper II, a working population sample (N = 78) was analysed. Exhaustion was assessed by means of the (inverted) SF-36 vitality measure. In Paper I, exhaustion emerged separately from depression and anxiety in factor analysis, supporting the conceptual integrity of exhaustion. In Paper II, HPA dysregulation in terms of a flattened diurnal cortisol rhythm (due to lower morning cortisol) was found in exhaustion. In Paper III, relationships with work-related stressors were demonstrated. Finally, in Paper IV, the contribution of exhaustion, independent from depression and anxiety, in development of coronary heart disease was indicated in men. The findings point to a unique and potentially important role of exhaustion in stress theory. It may, however, be important to focus gender in search of relevant concepts and mechanisms for development of stress-related disease. The search for preventive measures should be essential in future research.

Research paper thumbnail of Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women

The European Journal of Public Health, 2010

Background: Exhaustion is a concept of interest for both occupational health research and stress-... more Background: Exhaustion is a concept of interest for both occupational health research and stress-disease theory research. The aim of the present study was to explore associations between chronic stressors, in terms of psychosocial working conditions, and exhaustion in a Swedish middle-aged population sample. Methods: A vocationally active population sample of the Malmö Shoulder and Neck Study cohort, comprising 2555 men and 2466 women between 45 and 64 years of age, was used. Psychosocial working conditions, assessed by means of the demand-control-support model, were measured longitudinally with a 1-year interval. Exhaustion was assessed by the SF-36 vitality scale and measured at follow-up, yielding a cross-sectional study design. Results: Exhaustion was twice as common in women as in men. High psychological job demands, low job control and low job support were independently associated with exhaustion in both men and women. These associations remained after controlling for a variety of potential confounders and mediators, including socio-demographic factors, lifestyle factors, musculoskeletal pain, disease, other work-related factors (including physical workload) and non-work-related factors. High demands in combination with low control (job strain), and job strain combined with low job support (iso-strain), increased the risk for exhaustion. Conclusion: Psychosocial working conditions seem to contribute to exhaustion in middle-aged men and women. Future research should include exploration of exhaustion as a possible mediator between work stress and disease, as well as exploration of other chronic stressors, including non-work-related stressors, regarding their effects on exhaustion in men and women.

Research paper thumbnail of Exhaustion is differentiable from depression and anxiety: Evidence provided by the SF-36 vitality scale

Stress: The International Journal on the Biology of Stress, 2006

Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet ... more Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet fully conceptualised. This is perhaps partly due to the fact that the distinction between exhaustion and other already established concepts, such as depression, is not clear. This study explores whether exhaustion can be differentiated from depression and anxiety, by means of introducing the SF-36 vitality scale as a strategy for the measurement of exhaustion. The Malmö Shoulder and Neck Study cohort, in this study including 12,607 middle-aged men and women, was utilized. Depression and anxiety were assessed by the general health questionnaire (GHQ). Factor analysis was performed in order to potentially discriminate between the included measures. Factor analysis showed that all four exhaustion items of the (inverted) SF-36 vitality scale loaded on a single factor, separate from the GHQ depression and anxiety factors. These results support the notion that exhaustion can be distinguished from depression and anxiety, providing an empirical foundation for defining exhaustion as a unique concept. Furthermore, since SF-36 has been widely used in clinical and epidemiological studies, the benefits of using the SF-36 vitality scale in the assessment of exhaustion could be substantial.

Research paper thumbnail of Conflict between the work and family domains and exhaustion among vocationally active men and women

Social Science & Medicine, 2010

Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job... more Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job strain more often, which may constitute a partial explanation for this phenomenon, but experienced shortcomings in combining work and family demands may also contribute to ill health. The aim of this study was to investigate, and analyse by gender, how work-related and family-related factors, as well as the interface between them, i.e. work-to-family conflict (WFC) and family-to-work conflict (FWC), are related to exhaustion. The study was cross-sectional with self-administered questionnaires assessing exposures and outcome with previously well-validated instruments. The participants were 2726 men and 2735 women, aged 45-64, vocationally active, and residing in Malmö , Sweden. Sixteen percent of the women and 8% of the men considered themselves exhausted. WFC, FWC, job strain, and low job support were all strongly correlated to exhaustion in both genders. In the multivariate analyses, adjusting for other work and family risk factors, WFC and FWC remained statistically significant risk factors for exhaustion in both men and women. Job strain, low job support, and having a somatic disorder were also independently associated with exhaustion. While WFC was more prevalent among men, it was more strongly associated with exhaustion in women than in men. In women, WFC and FWC contributed to a larger part of the explanatory power of the model, which amounted to 22% of the variance in women and 14% in men. The results imply that the concept of 'work stress' should be regarded in a wider context in order to understand gender related issues of exhaustion among vocationally active individuals.

Research paper thumbnail of Exhaustion measured by the SF-36 vitality scale is associated with a flattened diurnal cortisol profile

Psychoneuroendocrinology, 2008

The possible association between stress-related exhaustion and reduced activity in the HPA axis i... more The possible association between stress-related exhaustion and reduced activity in the HPA axis is increasingly in focus. The aim of the present study was to examine whether exhaustion measured in a non-patient population is associated with alterations in diurnal cortisol profile. The study population included 78 working individuals. The study group was dichotomised into exhausted and non-exhausted groups by means of the SF-36 vitality scale. Salivary cortisol was measured at three times during one workday: at awakening, 30 minutes after awakening, and in the evening. The results showed that diurnal cortisol variation was significantly reduced in exhausted individuals. The difference in cortisol variation was mainly due to lowered morning cortisol in the exhausted group. Differences in cortisol levels at each sampling time or in mean diurnal output of cortisol were not statistically significant. The results would support the notion that exhaustion is associated with HPA axis hypoactivity as assessed by salivary cortisol. Furthermore, the SF-36 vitality provides a measure of exhaustion that may be useful in epidemiological studies in order to explore long-term health effects of stress-related exhaustion.

Research paper thumbnail of Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: A longitudinal, register-based study

Journal of Psychosomatic Research, 2014

Objectives: Insomnia, and short and long sleep duration, have all been linked to cardiovascular d... more Objectives: Insomnia, and short and long sleep duration, have all been linked to cardiovascular disease. Male gender and low socioeconomic status are also related to cardiovascular disease, but it is unclear whether these two factors modify the impact of poor sleep on cardiovascular disease incidence.

Research paper thumbnail of Exhaustion predicts coronary heart disease independently of symptoms of depression and anxiety in men but not in women

Journal of Psychosomatic Research, 2012

Objective: Exhaustion is hypothesised to be a risk-factor for coronary heart disease (CHD), but a... more Objective: Exhaustion is hypothesised to be a risk-factor for coronary heart disease (CHD), but as such its independence from emotional states, in particular depression, has not been established in previous investigations. This study aimed to explore the unique contribution of exhaustion, independent from symptoms of depression and anxiety, to CHD development. Methods: The study sample was 5061 men and 6734 women from the Malmö Shoulder and Neck Study cohort examined in 1993-96. Exhaustion was measured by the SF-36 vitality scale. Symptoms of depression and anxiety were measured by the General Health Questionnaire. 571 first coronary events were ascertained through record linkage until 2005. Cox regression analysis was used to assess the contribution of exhaustion to CHD. Results: In age-adjusted analysis exhaustion predicted coronary events in a non-linear way in both men (HR = 1.49, 95% CI 1.06-2.11 in the highest exhaustion category) and women (HR = 1.78, 95% CI 1.23-2.58 in the second highest exhaustion category). After adjustment for traditional risk-factors for CHD and socioeconomic status, the effect was attenuated and statistically significant only in women. However, further adjustment for symptoms of depression and anxiety strengthened the association between exhaustion and CHD in men (HR = 1.62, 95% CI 1.05-2.50), whereas in women, exhaustion no longer predicted CHD. Conclusion: In age-adjusted analysis, exhaustion predicted CHD in both men and women, but its independence from depression and anxiety was demonstrated only in men. Further studies on the topic are required. A larger focus on potential gender differences should seem warranted in future research.

Research paper thumbnail of Insomnia Symptoms, Sleep Duration, and Disability Pensions: a Prospective Study of Swedish Workers

International Journal of Behavioral Medicine, 2014

Previous studies have found insomnia and long sleep duration to be independently associated with ... more Previous studies have found insomnia and long sleep duration to be independently associated with subsequent disability pension (DP). However, the issue of a possible gender-based pattern in this context has received little attention. This study aims to assess the impact of insomnia symptoms and sleep duration on the DP rates among Swedish women and men during a 12-year follow-up period. The participants, from the general population of Malmö, Sweden, were enrolled from 1992 to 1994 (n = 4,319; participation rate 41 %), aged 45-64, healthy, and employed ≥30 h per week. Baseline inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with official register-based DP rates. Five hundred and nine persons were granted a DP. Insomnia symptoms, affirmed by 33 % of the men and 41 % of the women, were associated with receiving a DP; the hazard ratios in the fully adjusted model were 1.4 for both men [95 % confidence interval (CI) 1.1, 1.9] and women (95 % CI 1.1, 1.7). The fully adjusted hazard ratio for women sleeping ≥9 h was 7.8 (95 % CI 3.7, 16.6) for DP due to a mental disorder. In the age-adjusted analyses, the sub-domain "difficulties falling asleep" was related to DP due to mental disorders in men and DP due to cardiovascular diseases in women. The findings suggest that preventing and treating insomnia symptoms could reduce DP and that disease mechanisms linking sleep disturbances to DP may differ by gender.

Research paper thumbnail of Synergistic interaction effect between job control and social support at work on general psychological distress

International Archives of Occupational and Environmental Health, 2011

Purpose Little is known about the interaction between job control and social support at work on c... more Purpose Little is known about the interaction between job control and social support at work on common mental disorders. To examine whether there is a synergistic interaction eVect between job control and social support at work on general psychological distress and whether it diVers by the level of job demands. Methods About 1,940 male and female workers from the Malmö Shoulder and Neck Study were chosen for this cross-sectional study. Job control, social support at work, and job demands were measured by the Swedish version of the Job Content Questionnaire, and general psychological distress was assessed by the General Health Questionnaire. Results A signiWcant excessive risk increase for general psychological distress was observed when workers had both low job control and low social support at work in both men and women. The synergistic eVect was stronger in women, when job demands were low (Rothman's synergy index was 2.16 vs. 1.51 when job demands were high). However, in male workers, while a strong synergistic eVect between job control and social support at work was found when job demands were low (synergy index was 9.25), there was an antagonistic eVect when job demands were high (synergy index was 0.52). Conclusions There was a synergistic interaction eVect between job control and social support at work on general psychological distress, but the synergistic eVect or its eVect size diVered by the level of job demands and gender. An atomic, additive approach to the risk assessment of the psychosocial work characteristics on common mental disorders could be misleading or lead to a risk underestimation.

Research paper thumbnail of Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women

The European Journal of Public Health, 2011

Background: Exhaustion is a concept of interest for both occupational health research and stress-... more Background: Exhaustion is a concept of interest for both occupational health research and stress-disease theory research. The aim of the present study was to explore associations between chronic stressors, in terms of psychosocial working conditions, and exhaustion in a Swedish middle-aged population sample. Methods: A vocationally active population sample of the Malmö Shoulder and Neck Study cohort, comprising 2555 men and 2466 women between 45 and 64 years of age, was used. Psychosocial working conditions, assessed by means of the demand-control-support model, were measured longitudinally with a 1-year interval. Exhaustion was assessed by the SF-36 vitality scale and measured at follow-up, yielding a cross-sectional study design. Results: Exhaustion was twice as common in women as in men. High psychological job demands, low job control and low job support were independently associated with exhaustion in both men and women. These associations remained after controlling for a variety of potential confounders and mediators, including socio-demographic factors, lifestyle factors, musculoskeletal pain, disease, other work-related factors (including physical workload) and non-work-related factors. High demands in combination with low control (job strain), and job strain combined with low job support (iso-strain), increased the risk for exhaustion. Conclusion: Psychosocial working conditions seem to contribute to exhaustion in middle-aged men and women. Future research should include exploration of exhaustion as a possible mediator between work stress and disease, as well as exploration of other chronic stressors, including non-work-related stressors, regarding their effects on exhaustion in men and women.

Research paper thumbnail of Region Skånes sociala investeringsfond

Socialmedicinsk Tidskrift, Sep 3, 2014

Research paper thumbnail of Synergistic interaction eVect between job control and social support at work on general psychological distress

Int Arch Occup Envir Health, 2011

Research paper thumbnail of Exhaustion is differentiable from depression and anxiety: Evidence provided by the SF-36 vitality scale

Stress, 2006

Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet ... more Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet fully conceptualised. This is perhaps partly due to the fact that the distinction between exhaustion and other already established concepts, such as depression, is not clear. This study explores whether exhaustion can be differentiated from depression and anxiety, by means of introducing the SF-36 vitality scale as a strategy for the measurement of exhaustion. The Malmö Shoulder and Neck Study cohort, in this study including 12,607 middle-aged men and women, was utilized. Depression and anxiety were assessed by the general health questionnaire (GHQ). Factor analysis was performed in order to potentially discriminate between the included measures. Factor analysis showed that all four exhaustion items of the (inverted) SF-36 vitality scale loaded on a single factor, separate from the GHQ depression and anxiety factors. These results support the notion that exhaustion can be distinguished from depression and anxiety, providing an empirical foundation for defining exhaustion as a unique concept. Furthermore, since SF-36 has been widely used in clinical and epidemiological studies, the benefits of using the SF-36 vitality scale in the assessment of exhaustion could be substantial.

Research paper thumbnail of Conflict between the work and family domains and exhaustion among vocationally active men and women

Social Science & Medicine, 2010

Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job... more Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job strain more often, which may constitute a partial explanation for this phenomenon, but experienced shortcomings in combining work and family demands may also contribute to ill health. The aim of this study was to investigate, and analyse by gender, how work-related and family-related factors, as well as the interface between them, i.e. work-to-family conflict (WFC) and family-to-work conflict (FWC), are related to exhaustion. The study was crosssectional with self-administered questionnaires assessing exposures and outcome with previously well validated instruments. The participants were 2,726 men and 2,735 women, aged 45 to 64, vocationally active, and residing in Malmö, Sweden. Sixteen percent of the women and 8% of the men considered themselves exhausted. WFC, FWC, job strain, and low job support were all strongly correlated to exhaustion in both genders. In the multivariate analyses, adjusting for other work and family risk factors, WFC and FWC remained statistically significant risk factors for exhaustion in both men and women. Job strain, low job support, and having a somatic disorder were also independently associated with exhaustion. While WFC was more prevalent among men, it was more strongly associated with exhaustion in women than in men. In women, WFC and FWC contributed to a larger part of the explanatory power of the model, which amounted to 22% of the variance in women and 14% in men. The results imply that the concept of 'work stress' should be regarded in a wider context in order to understand gender related issues of exhaustion among vocationally active individuals.

Research paper thumbnail of Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: A longitudinal, register-based study

Journal of Psychosomatic Research, 2014

Insomnia and short and long sleep durations have all been linked to cardiovascular disease. Male ... more Insomnia and short and long sleep durations have all been linked to cardiovascular disease. Male gender and low socioeconomic status are also related to cardiovascular disease, but it is unclear whether these two factors modify the impact of poor sleep on cardiovascular disease incidence. Participants (5875 men and 7742 women ages 45 to 64 with no history of cardiovascular disease from the general population of Malmö, Sweden; participation rate 41%) were enrolled from 1992 to 1994 and followed until 2005 or until the first cardiovascular event (defined as myocardial infarction, stroke, or death due to ischemic heart disease), as recorded by official registers. Baseline blood pressure, BMI, and inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with hazard ratios (HRs) of cardiovascular events. Affirming 'moderate' or 'considerable' problems with at least one out of the four insomnia symptoms was associated with cardiovascular event in women (fully-adjusted HR 1.4 [95% CI 1.2-1.6] and population attributable fraction 17.3%). The same was true of men with past or present manual occupation (HR 1.3 [95% CI 1.1-1.6] and population attributable fraction 11.8%). The HRs increased further in women where insomnia symptoms were combined with short or long sleep duration. Insomnia is a significant public health problem with implications for cardiovascular disease incidence. Taking gender and socioeconomic status into account is a worthwhile approach in research on sleep and cardiovascular disease outcomes.

Research paper thumbnail of Insomnia Symptoms, Sleep Duration, and Disability Pensions: a Prospective Study of Swedish Workers

International Journal of Behavioral Medicine, 2013

Background Previous studies have found insomnia and long sleep duration to be independently assoc... more Background Previous studies have found insomnia and long sleep duration to be independently associated with subsequent disability pension (DP). However, the issue of a possible gender-based pattern in this context has received little attention. Purpose To assess the impact of insomnia symptoms and sleep duration on the DP rates among Swedish women and men during a 12-year follow-up period. Methods The participants, from the general population of Malmö, Sweden, were enrolled from 1992 to 1994 (n = 4,319; participation rate 41%), aged 45-64, healthy and employed ≥ 30 hours per week. Baseline inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with official register-based DP rates. Results Five-hundred-and-nine persons were granted a DP. Insomnia symptoms, affirmed by 33% of the men and 41% of the women, was associated with receiving a DP; the hazard ratios in the fully-adjusted model were 1.4 for both men (95% CI: 1.1, 1.9) and women (95% CI: 1.1, 1.7). The fully-adjusted hazard ratio for women sleeping ≥ 9 hours was 7.8 (95% CI: 3.7, 16.6) for DP due to a mental disorder. In the age-adjusted analyses, the sub-domain 'difficulties falling asleep' was related to DP due to mental disorders in men and DP due to cardiovascular diseases in women. Conclusions The findings suggest that preventing and treating insomnia symptoms could reduce DP, and that disease mechanisms linking sleep disturbances to DP may differ by gender. Table 1. Baseline sociodemographic characteristics and new cases of disability pension awards, in a cohort of healthy men (n = 2254) and women (n = 2065). Mamö Shoulder and Neck Study Men Women No. Cases % HR 95% CI No. Cases % HR 95% CI

Research paper thumbnail of Synergistic interaction effect between job control and social support at work on general psychological distress

International Archives of Occupational and Environmental Health, 2010

Research paper thumbnail of An epidemiological study of exhaustion in the context of chronic stress – concept, cortisol, causes and consequences

Socialmedicinsk Tidskrift, Jan 10, 2012

The interest in exhaustion has increased rapidly during the last few decades in many developed co... more The interest in exhaustion has increased rapidly during the last few decades in many developed countries. In Sweden, prevalence of exhaustion increased by 50 percent on average between 1989 and 2005, and recent data reveals that exhaustion still remains at this higher level. Scientifically, exhaustion is not clearly defined. Chronic stress is acknowledged to give rise to exhaustion, but specific mechanisms involved have generally been overlooked in stress research. The relatively new concept of "hypocortisolism" in this context, referring to low levels of circulating cortisol, and observed in disorders featuring exhaustion, should be of interest. Hypocortisolism has also been suggested to comprise a mechanism for development of stress-related disease that challenges the previous general view of stress pathophysiology. The main objective of this thesis was to evaluate whether exhaustion as concept may be helpful in elucidating stress mechanisms. The four included Papers explored the discriminant validity of exhaustion in relation to depression and anxiety; HPA activity in exhaustion; associations with psychosocial work stressors; and significance for onset of a "stress-related disease", i.e. cardiac disease. Two study populations were used. For Papers I, III, and IV, analyses were performed on data from the Malmö Shoulder and Neck Study (N = 12,607); prospective data on coronary heart disease for Paper IV was obtained through data linkage. For Paper II, a working population sample (N = 78) was analysed. Exhaustion was assessed by means of the (inverted) SF-36 vitality measure. In Paper I, exhaustion emerged separately from depression and anxiety in factor analysis, supporting the conceptual integrity of exhaustion. In Paper II, HPA dysregulation in terms of a flattened diurnal cortisol rhythm (due to lower morning cortisol) was found in exhaustion. In Paper III, relationships with work-related stressors were demonstrated. Finally, in Paper IV, the contribution of exhaustion, independent from depression and anxiety, in development of coronary heart disease was indicated in men. The findings point to a unique and potentially important role of exhaustion in stress theory. It may, however, be important to focus gender in search of relevant concepts and mechanisms for development of stress-related disease. The search for preventive measures should be essential in future research.

Research paper thumbnail of Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women

The European Journal of Public Health, 2010

Background: Exhaustion is a concept of interest for both occupational health research and stress-... more Background: Exhaustion is a concept of interest for both occupational health research and stress-disease theory research. The aim of the present study was to explore associations between chronic stressors, in terms of psychosocial working conditions, and exhaustion in a Swedish middle-aged population sample. Methods: A vocationally active population sample of the Malmö Shoulder and Neck Study cohort, comprising 2555 men and 2466 women between 45 and 64 years of age, was used. Psychosocial working conditions, assessed by means of the demand-control-support model, were measured longitudinally with a 1-year interval. Exhaustion was assessed by the SF-36 vitality scale and measured at follow-up, yielding a cross-sectional study design. Results: Exhaustion was twice as common in women as in men. High psychological job demands, low job control and low job support were independently associated with exhaustion in both men and women. These associations remained after controlling for a variety of potential confounders and mediators, including socio-demographic factors, lifestyle factors, musculoskeletal pain, disease, other work-related factors (including physical workload) and non-work-related factors. High demands in combination with low control (job strain), and job strain combined with low job support (iso-strain), increased the risk for exhaustion. Conclusion: Psychosocial working conditions seem to contribute to exhaustion in middle-aged men and women. Future research should include exploration of exhaustion as a possible mediator between work stress and disease, as well as exploration of other chronic stressors, including non-work-related stressors, regarding their effects on exhaustion in men and women.

Research paper thumbnail of Exhaustion is differentiable from depression and anxiety: Evidence provided by the SF-36 vitality scale

Stress: The International Journal on the Biology of Stress, 2006

Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet ... more Stress-related exhaustion is an increasingly focused phenomenon, although scientifically not yet fully conceptualised. This is perhaps partly due to the fact that the distinction between exhaustion and other already established concepts, such as depression, is not clear. This study explores whether exhaustion can be differentiated from depression and anxiety, by means of introducing the SF-36 vitality scale as a strategy for the measurement of exhaustion. The Malmö Shoulder and Neck Study cohort, in this study including 12,607 middle-aged men and women, was utilized. Depression and anxiety were assessed by the general health questionnaire (GHQ). Factor analysis was performed in order to potentially discriminate between the included measures. Factor analysis showed that all four exhaustion items of the (inverted) SF-36 vitality scale loaded on a single factor, separate from the GHQ depression and anxiety factors. These results support the notion that exhaustion can be distinguished from depression and anxiety, providing an empirical foundation for defining exhaustion as a unique concept. Furthermore, since SF-36 has been widely used in clinical and epidemiological studies, the benefits of using the SF-36 vitality scale in the assessment of exhaustion could be substantial.

Research paper thumbnail of Conflict between the work and family domains and exhaustion among vocationally active men and women

Social Science & Medicine, 2010

Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job... more Exhaustion is consistently found to be more prevalent in women than in men. Women suffer from job strain more often, which may constitute a partial explanation for this phenomenon, but experienced shortcomings in combining work and family demands may also contribute to ill health. The aim of this study was to investigate, and analyse by gender, how work-related and family-related factors, as well as the interface between them, i.e. work-to-family conflict (WFC) and family-to-work conflict (FWC), are related to exhaustion. The study was cross-sectional with self-administered questionnaires assessing exposures and outcome with previously well-validated instruments. The participants were 2726 men and 2735 women, aged 45-64, vocationally active, and residing in Malmö , Sweden. Sixteen percent of the women and 8% of the men considered themselves exhausted. WFC, FWC, job strain, and low job support were all strongly correlated to exhaustion in both genders. In the multivariate analyses, adjusting for other work and family risk factors, WFC and FWC remained statistically significant risk factors for exhaustion in both men and women. Job strain, low job support, and having a somatic disorder were also independently associated with exhaustion. While WFC was more prevalent among men, it was more strongly associated with exhaustion in women than in men. In women, WFC and FWC contributed to a larger part of the explanatory power of the model, which amounted to 22% of the variance in women and 14% in men. The results imply that the concept of 'work stress' should be regarded in a wider context in order to understand gender related issues of exhaustion among vocationally active individuals.

Research paper thumbnail of Exhaustion measured by the SF-36 vitality scale is associated with a flattened diurnal cortisol profile

Psychoneuroendocrinology, 2008

The possible association between stress-related exhaustion and reduced activity in the HPA axis i... more The possible association between stress-related exhaustion and reduced activity in the HPA axis is increasingly in focus. The aim of the present study was to examine whether exhaustion measured in a non-patient population is associated with alterations in diurnal cortisol profile. The study population included 78 working individuals. The study group was dichotomised into exhausted and non-exhausted groups by means of the SF-36 vitality scale. Salivary cortisol was measured at three times during one workday: at awakening, 30 minutes after awakening, and in the evening. The results showed that diurnal cortisol variation was significantly reduced in exhausted individuals. The difference in cortisol variation was mainly due to lowered morning cortisol in the exhausted group. Differences in cortisol levels at each sampling time or in mean diurnal output of cortisol were not statistically significant. The results would support the notion that exhaustion is associated with HPA axis hypoactivity as assessed by salivary cortisol. Furthermore, the SF-36 vitality provides a measure of exhaustion that may be useful in epidemiological studies in order to explore long-term health effects of stress-related exhaustion.

Research paper thumbnail of Insomnia increases risk for cardiovascular events in women and in men with low socioeconomic status: A longitudinal, register-based study

Journal of Psychosomatic Research, 2014

Objectives: Insomnia, and short and long sleep duration, have all been linked to cardiovascular d... more Objectives: Insomnia, and short and long sleep duration, have all been linked to cardiovascular disease. Male gender and low socioeconomic status are also related to cardiovascular disease, but it is unclear whether these two factors modify the impact of poor sleep on cardiovascular disease incidence.

Research paper thumbnail of Exhaustion predicts coronary heart disease independently of symptoms of depression and anxiety in men but not in women

Journal of Psychosomatic Research, 2012

Objective: Exhaustion is hypothesised to be a risk-factor for coronary heart disease (CHD), but a... more Objective: Exhaustion is hypothesised to be a risk-factor for coronary heart disease (CHD), but as such its independence from emotional states, in particular depression, has not been established in previous investigations. This study aimed to explore the unique contribution of exhaustion, independent from symptoms of depression and anxiety, to CHD development. Methods: The study sample was 5061 men and 6734 women from the Malmö Shoulder and Neck Study cohort examined in 1993-96. Exhaustion was measured by the SF-36 vitality scale. Symptoms of depression and anxiety were measured by the General Health Questionnaire. 571 first coronary events were ascertained through record linkage until 2005. Cox regression analysis was used to assess the contribution of exhaustion to CHD. Results: In age-adjusted analysis exhaustion predicted coronary events in a non-linear way in both men (HR = 1.49, 95% CI 1.06-2.11 in the highest exhaustion category) and women (HR = 1.78, 95% CI 1.23-2.58 in the second highest exhaustion category). After adjustment for traditional risk-factors for CHD and socioeconomic status, the effect was attenuated and statistically significant only in women. However, further adjustment for symptoms of depression and anxiety strengthened the association between exhaustion and CHD in men (HR = 1.62, 95% CI 1.05-2.50), whereas in women, exhaustion no longer predicted CHD. Conclusion: In age-adjusted analysis, exhaustion predicted CHD in both men and women, but its independence from depression and anxiety was demonstrated only in men. Further studies on the topic are required. A larger focus on potential gender differences should seem warranted in future research.

Research paper thumbnail of Insomnia Symptoms, Sleep Duration, and Disability Pensions: a Prospective Study of Swedish Workers

International Journal of Behavioral Medicine, 2014

Previous studies have found insomnia and long sleep duration to be independently associated with ... more Previous studies have found insomnia and long sleep duration to be independently associated with subsequent disability pension (DP). However, the issue of a possible gender-based pattern in this context has received little attention. This study aims to assess the impact of insomnia symptoms and sleep duration on the DP rates among Swedish women and men during a 12-year follow-up period. The participants, from the general population of Malmö, Sweden, were enrolled from 1992 to 1994 (n = 4,319; participation rate 41 %), aged 45-64, healthy, and employed ≥30 h per week. Baseline inquiry data concerning psychosocial circumstances and self-reported sleep habits were compared with official register-based DP rates. Five hundred and nine persons were granted a DP. Insomnia symptoms, affirmed by 33 % of the men and 41 % of the women, were associated with receiving a DP; the hazard ratios in the fully adjusted model were 1.4 for both men [95 % confidence interval (CI) 1.1, 1.9] and women (95 % CI 1.1, 1.7). The fully adjusted hazard ratio for women sleeping ≥9 h was 7.8 (95 % CI 3.7, 16.6) for DP due to a mental disorder. In the age-adjusted analyses, the sub-domain "difficulties falling asleep" was related to DP due to mental disorders in men and DP due to cardiovascular diseases in women. The findings suggest that preventing and treating insomnia symptoms could reduce DP and that disease mechanisms linking sleep disturbances to DP may differ by gender.

Research paper thumbnail of Synergistic interaction effect between job control and social support at work on general psychological distress

International Archives of Occupational and Environmental Health, 2011

Purpose Little is known about the interaction between job control and social support at work on c... more Purpose Little is known about the interaction between job control and social support at work on common mental disorders. To examine whether there is a synergistic interaction eVect between job control and social support at work on general psychological distress and whether it diVers by the level of job demands. Methods About 1,940 male and female workers from the Malmö Shoulder and Neck Study were chosen for this cross-sectional study. Job control, social support at work, and job demands were measured by the Swedish version of the Job Content Questionnaire, and general psychological distress was assessed by the General Health Questionnaire. Results A signiWcant excessive risk increase for general psychological distress was observed when workers had both low job control and low social support at work in both men and women. The synergistic eVect was stronger in women, when job demands were low (Rothman's synergy index was 2.16 vs. 1.51 when job demands were high). However, in male workers, while a strong synergistic eVect between job control and social support at work was found when job demands were low (synergy index was 9.25), there was an antagonistic eVect when job demands were high (synergy index was 0.52). Conclusions There was a synergistic interaction eVect between job control and social support at work on general psychological distress, but the synergistic eVect or its eVect size diVered by the level of job demands and gender. An atomic, additive approach to the risk assessment of the psychosocial work characteristics on common mental disorders could be misleading or lead to a risk underestimation.

Research paper thumbnail of Psychosocial working conditions and exhaustion in a working population sample of Swedish middle-aged men and women

The European Journal of Public Health, 2011

Background: Exhaustion is a concept of interest for both occupational health research and stress-... more Background: Exhaustion is a concept of interest for both occupational health research and stress-disease theory research. The aim of the present study was to explore associations between chronic stressors, in terms of psychosocial working conditions, and exhaustion in a Swedish middle-aged population sample. Methods: A vocationally active population sample of the Malmö Shoulder and Neck Study cohort, comprising 2555 men and 2466 women between 45 and 64 years of age, was used. Psychosocial working conditions, assessed by means of the demand-control-support model, were measured longitudinally with a 1-year interval. Exhaustion was assessed by the SF-36 vitality scale and measured at follow-up, yielding a cross-sectional study design. Results: Exhaustion was twice as common in women as in men. High psychological job demands, low job control and low job support were independently associated with exhaustion in both men and women. These associations remained after controlling for a variety of potential confounders and mediators, including socio-demographic factors, lifestyle factors, musculoskeletal pain, disease, other work-related factors (including physical workload) and non-work-related factors. High demands in combination with low control (job strain), and job strain combined with low job support (iso-strain), increased the risk for exhaustion. Conclusion: Psychosocial working conditions seem to contribute to exhaustion in middle-aged men and women. Future research should include exploration of exhaustion as a possible mediator between work stress and disease, as well as exploration of other chronic stressors, including non-work-related stressors, regarding their effects on exhaustion in men and women.