Risk of second heart attack doubles with job stress

Do a better job of reaching out to workers with burnout

When an employee returns to work after a heart attack, chronic job stress doubles their risk for another coronary heart disease event, according to a recent study.1

After 972 men and women, aged 35 to 59 years, came back to work after a heart attack, researchers performed follow-up at regular intervals between February 1996 and June 2005. Patients were first interviewed about six weeks after their return to work, then two years and six years later. During the last follow-up, researchers found that 206 employees had a confirmed recurrent coronary heart disease event, including 13 deaths. Chronic job strain (defined as high psychological demands and low decision control) was linked with a twofold increased risk in these workers.

To make the problem even more challenging, workers with burnout are less likely to participate in stress reduction or occupational training and are at risk for taking inappropriate antidepressants, says another study.2 Researchers surveyed 3,276 Finnish employees aged 30 to 64 about burnout (defined as exhaustion accompanied by feelings of incompetence or that one's work isn't valuable). They found that 25% had mild burnout symptoms, and 2.4% had severe burnout.

Workers with severe burnout were about 40% less likely to participate in work practice improvement, occupational training, stress reduction, or vocational rehabilitation programs. However, these workers were more likely to take medications for mental health problems, with increased rates of antidepressant use even after adjustment for the presence of depression and anxiety.

These data suggest that in some cases burnout has been misinterpreted as a mental disorder requiring medications, says Kirsi Ahola, the study's author and a researcher at the Finnish Institute of Occupational Health in Helsinki. "Especially when they have no contact with the patient's workplace, doctors may feel medications are the only help they can offer," says Ahola.

In fact, the most effective interventions for workers with burnout combine individual and occupational approaches, says Ahola. "Successful recovery from burnout includes accommodations and activities to restore health and support," she says. "Occupational health professionals can suggest workplace modifications based on scientific evidence." Examples of these modifications are clarified responsibilities, reassigned tasks, increased flexibility and supervisory support, and training, says Ahola. Encourage workers to actively communicate with supervisors about the new work arrangements, advises Ahola. "If necessary, additional support for these discussions from occupational health professionals should be considered," she says. "A follow-up should also be arranged to ensure successful recovery."

Identify cause of burnout

In most cases, the most effective interventions focus on the organization, not the worker, says Mary K. Salazar, EdD, RN, COHN-S, FAAOHN, FAAN, professor in the Department of Psychosocial and Community Health at the Seattle-based University of Washington School of Nursing.

Several studies provide evidence that excessive workloads, role ambiguity, conflict, and lack of social support are major contributors to occupational stress and worker burnout.3, 4, 5

"Management's leadership styles have also been related to stress and burnout. Over-demanding employers are particularly problematic," says Salazar.

A first step in dealing with stress-related problems is to determine if employees are suffering from burnout and, if they are, determine the root cause, says Salazar. For example, burnout may be related to work overload, lack of control, no sense of personal accomplishment, or an intolerant employer, she explains. "Once the cause of the burnout is identified, then it can be addressed," says Salazar.

In most cases, it is not useful to require employees to attend self-help classes such as stress reduction, according to Salazar. "Studies have found that workers suffering from burnout tend not to attend these classes," she says. "Furthermore, individually focused strategies such as counseling or medication do not address the problem of burnout."

However, when there are indicators of psychological problems, workers should be evaluated for depression and anxiety, which would require a different type of intervention, she says. "But even in these cases, if burnout is a part of the problem, it needs to be addressed through some type of workplace intervention," says Salazar.

Prevention is key

Leaders at Philadelphia-based GlaxoSmithKline believe it is more important to prevent worker burnout, rather than waiting to devote a great deal of resources once someone is approaching burnout, says Ann Kuhnen, MD, MPH, vice president of employee health management. A two-day "Energy for Performance" course given by trained facilitators at the Orlando, FL-based Human Performance Institute was piloted in one of the company's businesses with 350 participants, and it now is being offered to all employees onsite each month during 2008.

"It is geared at helping people become better stewards of energy so that they can best engage when it really matters, at work and in personal life," says Kuhnen. "Participants learn to maximize their energy by fully engaging their hearts, minds, spirits, and bodies in completion of the important missions they take on each day. If heeded, this is a fundamental step in avoiding burnout."

Employees can also attend a half-day "Personal Resilience" training course that was developed internally and explores energy, self-awareness, and purposeful living, says Kuhnen. Over the past two years, 18,000 employees have participated. "We have already seen increased engagement, job satisfaction, and willingness to experiment with new ways of working, plus decreased pressure from work-related conflicts," reports Kuhnen.

At Rochester, NY-based Xerox Corp., employees are given several tools to manage stress, including electronic tips, bulletin board materials, and newsletter and intranet articles, says Sandi Alexander Tuttle, manager of the Xerox Recreation Association. The information is pulled from a variety of sources, including the Wellness Council of America. "Additionally, we offer an on-line stress management course with personalized strategies to manage stress, regardless of the source of that stress," says Tuttle, who adds that the course was developed internally. Each year during open enrollment, employees are offered a $200 credit to their benefit allowance if they complete a health risk assessment and, if someone scores high in the area of stress, they are encouraged to take the on-line stress program, says Tuttle.

The company also offers a LifeWorks program provided by Minneapolis, MN-based Ceridian, a workplace effectiveness service providing information and resources for a well-balanced life, says Tuttle. To inform employees about the programs, "health education leaders," a network of employees who volunteer to communicate wellness information, periodically receive fliers to post, she adds.

In most of Xerox's large locations, on-site fitness facilities are provided so employees can participate in Yoga, Tai Chi, go for a walk or run, lift some weights, or participate in a group exercise class to relieve stress, says Tuttle. "Understanding the many ways our employees are stretched and stressed, and making these programs available, is well worth the resources necessary to do so," she says.


  1. Aboa-Éboulé C, Brisson C, Manusell E, et al. Job strain and risk of acute recurrent coronary heart disease events. JAMA 2007; 298:1,652-1,660.
  2. Ahola K, Honkonen T, Virtanen M, et al. Interventions in relation to occupational burnout: the population-based health 2000 Study J Occup Environ Med. 49: 943-952.
  3. National Institute for Occupational Safety and Health. The changing organization of work and the safety and health of working people: Knowledge gaps and research directions. DHHS (NIOSH) Publication No. 2002-116. 2002: Cincinnati, OH.
  4. National Institute for Occupational Safety and Health. Stress... at Work. DHHS (NIOSH) Publication No. 99-101. 1999: Cincinnati, OH.
  5. Salazar MK, Beaton R. Managing psychosocial factors in occupational settings. In Salazar, K.K. (Ed.) Core Curriculum for Occupational & Environmental Health Nursing, 3rd edition, 2002: St. Louis, MO: Saunders Elsevier.