Changes in perceived stress during a mindfulness-based stress reduction (MBSR) intervention predicting occupational recovery from work-related stress: a longitudinal study

doi:10.21203/rs.3.rs-3110351/v1

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Changes in perceived stress during a mindfulness-based stress reduction (MBSR) intervention predicting occupational recovery from work-related stress: a longitudinal study

https://doi.org/10.21203/rs.3.rs-3110351/v1

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Purpose

The Mindfulness-Based Stress Reduction (MBSR) group intervention is increasingly being used in clinics to alleviate stress-related symptoms. The aim was to evaluate the association between pre-post changes in levels of perceived stress during the MBSR program and occupational recovery from prolonged work-related stress. Potential moderators of the association were assessed.

Methods

This study was based on secondary analyses of pre-existing data from 450 patients commencing an MBSR program between 15 October 2015 and 2 April 2019. Data on clinical, sociodemographic, and psychosocial factors were collected via an online survey administered at baseline and the end of the MBSR program. Pre-post changes in levels of perceived stress were evaluated using Cohen’s Perceived Stress Scale (PSS-10). The outcome was stable (versus unstable) employment for at least four consecutive weeks evaluated at 26-week and 52-week follow-ups. Missing data were managed with multiple imputation. Associations were analyzed using logistic regression, with adjustment for confounding factors from clinical, occupational, and psychosocial factors in the latest held job.

Results

The average reduction in PSS-10 scores was 5.0 (SD = 5.5). Each one-point pre-post reduction on the PSS-10 scale was associated with a lower risk of full-time sick-leave at 26-week (OR = 1.12, 95% CI = 1.04, 1.20) and 52-week follow-up (OR = 1.19, 95% CI = 1.09, 1.30). None of these associations were moderated by any predictors.

Conclusion

A greater reduction in levels of perceived stress during participation in an MBSR program, predicts enhanced occupational recovery from long-term work-related stress.

burnout

employment

exhaustion

fatigue

sick leave

workability

Job stress is ubiquitous in modern work life. Short-term psychological stress may be helpful in meeting extraordinary job demands and deadlines. However, compelling evidence suggests that long-term exposure to stressors at work increases the risk of impaired mental health and workability [1–4]. Several models have been developed to explain the causes of job stress [5]. The job demand-control-support model emphasizes the imbalance between high psychological demands and low job control, with potential mitigating effects of social support from colleagues/superiors [6]. Another model highlights the detrimental impact of organizational injustice at work [7]. Unfortunately, only about 50% of employees who are on sick-leave for more than six months due to mental health reasons return to the labor market [8], while another 20–30% experience recurrent episodes of sickness absence [9], indicating a need for improved occupational rehabilitation.

Recently, the World Health Organization has recommended considering mindfulness-based interventions for managing work-related stress [4]. Mindfulness refers to the practice of intentionally directing one's attention and awareness to the present moment in a non-judgmental manner [10]. The Mindfulness-Based Stress Reduction (MBSR) program is a structured nine-session weekly group-treatment intervention that incorporates meditation, body awareness, and yoga practices [11]. Systematic reviews have documented the benefits of the MBSR program for reduction of stress, anxiety, and other psychological symptoms in clinical and healthy populations [12–15]. In addition, higher levels of mindfulness disposition have been associated with increased rates of return to work [16]. However, certain studies have indicated that individuals with lower socioeconomic status and higher symptom burden may have poorer outcomes in mindfulness-based interventions [17–20]. Despite the widespread use of mindfulness-based interventions for work-related stress management [16, 21, 22], there is a lack of research investigating the hypothesized association between changes in levels of perceived stress during MBSR and sustained return to work. A better understanding of this relationship can inform professionals in supporting the management of work-related stress, such as when providing guidance to patients, job centers, and workplaces regarding resuming work [9].

Occupational recovery from mental disorders is a multifaceted process influenced by various factors, including individual, social, and work-related determinants [23–25]. A recent systematic review of studies of individuals on sick-leave with common mental disorders (including work-related disorders) concluded that reduced job resumption was predicted by older age, being male, previous sickness absence, and higher symptom burden [24]. Another study – specifically among people enrolled for mindfulness-treatment of work-related stress – found that failure to return to work after one year was predicted by the demand-control-support model, bullying experienced at work, greater symptoms, and length of sick-leave. Additionally, not having a partner was a predictor at three-year follow-up [26]. Predictors of return to work may potentially buffer or moderate the presumed association between reduction in perceived stress during MBSR and increased return to work [27]. Understanding such moderating factors may identify potential targets for tailored initiatives aimed at strengthening the management of work-related stress and facilitating occupational recovery.

This study aims to evaluate the association between changes in levels of perceived stress during an MBSR program and subsequent stable employment among patients experiencing prolonged work-related stress. In addition, we will explore potential clinical, occupational, psychosocial predictors of occupational status as potential moderators of this association. It is important to note that this study does not aim to establish causality in the examined relationships.

Study design and population

This secondary data analysis used clinical and register data from 450 patients who enrolled in one of 34 group-based MBSR intervention programs for the treatment of work-related stress. The MBSR groups included up to 15 patients and were facilitated by a trained MBSR teacher with an educational background in either psychology or medicine. The MBSR programs were conducted as standard treatment at [CENSORED] between 15 October 2015 and 2 April 2019.

All patients were referred either by their general practitioner or labor union to [CENSORED]. Physicians specialized in occupational medicine examined the patients to diagnose work-related stress conditions using the following ICD-10 codes (F43.2: Adjustment disorders; F43.9: Other reactions to stress, unspecified; Z56: Problems related to employment and unemployment). Following that, eligibility for enrolment in a group-based MBSR program for stress management was determined through a screening by a clinical psychologist.

Inclusion criteria for the study were prolonged exposure to work-related stress, sufficient motivation, and Danish language skills for participation in the MBSR program. Exclusion criteria included ongoing stress treatments that had not concluded within 1–2 months since the referral date, ≥ 3 months of unemployment, severe somatic or mental illness (e.g., post-traumatic stress or psychotic disorders), bullying as the main cause of the stress reaction, and substance or alcohol abuse.

Prior to the first MBSR session, enrolled patients were invited to complete an online survey for clinical purposes providing data on background information, psychosocial stressors (i.e., exposure), and symptom severity (baseline). A follow-up survey excluding all psychosocial exposure items, was administered at the conclusion of the MBSR program (Supplementary Information 1).

Explanatory variable: Changes in perceived stress levels

The explanatory variable in this study was the changes in perceived stress level from baseline to end of the MBSR program. Perceived stress was assessed using the 10-item Perceived Stress Scale (PSS-10), where each item is scored on a 5-point Likert scale (ranging 0 = Never to 4 = Very often) (Supplementary Information 1) [28, 29]. First, the PSS-10 total score was calculated by summing all ten item scores at each time point (0–40: low-high). The change measure was then determined by subtracting the baseline PSS-10 total score from the PSS-10 total score at the end of the program. To facilitate interpretation of the results, we reversed the pre-post change scale so that positive change scores indicated reductions in levels of perceived stress, whereas negative change scores indicated increases in perceived stress levels. The internal consistency of PSS-10 was assessed using Cronbach’s alpha values, which were 0.68 at baseline and 0.87 at the end of treatment.

Outcome variables: occupational status at 26- and 52-week follow-up

The two binary outcomes of “stable employment” were defined as not receiving any unemployment benefit transfer for being on full-time sick-leave for a continuous period of four weeks ending at the 26-week and 52-week follow-up after the first MBSR session (stable/unstable employment). Both outcomes were determined by extracting data through linkage to the Danish Register for Evaluation of Marginalization (DREAM), which contains weekly information on all Danish social transfer payments since 1991 [30, 31].

Baseline covariates

The following variables were defined a priori as covariates of the association between changes in perceived stress levels and occupational status: age, gender (female/male), occupational group (blue/white collar), registered partnership (yes/no), personal annual gross income (per 1000 €, where 1 € = 7.5 DKK), long-term sickness absence at baseline (yes/no; number of weeks), previous long-term sickness absence during the past 5 years (yes/no; register data), general severity index [32], self-reported health, job demands, job control, social support, organizational justice (scale ranges: 0–4, good-bad), and violence/threats (yes/no; survey data; Supplementary Information 1). The items used for self-reported health and psychosocial work environment were the same as those used in the PRISME study [33].

Statistical analyses

Missing data for both continuous and categorical variables were handled using multiple imputation with the fully conditional specification algorithm and 200 iterations [34].

To analyze the association between changes in perceived stress and occupational status at the 26-week and 52-week follow-up, separate multivariate logistic regression models were used for each outcome (main models). Specifically, we assessed stable employment (relative to unstable as reference in each model) according to reductions in levels of perceived stress, indicated by greater pre-post change scores. Adjustments were made for confounding variables mentioned above. To assess potential moderators of the associations, significant predictors of each outcome were identified, and the analyses were rerun with an interaction term between the variable for change in stress and the relevant predictor on the multiplicative scale. The statistical significance threshold was set at 0.05.

Sensitivity analyses were conducted by rerunning each main model only using the non-imputed data to compare the results with those obtained through multiple imputation.

All analyses were conducted using SAS 9.4 (SAS Inst., Cary, NC, US) by accessing pseudo-anonymized data uploaded to Statistics Denmark via remote access.

Table 1 shows the data on the patient characteristics before imputation and after multiple imputation of missing data (≤ 25%). The study sample consisted mainly of females, middle-aged individuals, and individuals on long-term sick-leave at baseline. The mean pre-post change in the perceived stress score was 5.0 (SD = 5.5), indicating an overall reduction in stress levels within the study sample. At the 26- and 52-week follow-up, 81% and 87% of the participants, respectively, were in stable employment (Table 2).

Table 1

*Variables and distribution of data across non-imputed and multiply imputed data samples* among 450 patients participating in a mindfulness-based stress reduction program *(imputations = 200).*
		Non-imputed data, N = 450				Imputed data, N = 450*200 (study sample)
		n	% of N	M	SD	N	% of N	M	SD
Explanatory variable
Change in Perceived Stress*		337	75	5.0	5.4	450*200	100	5.0	5.5
Baseline covariates
Age (year)		422	94	46.7	9.6	450*200	100	46.7	9.6
Personal gross income (per 1000€)		421	94	31.3	12.4	450*200	100	31.2	12.4
Self-reported health		426	94	2.4	0.8	450*200	100	2.5	0.8
Weeks of long-term sickness absence, baseline		424	95	9.7	14.7	450*200	100	9.6	14.7
Perceived Stress score		426	95	21.8	3.9	450*200	100	21.8	3.9
General Severity Index		426	95	1.2	0.5	450*200	100	1.1	0.5
Job demands		426	95	2.6	0.9	450*200	100	2.6	0.9
Job control		426	95	1.9	0.5	450*200	100	1.9	0.5
Social support		426	95	1.9	0.8	450*200	100	1.9	0.8
Organizational justice		426	95	2.4	0.8	450*200	100	2.4	0.9
Gender	Female	329	73			351*200	78
	Male	93	21			99*200	22
Occupational group	Blue collar	41	9			43*200	10
	White collar	382	85			407*200	90
Partnership	Partner	183	41			194*200	43
	No partner	239	53			256*200	57
Long-term sickness absence, baseline	Yes	247	55			262*200	58
	No	177	39			188*200	42
Previous long-term sickness absence	Yes	79	18			365*200	81
	No	371	77			85*200	19
Violence/threats experienced at work	Yes	165	37			277*200	62
	No	261	58			173*200	38
Outcome variables
Stable employment at 26-week follow-up	Yes	363	81			363*200	81
	No	87	19			87*200	19
Stable employment at 52-week follow-up	Yes	390	87			390*200	87
	No	60	13			60*200	13
* Changes in perceived stress = (Perceived Stress score_{end of treatment}– Perceived Stress score_baseline)*-1. Scale reversed with higher scores indicating greater reduction in levels of perceived stress.

Table 2

Cross table of 450 patients in stable employment at week 26 and 52 (yes/no, imputations = 200).
		Stable employment, week 52
		No	Yes	Total
Stable employment, week 26	No	44*200, 10%	43*200, 10%	87*200, 19%
Stable employment, week 26	Yes	16*200, 4%	347*200, 77%	363*200, 81%
	Total	60*200, 13%	390*200, 87%

Table 3 presents the odds ratios (OR) and 95% confidence intervals (95% CI) from the analyses modelling subsequent occupational status according to pre-post changes in perceived stress levels during the MBSR program.

Table 3

Odds ratios of stable employment for at least four weeks (versus unstable) according to reductions in perceived stress indicated by higher change scores.
	26-week follow-up			52-week follow-up
	OR	95% CI		OR	95% CI
Explanatory variable
Changes in Perceived Stress*	1.12	1.04,	1.20	1.19	1.09,	1.30
Baseline covariates
Age (year)	1.00	0.97,	1.03	0.98	0.95,	1.02
Gender, female	1.20	0.60,	2.42	0.98	0.42,	2.25
Occupational group, blue collar (vs. white)	3.52	1.17,	10.63	1.98	0.57,	6.83
Partnership, no partner (vs. partner)	1.34	0.73,	2.47	1.64	0.80,	3.38
Personal gross income (per 1000€)	0.98	0.96,	1.00	0.99	0.96,	1.02
Self-reported health	0.56	0.38,	0.83	0.55	0.35,	0.87
Long-term sickness absence, yes (vs. no)	0.35	0.14,	0.87	0.32	0.10,	0.99
Weeks of long-term sickness absence	0.98	0.96,	1.00	0.98	0.96,	1.00
Perceived Stress score, baseline	0.93	0.83,	1.01	0.96	0.86,	1.08
General Severity Index	0.71	0.38,	1.35	0.87	0.40,	1.91
Previous long-term sickness absence (vs. no)	0.67	0.24,	1.88	0.80	0.21,	3.07
Job demands	0.72	0.53,	0.98	0.76	0.54,	1.09
Job control	0.94	0.51,	1.76	0.59	0.28,	1.24
Social support	1.00	0.64,	1.57	0.65	0.38,	1.11
Organizational justice	0.82	0.53,	1.31	1.08	0.64,	1.82
Violence/threats experienced at work (vs. no)	0.72	0.40,	1.29	0.56	0.28,	1.12
* Changes in perceived stress = (Perceived Stress score_{end of treatment}– Perceived Stress score_baseline)*-1. Scale reversed with higher scores indicating greater reduction in levels of perceived stress.
Logistic regression models based on multiply imputed data (N = 450200).*
OR = Odds ratio, 95% CI = confidence intervals.

A one-point increase on the PSS-10 from baseline to end of MBSR treatment, indicating a reduction in perceived stress, was associated with higher odds ratio (OR) and 95% confidence intervals (CI) of stable employment at 26-week (OR = 1.12, 95% CI = 1.04, 1.20) and 52-week follow-up (OR = 1.19, 95% CI = 1.09, 1.30). These findings corroborated results obtained from the non-imputed data (n = 333, 26-week follow-up: OR = 1.14, 95% CI = 1.05, 1.22; 52-week follow-up: OR = 1.21, 95% CI = 1.11., 1.32).

In the presented models, stable employment was predicted by the following baseline covariates: better self-reported health, blue-collar occupational group, and long-term sickness absence by indication (no presence) and length at baseline (fewer weeks) at both 26-week and 52-week follow-up. Lower job demands predicted enhanced employment at week 26, specifically, while a better psychosocial work environment generally seemed to predict stronger employment at week 52, i.e., job demands, control, support, violence/threats. However, none of these covariates significantly moderated the association between the change in perceived stress score and stable employment (p-values ranged: 0.26–0.96).

This study evaluated occupational status according to pre-post changes in perceived stress during an MBSR program. The results indicated that greater reduction in levels of perceived stress was prospectively associated with stable employment for at least four weeks at 26-week and – particularly – at 52-week follow-up. It should be noted that the mean change on the PSS-10 in the study population was a 5.0-point decrease (SD = 5.5), which can be considered substantial. Specifically, a 5-point drop corresponded to a 2.41-fold higher odds ratio (95% CI = 1.36, 3.70) of achieving stable employment 52 weeks after baseline [35]. However, it is important to highlight that this finding does not provide evidence of a direct treatment effect of MBSR on occupational recovery.

To the best of our knowledge, this is the first study to examine the association between changes in levels of symptom severity during the MBSR program and occupational recovery from work-related stress. Our findings are consistent with a recent systematic review of 29 studies, which concluded that higher baseline symptom scores predicted a decreased return to work among individuals on sick-leave with common mental disorders [24]. Additionally, a Norwegian study found that acquisition of greater mindfulness skills enhanced return to work indirectly through higher quality of life [16], a finding supported by a recent prediction study [36]. However, it is important to note that the changes in stress levels observed during the MBSR program cannot be attributed solely to the mindfulness treatment effect, as the study did not include a control group of patients receiving no treatment for comparison. Thus, we cannot determine what the spontaneous changes in perceived stress would have been with no treatment or how such potential changes may be connected to occupational recovery. Instead, this study compared patients who experienced greater reductions in perceived stress relative to those who had less favorable changes.

Yet, a Danish randomized-controlled trial with a similar patient sample demonstrated that the average drop on the PSS-10 (perceived stress) was 1.1 point (p = 0.23) during a 3-month waitlist period for a stress management intervention [37] compared to the 5.0-point drop during our 8-week MBSR treatment program. This suggests that patients experiencing greater reductions in perceived stress during our 8-week period may be influenced by factors other than mindfulness practices, such as stable work resumption contributing to financial and social stability. Indeed, a stronger association with occupational stability was found at 52-week follow-up than week 26, suggesting potential long-term benefits of mindfulness practices for occupational recovery.

Consistent with previous findings on return to work in stress-related disorders, greater self-reported health and less sick leave consistently predicted occupational recovery at both the 26-week and 52-week follow-up [24, 26, 36]. The study also found that a better psychosocial work environment, specially indicated by lower job demands, predicted stable employment in line with existing reports [26]. Surprisingly, being a blue-collar worker predicted stable employment, particularly at week 26, which has not been demonstrated previously. No evidence was found to support the moderating effect of any variables on the associations between changes in stress and occupational status. Further studies using a longitudinal study design that include both a treatment and control group are required to potentially validate the current findings.

Methodological considerations

As previously discussed, this study has limitations. First, the absence of a control group limits our ability to determine whether the changes in perceived stress were specifically due to the development of greater mindfulness skills. In addition, the validity of the occupational status outcome may be questioned as this was based solely on public benefit transfers for sickness absence. Some patients continue working despite being sick (i.e., sickness presence), while others may decline public benefits without having a job and rely on alternative financial sources such as spouse’s income. However, it is important to note that the focus of this study was on stable employment rather than the overall health status of employees. Another limitation is the homogeneous composition of the sample, in terms of race, ethnicity, and socioeconomic status. The vast majority of the study sample included white middleclass, Danish natives employed in the public sector (anecdotal evidence), which may limit generalizability of the findings to other populations and contexts [24]. Nevertheless, studies on the association between socioeconomic position and occupational recovery in adjustment and exhaustion disorders in Nordic countries have yielded mixed results, with no or weak associations found [36, 38]. Finally, the internal consistency of the PSS-10 at baseline (α = 0.68) was lower than at the end of treatment (α = 0.87) and compared to reports from a Danish PSS-10 validation study (α = 0.84) [39]. One potential explanation for this lower α-value may be limited attention capacity of the patients at baseline [40], as the correlations with the total α-value were lowest for PSS-10 items with reversed scoring (r-values ranged 0.08–0.22 at baseline and 0.49–0.59 at end of treatment).

On the other hand, this study had several strengths. The relatively large sample size of the study provided sufficient statistical power for the analyses. Additionally, missing data (particularly on changes in perceived stress: 25%) were managed using multiple imputation, which increased the effective sample size and reduced potential bias. Sensitivity analyses using the non-imputed data supported the findings of the imputed data, suggesting that missing data did not significantly impact the results. The study also benefited from the use of well-validated and commonly used measures collected in a naturalistic setting, enhancing the clinical validity of the findings. Moreover, the explanatory variable (reduction in perceived stress) and outcome (occupational status) were derived from self-reports and a highly reliable register [30], respectively, which mitigated common method bias concerns [41]. Finally, the study’s follow-up was completed on April 1, 2020, before the onset of COVID-19-related national lockdowns starting on March 13, 2020, minimizing potential confounding effects of the pandemic on recruitment measures and the occupational status outcome.

This study provided evidence of an association between greater reduction in levels of perceived stress levels during the Mindfulness-based Stress Reduction (MBSR) program and a higher likelihood of occupational recovery from prolonged work-related stress. Self-reported health, occupational group, psychosocial work environment, and sickness absence before starting the MBSR program were identified as predictors of stable employment at 26 and 52 weeks. However, we did not find any evidence supporting the role of the predictors as moderators of the association of changes in perceived stress and occupational recovery. Further research including a control group is necessary to determine whether the MBSR program effectively facilitates return to work.

Funding: The study was sponsored by the Research Fund for Health Science of the Capital Region of Denmark (A6837) and the Velliv Foundation (20-0315). Additionally, the Torben & Alice Frimodts Foundation provided financial support for JHJ's research stay in the McGill Mindfulness Research Lab during the fall of 2022.

Competing interests: The authors have no relevant financial or non-financial interests to disclose.

Ethics approval: Upon inquiry, the local ethics committee confirmed that ethical approval was not required. This study complies with the principles outlines in the Helsinki Declaration of 1964 and its subsequent amendments.

Consent to participate: Legal specialists in the Capital Region of Denmark explicated that consent from the included participants was not required for the present study.

Consent to publish: This study was registered and approved by the Danish Data Protection Agency (P-2021-517).

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No competing interests reported.

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Changes in perceived stress during a mindfulness-based stress reduction (MBSR) intervention predicting occupational recovery from work-related stress: a longitudinal study

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Abstract

Purpose

Methods

Results

Conclusion

INTRODUCTION

MATERIAL AND METHODS

Study design and population

Explanatory variable: Changes in perceived stress levels

Outcome variables: occupational status at 26- and 52-week follow-up

Baseline covariates

Statistical analyses

RESULTS

DISCUSSION

Methodological considerations

CONCLUSION

Declarations

References

Additional Declarations

Supplementary Files

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