Perceived stress
Using the QPS Nordic single item definition, more than half of the primary care population in this study reported some stress, women generally more often than men. One third of women perceived rather much/very much stress, but only about one of four men. The same measure of stress was used in a longitudinal study of more than 3000 employees (87% women) in public health care and social insurance offices in the same geographical region. In that population, the prevalence of rather much/very much stress was 17% at baseline in 2004 [30]. It seems reasonable that the prevalence of high levels of stress among persons of working age seeking primary care is about double that of employees in this female dominated sector of the labour market [6]. Earlier studies have indicated that women’s domestic work takes more time than men’s [31,32]. This could be one plausible explanation, at least to some extent, to why women experience higher levels of stress than men.
There was no indication that experience of stress was related to age, i.e. there was a similar age distribution in the three different stress level groups. A Finnish study from 2003 among employees 25–64 years of age, in which the single stress item was validated, indicated that the stress symptoms increased with age [26]. The lack of such an effect of age in our study population could possibly be explained, at least partly, by the fact that all participants experienced a health problem, a stress exposure in itself.
A higher proportion of singles was found in the high stress level group. We did not separate singles living with or without children, however. In a Scandinavian study, working single mothers reported higher stress levels than working non-single mothers [33]. A similar finding was made in a study by Kushnir et al. [33,34]. Low income, common among single mothers, was associated with higher psychosocial stress in a recent study of 3000 single mothers in Germany aged 17–60 years [35]. Married women on the other hand, are more likely to report somatic discomfort according to a study by Nakao et al. [36]. It is tempting to assume that single mothers were overrepresented among the highest stress level group.
There was a low proportion (5%) of unemployed persons in our study population. Nevertheless, there was an indication that unemployed people were overrepresented in the higher stress level group. Unemployment, as well as low income, was associated with a higher prevalence of psychological distress in a study of hospitalized patients in Israel [37]. This was confirmed in a Japanese study [38]. It was interesting to note that a rather high proportion of our participants in the lower stress category reported being on parental leave (32%). The Swedish social insurance system makes it possible to be on parental leave with economic compensation for a long time compared to most other countries, which might contribute to a lower level of stress during this period compared to being a working parent.
Symptoms of burnout, ED, depression and anxiety
Primary care patients, especially women, who perceive stress, seem to experience symptoms of burnout as well as ED to a greater extent than what we would expect in a general population sample with the same gender and age distribution. Recent Swedish general population surveys, using various burnout measures [22,39], have indicated a high prevalence of burnout; between 13% and 21%. The Swedish study among healthcare workers and social insurance officers by Glise et al.(2004), using the same measure as this study [14] showed a prevalence of burnout of 26%. The same study showed a prevalence of ED of 16%; less than one third of the prevalence in our population of patients seeking primary care. Self-reported ED was more common among women than men, especially in the highest stress level group of our study. A perception of s-ED does not mean that the respondent actually has ED, but rather reports symptoms indicating increased risk of developing or possibly having this condition. A high SMBQ score can be interpreted in a similar way in relation to clinical burnout.
Discriminant validity between burnout and major depression has been studied [9], and both conditions share common features such as cognitive weariness, but they are not identical. A major dissimilarity is a feeling of loss of status and “giving up” which is often reported by patients with depression [40]. We were interested to find out to what extent patients in a primary care setting, who score high on measures of burnout and exhaustion, also show co-morbid symptoms of depression and/or anxiety. A previous waiting room study in Sweden (n = 1392) indicated that 17% had symptoms of depression (HAD-D >7) and 29% had symptoms of anxiety (HAD- A >7) regardless of stress [41]. No gender differences were found. The population was similar to ours in terms of gender proportion (38% men and 62% women), but also included patients over 65 years. We did not assess symptoms of depression or anxiety among all participants, but among those reporting stress the prevalence was high, 35% and 71% respectively. The symptom scores thus increased with the level of stress. It is well known from previous studies that in a general population, depression is about twice as common among women as among men [15]. In our study, in the group with a low level of stress, depression was twice as common among women, while, surprisingly, no gender difference was seen in the group reporting pronounced stress.
Both men and women with stress symptoms suffered from a high degree of anxiety symptoms, especially those reporting the highest stress level.
It is previously known that depression and anxiety with co-morbid ED is associated with a long recovery period [11]. Among patients with symptoms of depression/anxiety, it is thus essential to identify significant stressor exposure and possible co-morbid ED.
Methodological considerations
Screening for stress with a single item may seem too simple to capture such a complex concept. We decided to use this method for two main reasons: feasibility and validity. It was obvious that an extensive questionnaire or interview could not be used in the first screening step of all patients with a doctor’s appointment in the waiting rooms. The single item used was previously validated and shown to correlate well with e.g. established burnout scales [26]. There are several instruments available to assess burnout, depression and anxiety. We have previously used both SMBQ and HAD in studies of working populations as well as in clinical studies [11,14]. The instruments have also been validated in such populations [42].
Strengths and limitations
The study had a high response rate (85%). This was partly due to the use of an easily understandable questionnaire, distributed by regular staff at the five participating health centers. These health centers represented both urban and more rural districts, to avoid selection on socio-economic grounds. We believe the sample in the study to be fairly representative of patients in a primary care population, at least in similar Nordic contexts.
All instruments used were at least partly validated, and the QPS Nordic screening question regarding stress used in the screening form, included a definition of stress which was not dependent on the source of the stress (work or home). To be useful in a primary care setting, it was important that the instrument used referred to the general experience of stress in a working population, in a Nordic context. In the first two steps of this study, we were not able to distinguish between different sources of stress, however.
There could be a restriction in the definition of stress in the screening item, since it includes anxiety symptoms and sleep disturbance, but not, e.g., stress-related somatic symptoms. Words like anxiety and nervousness are likely to be considered negatively charged words, especially by men of a younger age. This could result in an underestimation of stress experience.
The study results cannot be extrapolated to other countries as it come to ED, since this is a diagnose not used in other countries yet.
It may be seen as a limitation that the assessments of stress and burnout/exhaustion, as well as symptoms of anxiety and depression, were dependent on self-reports. Numerous studies reveal that women are more likely to self-report health-related problems than men [43]. Men also seek medical care to a lower extent than women, and this should be taken into consideration when comparing the results with those from e.g. general population studies.
More knowledge is needed in order to better understand and handle the increasing problem of mental disorders among patients seeking primary care. This study contributes to existing knowledge by giving an indication of the extent to which primary care patients perceive stress and repot symptoms of burnout, exhaustion, depression and anxiety. Our intension further on is to find out whether there are any special reasons for encounters that correlate with diagnose ED with or without co-existing depression and/or anxiety. By analysing data from the clinical specialist examination (step three) hopefully we will find methods for early identifying patients with or at risk of developing ED, and thereby likely prevent long lasting sick leave.