Article Text

Long-term follow-up of cortisol awakening response in patients treated for stress-related exhaustion
  1. Anna Sjörs1,2,
  2. Thomas Ljung3,4,
  3. Ingibjörg H Jonsdottir1,5
  1. 1The Institute of Stress Medicine, Gothenburg, Sweden
  2. 2Rehabilitation Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  3. 3County Council of Jämtland, R&D-unit, Östersund, Sweden
  4. 4Mid Sweden University, IHV, Östersund, Sweden
  5. 5Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  1. Correspondence to Dr Anna Sjörs; anna.sjors{at}


Objectives Studies on hypothalamus–pituitary–adrenal (HPA) axis activity in stress-related exhaustion and burnout have revealed incongruent results, and few longitudinal studies on clinical populations have been performed. This study was designed to investigate differences in HPA axis activity between patients with stress-related exhaustion and healthy controls and to investigate longitudinal changes in HPA axis activity in the patient group as they entered a multimodal treatment programme.

Design HPA axis activity was assessed through the cortisol awakening response (CAR). Salivary cortisol was sampled at awakening and after 15 min. Follow-up measurements were performed in the patient group after 3, 6, 12 and 18 months.

Setting An outpatient clinic specialising in stress-related illness.

Participants Patients with clinically diagnosed stress-related exhaustion (n=162) and healthy controls (n=79).

Primary and secondary outcome measures The primary measure was CAR measured as the difference between the two salivary cortisol samples. Changes in CAR during follow-up were related to changes in symptoms of burnout, depression and anxiety.

Results Patients showed similar CAR as the controls and their CAR did not change significantly during treatment. No association was found between CAR and symptom development during treatment.

Conclusions The authors conclude that CAR does not seem to discriminate clinically defined patients with exhaustion from healthy controls and it appears not to change during treatment. CAR, measured as salivary cortisol, at awakening and after 15 min, is thus not a valid marker for stress-related exhaustion.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • To cite: Sjörs A, Ljung T, Jonsdottir IH. Long-term follow-up of cortisol awakening response in patients treated for stress-related exhaustion. BMJ Open 2012;2:e001091. doi:10.1136/bmjopen-2012-001091

  • Contributors AS analyzed and interpreted the data and drafted the article, TL and IHJ contributed to conception and design of the study, interpretation of the data and revised the article for critical intellectual content. All authors approved the final version of the article.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None.

  • Ethics approval The Regional Ethical Review Board in Gothenburg.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional unpublished data from the study are available.