The Tired, Retired, and Recovered Physician: Professional Burnout Versus Major Depressive Disorder
“Dr. A” retired from the practice of medicine at the age of 49. At the time, he felt frustrated with the monotony of his work, worn out at the end of each working day, and exhausted at the thought of another day at work.
Dr. A grew up in the southeastern United States and attended medical school at a large public university. After completing his residency in his late 20s, in a specialty categorized as having a controllable lifestyle (1), he joined a small private group practice in his hometown. After working full-time for 18 years, raising a family, and saving for retirement, he felt he had done “all the procedures I could do in a lifetime,” and, with a sense of exhaustion, he decided to retire. His plans for retirement included enjoying a few lifetime hobbies and being with his wife and children. At that time, Dr. A scored 50 or above in five out of seven items in the Copenhagen Burnout Inventory work-related burnout subscale—resulting in a mean score of 50, which is the usual cutoff for work-related burnout—and zero in the items of the Patient Health Questionnaire–9 (PHQ-9), a screening tool for depression (both instruments were scored retrospectively).
By the time he made his decision to retire, he reported having concerns about growing old and being unable to engage in his hobbies, one of which required significant physical strength and coordination. He considered a sabbatical, but the practice “did not care”; his colleagues did not allow part-time options or longer vacation time, even with adjustment in pay. So he left medicine “without any definite plan to return.”
After 2 years spending time in his hobbies and with his family, Dr. A found that he missed some aspects of medical practice, and he decided to complete a fellowship in a subspecialty, which lasted for 1 year, followed by 2 years of research training. With these newly acquired skills and a more restricted scope of practice, he found that he enjoyed medicine again as well as research and teaching. He joined a large academic medical center and has worked there full-time ever since. As of this writing, at age 70, he had a mean score of 35.7 on the Copenhagen Burnout Inventory and had positive scores (≥50) on only two items: being “somewhat frustrated” and “feeling worn out at the end of the working day.” He never screened positive on the PHQ-9, and he has never been diagnosed with or treated for depression.
Professional burnout is prevalent and consequential in health care today. Burnout is traditionally defined as an experience in response to chronic job stressors and as having three components: exhaustion, cynicism, and inefficacy (2). The prevalence of physician burnout was estimated at 54.4% in 2014, up from 45.5% in 2011 (3). Similarly, 43.2% of nurses reported having levels of high emotional exhaustion in a large U.S. national sample (4), as did 50% of resident physicians (5). The consequences of burnout include increased patient mortality (4), reduction in work effort (6), increase in self-reported medical errors (7), and overall decreased satisfaction with work-life balance (3).
Although there are a plethora of instruments to measure burnout, the Maslach Burnout Inventory has been the most widely adopted in surveys in recent decades. The Maslach Burnout Inventory has U.S. national benchmarks, appears relevant to a variety of health professions, and has shown correlations with relevant outcomes (8). The Copenhagen Burnout Inventory, which was developed as part of the Danish Project on Burnout, Motivation, and Job Satisfaction, consists of three scales measuring personal, work-related, and client-related burnout. Its normative values for personal, work-related, and client related burnout, defined as a score ≥50, were 22.2%, 19.8%, and 15.9%, respectively. The scale has been shown to have high internal reliability and is associated with sickness absence, sleep problems, and intention to quit (9).
The driver dimensions of burnout among physicians (8) include workload and job demands; efficiency and resources; meaning in work; organizational values and culture; control and flexibility; social support and community at work; and work-life integration.
Interventions to Address Burnout in Health Care Professionals
A comprehensive review of the efficacy of interventions addressing physician burnout (10) yielded 52 eligible studies, most of which were observational. Those interventions were classified as either individual or structural/organizational. Effective individual-level interventions included mindfulness-based approaches, stress management training, and small group curricula. Effective organizational-level interventions included duty-hour requirements and locally developed modifications to clinical work processes. A Cochrane systematic review of interventions to prevent occupational stress also found “low-quality evidence” that cognitive-behavioral therapy and other relaxation interventions reduced stress as well as “low-quality evidence” that changing work schedules is an effective strategy (11). Both systematic reviews called for higher-quality studies with adequate sample sizes to investigate the effectiveness of such interventions on burnout prevalence and incidence. Several professional organizations, including the American Psychiatric Association (12), are starting to address the problem of physician burnout and professional well-being. The American Medical Association is promoting a framework (13) that includes the following seven steps organizations can take to prevent or reduce burnout:
Establish wellness as a quality indicator.
Start a wellness committee or choose a wellness champion.
Distribute an annual wellness survey.
Meet regularly with leaders and staff to discuss data and interventions.
Initiate selected interventions.
Repeat the survey to reevaluate the situation.
Seek answers within the data, refine the interventions, and continue improvements.
Table 1 lists steps included in other organizational frameworks to address burnout and promote professional well-being. Notably, one common recommendation of these different frameworks is to engage organizational leadership, which emphasizes the role of physician leaders with knowledge and first-hand experience of multiple drivers as well as those specific to each work unit.
| Mayo Clinic: Nine Organizational Steps | Institute for Healthcare Improvement: Improving Joy in Work | Joy in Practice Framework |
|---|---|---|
| 1. Acknowledge and assess the problem | 1. Physical and psychological safety | 1. Design organizational systems to address human needs |
| 2. Harness the power of leadership | 2. Meaning and purpose | 2. Develop leaders with participative management competency |
| 3. Develop and implement targeted interventions | 3. Choice and autonomy | 3. Build social community |
| 4. Cultivate community at work | 4. Recognition and rewards | 4. Remove sources of frustration and inefficiency |
| 5. Use rewards and incentives wisely | 5. Participative management | 5. Reduce preventable patient harm and support second victim |
| 6. Align values and strengthen culture | 6. Camaraderie and teamwork | 6. Bolster individual wellness |
| 7. Promote flexibility and work-life integration | 7. Daily improvement | |
| 8. Provide resources to promote resilience and self-care | 8. Wellness and resilience | |
| 9. Facilitate and fund organizational science | 9. Real-time measurement |
TABLE 1. Examples of Organizational Frameworks for Professional Well-Being
Burnout Versus Depression
Physicians and other health care professionals have elevated risks of both depression and professional burnout. The prevalence of depression or depressive symptoms among resident physicians has been estimated at 28.8% (14) and among medical students at 14.3% (15). A few studies have specifically addressed the question of differentiating burnout from depression. In a study of Austrian physicians, while 10.3% met criteria for depression, 50.7% appeared to be affected by symptoms of burnout (16). A study that used both the Maslach Burnout Inventory and the Patient Health Questionnaire–9 to examine 5,575 schoolteachers reported that 90% of those identified as having burnout met criteria for depression (17). The same group of authors has been critical of the conceptualization of burnout as distinguished from depression, having called into question the methodology used in burnout studies (18). Others have also noticed methodological inconsistencies in the application of scales, cutoffs, and scoring in burnout research in general (19). In terms of measurement, a study on the discriminant validity of a burnout scale found support for three unidimensional measures: anxiety, depression, and exhaustion (20).
Because the above-mentioned studies are cross-sectional and thus limited in their ability to assess causality, longitudinal studies are needed to disentangle these relationships. One such longitudinal study, in dental students, concluded that burnout and depressive symptoms cluster together and develop in tandem (21). Another longitudinal study showed strong correlations between burnout and depression both at baseline and at 2-year follow-up (22). It is important that future longitudinal studies investigate the trajectory of professional burnout over the length of physicians’ careers.
Advantages and Disadvantages of Conceptualizing Burnout as Depression
The main advantage of bringing burnout into the depressive disorder category would be to allow for the use of health care resources and tools to address it. In psychiatry, the tools of psychotherapy and psychopharmacology have been shown to be effective in helping many individuals overcome depressive episodes. Health care policies, including Family and Medical Leave Act regulations and sick leave time, would also be available for medical necessity.
The main disadvantage of conceptualizing burnout as depression would be missing the opportunity to address its organizational, structural, and societal drivers. By medicalizing burnout, one runs the risk of advocating antidepressants as its remedy (23). One might consider this a reductionist view of mental health in general, and psychiatry in particular, since mental health interventions can and should include psychotherapy and efforts to engage a supportive environment.
Distinguishing Burnout From Depression
The debate about the boundaries of burnout and depression has similarities to that regarding the difference between depression and grief. To address that debate, a highly consequential footnote on bereavement was attached to the criteria for major depressive episode in DSM-5. A similar approach might help delineate these limits in sorting out burnout from depression. Such a footnote might read as follows:
“In distinguishing burnout from a major depressive episode, it is useful to consider that in burnout the predominant affect is feelings of exhaustion, cynicism, and inefficacy, whereas in major depressive episode it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in burnout is likely to correlate with fluctuations in workload demands (24), whereas the depressed mood in a major depressive episode is more persistent and is not tied to specific thoughts and preoccupations. The pain of burnout may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery seen in a major depressive episode. The thought content associated with burnout generally features a preoccupation with work rather than the self-critical or pessimistic ruminations seen in major depressive episode. In burnout, self-esteem is generally preserved, whereas in major depressive episode, feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in burnout, it typically involves perceived failings related to work.”
Table 2 summarizes the main components of major depressive episode and burnout syndrome. Note that suicidal ideation is not considered a part of the burnout syndrome.
| Major Depressive Episode (DSM–5) | Burnout Syndrome |
|---|---|
| Depressed mood | Emotional exhaustion—stress response |
| Diminished interest or pleasure | Depersonalization or cynicism—negative response to job and to others |
| Changes in body weight or appetite | Reduced personal accomplishment or inefficacy—negative response to self |
| Changes in sleep habits | |
| Psychomotor agitation or retardation | |
| Fatigue or loss of energy | |
| Diminished ability to think or make decisions | |
| Feelings of worthlessness or unwarranted guilt | |
| Recurrent thoughts of death |
TABLE 2. Elements of Major Depression and Burnout
Conclusions
Although depression and burnout appear to be distinct constructs, the former being categorical and the latter dimensional, and although at present the debate on their boundaries and overlap cannot be settled, mental health professionals may take home several lessons from this discussion. First, professional burnout should not be overlooked as a modifiable risk and aggravating factor for depression. Second, we should not let burnout prevent the correct diagnosis of depression when warranted. Third, psychiatrists and other mental health professionals should fully engage in the ongoing discussion on how to address professional burnout, as this discussion will benefit from their expertise in the biopsychosocial model. Fourth, we have a shared obligation to act to address burnout as a challenge not only to individual clinicians but to our medical profession of caring for others (25).
1 : Controllable lifestyle: a new factor in career choice by medical students. Acad Med 1989; 64:606–609Medline, Google Scholar
2 : The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco, Jossey-Bass, 1997Google Scholar
3 : Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90:1600–1613Crossref, Medline, Google Scholar
4 : Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288:1987–1993Crossref, Medline, Google Scholar
5 : Burnout comparison among residents in different medical specialties. Acad Psychiatry 2004; 28:240–242Crossref, Medline, Google Scholar
6 : Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 2016; 91:422–431Crossref, Medline, Google Scholar
7 : Burnout and medical errors among American surgeons. Ann Surg 2010; 251:995–1000Crossref, Medline, Google Scholar
8 : Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017; 92:129–146Crossref, Medline, Google Scholar
9 : The Copenhagen Burnout Inventory: a new tool for the assessment of burnout. Work Stress 2005; 19:192–207Crossref, Google Scholar
10 : Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016; 388:2272–2281Crossref, Medline, Google Scholar
11 : Preventing occupational stress in healthcare workers. Cochrane Database Syst Rev 2015; (4):CD002892Medline, Google Scholar
12
13
14 : Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA 2015; 314:2373–2383Crossref, Medline, Google Scholar
15 : Depression, stigma, and suicidal ideation in medical students. JAMA 2010; 304:1181–1190Crossref, Medline, Google Scholar
16 : Depression-burnout overlap in physicians. PLoS One 2016; 11(3):e0149913Crossref, Medline, Google Scholar
17 : Is burnout a depressive disorder? A reexamination with special focus on atypical depression. Int J Stress Manag 2014; 21:307Crossref, Google Scholar
18 : Can we trust burnout research? Ann Oncol 2017; 28:2320–2321Crossref, Medline, Google Scholar
19 : The problems with burnout research. Acad Med 2017; 93:367–370Crossref, Google Scholar
20 : On the discriminant validity of burnout, depression, and anxiety: a re-examination of the burnout measure. Anxiety Stress Coping 2003; 16:83–97Crossref, Google Scholar
21 : Relationship between burnout and depressive symptoms: a study using the person-centred approach. Burn Res 2014; 1:29–37Crossref, Google Scholar
22 : Is burnout separable from depression in cluster analysis? A longitudinal study. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1005–1011Crossref, Medline, Google Scholar
23 : In reply: Defining physician burnout, and differentiating between burnout and depression. Mayo Clin Proc 2017; 92:1456–1458Crossref, Medline, Google Scholar
24 : The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff (Millwood) 2012; 31:2501–2509Crossref, Medline, Google Scholar
25 : The influence of personal and environmental factors on professionalism in medical education. BMC Med Educ 2007; 7:29Crossref, Medline, Google Scholar
