Renzo Bianchi

Burnout–depression overlap: A review

Whether burnout is a form of depression or a distinct phenomenon is an object of controversy. The aim of the present article was to provide an up-to-date review of the literature dedicated to the question of burnout-depression overlap. A systematic literature search was carried out in PubMed, PsycINFO, and IngentaConnect. A total of 92 studies were identified as informing the issue of burnout-depression overlap. The current state of the art suggests that the distinction between burnout and depression is conceptually fragile. It is notably unclear how the state of burnout (i.e., the end stage of the burnout process) is conceived to differ from clinical depression. Empirically, evidence for the distinctiveness of the burnout phenomenon has been inconsistent, with the most recent studies casting doubt on that distinctiveness. The absence of consensual diagnostic criteria for burnout and burnout researchs insufficient consideration of the heterogeneity of depressive disorders constitute major obstacles to the resolution of the raised issue. In conclusion, the epistemic status of the seminal, field-dominating definition of burnout is questioned. It is suggested that systematic clinical observation should be given a central place in future research on burnout-depression overlap.

Comparative symptomatology of burnout and depression.

The link between burnout and depression remains unclear. In this study, we compared depressive symptoms in 46 burned-out workers, 46 outpatients experiencing a major depressive episode, and 453 burnout-free workers to test the distinctiveness of burnout as a clinical entity. Participants with burnout and major depressive episode reported similar, severe levels of overall depressive symptoms. The between-syndrome overlap was further verified for eight of the nine major depressive episode diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Our findings do not support the view hypothesizing that burnout and depression are separate entities and question the nosological added value of the burnout construct.

Is it time to consider the "burnout syndrome" a distinct illness?

The “burnout syndrome” has been defined as a combination of emotional exhaustion, depersonalization, and reduced personal accomplishment caused by chronic occupational stress. Although there has been increasing medical interest in burnout over the last decades, it is argued in this paper that the syndrome cannot be elevated to the status of diagnostic category, based on (1) an analysis of the genesis of the burnout construct, (2) a review of the latest literature on burnout-depression overlap, (3) a questioning of the three-dimensional structure of the burnout syndrome, and (4) a critical examination of the notion that burnout is singularized by its job-related character. It turns out that the burnout construct is built on a fragile foundation, both from a clinical and a theoretical standpoint. The current state of science suggests that burnout is a form of depression rather than a differentiated type of pathology. The inclusion of burnout in future disorder classifications is therefore unwarranted. The focus of public health policies dedicated to the management of “burnout” should not be narrowed to the three definitional components of the syndrome but consider its depressive core.

Is burnout solely job-related? A critical comment

Within the field-dominating, multidimensional theory of burnout, burnout is viewed as a work-specific condition. As a consequence, the burnout syndrome cannot be investigated outside of the occupational domain. In the present paper, this restrictive view of burnouts scope is criticized and a rationale to decide between a work-specific and a generic approach to burnout is presented. First, the idea that a multidimensional conception of burnout implies a work-restricted scope is deconstructed. Second, it is shown that the burnout phenomenon cannot be confined to work because chronic, unresolvable stress - the putative cause of burnout - is not limited to work. In support of an integrative view of health, it is concluded that the field-dominating, multidimensional theory of burnout should abandon as groundless the idea that burnout is a specifically job-related phenomenon and define burnout as a multi-domain syndrome. The shift from a work-specific to a generic approach would allow both finer analysis and wider synthesis in research on chronic stress and burnout.

On the depressive nature of the “burnout syndrome”: A clarification

The ‘‘burnout syndrome’’ has become popularly known since it was described in the 1970s and is today an emblem of workrelated ill-health [1,2]. Its phenomenological and nosological status, however, remains strongly debated [3]. In this viewpoint article, we defend the controversial position that burnout is a depressive syndrome. Our objective is to provide the psychiatry community with a different reading of burnout, a syndrome that in recent years has elicited increasing interest among psychiatrists.

Emotional information processing in depression and burnout: an eye-tracking study

Abstract Whether burnout is a form of depression is unclear. The aim of this study was to examine the relevance of the burnout–depression distinction by comparing attentional processing of emotional information in burnout and depression. Eye-tracking technology was employed for assessing overt attentional deployment. The gaze of 54 human services employees was monitored as they freely viewed a series of emotional images, labeled as dysphoric, positive, anxiogenic, and neutral. Similar to depression, burnout was associated with increased attention for dysphoric stimuli and decreased attention for positive stimuli. Hierarchical multiple regression analyses revealed that burnout no longer predicted these attentional alterations when depression was controlled for and vice versa, suggesting interchangeability of the two entities in this matter. To our knowledge, this study is the first to (a) investigate emotional attention in burnout and (b) address the issue of the burnout–depression overlap at both cognitive and behavioral levels using eye movement measurement. Overall, our findings point to structural similarities between burnout and depression, thus deepening concerns regarding the singularity of the burnout phenomenon.

The Dead End of Current Research on Burnout Prevalence

1. Colorectal Writing Group for the SCOAP-CERTAIN Collaborative, Ehlers AP, Simianu VV, Bastawrous AL, et al. Alvimopan use, outcomes, and costs: A report from the surgical care and outcomes assessment program comparative effectiveness research translation network collaborative. J Am Coll Surg 2016;222:870e877 2. Harbaugh CM, Al-Holou SN, Bander TS, et al. A statewide, community-based assessment of alvimopan’s effect on surgical outcomes. Ann Surg 2013;257:427e432 3. Simorov A, Thompson J, Oleynikov D. Alvimopan reduces length of stay and costs in patients undergoing segmental colonic resections: Results from multicenter national administrative database. Am J Surg 2014;208:919e925 4. Viscusi ER, Goldstein S, Witkowski T, et al. Alvimopan, a peripherally acting mu-opioid receptor antagonist, compared with placebo in postoperative ileus after major abdominal surgery: Results of a randomized, double-blind, controlled study. Surg Endosc 2006;20:64e70 5. Ludwig K, Enker WE, Delaney CP, et al. Gastrointestinal tract recovery in patients undergoing bowel resection: Results of a randomized trial of alvimopan and placebo with a standardized accelerated postoperative care pathway. Arch Surg 2008;143: 1098e1105

Burnout: absence of binding diagnostic criteria hampers prevalence estimates.

In a recent review paper, Adriaenssens et al. (2015) cluded that about 26% of emergency nurses (EN) suffer burnout and described their results as alarming. ile we applaud Adriaenssens et al.’s efforts to provide a rer picture of ill-health in EN, we think that these hors’ conclusions are weakened by a fundamental fact, ely, the absence of consensual, clinically valid gnostic criteria for burnout (Bianchi and Laurent, in ss; Weber and Jaekel-Reinhard, 2000). Trying to determine the prevalence of a condition that no binding diagnostic criteria is problematic. Indeed, ending on how researchers decide to define (cases of) nout, very different results can be obtained, and ually any kind of conclusions can be drawn regarding importance of the burnout phenomenon (for an stration of this problem, see Prins et al., 2007). Within h a context, the clinical meaning of the findings is unclear, compromising effective decision-making in terms of interventions and health policies. More than 30 years after the introduction of the burnout construct in the scientific literature (Freudenberger, 1974), Shirom (2005) pointed out that ‘‘burnout researchers should begin with a clear definition of the construct of burnout’’ (p. 268). Shirom’s (2005) observation remains relevant today. The nosological status of burnout is uncertain. Burnout is not recognized as a disorder, neither in the DSM-5, nor in the ICD-10. Moreover, a growing corpus of research suggests that burnout is a form of depression rather than a distinct type of psychopathology (Ahola et al., 2014; Bianchi and Laurent, in press; Bianchi et al., 2014; Hintsa et al., in press). The development of the burnout construct has been marked by arbitrary choices (see Schaufeli and Enzmann, 1998, p. 188), notably in the process that led to the elaboration of the Maslach Burnout Inventory (MBI), the ‘‘gold standard’’ for the measurement of burnout—the MBI has been used in 15 of the 17 studies reviewed by Adriaenssens and his colleagues. These arbitrary choices do not only concern the cutpoints that have been proposed by the developers of the MBI (as noted by Adriaenssens et al.); arbitrariness also haunts the initial selection of the items that, when submitted to a factor analysis, gave birth to the three dimensions of burnout—emotional exhaustion, depersonalization, and (reduced) personal accomplishment—(Schaufeli and Enzmann, 1998). This state of affairs undermines the MBI-related, field-dominating conceptualization and operationalization of burnout. Burnout has become popularly known. There is a worrying discrepancy, however, between this popularity and the definitional clarity of the phenomenon. In our view, priority should be given to systematic clinical observation in order to clarify the nosological status of burnout and allow researchers to propose—if justified—sound diagnostic T I C L E I N F O

Burnout and depression: Label-related stigma, help-seeking, and syndrome overlap

We investigated whether burnout and depression differed in terms of public stigma and help-seeking attitudes and behaviors. Secondarily, we examined the overlap of burnout and depressive symptoms. A total of 1046 French schoolteachers responded to an Internet survey in November-December 2015. The survey included measures of public stigma, help-seeking attitudes and behaviors, burnout and depressive symptoms, self-rated health, neuroticism, extraversion, history of anxiety or depressive disorder, social desirability, and socio-demographic variables. The burnout label appeared to be less stigmatizing than the depression label. In either case, however, fewer than 1% of the participants exhibited stigma scores signaling agreement with the proposed stigmatizing statements. Help-seeking attitudes and behaviors did not differ between burnout and depression. Participants considered burnout and depression similarly worth-treating. A huge overlap was observed between the self-report, time-standardized measures of burnout and depressive symptoms (disattenuated correlation: .91). The overlap was further evidenced in a confirmatory factor analysis. Thus, while burnout and depression as syndromes are unlikely to be distinct, how burnout and depression are socially represented may differ. To our knowledge, this study is the first to compare burnout- and depression-related stigma and help-seeking in the French context. Cross-national, multi-occupational studies examining different facets of stigma are needed.

What is “severe burnout” and can its prevalence be assessed?

Dear Editor, In a recent study [1], Burghi and his colleagues sought to determine the prevalence of ‘‘severe burnout’’ in intensive care unit (ICU) clinicians in Uruguay, to ‘‘highlight the importance of the problem’’ in this country (p. 1,785). While I applaud Burghi et al.’s efforts to better understand ICU clinicians’ ill-being at work, I think that a major obstacle prevents these authors’ aim from being achieved: the current absence of clinically valid cutpoints for grading the severity of burnout [2, 3]. Indeed, the cutoff scores provided by the developers of the Maslach burnout inventory (MBI)—the instrument used by Burghi and his colleagues for categorizing burnout— are arbitrary [3], and MBI’s developers indicate that ‘‘neither the coding nor the original numerical scores should be used for diagnoses purposes’’ ([3, p. 9]). In sum, there is no clear-cut definition of ‘‘severe burnout’’ (or of clinical burnout) to date and, therefore, the prevalence of (severe) burnout cannot be established in a clinically meaningful way. When the authors report that ‘‘a severe level of burnout was identified in 51 % of intensivists and 42 % of the nursing staff’’ (p. 1,785), the implications of these findings (e.g., in terms of necessity for intervention) are thus difficult to interpret. The absence of binding diagnostic criteria for burnout [2] has led to a multiplication of the conceptions and operationalizations of the syndrome (Table 1). As a consequence, the prevalence of burnout has varied dramatically from one study to another (e.g., [4, 5]). Inevitably, as long as what is meant by ‘‘burned out’’ remains elusive, estimating the importance of the burnout phenomenon will remain challenging. Pending clinically valid cutpoints for grading the severity of burnout, and given the overlap of burnout with depression, relying on depressive symptoms measures may be an alternative [5]. By contrast with the MBI, many depression scales have clinically valid cutoff scores [5]. Such scales could at least be used as complements to the MBI in order to facilitate the clinical interpretation of the obtained results and allow for better-calibrated interventions.