The Tired, Retired, and Recovered Physician: Professional Burnout Versus Major Depressive Disorder

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:

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.

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.

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.

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.

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).