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Burnout

Essentials

  • Burnout is not an illness but a syndrome. It should not be medicalized.
  • The three key features of burnout are
    • intense, overwhelming fatigue
    • cynical relationship to work
    • diminished professional self-esteem.
  • Depression and burnout overlap. Burnout may be a precipitating factor in the development depression. Depression should be actively treated as in other cases Planning the Treatment of Patients with Depression. Fatigue may be the symptom of a somatic disease Fatigue.

Epidemiology

  • Burnout does not appear overnight. Instead, it develops gradually through the interaction of one's personality, work and work community.
  • Burnout is not the same as work stress. Stress is created when a person tries to adapt to his or her workload, and it is not entirely negative. Burnout develops when mere adaptation does not suffice, recovery fails, and the state of stress is prolonged.

Differential diagnosis

  • Common psychiatric differential diagnoses (clinical clues given in parentheses)
    • Severe depression (especially when feelings of worthlessness or guilt are associated)
    • Alcohol or drug abuse problem (recurring short periods of absence from work, sedation and difficulties in concentration, for example)
    • So-called atypical depression (getting emotionally hurt at workplace triggers strong fluctuations in mood, for example)
    • Stress disorders (a distinct external triggering factor must be identified)
    • Generalized anxiety disorder (worry over one's performance, constant restlessness)
    • Fear of social situations (fatigue in social situations, avoidance behaviour)
    • Somatization disorder (several somatic symptoms)
    • Personality disorders (functional capacity may vary, but problems have continued throughout adulthood; a person with so-called anancastic personality may perform well, but push themselves unreasonably hard)
    • Adjustment disorders (identifiable external stress factor that impairs functioning unexpectedly)
  • Somatic differential diagnostics: see Fatigue

Treatment

  • Speaking about “treatment” may cause unnecessary medicalization of the problem. It would be better to talk about rehabilitation or empowerment to manage one's own affairs. Job modification is among the most important means in this.
  • The amount and perceived loading of work tasks can be influenced by interventions directed at the work place and well-being at work. Interventions targeting the work place may often decrease the time required for return to work.
  • Part of the rehabilitation consists of an individual assessment of what has caused the burnout, where it has led to and how the situation can be resolved.
  • Stress from sources beyond just work also plays a role 3.
  • Releasing the tensions that have led to burnout and developing structures is essential. In practice this entails job modification.
  • If burnout is manifested as a part of depression or an adjustment disorder, the need of treatment and sick leave are determined on terms generally applicable in these disorders, albeit the role of job modification requires special emphasis.
    • It usually requires a few days and nights to normalize a patient's sleep rhythm.
    • Severe fatigue impairing functional capacity e.g. in association with an adjustment disorder requires a sick leave of 2-3 weeks.
    • A severe state of depression often requires even longer sick leave because it takes longer to regain functional capacity than it does for symptoms to disappear.
    • Sick leave does not substitute for treatment and follow-up. Book regular appointments with the patient.
    • If the patient has burnout without a psychiatric or somatic illness and he/she needs time off work, the solution is not a sick leave but a reduction of work burden or other arrangements of work tasks. Take into account all the different forms of such arrangements made possible by the social security system or by the employer. Different methods may include, for example and if locally available, partial sickness allowance, reduced working time, remote work, different types of leave of absence, job rotation, partial early retirement, and in some cases partial disability pension.
    • Occupational health care services may offer versatile services relevant for well-being at work. Good-quality studies on their effectiveness are scarce.
    • If the work load is objectively unreasonable, the labour protection system should have a central role in solving the problem.
  • According to the present classification of diseases, burnout is a symptom diagnosis. Depending on the local social security system, this may entail that it does not require compensation on the part of the employer. Health insurance may require that the loss of work ability must be a result of an illness.
  • If the patient is unable to work because of burnout, it is very important to carefully assess whether the condition is associated with a psychiatric disorder such as a depressive disorder. In such a case, the main diagnosis is a mental disorder (e.g., state of depression, adjustment disorder, stress reaction or somatoform disorder). Burnout can be recorded as an additional diagnosis (Z73.0).
  • Treatment should be planned individually and can include, for example, stress management, medication of symptoms or psychotherapy. Good sleep is essential. One of the most important perspectives in rehabilitation is the empowerment of the patient to manage his/her own affairs, possibly in cooperation with the employer. Tripartite consultation is in routine use in occupational health services.
  • Mental problems, such as depression, must be actively treated. A person with mental health problems or under stress has an even lower tolerance to alcohol than an otherwise healthy person.
  • It is important to take into consideration the subjective experience of the patient and to familiarize oneself with his or her life conditions in a comprehensive way.
  • The patient should be referred for an assessment by a psychiatrist if there is no notable improvement in 1-2 months or if the diagnosis remains uncertain.
  • If occupational health care services believe that burnout is prevalent at a specific workplace, actions can be planned to influence the work place and well-being at work, including group-based interventions.

Prevention of burnout

  • Interventions targeted at individuals may be more effective than organizational interventions, but the overall research evidence is fairly weak 1. The quality of leadership affects the well-being at work in many ways 2.
  • Burnout can be prevented by
    • making clear the difference between work and leisure time
    • the ability to say "no", i.e. bold prioritization of tasks
    • the ability to plan one's work in advance
    • taking care of one's physical condition
    • admitting one's own limits
    • good relationships at home
    • conflict-free relationships at work
    • an open work climate
    • consistent career development
    • a supportive employer
    • clear definitions of work assignments
    • perception of one's job as meaningful
    • inclusion of field-level workers in work development activities
    • maintenance of expertise.
  • Work supervision may prevent burnout of at least health care and teaching personnel.

    References

    • Haslam A, Tuia J, Miller SL, et al. Systematic Review and Meta-Analysis of Randomized Trials Testing Interventions to Reduce Physician Burnout. Am J Med 2024;137(3):249-257.e1 [PubMed]
    • Lundqvist D, Wallo A, Reineholm C. Leadership and well-being of employees in the Nordic countries: A literature review. Work 2023;74(4):1331-1352 [PubMed]
    • Upadyaya K, Salmela-Aro K. Social demands and resources predict job burnout and engagement profiles among Finnish employees. Anxiety Stress Coping 2020;33(4):403-415 [PubMed]
    • Madsen IEH, Nyberg ST, Magnusson Hanson LL, et al. Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data. Psychol Med 2017;47(8):1342-1356. [PubMed]
    • Enns J, Holmqvist M, Wener P, et al. Mapping interventions that promote mental health in the general population: A scoping review of reviews. Prev Med 2016;87:70-80. [PubMed]
    • Ahola K, Honkonen T, Isometsä E, et al. The relationship between job-related burnout and depressive disorders--results from the Finnish Health 2000 Study. J Affect Disord 2005 Sep;88(1):55-62. [PubMed]