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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 is 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, normalization is not achieved, and the state of stress is prolonged.

Differential diagnosis

  • Common psychiatric differential diagnoses are (clinical clues given in parentheses)
    • severe depression (especially when feelings of worthlessness or guilt are associated)
    • alcohol and drug abuse problem (for example, recurring short absence from work)
    • so-called atypical depression (for example, getting emotionally hurt at workplace triggers strong fluctuations in mood)
    • 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)
    • somatization disorder (several somatic symptoms)
    • personality disorder (functioning may vary, but problems have continued throughout adulthood)
    • 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.
  • 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 is more important.
    • 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.
    • 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 that does not require compensation on the part of the employer. Health insurance requires that the loss of work ability must be a result of an illness.
  • If the patient is unable to work because of burnout, his or her state can be considered a disease, and the main diagnosis is some sort of mental disorder (e.g., state of depression, adjustment disorder, stress reaction or somatoform disorder). Burnout can be recorded as an additional diagnosis.
  • Treatment is planned individually and can include, for example, stress management, medication 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.
  • Mental problems, such as depression, must be actively treated.
  • It is important to take into consideration the subjective experience of the patient and to familiarize oneself with his or her life conditions.
  • The patient should be referred for psychiatric assessment 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.
  • 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
    • working 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

    • Madsen IEH, Nyberg ST, Magnusson Hanson LL ym. 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]
    • West CP, Dyrbye LN, Rabatin JT et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014;174(4):527-33. [PubMed]
    • Sonnenschein M, Sorbi MJ, Verbraak MJ, Schaufeli WB, Maas CJ, van Doornen LJ. Influence of sleep on symptom improvement and return to work in clinical burnout. Scand J Work Environ Health 2008 Feb;34(1):23-32. [PubMed]
    • Ahola K, Honkonen T, Pirkola S, Isometsä E, Kalimo R, Nykyri E, Aromaa A, Lönnqvist J. Alcohol dependence in relation to burnout among the Finnish working population. Addiction 2006 Oct;101(10):1438-43. [PubMed]
    • Ahola K, Honkonen T, Isometsä E, Kalimo R, Nykyri E, Aromaa A, Lönnqvist J. 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]