Burnout–depression overlap: A review
Introduction
The overlap of burnout and depression has been debated since the birth of the burnout construct in the 1970s. In what is generally considered the inaugural article on burnout, Freudenberger (1974) already indicated that when suffering from burnout, “the person looks, acts and seems depressed” (p. 161). Despite a considerable amount of research on burnout since that time (Schaufeli, Leiter, & Maslach, 2009), the singularity of the burnout phenomenon vis-à-vis depression has remained unclear because of common etiological pathways and shared symptoms (Ahola et al., 2014, Bianchi et al., 2013, Hallsten, 1993, Rydmark et al., 2006, Schonfeld, 1991, Shirom, 2005, Taris, 2006a).
Previous literature reviews focusing on the distinction of burnout and depression have yielded mixed conclusions, while somewhat favoring the hypothesis that burnout is distinct from depression. Based on the analysis of 18 studies dealing with burnout and depression, Glass and McKnight (1996) argued that burnout and depressive symptomatology do not show complete isomorphism and, therefore, are not redundant concepts. In a similar vein, Schaufeli and Enzmann (1998) advanced the view that “burnout and depression (…) are distinct, albeit related constructs” (p. 41); the authors went on to write that “it seems that burnout is a genuine phenomenon” (p. 41). For Iacovides, Fountoulakis, Kaprinis, and Kaprinis (2003), “empirical research suggests that burnout and depression are separate entities, even though they may share several common characteristics” (p. 218). Schaufeli (2003), in a discussion of the nosological status of burnout, contended that “burnout can be considered a mental disorder that may be differentiated clinically as well as empirically from other mental disorders, most notably depression” (p. 5). Finally, according to Thomas (2004) who proposed an overview of burnout in medical residents, “the nature and direction of the association between depression and burnout for residents remain unclear” (p. 2887). Although the burnout–depression overlap has been reviewed and discussed in the past (see also Maslach & Schaufeli, 1993), important work has been dedicated to this issue in the last decade (e.g., Ahola and Hakanen, 2007, Hakanen and Schaufeli, 2012), with several studies having challenged the hypothesis that burnout is distinct from depression (e.g., Ahola et al., 2014, Bianchi et al., 2013). This evolution of research in recent years suggests that a new literature review is timely. The aim of the present article is to propose an up-to-date review of the literature dealing with the burnout–depression overlap.
Many conceptions of burnout have been proposed during the last four decades (e.g., Farber, 2000, Halbesleben and Demerouti, 2005, Kristensen et al., 2005, Malach-Pines, 2005, Maslach et al., 2001, Shirom, 2003; for an overview of earlier conceptions, see Schaufeli & Enzmann, 1998). According to the most consensual of these conceptions, burnout is a three-dimensional syndrome made up of (emotional) exhaustion, cynicism (also termed depersonalization), and lack of professional efficacy (or reduced personal accomplishment) that develops in response to chronic occupational stress (Maslach and Jackson, 1981, Maslach and Jackson, 1986, Maslach et al., 1996, Maslach et al., 2001). Exhaustion refers to the feelings of being emotionally drained and physically overextended; energy is lacking and mood is low. Cynicism characterizes a distant and callous attitude toward one's job; the individual is de-motivated and withdraws from his/her work. Lastly, lack of professional efficacy includes feelings of inadequacy and incompetence associated with loss of self-confidence. Thus defined, burnout is assessed with the Maslach Burnout Inventory (MBI), a self-administered questionnaire (Maslach and Jackson, 1981, Maslach and Jackson, 1986, Maslach et al., 1996). The MBI was the first standardized instrument designed to assess burnout. The MBI has played a key role in shaping burnout research (Schaufeli et al., 2009). By the end of the 1990s, the MBI was used in more than 90% of the journal articles concerning burnout (see Schaufeli & Enzmann, 1998, p. 71). Although the MBI-related definition of burnout dominates the field (Schaufeli et al., 2009), other conceptions of the phenomenon have been proposed and other assessment instruments have been designed, notably the Burnout Measure (BM; Malach-Pines, 2005, Pines, 1993, Pines and Aronson, 1988, Pines et al., 1981), the Shirom–Melamed Burnout Measure (SMBM; Melamed et al., 1992, Shirom, 1989, Shirom, 2003), and the Oldenburg Burnout Inventory (OLBI; Demerouti et al., 2003, Halbesleben and Demerouti, 2005). To our knowledge, no structured clinical interview has been developed for the assessment of burnout.
The main conceptions of burnout share the general idea that burnout is the result of prolonged, unresolvable stress at work or, put differently, that burnout is caused by a long-term mismatch between the demands associated with the job and the resources of the worker (Hobfoll and Shirom, 2001, Maslach et al., 2001, Weber and Jaekel-Reinhard, 2000). Thus, burnout is the product of an enduring adaptive failure and should not be confused with nonmorbid, acute job stress (Schaufeli and Buunk, 2004, Schaufeli and Enzmann, 1998). Similarly, the chief conceptions of burnout unanimously posit that fatigue (typically called “exhaustion”) is the core of burnout (Cox, Tisserand, & Taris, 2005), although recent findings suggest that both the level of fatigue and the appraisal of fatigue in burned out individuals do not differ from those reported in patients with major depression or anxiety disorders and may therefore not be relevant to the understanding of the specific pathological processes associated with burnout (Bianchi et al., 2013, Van Dam et al., 2013).
No biological marker of burnout has been found (Danhof-Pont, van Veen, & Zitman, 2011). Nevertheless, burnout has increasingly been regarded as a hypocortisolemic disorder (Chida and Steptoe, 2009, Fries et al., 2005), consistent with the fact that cortisol reduces both normal and pathological fatigue (e.g., Tops et al., 2006, Wheatland, 2005; see also Kumari et al., 2009). Cortisol is the end product as well as a key effector of the neuroendocrine stress response. It has been involved in general pathogenesis, due to its systemic effect on the organism (Hellhammer and Hellhammer, 2008, Sapolsky, 2004). Burnout being considered a stress-related condition (Maslach et al., 2001), growing attention has been directed toward cortisol in burnout research (Danhof-Pont et al., 2011, Kakiashvili et al., 2013).
Depending on the way it is conceptualized, burnout is viewed as a process within a dimensional approach or a state (i.e., the end stage of the aforementioned process) within a categorical approach (Brenninkmeijer and van Yperen, 2003, Hallsten, 1993, Paine, 1982, Schaufeli, 2003, Schaufeli and Enzmann, 1998). A dimensional approach allows for a quantification of burnout and situates the afflicted individual on a continuum—the individual experiences burnout to a given degree. A categorical approach allows for a qualification of the phenomenon—burnout is either present or absent—that is particularly relevant to medical decision-making (e.g., as to whether a given individual should benefit from sick leave). The end stage of the burnout process is regarded as the clinical form of burnout (see Schaufeli & Enzmann, 1998, p. 74).
However, no binding diagnostic criteria are available for identifying cases of burnout (Weber & Jaekel-Reinhard, 2000). Burnout is not present in the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5; American Psychiatric Association, 2013), and only appears as a factor influencing health status and contact with health services (coded Z73.0 and defined as a “state of vital exhaustion”) in the International Classification of Diseases (ICD-10; World Health Organization, 1992). This state of affairs has led burnout researchers to develop a variety of working criteria when their goal is to diagnose burnout or grade burnout's severity (Bianchi, Schonfeld and Laurent, 2014, Kalimo et al., 2003, Schaufeli et al., 2001). To date, the burnout construct has been questioned regarding its basic structure (unidimensional versus multidimensional), scope (work-related versus cross-domain or context-free), cardinal symptoms (e.g., as to whether cognitive impairment should be included), course (e.g., onset, duration, offset, relapse), and distinctiveness with respect to depressive, anxiety, adjustment, and fatigue disorders (e.g., Bianchi et al., 2013, Cathébras, 1991, Cox et al., 2005, Hakanen and Schaufeli, 2012, Jonsdottir et al., 2013, Kristensen et al., 2005, Leone et al., 2010, Schaufeli and Enzmann, 1998, Schaufeli and Taris, 2005, Schonfeld, 1991, Shirom, 2003, Shirom, 2005, Shirom and Ezrachi, 2003, Taris, 2006a, Toker et al., 2005).
Given the absence of consensually accepted diagnostic criteria, the prevalence of burnout, strictly speaking, is unknown. Nevertheless, burnout has been increasingly regarded as a serious burden for working individuals, organizations, and society as a whole (Maslach et al., 2001, Morse et al., 2012, Schaufeli et al., 2009). At an occupational level, burnout has been associated with absenteeism (Ahola et al., 2008, Toppinen-Tanner et al., 2005), presenteeism1 (Demerouti, Le Blanc, Bakker, Schaufeli, & Hox, 2009), poorer work performance (Taris, 2006b), job turnover (Leiter and Maslach, 2009, Shimizu et al., 2005, Swider and Zimmerman, 2010), and chronic work disability and disability pensions (Ahola, Toppinen-Tanner, Huuhtanen, Koskinen and Vaananen, 2009, Ahola, Gould, et al., 2009). At a more global level, burnout has been shown to prospectively predict severe injuries (Ahola, Salminen, Toppinen-Tanner, Koskinen, & Vaananen, 2014), insomnia (Armon, Shirom, Shapira, & Melamed, 2008), cases of coronary heart disease (Toker, Melamed, Berliner, Zeltser, & Shapira, 2012) as well as hospitalization for mental and cardiovascular disorders (Toppinen-Tanner, Ahola, Koskinen, & Väänänen, 2009). In addition, burnout has been related to accelerated biological aging (Ahola et al., 2012) and all-cause mortality (Ahola, Väänänen, Koskinen, Kouvonen, & Shirom, 2010).
Today, burnout has become a privileged construct in the study of ill-health at work. The creation of the scientific journal Burnout Research illustrates the structuring of burnout research as an emancipated field of research. However, the social focus of burnout research (Maslach et al., 2001) has partly eclipsed the clinical characterization of the “burnout syndrome” (Weber & Jaekel-Reinhard, 2000), contributing to definitional ambiguity, and resulting in “diagnostic noise” vis-à-vis depression. Several authors, indeed, have warned against the use of the burnout label in medical settings in the current context of diagnostic uncertainty because of a risk of leaving depressive episodes untreated, or of providing inappropriate treatment (Bahlmann et al., 2013, Rössler et al., 2014). This state of affairs underlines a pressing need to clarify the nosological status of burnout in relation to depression.
The concept of depression is deeply rooted in the history of medical science. Its genesis can be traced back to Greek antiquity and Hippocrates's theory of melancholic humor, and continued through Galenic medicine and medieval times (Paykel, 2008). The emergence of the modern concept of depression is linked to the rise of psychiatry during the 19th century. Nowadays, the DSM is widely recognized as the classification system that defines depression for research and clinical purposes (Ingram & Siegle, 2009). The DSM-5 (American Psychiatric Association, 2013) distinguishes several depressive disorders and provides diagnostic criteria for each of them. For instance, the DSM-5 lists nine main symptoms characterizing major depression: Depressed mood, anhedonia (loss of interest and pleasure), decreased or increased appetite and/or weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness and/or guilt, impaired concentration or decision making, and suicidal ideation (American Psychiatric Association, 2013, Beck and Alford, 2009). A diagnosis of major depressive episode requires at least two weeks of depressed mood or anhedonia accompanied by at least four additional depressive symptoms (American Psychiatric Association, 2013). A diagnosis of depression can be refined through subtype specification. Distinct subtypes of depression have been related to distinct neurobiological profiles. For example, melancholic depression—a subtype of depression marked by nonreactive mood and responsiveness to tricyclic antidepressants (TCAs)—is considered a hypercortisolemic disorder and has been associated with appetite–weight decrease and insomnia whereas atypical depression—a subtype of depression marked by reactive mood and nonresponsiveness to TCAs—is considered a hypocortisolemic disorder and has been associated with appetite–weight increase and hypersomnia (American Psychiatric Association, 2013, Gold and Chrousos, 2002, Hellhammer and Hellhammer, 2008). Thus, depression covers a broad spectrum of disorders.
Depression has been investigated both in its clinical and subclinical forms (sometimes referred to as dysphoria; e.g., Ellis, Beevers, & Wells, 2011), and both from categorical and dimensional approaches (Ingram & Siegle, 2009). Depression measures can be divided into two categories, clinician ratings and self-report inventories (Nezu, Nezu, Friedman, & Lee, 2009). An example of an instrument allowing clinician ratings is the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 1997). Whereas the SCID is structured to match specific DSM-IV (American Psychiatric Association, 1994) diagnostic criteria, it utilizes the skills of trained clinicians by permitting them to probe, restate questions, challenge respondents, and ask for clarification (Nezu et al., 2009). Clinician ratings constitute the method of reference for diagnosing clinical depression. Among self-report inventories, the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), the Beck Depression Inventory—II (BDI-II; Beck, Steer, & Brown, 1996), and the 9-item depression scale of the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001) have been commonly used. Self-report inventories are notably employed for investigating subclinical forms of depression or grading the severity of depressive disorders once formal diagnoses have been established. Depression has been examined in various contexts, including the occupational context (Adler et al., 2006, Grynderup et al., 2013, Kahn, 2008, McTernan et al., 2013, Rydmark et al., 2006, Schonfeld, 2001), and studied extensively from an infra-individual (e.g., cellular, molecular), an individual, and a supra-individual (social) standpoint (Allen and Badcock, 2006, Barnett and Gotlib, 1988, Billings and Moos, 1982, Bonde, 2008, Krishnan and Nestler, 2008, Lara and Klein, 1999, Netterstrøm et al., 2008, Post, 1992, Ritsher et al., 2001).
As in the etiology of burnout, unresolvable stress plays a central role in the etiology of depression (e.g., Caspi et al., 2003, Daley et al., 2000, Hammen et al., 2010, Leonard, 2010; regarding work stress and depression, see Melchior et al., 2007, Stansfeld and Candy, 2006, Tennant, 2001, Wang, 2005, Wang et al., 2012). The sustained impossibility of controlling one's environment and actively neutralizing stressors is a key pathogenic factor in many theories of depression (Abramson et al., 1989, Allen and Badcock, 2006, Beck and Alford, 2009, Hill et al., 2012, Laborit, 1993, Nesse, 2000, Peterson et al., 1993, Seligman, 1972, Seligman, 1975, Ursin and Eriksen, 2004). Sapolsky (2004) affirmed that “it is impossible to understand either the biology or psychology of major depressions without recognizing the critical role played in the disease by stress” (p. 271). Thase (2009) noted that “(…) most, if not all, forms of depression involve dysfunctional adaptations of the brain systems that regulate adaptations to stress” (p. 188). Depression is a nodal public health problem. In the United States, 17% of adults experience at least one episode of major depression during their life (Kessler et al., 2005).
In the present article, the issue of the burnout–depression overlap is first addressed from a theoretical viewpoint through an analysis of the way the added value of the burnout construct has been presented and justified so far (for an overview, see Table 1). In the second part of the paper, findings from empirical studies that examined the link between burnout and depression are synthesized in order to determine whether the distinctiveness of burnout has been clearly demonstrated (for an overview, see Table 2). Throughout the paper, future avenues of investigation are outlined based on gaps identified in current literature.
Section snippets
Method
A systematic literature search was carried out in PubMed, PsycINFO, and IngentaConnect to October 2014 using the conjunction of keywords “burnout AND depression.” The following filters were applied: “English language,” “peer-reviewed journals,” and “humans.” To be included in the present literature review, an article had to inform the comparison of burnout with depression. The systematic search was accompanied of a hand search based on the literature referenced in the retained articles. A total
Conceptual and theoretical considerations
At the heart of the distinction between burnout and depression lies the idea that burnout—at least initially—is job-related and situation-specific whereas depression is context-free and pervasive (e.g., Freudenberger and Richelson, 1980, Iacovides et al., 2003, Maslach et al., 2001, Shirom, 2005, Warr, 1987). Following this line of reasoning, burnout and depression would fundamentally differ in scope (Maslach & Schaufeli, 1993), the former being relatively work-restricted, the latter
Empirical and practical investigations
Having examined the burnout–depression overlap from a strictly conceptual standpoint, we now turn to empirical levels of analysis. Six questions will be successively dealt with:
- 1.
Are burnout and depression distinguishable in terms of symptoms?
- 2.
How are burnout and depression correlated?
- 3.
Are burnout and depression distinguishable in factor analyses?
- 4.
Does burnout predict depression and/or vice versa?
- 5.
Can burnout and depression be distinguished at somatic and biological levels?
- 6.
Are job-related versus
Conclusion
Relatively fragile from a strictly conceptual standpoint (Table 1), the distinction between burnout and depression is partly supported by empirical research (Table 2). Close scrutiny of the available literature, however, suggests that the evidence for the singularity of the burnout phenomenon is inconsistent. The paucity of research on the relationship between the state of burnout and clinical depression and insufficient consideration of the heterogeneity of the spectrum of depressive disorders
Role of funding sources
No funding source involved.
Contributors
The first author conducted literature searches and wrote the initial draft of the manuscript. All authors contributed to review several versions of the manuscript and have approved the final manuscript.
Conflict of interest
The authors state that there is no conflict of interest.
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