Is It Burnout or Depression or Both?

“Hi Dr. Myers, this is Dr. Green calling. I’ve been feeling more and more burned out at work over the past 6-9 months but I can’t tell if it really is burnout or if I’ve slipped into a depression. Can you help me sort that out?”  

Given the high rates of burnout in doctors in this country—and recent research that shows the rates are actually increasing—a telephone call like the above is not uncommon (1). There is much we can do to assist our physician colleagues, and making the correct diagnosis is pivotal because of important treatment implications. What follows are some features that may help in trying to sort this out:

1. Burnout has many descriptions, but most include a sense of emotional exhaustion, decreased personal achievement, and depersonalization with a negative or cynical attitude toward patients (2). Other authors take a broader perspective that includes a range of physiological, behavioral, psychological, spiritual, and clinical signs and symptoms in its sufferers (3). This latter type of clinical picture is tough to distinguish phenomenologically from the descriptive presentation of major depressive disorder in DSM-5.
2. Burnout is an occupational illness (4). It is a state of fatigue or frustration brought about by devotion to a cause or way of life that is failing to produce the expected reward. It is not just tiredness—it is an erosion of the soul in people with ideals and commitment. These statements resonate with those uttered by burned out physicians. However, this does not completely rule out major depressive disorder, because vulnerable physicians can become clinically depressed when/if their work stress becomes overwhelming.
3. Taking a detailed history from your physician-patient of a previous episode of depression in childhood, adolescence, college, medical school or residency— even if undiagnosed and untreated—can be very helpful. Ditto to a careful family history of mood disorders. If criteria are met for major depressive disorder, this might indicate a recurrence. Also, when trying to tease out temporal details about onset, some articulate physician-patients can decipher what came first—mood slippage and consequent negative work thoughts and weariness (supporting major depressive disorder) or the other way around, with many negative cognitions resulting in lowering of their spirits and energy (supporting burnout). Statements like “I used to love my job until we got that new CEO and a bunch of crazy regulations were implemented” can be very revealing.
4. If your patient describes a picture that is unifocal and restricted to his work life, that sounds more like burnout. And in the early stages, happiness, interest, and healthy energy in one’s personal and family life are indeed preserved. However, too often, by the time a physician consults us, the clinical picture is more pervasive and enveloping. Details may help. If your patient makes statements like “My wife and kids say I’ve got a black cloud over my head. That I’m all doom and gloom. That they dread my coming home from work, and that I’m bringing them down”, this supports burnout. Especially if your patient’s mood and energy pick up on weekends or on vacation. If they don’t, it is much more suggestive of the all-encompassing nature of major depression.
5. Because there are so many overlapping symptoms with burnout and depression, some clinicians opt to prescribe antidepressant medication right away to provide some symptom relief and to buy time to sort this out. Others take a wait-and-see approach offering a short course of weekly supportive psychotherapy or cognitive behavioral therapy. What is most important is that you encourage your patient NOT to make any immediate major decisions about her job. Some are very tempted to quit or retire. Urge your patient to wait a few weeks with the proviso that clarity will come and she will then know the right course of action.
6. If the diagnosis is depression and your patient is now euthymic, it is distinctly possible—if not probable—that his zest for work and commitment to it will return. No bridges will have been burned. If the diagnosis is burnout (or both), then you can offer much guidance, assistance, validation, and reassurance to see if the work itself can be reconfigured. In other words, can some especially toxic dimensions of the work week be diminished or eliminated and replaced by work that is more rewarding and restorative of personal agency? If not, you can help your patient creatively look at career options that are more rewarding and health promoting. You should both enjoy this process.

References

1.    Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings . 2015. 90(12);600-1613.

2.    Salyers MP, Flanagan ME, Firmin R, et al. Clinicians’ perceptions of how burnout affects their work. Psych Services . 2015. 66(2);204-207. 3.     Grosch WN and Olsen DC. When Helping Starts to Hurt: A New Look at Burnout Among Psychotherapists . WW Norton & Co. New York.1994.

3.    Grosch WN and Olsen DC. When Helping Starts to Hurt: A New Look at Burnout Among Psychotherapists . WW Norton & Co. New York.1994.

4.    Freudenberger HJ and Richelson G. Burnout: The High Cost of High Achievement . Doubleday. New York. 1980.

Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of seven books the most recent of which are “Touched by Suicide: Hope and Healing After Loss” (with Carla Fine) and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.  

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.