What is the difference between depression and burnout?
An ongoing debate

Qual è la differenza tra depressione e burnout? Un dibattito in corso

*E-mail: ischonfeld@ccny.cuny.edu

1Department of Psychology, The City College of the City University of New York, USA
2Institut de Psychologie du Travail et des Organisations, Université de Neuchâtel, Svizzera
3Unità Operativa di Neuropsichiatria AUSL, Università di Ferrara

SUMMARY. Burnout has been viewed as a syndrome developing in response to chronically adverse working conditions. Burnout is thought to comprise emotional exhaustion, depersonalization, and reduced personal accomplishment. Historically, however, burnout has been difficult to separate from depression. Indeed, the symptoms of burnout coincide with symptoms of depression. Evidence for the discriminant validity of burnout with regard to depression has been weak, both at an empirical and a theoretical level. Emotional exhaustion, the core of burnout, itself reflects a combination of depressed mood and fatigue/loss of energy and correlates very highly with other depressive symptoms. Work-related risk factors for burnout are also predictors of depression. Individual risk factors for depression (e.g., past depressive episodes) are also predictors of burnout. Overall, burnout is likely to reflect a “classical” depressive process unfolding in reaction to unresolvable stress.

KEY WORDS: depression, burnout, stress.

RIASSUNTO.  Il burnout è concepito come una sindrome che si sviluppa in risposta a condizioni di lavoro cronicamente avverse. Si ritiene che il burnout comporti esaurimento emotivo, depersonalizzazione e riduzione della realizzazione personale. Storicamente, tuttavia, il burnout è stato difficile da separare dalla depressione. In effetti, i sintomi del burnout coincidono con i sintomi della depressione. L'evidenza della validità discriminante del burnout nei confronti della depressione è debole, sia a livello empirico sia a livello teorico. L'esaurimento emotivo, il nucleo del burnout, riflette una combinazione di umore depresso e affaticamento/perdita di energia e si correla molto bene con altri sintomi depressivi. I fattori di rischio correlati con il lavoro per il burnout sono i medesimi fattori predittivi della depressione. I fattori individuali di rischio per la depressione (per es., episodi depressivi pregressi) sono gli stessi del burnout. Nel complesso, è probabile che il burnout rifletta un processo depressivo “classico” che si manifesta in reazione a uno stress irrisolvibile.

PAROLE CHIAVE: depressione, burnout, stress.

Burnout is a syndrome thought to develop in response to chronically poor and uncontrollable working conditions. Considerable research has demonstrated that depressive symptoms and disorders can also emerge as a response to chronically adverse working conditions1,2. Workplace depression is not rare3.
Manna and Dicuonzo4 claimed that our finding5 substantial burnout-depression overlap is questionable because five of the items of the PHQ-96, the instrument we used to assess depressive symptoms and generate provisional diagnoses of depression, are fatigue-related. Two items clearly are (sleep problems and tired/low energy) although the other items in question are arguably not specifically fatigue-related. The problem with the authors’ view is that the PHQ-9 is in fact keyed to the nine symptoms used for diagnosing depression7. That some PHQ-9 items refer to fatigue is fully justified given that fatigue is directly involved in the diagnosis of depression. Moreover, fatigue is often the presenting complaint in depressed individuals seeking care7.
Instead of suggesting that the assessment of fatigue in the PHQ-9 is problematic, Manna and Dicuonzo should have asked why the creators of burnout instruments borrowed so heavily from the symptoms used to diagnose depression. We note that Freudenberger, the researcher who published the first widely recognized paper on burnout, observed that the burned out individual «looks, acts and seems depressed»8 (p. 161). From the very beginning of research on burnout, investigators have thus experienced difficulties distinguishing burnout from depression. As observed elsewhere, «it can be hypothesized that the burned-out person looks, acts, and seems depressed because he or she is depressed»9 (p. 67).
Other problems undermine Manna and Dicuonzo’s view that burnout has discriminant validity with regard to depression. For example, Manna and Dicuonzo cite the confirmatory factor analysis (CFA) conducted by Leiter and Durup10 in a study of hospital staff. What Manna and Dicuonzo did not mention is that the statistical model developed by Leiter and Durup to show that burnout and depression are distinct constructs fit the data poorly (AGFI ≈ .810). Moreover, despite Leiter and Durup’s decision not to use almost half the depression items in their CFA, the depression and burnout factors still correlated .72.
A more recent CFA study showed that emotional exhaustion (the main component of burnout) and depression factors correlated .85 when measurement error, skew (a characteristic of symptom items used in nonclinical samples), and potential overlap in item content were controlled11. This correlation was higher than the correlation of emotional exhaustion with the other two burnout factors. In a more elaborated model based on the same data, an exploratory structural equation model12 (ESEM) was developed11. The ESEM model showed that depression and emotional exhaustion symptoms loaded heavily on the main factor, a psychopathology/distress factor. Why the model is so important is that emotional exhaustion is the very core of burnout13. The depersonalization dimension is ancillary. Kristensen et al.14 point out that distancing oneself from clients is a way of coping with emotional exhaustion. Interesting, the loss of personal involvement with others is also evident in individuals suffering from depressed mood7,15. Kristensen et al.14 also underline that reduced personal accomplishment is more likely to be a consequence of emotional exhaustion in the long run than a component of burnout as such. This being noted negative self-evaluations and feelings of failure are consistent with the experience of depression15.
Manna and Dicuonzo4 identified risk factors for burnout in psychiatrists and other professionals. These risk factors include lack of equity at work, high workload, lack of support and other work-related resources, violence exposure, and problems influencing workplace decisions. These are the very same risk factors that predict depressive symptoms and disorders in individuals across many different types of employment1. Although Manna and Dicuonzo mention individual risk factors along with situational factors, the authors did not emphasize individual risk factors in their paper. Individual risk factors closely link burnout with depression. A series of studies links current burnout to a history of depressive disorders as well as to current intake of anti-depressant medication5,16,17.
Much of what Manna and Dicuonzo4 report raises another problem that must be addressed. Their disquisition underplays the distinction between a categorical/diagnostic approach and a dimensional approach to burnout and depression. Both burnout (and its central constituent emotional exhaustion) and depression can be treated as continua. Manna and Dicuonzo wrote that depression is a mental disorder; however, recent research on psychopathology suggests that depression is better conceptualized on a continuum 18,19. Nonetheless, the lack of attention to the distinction between categorical and continuous approaches to burnout and depression further muddies the debate.
In conclusion, we think that Manna and Dicuonzo’s4 argument that burnout and depression are “distinct” is misleading. The evidence suggests that what is labeled “burnout” is a depressive condition. We recommend that organizations, including the clinical settings in which psychiatrists work, take steps to minimize depressogenic working conditions, such as threats of violence, unreasonably high workloads, and unsupportive managers.

Conflict of interests: the authors have no conflict of interests to declare.
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