Depression

Is Burnout Actually a Form of Depression?

How do we focus on work-life balance without downplaying clinical depression?

Posted Jan 19, 2020

"Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.” —William Styron, Darkness Visible: A Memoir of Madness

By Grant H. Brenner

An arduous work environment, full of physical and emotional strain, takes a toll on even the hardiest. Long hours, poor sleep, challenging interpersonal interactions, lack of success, degraded self-care, trauma and harassment—and a myriad of other factors—make many workplaces toxic.

The toxicity is managed with maladaptive coping strategies: Short-term relief, binge-watching TV, superficial relationships, the use of alcohol and other substances, comfort food, and other common factors add fuel to the fire.

We can be tough, but stoicism coupled with denial means people often don’t realize what is going on until too late.

Politics and Polarization

The distinction between burnout and depression is blurry, distracted by impassioned debate. The World Health Organization presents depression and burnout as serious problems—one as a medical illness, and the other as the result of professional factors. Yet they are similar, and depression has been around much longer.

Furthermore, missing from the discussion is the concept of "moral injury", related to but different from posttraumatic stress. With moral injury, being forced to act or stand-by and not act in the face of a violation of one's ethics and principles causes harm. Many argue that moral injury is the real culprit, and not depression or burnout, when it comes to systemic issues.

On one end of the spectrum, depression is seen as a dangerous idea, perhaps a marketing ploy by the medical establishment or drug companies, or a misguided if well-intentioned framework at best devoid of reality. On the other end, depression is recognized as a serious medical condition, under-recognized, poorly understood, and hard to treat, even under the best of circumstances. Hopelessness, impaired awareness of recognizing illness, and self-recrimination make it easy to ignore.

Burnout highlights that workplace factors need to change, and that the way we work is sick, on a societal level. This issue is less explicit with depression, for which stress may be one of many contributing factors.

Would it be better to say that workplace problems can cause clinical depression, as we do for more traditional physical ailments? Would saying that the workplace causes depression have enough impact, or is calling it something else necessary to move the needle?

What Is Burnout?

Burnout is an appealing construct because it resonates on an intuitive level, directing us away from ourselves to external factors. First described by Herbert Freudenberger in the 1970s, and developed into a standardized rating in the early 1980s by Maslach and colleagues, burnout covers three core factors in its original form: emotional exhaustion, depersonalization, and loss of sense of professional accomplishment. 

Burnout fits into a wellness orientation, with the advantage of side-stepping stigma by avoiding pathologizing. In line with this, the World Health Organization recently recognized burnout as a discrete syndrome, though not a medical diagnosis, stemming from “problems associated with employment or unemployment," and therefore exclusively work-related, although burnout is useful for understanding strain in situations like parenting and caring for an ailing loved one as well.

Missed Opportunities

The World Health Organization recognizes depression as a major cause of global disability, affecting almost 300 million people annually, contributing to high suicide rates especially in younger people but across the age range, and adequately treated in fewer than 25 percent of people in low- and middle-income countries.

Depression is considered a medical illness, diagnosed by the presence of several symptoms present over a significant period of time. Depression is understood to have both biological and environmental determinants, and stress is one trigger. Depression is also more common following trauma, whether in adulthood or childhood—trauma which is often itself under-recognized.

Critics of the burnout model suggest that burnout strongly overlaps with clinical depression. Burnout may actually be depression, but calling it "burnout" makes it harder to get treatment where it is sorely needed, giving people an out by putting it all on the system.

The Current Study

In order to look at whether burnout is really depression in another guise, Bianchi, Schonfeld, and Verkuilen (2020) of the City University of New York and the University of Neuchâtel in Switzerland conducted a study of 3,113 employed individuals across five different samples, measuring both burnout and depression, to determine whether there was any difference between the two in a large sample. 

They assessed burnout with the Shirom-Melamed Burnout Measure (SMBM) and the Maslach Burnout Inventory (MBI); and depression with the Patient Health Questionnaire-9 (PHQ), which accurately screens for cardinal symptoms of depression. They statistically analyzed the scores for burnout and depression to see if they detected different issues or if they were measuring the same thing.

The study authors found that not only did burnout correlate strongly with clinical depression, but that individual burnout factors correlated better with depression symptoms than with one another.

Because of past arguments that fatigue overlaps between depression and burnout, making them look similar when they are not, fatigue was controlled statistically. If fatigue were a hidden culprit, then controlling for it should have really made depression and burnout stand apart from one another. When they factored in fatigue, depression and burnout were more similar, rather than less.

The authors conclude, “Our findings do not support the view that burnout is adequately characterized as an entity that is distinct from depression,” suggesting that burnout is a depressive condition. 

A Rational Approach

These conclusions support greater recognition of depression, highlighting that depression is under-recognized, leading to missed opportunities for potentially life-saving treatment. Calling depression “burnout” highlights the need to alleviate environmental factors, but may make it harder for individuals to get help when they need it. Does the burnout label increase denial of one issue while raising awareness the other? Future research examining this question is critical.

Additional work is also needed to see if these results carry out over other samples, with more robust study designs and the inclusion of more detailed measures of depression, stressful and traumatic experiences, and related factors.

A wise approach, for now, is to use both perspectives, advocating for systemic changes to address the macro issues highlighted with burnout while being careful to look for and name depression early on, closely attending to individual needs without delaying proper diagnosis.

Being vehement about one or the other may distract from getting help where it is needed, when help is needed in many places. Perhaps at some point "burnout” will be an official subtype of depression.

Because depression can be hard to see, even when obvious in retrospect, it’s important to be vigilant and responsive. Calling depression "burnout" runs the risk of minimizing the situation when it's already hard to identify depression when it is present. Whenever we consider whether someone has burnout, we also need to ask if they are experiencing clinically-significant depression.

Like it or not, burnout and depression are both concepts in regular use. Advocates on both sides of the debate can work together to catalyze change while moving toward ways of talking about individual and systemic factors we can all respect. Addressing individual needs, treating and preventing depression, changing work culture, building individual and collective resilience, and making sure wellness programs really work, is all necessary and important.

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