Burnout or Depression? Two Dead Ends Facing Overlooked Healthcare Workers

Awareness of mental exhaustion among physicians and other healthcare workers is increasing substantially. The number of scientific articles published on this topic so far in 2022 has increased 10-fold compared with the previous 20 years.

This increase has highlighted that the main problem behind physicians' exhaustion lies in the healthcare system rather than the individual. In fact, efforts to address burnout —in the hope of demonstrating that it is not an individual weakness —often emphasize a strong distinction between burnout and depression. Yet statements arguing against all this appear very often:

“Equating burnout with depression shifts responsibility from the workplace to the individual.”

“In many work environments, burnout is described as a sign of weakness, inadequacy or even mental illness.”

Such statements imply that burnout is a systemic problem that should be alleviated through systemic interventions, while depression is an individual problem that should be alleviated through individual interventions.  

However, there are misconceptions about depression. These misconceptions also discourage us from making full use of tools developed to prevent and treat depression in our efforts to improve doctors' working conditions.

Differences Between Burnout and Depression

The distinction—or lack of a distinction—between burnout and depression experienced by physicians has often caused debate and confusion. In particular, some of this confusion arises because the term “burnout” is defined differently in different studies. A review covering 182 different studies found that “physician burnout” had been defined in 142 different ways.

The most commonly used tool for diagnosing and assessing burnout is the Maslach Burnout Inventory, which scores three domains:

• emotional exhaustion,
• depersonalization (detachment) and
• a reduced sense of personal accomplishment.

Emotional exhaustion, the core component, is more strongly associated with depressive symptoms than with the other two components of burnout.

Furthermore, contrary to the conceptualization of burnout as a unique work-related phenomenon, work-related stress is the primary driver of depression among doctors. One example is that, before beginning training, physicians in training have a prevalence of depression similar to that of the general young adult population, but immediately after starting training, their depression rates increase fivefold. This dramatic increase suggests that the conditions of practicing medicine, rather than individual factors, cause depression among physicians.

In addition, the major work-related and non-work-related factors that can predict depression (such as workload, workplace environment, mental health and personal characteristics) are almost identical to those that can predict burnout. The importance of these factors is generally similar for depression and burnout. Researchers need to continue efforts to assess whether depression and burnout can be meaningfully distinguished. To date, however, the evidence does not support claims that depression and burnout arise from fundamentally different triggers.

Interventions to Improve Physicians' Working Conditions and Quality of Life

The conclusion generally drawn from the assumption that physicians' distress arises from systemic or environmental factors is that individual-level interventions have a minimal role in improving physician well-being. Yet there are many circumstances in which individual-level interventions can be used even if the primary cause lies at the system level. If people develop lung cancer because they were exposed to asbestos at work, the first obvious priority is to remove the toxic asbestos from the environment. However, no one concludes that affected people do not need individual treatment because their illnesses arose in the workplace. Similarly, although improving the work environment is key to improving doctors' quality of life in the long term, increasing access to and use of effective individual interventions is also critical for people already affected.

Current and proposed interventions for burnout are primarily implemented at the healthcare-system level, while many effective interventions for depression are delivered at the individual level. These interventions include not only psychiatric medicines but also evidence-based preventive and therapeutic approaches that can be tailored to the nature and severity of the particular distress a physician feels.

Most importantly, identifying and treating depression can help reduce the risk of suicide among physicians. Unfortunately, when we tell doctors that they are right to regard themselves as burned out rather than depressed, they become less inclined to seek, turn to and use individual interventions that could improve their well-being.

Research on physician burnout has successfully raised awareness of the problem. However, it has also led to insistence that burnout is not the individual's fault and that systemic change is needed, as well as an emphasis on major differences between burnout and depression.

Unintended consequences include further stigmatization of mental health conditions, stronger barriers to seeking healthcare and incomplete implementation of established, effective depression interventions to improve physicians' well-being. If we are to alleviate what troubles physicians, we must stop reinforcing the existing stigma surrounding mental health conditions in our efforts to combat the stigma attached to burnout.

Broadening reform efforts to include depression and mental health more generally will not reduce the urgency of reforming our healthcare system. On the contrary, it will increase the likelihood that struggling doctors can access the range of evidence-based individual interventions already available. In addition, our knowledge of depression and its systemic drivers may help identify key factors to target for reform. With these steps, we can help make medicine healthier for both doctors and the patients they care for.