An article published in the Journal of General Internal Medicine looks at the relationship between burnout and depressive symptoms in medical interns.
The article is authored by Constance Guille, M.D., an associate professor in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina, and Lisa Rotenstein, M.D., an internal medicine resident at Harvard Medical School/Brigham and Women’s Hospital, among others.
According to Rotenstein, these findings help correct a long-held misconception about burnout and depression.
“There is a long-standing thought that burnout is associated with workplace factors and that depressive symptoms are associated with workplace factors but also heavily influenced by personal factors,” explained Rotenstein.
“We found that the factors that drive burnout are much more closely related to the factors that drive depressive symptoms than previously realized.”
In this study, Rotenstein and Guille uncover that there is substantial overlap between the factors that predict burnout and depressive symptoms. The study surveyed 1,552 medical interns entering residency programs at 68 different institutions about depressive symptoms, emotional exhaustion and depersonalization, as well as about potential contributing factors.
Depressive symptoms were measured by a standard 9-item Patient Health Questionnaire, while emotional exhaustion and depersonalization were measured with a 9-item abbreviated Maslach Burnout Inventory.
Workload and learning environment satisfaction were assessed with a standardized instrument. Personal factors assessed included age, gender, ethnicity, relationship status, sexual orientation, parenting status, specialty, self-reported history of depression, early life stress and neuroticism score.
The study found significant overlap between factors that contribute to depressive symptoms and those that contribute to burnout, with about two-thirds of variance in both depressive symptoms and burnout attributable to personal factors, and one-third of the variance in these measures attributable to workplace factors.
With more than 142 definitions circulating in the literature, the definition of burnout has historically been unclear. This lack of clear definition has led to highly variable rates of burnout being reported among medical interns, residents and attending physicians.
In contrast, depressive symptoms are well-defined and have been clinically validated. The results of this study suggest that assessing for depressive symptoms may be a validated, standardized alternative to assessing for burnout among medical personnel.
They also underscore that interventions that help address burnout may be effective in addressing depressive symptoms and vice versa. Examples of such interventions include leveraging resources such as scribes to address documentation burdens, time banking for physician service and resources such as childcare to take stress off those physicians with familial obligations.
For Guille, the takeaway message from this study is clear.
“Previous to this work, depression and burnout were conceptualized as separate entities with different factors contributing to these outcomes,” explained Guille. “This work suggests there is substantial overlap between both workplace and personal factors that contribute to an increase in both depressive symptoms and burnout.”
Despite this, several studies have found more suicide among physicians than in other occupational groups.7,8 This may be partly due to their attempts in committing suicide being more frequently successful; yet, this may also represent the tip of an iceberg of frustration and inadequate mental health care among medical doctors.9
Presumed risk factors from longitudinal studies
What do we know about individual and work-related predictors and risk factors of mental distress from the prospective and longitudinal studies so far?
Some landmark early follow-up studies in the United States and United Kingdom put doctors’ work and mental health on the agenda in the 1970s and 1980s.10–12 In the following, we will pay most attention to the Longitudinal Study of Norwegian Medical Students and Doctors (NORDOC).13,14
This study has since 1993/1994 followed repeatedly 2 cohorts of medical students (N = 1052) with 6 years apart for 20 years (2014), and there is now an ongoing 25-year follow up. For more information, see Facebook: @docsinrush.
There are 2 main hypotheses with regard to possible risks factors. First, it may be due to individual factors such as personality traits, past mental health problems, etc. Second, contextual stress may influence mental health among doctors, whether this is unhealthy working conditions or negative life events (ie, stress outside of work).
Both individual and work-related factors seem to be of importance. Individual factors may be more important with respect to more severe clinical mental disorders, whereas work-related factors are more important for stress, burnout, and minor emotional disturbance.5,15
In terms of individual factors, NORDOC has included personality traits, as one of very few studies in doctors. Neuroticism personality trait is related to vulnerability, self-criticism, low self-esteem, and proneness to stress compatible with the modern common term “hypersensitivity.”
This trait predicts stress, anxiety, and depression in the general population,16 and, as expected, in NORDOC it predicts work stress, burnout, and even severe depressive symptoms among doctors.14,17,18
Studies among medical students and young doctors have found the combination of conscientiousness (or obsessiveness) and neuroticism seems to be especially important for school and work stress.19,20 In addition, NORDOC has identified a particular trait (reality weakness) that is associated with severe personality pathology.6
This trait predicts independently a need for mental health treatment,21 lack of help-seeking,22 severe depressive symptoms,18 and even aggravation of suicidal ideation among medical students and doctors.23 Another important individual factor is the increased rate of female medical students and young doctors.
In Norway, there has been an increase from 55% to 70% of women in medical schools during the past 2 decades. We have previously found little gender differences in NORDOC, but a recent study among Norwegian medical students find considerable reduction in subjective well-being in 2015 compared to that 20 years ago, and this reduction was most prominent among the female students.24 This reflects recent trends in Norway and other Western societies which observe increased anxiety and depressive symptoms among young female adults.25,26
With regard to contextual stress, it seems that both work-related stress and stress outside of work are of importance. NORDOC studies have found that demanding patient work is associated with mental health problems early in the medical career,27 and that difficulty with balancing life—such as work–home interface stress—is a sustaining problem over the course of the career.28
The detrimental role of such stress is also in keeping with studies among US doctors.5 Work–home stress predicts burnout (emotional exhaustion) in a NORDOC 5-year follow-up study.29 A promising finding is that such stress was less prominent in the youngest cohort of Norwegian doctors 10 years after leaving medical school.30 This may be due to increased coverage of kindergarten as well as changed and more liberal gender roles in our Scandinavian society over recent years.
There are also studies that associate time pressures and burnout with suicidal ideation among medical students and doctors.31,32 Sleep-deprivation due to call work and long hours may be one important reason for more depressive symptoms measured in young doctors.2
A recent NORDOC study of life satisfaction during 15 years of the career controlled for all possible individual factors, and found the following work-related predictors and possible risk factors: work–home stress, lack of colleague support, and emotional demands at work.33 Doctors often feel a 24/7 responsibility and obligation for individual patients and their treatment and this puts extraordinary emotional demands on this occupational group.
Does stress among doctors have consequences for their patient care?
Many studies can indicate lowered quality of patient care among stressed doctors with burnout, but a large majority of these studies build on self-report by the doctors themselves of more errors and poorer care.5,34 We lack an empirical foundation for the notion that stress and burnout really impair doctors’ functioning with respect to observed poorer quality of care.
There are 2 classical observation studies demonstrating that long hours and time pressures interfere with doctors functioning,35,36 but we lack studies that find burnout to lead to observed errors or poorer care.37
The burnout concept and scales are not very valid with respect to impaired functioning, for example, with respect to valid cut-off for defining a case.38 On the other hand, depression and other mental disorders lead to poor functioning.39 We need more studies on working conditions and the levels of stress and poor health among young doctors that lead to lowered patient care.
What are the most common mental disorders among doctors?
In general, doctors may have the same disorders that strike anyone else; doctors are not invincible. Although depressive symptoms seem to be prevalent in the early years of the medical career, some of this may be due to exhausting work stress by frequent on-call work.40 We lack representative studies on the occurrence of valid depression among doctors compared to that in other occupational groups.
Suicide is more common among doctors than among other groups of academics, but since it is also very common in veterinarians, this may also be due to available knowledge and means (drugs) for committing suicide during mental health deterioration.41 Alcoholism and drug abuse is an additional known risk factor for suicide and the SAD triad (suicidal behavior–alcoholism–depression) may be particularly important for medical doctors.42 From clinical experience with doctor–patients, we know the slippery slope from self-medication with tranquilizers to cope with the stresses to dependency of alcohol and drugs, in addition to other boundary violations.43
There are very few clinical studies including diagnostic interviews among doctors. One previous Spanish study emphasizes the importance of dual diagnoses, especially in alcohol dependence and mood disorders.44 From own experience, we know that bipolar disorder (type II) is quite common among physicians, but we lack sound empirical studies that compare occurrence of mental disorders in doctors with that in other groups.
American impaired physician programs have for many years shown high and promising recovery rates (70–80%).4 The programs used to focus on addiction and substance abuse, but they now put increasing emphasis on psychiatric diagnoses. A family history, opioid use, and psychiatric comorbidity predicted relapse of substance abuse among doctors and other healthcare workers.45
In Norway, we have implemented a successful low-threshold intervention, the Villa Sana program.17 This intervention seems to reduce burnout in doctors. It includes 2 separate schemes, a 1-day individual counseling scheme, and a 1-week group-based scheme in a psychiatric hospital. The Norwegian Medical Association pays for the program that is free for all doctors.
With respect to medical students and young doctors, we have also a large longitudinal study on mindfulness-based stress reduction.46 This is a randomized-controlled trial of second year medical and psychology students, and they have now been followed-up for 6 years, for the medical students into the first 2 postgraduate years.47
The reduction of emotional distress by mindfulness training is most prominent in female students.46 The training has a stronger impact among those with vulnerable personality (high neuroticism and conscientiousness).48 During the follow-up, there is an increase in active coping and reduction in passive or avoidance coping—the effects on ways of coping may be important psychological mechanisms of mindfulness training.47
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. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314:2373–2383.
. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316:2214–2236.
. Tyssen R. Health problems and the use of health services among physicians: a review article with particular emphasis on Norwegian studies. Ind Health. 2007;45:599–610.
. West CP, Dyrbye LN, Shanafelt TD. Burnout: causes, consequences, and solutions. J Intern Med. 2018;283:516–629.
. Tyssen R. Brower KJ, Riba MB. Personality traits. Physician Mental Health and Well-Being: Research and Practice. Ann Arbor, MI: Springer; 2017;211–234.
. Hem E, Haldorsen T, Aasland O, et al. Suicide rates according to education with a particular focus on physicians in Norway. Psychol Med. 2005;35:873–880.
. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295–2302.
. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry. 2013;35:45–49.
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. Vaillant GE, Brighton JR, McArthur C. Physicians’ use of mood-altering drugs. A 20-year follow-up report. N Engl J Med. 1970;282:365–370.
. Mahmood JI, Stoen GK, Tesli M, et al. Contextual factors and mental distress as possible predictors of hazardous drinking in Norwegian medical doctors: a 15-year longitudinal, nationwide study. Eur Addict Res. 2016;23:19–27.
. Tyssen R, Vaglum P, Gr⊘nvold NT, et al. The relative importance of individual and organizational factors for the prevention of job stress during internship: a nationwide and prospective study. Med Teach. 2005;27:726–731.
. Tyssen R, Vaglum P. Mental health problems among young doctors: an updated review of prospective studies. Harv Rev Psychiatry. 2002;10:154–165.
. Jeronimus BF, Kotov R, Riese H, et al. Neuroticism’s prospective association with mental disorders halves after adjustment for baseline symptoms and psychiatric history, but the adjusted association hardly decays with time: a meta-analysis on 59 longitudinal/prospective studies with 443 313 participants. Psychol Med. 2016;46:2883–2906.
. R⊘ KE, Gude T, Tyssen R, et al. Counseling for burnout in Norwegian doctors: one year cohort study. BMJ. 2008;337:a2004.
. Grotmol KS, Gude T, Moum T, et al. Risk factors at medical school for later severe depression: a 15-year longitudinal, nationwide study (NORDOC). J Affect Disord. 2013;146:106–111.
. R⊘vik JO, Tyssen R, Gude T, et al. Exploring the interplay between personality dimensions: a comparison of the typological and the dimensional approach in stress research. Pers Individ Dif. 2007;42:1255–1266.
. Tyssen R, Dolatowski FC, R⊘vik JO, et al. Personality traits and types predict medical school stress: a six-year longitudinal and nationwide study. Med Educ. 2007;41:781–787.
. Midtgaard M, Ekeberg O, Vaglum P, et al. Mental health treatment needs for medical students: a national longitudinal study. Eur Psychiatry. 2008;23:505–511.
. Tyssen R, R⊘vik JO, Vaglum P, et al. Help-seeking for mental health problems among young physicians: is it the most ill that seeks help? A longitudinal and nationwide study. Soc Psychiatry Psychiatr Epidemiol. 2004;39:989–993.
. Tyssen R, Hem E, Vaglum P, et al. The process of suicidal planning among medical doctors: predictors in a longitudinal Norwegian sample. J Affect Disord. 2004;80:191–198.
. Sletta C, Tyssen R, Lovseth LT. Change in subjective well-being over 20 years at two Norwegian medical schools and factors linked to well-being today: a survey. BMC Med Educ. 2019;19:45.
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. Mahmood JI, Grotmol KS, Tesli M, et al. Life satisfaction in Norwegian medical doctors: a 15-year longitudinal study of work-related predictors. BMC Health Serv Res. 2019;(re-submitted for publication).
. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med. 2018;178:1317–1330.
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