A career in medicine is associated with increased risk of suicide. We have a recognized epidemic of physician burnout, an under-recognized higher rate of depression, and a suicide rate higher than the general public. How are these linked and what can be done? This article explores the thorny issue of physician burnout vs depression, attempting to tease out the similarities and differences.
Addressing physician well-being and reducing suicide risk requires understanding the associations between physician distress, including burnout and depression, and personal and professional outcomes.
Dr Corrigan is a reasonably successful, well-liked physician working in a busy hospital in an anonymous city. Like all hospitals it is under-resourced for the demands put upon it.
Over time, Dr Corrigan starts to experience emotional exhaustion, which he describes as fatigue. He struggles to get out of bed some mornings. Is that because he is chronically sleep-deprived like most doctors working nights?
Despite his exemplary record, he gets hit with an unexpected malpractice suit. It is defended successfully – he was not at fault – and life moves on.
A colleague gets cancer and retires early. Suddenly his workload doubles while the hospital are unable to recruit a replacement.
He starts to lose interest in his patients. Whereas once he cared deeply about his hospital, patients, and colleagues – and they appreciated that about him – he just doesn’t care anymore.
He then starts to think the modern medical system is really just about numbers and profits rather than people. That doctors are just doing their best in an impossible situation. That every patient contact is a possible lawsuit waiting to happen. That hospital management either don’t care wat it’s like on the wards, or don’t want to know or they would have to do something about it.
He starts to think that leaving medicine sounds like a good idea, but he is well paid, has a mortgage and school fees to pay, and that massive med-school debt is still hanging around despite his best efforts.
And so on.
Which would win in the diagnostic dilemma of physician burnout vs depression, Doctor?
Which DSM5/ICD-10/11 code would you add to the electronic health record?
Whether burnout is a form of depression or a distinct phenomenon is an object of controversy for several reasons.
Firstly, most of the research that has identified burnout as a factor associated with both depression and suicide in physicians (and physicians in training) lacked suitable control for comorbid depression. The few that do control for depression often use screening tools that may not be an optimal measure of symptom severity or specificity.
Secondly, the emotional exhaustion domain of burnout has been suggested to map more closely to depression, but the depersonalization and low personal accomplishment domains of burnout do not correlate well with depression or other psychological issues.
Thirdly, in the performance and perfection-oriented medical world, where stigma is rife and perceived weakness can be career-limiting, a burnout label may be less unattractive to the suffering doctor than a mental illness one (see below).
While the debate is ongoing – Is burnout just depression in disguise? Are they different disorders? — increasing lines of evidence point towards underlying depressive disorder as the main risk factor for suicidal thinking in physicians with burnout.
Firstly, Bianchi (2015) in a published review of 92 studies on the burnout-depression overlap, notes “that the distinction between burnout and depression is conceptually fragile”. Bianchi notes Further: “It is notably unclear how the state of burnout (i.e., the end stage of the burnout process) is conceived to differ from clinical depression.”
Secondly, a number of studies highlight the overlap between the two conditions.
A published review of 92 studies on the burnout-depression overlap notes “that the distinction between burnout and depression is conceptually fragile.”
For example:
That’s 47x the risk of depression if you have severe burnout. Not surprising, really.
However, current research is limited by the lack of consistent diagnostic criteria for burnout, lack of controlling for depression, and “burnout research’s insufficient consideration of the heterogeneity of depressive disorders” (Bianchi, 2015).
Given that ~20% of doctors have clinical depression and ~40% have burnout, it is likely (and evident) that these groups overlap considerably. And who could blame them for not wanting a mental illness diagnosis.
The fear, stigma, shame, and risks associated with a diagnosis of mental illness like depression, make it unsurprising that many physicians are more confident disclosing their burnout than depression. Physicians’ own doctors may be more likely to diagnose burnout than mental illness on the same basis. Burnout is less likely to require disclosure on regulatory/licensing body paperwork.
Also, the “blame” of burnout is on the workplace rather than perceived “weakness” of a depressed doctor.
That we can still think like that tells me that we have some way to go in destigmatizing mental illness in society.
Personally, I would choose the term depression. Not just because that is what I have – and it responds to therapy and SSRIs – but knowing what it is means I can manage it. Knowing the name of the beast is the first step to taming it.
Personally, I would choose the term depression. Not just because that is what I have - and it responds to therapy and SSRIs - but knowing what it is means I can manage it. Knowing the name of the beast is the first step to taming it.
That’s not an easy one. Even the experts disagree.
For me, the key differentiator comes from the WHO ICD-11 burnout definition:
“Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”
This says to me that if you experience these symptoms outside of work – e.g. on holiday or spending time with your family – then maybe it’s more than just burnout.
Any of these might indicate clinical depression rather than burnout:
If you are feeling suicidal, or think you may be depressed, please get help today. Not tomorrow, today.
If you think that a friend or loved one might be suicidal, you need to take action. Call 911 or your local emergency services.
US physicians in crisis can seek help by calling:
Physician Support Line 1 (888) 409-0141
Psychiatrists helping US physician colleagues and medical students. Free & Confidential | No appointment necessary
Open 7 days a week | 8:00AM – 1:00AM ET
or the National Suicide Prevention Lifeline at 800-273-8255.
I predict that researchers will find more than clinical overlaps between burnout and depression. Biological evidence will emerge of similarities in stress hormones, neurotransmitters, inflammatory markers, brain circuit activity, and other neuro- and biomarkers.
This will further support the epidemiological arguments above that depression in carers manifests as the more socially acceptable burnout syndrome.
I may be wrong but I suspect, like others, that many cases of burnout are depression by another name, and that burnout is either a milder or prodromal form of clinical depression, or a manifestation of depression commonly found in the caring professions.
Whether burnout is its own syndrome, depression by another name, or something else, the burnout epidemic has to be addressed.
The physician burnout vs depression debate will rage on, yet in the meanwhile:
Physicians are quitting, retiring early, going off sick, and sometimes ending their own lives. Something has got to change.
That is why we founded Physicians Anonymous: a safe doctor-led space for all physicians to get peer support, non-judgmental listening, and strength from those who have gone before.
Check out our Peer Groups and Forums on this website to find out more.
