Five decades of debate on burnout

First described in the mid‐1970s, “burnout” has elicited continued interest among occupational health specialists.1,2 The World Health Organization3 defines burnout as a triadic syndrome that comprises: (i) feelings of energy depletion or exhaustion; (ii) increased mental distance from one's job, or feelings of negativism or cynicism towards one's job; and (iii) a sense of ineffectiveness and lack of accomplishment. This definition closely aligns with the conceptualisation of burnout in the Maslach Burnout Inventory, the most prominent measure of the entity.2,4 Although burnout has become a popular indicator of job‐related distress, persistent controversies surround the construct. As burnout reaches its half‐century of existence, this article offers an overview of key research developments that have prompted investigators to revamp their views of the syndrome.

The aetiology of burnout

The conventional wisdom among researchers is that burnout arises from unresolvable job stress.2,5 The “job‐relatedness” of burnout has been considered a signature feature of the syndrome.2 These views have been incorporated by the World Health Organization, which characterises burnout as a syndrome “resulting from chronic workplace stress that has not been successfully managed”.3 Although widely shared, the idea that work‐related stress is the force driving the development of burnout has proven difficult to support. Substantial associations between work‐related stress and burnout have been documented in a wealth of cross‐sectional studies. However, longitudinal studies have showed a more subtle pattern of results. In a meta‐analysis of 74 follow‐up studies, Lesener and colleagues found that job demands and job resources predicted burnout only modestly.6 Similar results were obtained by Guthier and colleagues in a meta‐analysis of 48 follow‐up studies focusing on job stressors and burnout.7 Guthier and colleagues found that the association between job stressors and burnout was not only small but also likely overestimated.7 In both meta‐analyses, burnout was predictive of, rather than predicted by, work‐related stress. In summary, there is no clear evidence that burnout is primarily caused by work, or that work contributes more to burnout than it does to other stress‐related conditions — such as anxiety and depression. Recently, an increased focus on non‐work factors (eg, negative life events, lifestyle factors), personality traits (eg, neuroticism), and physical disorders (eg, sleep–wake disorders and thyroid disorders) has been encouraged.7,8 Studies capitalising on intensive longitudinal methods, objective (health) measures, and long term follow‐ups may be helpful in this endeavour. Without a deeper understanding of the determinants of burnout, designing effective interventions is likely to remain challenging.

The prevalence of burnout

Claims of an ongoing burnout epidemic have proliferated in recent decades. Sky‐high prevalence estimates have been circulating in both the scientific and general press. Yet, the validity and plausibility of these figures have been a cause for concern. Investigators have underscored that burnout prevalence cannot be estimated because burnout cannot be accurately diagnosed.8,9 In practice, burnout prevalence has been gauged using criteria that are not only clinically and theoretically arbitrary but also loose and heterogeneous.9 The use of such criteria has faced severe criticism, with calls to stop conducting (and publishing) prevalence studies until sound diagnostic criteria are established.8,9 If developing diagnostic criteria for burnout, researchers should be mindful of diagnosis creep10 to avoid pathologising ordinary variations in stress, fatigue or motivation.

Burnout and depression

Although many researchers have approached burnout and depression as two different animals,2 identifying tangible differences between the entities has been challenging.8 Examining the clinical picture ascribed to burnout, it is difficult not to notice that the symptomatology of burnout borrows heavily from that of depressive conditions. Maslach and colleagues2 themselves indicated that burnout is characterised by “a predominance of dysphoric symptoms”. A particularly puzzling finding is that burnout symptoms correlate less strongly with each other than with depressive symptoms.8 Based on such results, investigators have suggested that burnout symptoms could be regarded as fragments of depressive symptomatology rather than the components of a standalone syndrome.11 Aetiologically, unresolvable stress appears as a common denominator.8,12 Sen noted that burnout and depression are predicted by essentially the same factors.13 Studies of cognitive functioning, focusing on how people handle tasks and process stimuli in their environment, found that burnout involves alterations typical of depression.8 On the neurobiological front, research on burnout has been inconclusive.14 For instance, multiple cortisolic profiles have been found from study to study, from hypocortisolism to normal cortisolemia to hypercortisolism. On the therapeutic side, many clinicians have warned against drawing a demarcation line between burnout and depression. Depressive disorders require close medical attention and are a prime risk factor for suicidal behaviors.8 Separating burnout from depression may deprive people categorised as “burned out” of access to potentially life‐saving treatments. Promoting the burnout–depression distinction without compelling evidence that a distinction is warranted may have sombre consequences. Investigators seeking to contextualise depressive symptoms within the work domain can rely on instruments such as the Occupational Depression Inventory.8,11

Burnout and stigma

Perhaps because it did not emerge from psychiatry research, burnout has often been viewed as a benign label permitting safer communication on job‐related distress.15 Recent research has challenged this belief. For example, Sterkens and colleagues found that individuals with a history of burnout were less likely to be promoted.16 Interestingly, having a history of burnout mattered more when being considered for a promotion than current performance. Formerly burned‐out employees were perceived more negatively in multiple domains — for example, leadership capacities, motivation, autonomy, stress tolerance, current health, chances of future sick leave, and chances of finding another job. In a randomised online trial study, Smith and colleagues found that the burnout label was as stigmatising as the depression label.17 The authors underlined that “providing a burnout diagnosis to explain mild depressive symptoms in workplace/occupational contexts may not be more favourable in terms of alleviating stigma and increasing help‐seeking”. In conclusion, the burnout label may not be as socially accepted as previously thought and may require cautious use in organisations.

The burnout construct

For decades, researchers have regarded exhaustion, cynicism and inefficacy as the defining features and building blocks of the burnout syndrome.2,3,4 As an illustration, Maslach and Leiter5 indicated that “[t]he burnout syndrome occurs when people experience combined crises on all three of these dimensions”. Given its pivotal status, the burnout definition could be expected to rest on a solid foundation. Historical analysis reveals a more complicated picture.18,19,20,21 The development of the burnout construct did not originate from robust empirical investigations or in‐depth theorising. Burnout surfaced in the literature through anecdotal reports and rudimentary studies in which the construct appeared largely predefined.18 These studies barely met any scientific standard (eg, in terms of measurement, data analysis or replicability) and were highly susceptible to observer bias (eg, confirmation bias).2,18,19,20,21 Such studies were thus ill‐equipped to identify a syndrome. The Maslach Burnout Inventory, whose publication in 1981 formalised burnout's three‐component definition, was derived from this slippery research path.2 Interestingly, there is little evidence that exhaustion, cynicism and inefficacy can be subsumed under a general or higher‐order burnout factor.22 Put differently, exhaustion, cynicism and inefficacy do not show the unity expected of the components of a syndrome. In such a context, it is unsurprising that the characterisation of burnout remains widely debated.

The controversies surrounding the burnout construct have led some researchers to engage in redefinition initiatives. To our knowledge, the most recent redefinition attempt was undertaken by Tavella and colleagues.23 These authors asked individuals “who self‐identified as experiencing burnout” to complete a questionnaire covering multiple candidate burnout symptoms. The authors then used the symptoms reported to reshape the burnout construct. Although commendable in its clarifying intent, this redefinition attempt exhibits major limitations. Perhaps the most serious flaw is the reliance on participants self‐identifying as burned out. According to Maslach and Leiter, the method of asking people whether they feel burned out is “the worst” because it mistakenly assumes that everybody has the same definition of burnout.24 The modus operandi used by Tavella and colleagues23 contravenes a basic survey requirement, namely, the use of univocal terms.25 The term “burnout” is employed in everyday conversations with various meanings to describe various experiences. Assuming that non‐specialists have a common understanding of the term when even researchers and practitioners disagree on its definition is a nonstarter. The tendency to fetishise words — forgetting that words have no inherent meaning — constitutes an epistemological fallacy frequently encountered in burnout research.

Conclusions

Fifty years of research on burnout have allowed investigators to refine their views of the syndrome (Box). Many of the narratives that accompanied the introduction of the burnout construct have been debunked. Some misconceptions have reached the status of urban legends, continuing to haunt the field despite their lack of validity. Somewhat disconcertingly, the most pressing issue for burnout researchers may be to agree on the basic nature of their entity of interest. The question of whether burnout reflects a “genuine phenomenon”, irreducible to classical manifestations of distress (ie, anxiety and depressive symptoms) may require special attention as researchers further elucidate the burnout enigma.