There is growing concern about the increasing prevalence of burnout in those who work in health care, whether they are physicians, nurses, or other professionals [1]. All types of settings and specialties seem to be involved. A recent systematic review and meta-analysis of randomized trials testing interventions to reduce physician burnout has yielded disappointing results for various strategies including professional coaching, mindfulness programs, discussion groups, and changes in work environment and scheduling [1].
Some encouraging results have been reported in a randomized controlled trial (RCT) by Liu et al. [2], where a sample of 66 medical workers (physicians and nurses), who had been exposed to overwhelming stress during the COVID-19 epidemic in China, displayed significant and clinically meaningful benefits after receiving online Well-Being Therapy (WBT) [3, 4], compared to a psychoeducation program. This investigation introduced some technical novelties that deserve to be discussed here, also in light of the insights that we have gained with our extensive clinical experience in the field.
Clinical Evaluation
The term burnout is frequently used but seldom defined with a certain precision. Guseva Canu et al. [5] counted 88 distinct definitions. The initial definitions by Freudenberger [6] and Maslach [7] have emphasized feelings of exhaustion and fatigue, somatic symptoms, sleep problems, disengagement, and an impaired ability to interact with colleagues. Probably, this is what comes to mind to most clinicians when using the word “burnout.” Guseva Canu et al. [5] defined occupational burnout as exhaustion due to prolonged exposure to work-related problems. Such broad definition may find international consensus [5] but is devoid of clinical implications. Little clinical help may come also when using established burnout measures, such as Maslach Burnout Inventory [8], because of their deficiencies in content validity [9], which may also affect interpretation of trials [1].
Burnout thus appears a generic term, which may be used by patients themselves to describe their situation, but that needs proper evaluation. Is reference to DSM-5 [10] then sufficient? It may be important if the interview discloses the presence of a mood or anxiety disorder (e.g., a major depressive episode), which may account for all or part of the problems at work. But, if we look at diagnoses that may specifically apply to work-related stress, the clinical utility of DSM-5 [10] becomes questionable. One related diagnosis, in fact, is represented by adjustment disorders. However, such category suffers from major conceptual and methodological flaws [11]. It is an exclusion psychiatric diagnosis (it cannot be applied in comorbidity with other psychiatric disorders) and overlaps with subthreshold manifestations of mood and anxiety disorders. Further, a precise definition of the level of stress is missing [11]. Another DSM-5 diagnosis that may be performed in the setting of work-related stress is that of posttraumatic stress disorder [12]. However, it requires the presence of a major traumatic event, which is in contrast with the subtle, chronic nature of stress in many cases of burnout.
The COVID-19 epidemic in China provided the ground for extreme stressors in the work environment, particularly when this dreadful disease first appeared [13, 14]. We have no doubt that many of the physicians and nurses who were included in the study by Liu et al. [2] would have met the diagnostic criteria for adjustment disorders or posttraumatic stress disorder. However, Liu et al. [2] selected a different and novel approach, making reference to the concept of allostatic load [11, 15, 16]. Since DSM-5 [10] does not provide specific reference to the role of stress and social factors, the notion of allostatic load (the cost of chronic exposure to fluctuating or heightened neural and systemic physiologic responses exceeding the coping resources of an individual) provides a synthesis of the cumulative effects of biopsychosocial experiences in daily life that involve chronic stress, life events, as well as work experience, unemployment, adverse living conditions, and the burden of medical diseases [11, 15, 16]. When environmental challenges exceed the individual ability to cope, allostatic overload ensues [17]. Diagnostic criteria for allostatic overload, including a specific brief clinical interview, have been developed and validated [11, 17]. Further, a patient-reported outcome measure, the PsychoSocial Index (PSI), for assessing allostatic load is also available [11, 18, 19]. A part of this questionnaire refers to work-related stress and encompasses also other sources of stress, sleep patterns, psychological distress, health attitudes, and quality of life. The PSI is based on clinimetric principles, which are quite different from psychometrics [20]. Liu et al. [2] used a cut-off point of the PSI [11] for determining a state of allostatic overload and for including doctors and nurses in the RCT. Such choice provides a level of specification that is higher than any burnout definition [5] and fills a gap in the DSM-5 classification [10], which, unlike previous editions, fails to include an overall judgment of psychosocial stress [11, 21]. The presence of allostatic overload indicates a state of increased vulnerability to medical and psychiatric diseases and suggests careful evaluation of the patient’s physical state [16].
When clinicians are asked to evaluate a case of alleged burnout or such problems emerge in the course of clinical interviewing [22], exploration of the clinical features of allostatic load, whether by interview or questionnaire [11], is warranted. One needs to ascertain whether any form of mobbing or perceived lack of help from the work colleagues may occur, whether there is tension at home (the “double load,” stress both at work and at home) and whether manifestations of somatic and psychological manifestations of allostatic overload particularly occur during week-ends and vacation, indicating the inability to shut-off stress responses [11, 17].
In our clinical experience, other levels of clinimetric integration appear to be important. Allostatic overload is often closely related to demoralization, which is characterized by the patient’s consciousness of having failed to meet his or her own expectations or those of others or being unable to cope with some pressing problems [23, 24]. It is based on Schmale and Engel’s profile characterized by unpleasant, distressing feelings expressed in terms such as “it is too much,” “it is no use,” or “I cannot take it anymore,” ascribed by the patient to failures or deficiencies in one’s environment (helplessness) and/or to one’s own personal failures or inadequacies for which nothing can be done (hopelessness) [25]. Demoralization may be associated with perception of diminished competence and control in one’s own functioning; impairments in relationships with significant others; external environment or one’s own performance do not fulfill the subjects’ expectations given by previous experiences; loss of the sense of continuity between past and future, with diminished hope and confidence in projecting oneself into the future; proneness to revive previous unsuccessful or frustrating experiences [25]. Differential diagnosis from depression is feasible with the use of diagnostic criteria for demoralization and the Clinical Interview for Demoralization (CIDE) [23].
An additional area that needs to be explored by careful interviewing [22] is concerned with euthymia, which refers to lack of mood disturbances, presence of positive effect, and of balanced levels in psychological well-being dimensions, leading to integration of psychic forces (flexibility), a unifying outlook on life which guides actions and feelings for shaping the future accordingly (consistency), and resistance to stress (resilience) [26]. The Clinical Interview for Euthymia (CIE), a clinimetric observer-rated index, may be a source of valuable information [26]. Table 1 reports specific features that depart from euthymia and can often be found in the setting of allostatic overload and burnout. They may be illuminating in understanding difficulties at work. For instance, in our experience with mental health workers (particularly psychiatrists and psychologists), we have observed a marked impairment in personal growth, with a sense of personal stagnation and tiredness, which makes clinical duties in health systems less tolerable.
Impaired level . | Excessive level . |
---|---|
Environmental mastery | |
The person feels difficulties in managing everyday affairs; he/she feels unable to improve things around; he/she is unaware of opportunities | The person is looking for difficult situations to be handled; he/she is unable to savoring positive emotions and leisure time; he/she is too engaged in work or family activities |
Personal growth | |
The person has a sense of being stuck; he/she lacks sense of improvement over time; he/she feels bored and uninterested in life | The person is unable to elaborate past negative experiences; he/she cultivates illusions that clash with reality; he/she sets unrealistic standards and goals |
Purpose in life | |
The person lacks a sense of meaning in life; he/she has few goals or aims and lacks sense of direction | The person has unrealistic expectations and hopes; he/she is constantly dissatisfied with performance and is unable to recognize failures |
Autonomy | |
The person is overconcerned with the expectations and evaluations of others; he/she relies on judgment of others to make important decisions | The person is unable to get along with other people, to work in team, to learn from others; he/she is unable to ask for advice or help |
Self-acceptance | |
The person feels dissatisfied with self; he/she is disappointed with what has occurred in past life; he/she wishes to be different | The person has difficulties in admitting own mistakes; he/she attributes all problems to others’ faults |
Positive relations with others | |
The person has few close, trusting relationships with others; he/she finds difficult to be open | The person sacrifices his/her needs and well-being for those of others. Low self-esteem and sense of worthlessness induce excessive readiness to forgive |
Impaired level . | Excessive level . |
---|---|
Environmental mastery | |
The person feels difficulties in managing everyday affairs; he/she feels unable to improve things around; he/she is unaware of opportunities | The person is looking for difficult situations to be handled; he/she is unable to savoring positive emotions and leisure time; he/she is too engaged in work or family activities |
Personal growth | |
The person has a sense of being stuck; he/she lacks sense of improvement over time; he/she feels bored and uninterested in life | The person is unable to elaborate past negative experiences; he/she cultivates illusions that clash with reality; he/she sets unrealistic standards and goals |
Purpose in life | |
The person lacks a sense of meaning in life; he/she has few goals or aims and lacks sense of direction | The person has unrealistic expectations and hopes; he/she is constantly dissatisfied with performance and is unable to recognize failures |
Autonomy | |
The person is overconcerned with the expectations and evaluations of others; he/she relies on judgment of others to make important decisions | The person is unable to get along with other people, to work in team, to learn from others; he/she is unable to ask for advice or help |
Self-acceptance | |
The person feels dissatisfied with self; he/she is disappointed with what has occurred in past life; he/she wishes to be different | The person has difficulties in admitting own mistakes; he/she attributes all problems to others’ faults |
Positive relations with others | |
The person has few close, trusting relationships with others; he/she finds difficult to be open | The person sacrifices his/her needs and well-being for those of others. Low self-esteem and sense of worthlessness induce excessive readiness to forgive |
Another aspect that deserves clinical attention is concerned with irritable mood, a prolonged and generalized state, with difficult control over temper, or with angry-explosive attacks [27]. Further, in work settings, the presence of posttraumatic embitterment disorder, which can be assessed by clinimetric methods [28], appears to be important. The patient responds with embitterment in direct relation to negative events which are experienced as resulting from injustice, humiliation, and breach of trust [28].
Management
Liu et al. [2] used online WBT to address the state of allostatic overload. It yielded significantly lower levels of allostatic load, sleep problems, and psychological distress and significantly higher levels in various dimensions of psychological well-being and quality of life. The results were maintained at 3- and 6-month follow-ups. The findings thus indicate the effectiveness of WBT in treating allostatic overload in medical workers [2]. What could be its conceivable mechanisms of action?
WBT stands in the psychotherapeutic field for distinct features [3, 4]. A unique characteristic is self-observation of psychological well-being associated with specific homework. Another important aspect of WBT is the individualized focus (imbalances in well-being and distress may vary from one illness to another and from patient to patient) that requires a preliminary clinimetric assessment. A final distinctive feature is its reference to the concept of euthymia [26]. Patients are not simply encouraged pursing the highest possible levels in psychological well-being in all dimensions, as is found to be the case in most positive psychology interventions, but to obtain a balanced functioning. A major therapeutic ingredient of WBT is making the patients aware, by cognitive restructuring, of their imbalances in dimensions of psychological well-being (Table 1). For instance, two important dimensions of psychological well-being, environmental mastery (sense of competence in managing everyday challenges) and personal growth (a feeling of continued development and progress over time) progressively build up during a physician’s career [29]. Allostatic load may transform environmental mastery in a sense of subjective incompetence (the perception that one is unable to deal with stressful situations), and personal growth may be replaced by a sense of personal stagnation, feeling bored and uninterested in life. WBT may counteract such impairments, as well as excessive levels in psychological well-being dimensions such as positive relationships, that cause a selfless devotion to the giving of others with low self-esteem and a chronic sense of being unfulfilled [3, 4].
WBT, however, is not limited to cognitive restructuring but entails a strong behavioral component, which translates into specific homework assignments. The practice of lifestyle medicine [30, 31] may be applied to physicians and nurses themselves and be instrumental in lessening the burden of environmental stress, in terms of duties, work hours, unrealistic reliance on one’s physical endurance. Another behavioral component is concerned with the pursuit and encouragement of optimal experiences, which are characterized by the perception of high environmental challenges and environmental mastery, deep concentration, involvement, enjoyment, control of the situation, clear feedback on the course of activity, and intrinsic motivation [3]. Behavioral and cognitive ingredients are inextricably linked in WBT and tend to potentiate each other, as suggested by preliminary trials in medical patients where WBT was added to lifestyle modification [32‒34]. WBT would then help overcoming a major difficulty in lifestyle changes, which is represented by the prolonged effort required, with frequent discouragement and frustration when unavoidable drawbacks occur [30]. It is thus conceivable that WBT might have facilitated lifestyle changes in the physicians and nurses of the trial by Liu et al. [2].
A complementary explanation for the efficacy of WBT in medical workers with allostatic overload [2] may be provided by its efficacy in counteracting demoralization [3, 4, 23], as was found to be the case in a RCT concerned with cardiac patients [35]. WBT may address dysfunctional levels of psychological dimensions such as environmental mastery, self-acceptance, and purpose in life, which may lead to demoralization (subjective incompetence, feeling that performances do not fulfill the subject’s expectations, and diminished hope and confidence in the future) [3, 4, 23].
Management of burnout, however, is not simply based on the application of WBT but very much depends on the quality of assessment that has been performed. A first essential issue is the differentiation between primary and secondary forms of difficulties in occupational functioning. These latter occur when problems arise after the onset of a psychiatric disorder. For instance, a major depressive episode may affect a person’s performance at work (e.g., lack of concentration, fatigue). In these secondary cases, treatment of the primary condition thus becomes essential. It is then important to determine the characteristics of allostatic overload and whether it is associated with demoralization or posttraumatic embitterment disorder. Finally, the use of psychotropic drugs or substances (e.g., alcohol) needs to be evaluated. Pharmacological and non-pharmacological alternatives can be instituted. For instance, persons who have sleep difficulties frequently use hypnotics at bedtime, but this practice is seldom efficacious, even when the doses are high. Splitting a benzodiazepine in two divided doses may be more fruitful, particularly if the medication (e.g., clonazepam) has low affinity for the benzodiazepine receptor and lipid solubility with resulting slower effects, less dependence liability, and amnestic potential during the day [36]. Insomnia that is refractory to hypnotics may be reversed by switching the patient to very low-dose clonazepam (0.25 mg in two divided doses), with the benefit of avoiding a medication bulk at night [36]. Suggestions geared to good sleep quality need to be individualized and address unhealthy practices during daytime (e.g., insufficient physical activity, prolonged and/or frequent napping, getting home very late from work), before going to sleep (e.g., caffeine consumption, falling asleep in front of the TV). At times, lifestyle suggestions may help avoiding the use of medications; more frequently, they may increase their effectiveness and facilitate their tapering and discontinuation [36]. We have found the use of antidepressant medications to be exceedingly common in burnout/allostatic overload, despite lack of indications such as the presence of a diagnosed mood or anxiety disorder. In most of the cases, the benefits of these medications are questionable at best, while substantial adverse effects may ensue in the long term [37, 38].
Conclusions
The definition of burnout at work, regardless of the one that is chosen [5], is only the first step in the clinical evaluation. It indicates the presence of a troublesome situation, not how it should be handled. It requires a careful assessment that may lead to specific intervention strategies. Burnout in persons who operate in the medical system, particularly physicians and nurses, may produce a cascade effect on the patients they treat. As a result, medical workers deserve a high-quality assessment and not a hurried response to questions such as what is the best medication for sleep problems.
The trial conducted by Liu et al. [2] introduces important innovations in the assessment and treatment of burnout: the use of the clinical framework of allostatic load and of WBT. Such innovations, of course, need to be confirmed by subsequent independent trials. In the meanwhile, however, clinicians may become aware of the need for assessment strategies that go beyond standard psychiatric and psychological practice and for a comprehensive management reflecting such evaluation. Within the psychotherapeutic opportunities, WBT appears to be particularly suitable for addressing the problems related to work performance.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
The authors have no funding to declare.
Author Contribution
Jenny Guidi and Giovanni A. Fava conceived and wrote the entire manuscript.