Abstract
Introduction
There is no consistent definition of burnout. It is neither a defined diagnosis in ICD-10 nor in DSM-IV. Yet it is diagnosed by office-based doctors and clinicians. Mainly due to reimbursement reasons, diagnoses like depression are used instead of burnout diagnoses. Therefore burnout has a very high individual, social and economic impact.
Objectives
How is burnout diagnosed? Which criteria are relevant? How valid and reliable are the used tools?
What kind of disorders in case of burnout are relevant for a differential diagnosis?
What is the economic effect of a differential diagnosis for burnout?
Are there any negative effects of persons with burnout on patients or clients?
Can stigmatization of burnout-patients or -clients be observed?
Methods
Based on a systematic literature research in 36 databases, studies in English or German language, published since 2004, concerning medical and differential diagnoses, economic impact and ethical aspects of burnout, are included and evaluated.
Results
852 studies are identified. After considering the inclusion and exclusion criteria and after reviewing the full texts, 25 medical and one ethical study are included. No economic study met the criteria.
The key result of this report is that so far no standardized, general and international valid procedure exists to obtain a burnout diagnosis. At present, it is up to the physician’s discretion to diagnose burnout. The overall problem is to measure a phenomenon that is not exactly defined. The current available burnout measurements capture a three dimensional burnout construct. But the cutoff points do not conform to the standards of scientifically valid test construction.
It is important to distinguish burnout from depression, alexithymia, feeling unwell and the concept of prolonged exhaustion. An intermittent relation of the constructs is possible. Furthermore, burnout goes along with various ailments like sleep disturbance. Through a derogation of work performance it can have also negative effects on significant others (for example patients). There is no evidence for stigmatization of persons with burnout.
Discussion
The evidence of the majority of the studies is predominantly low. Most of the studies are descriptive and explorative. Self-assessment tools are mainly used, overall the Maslach Burnout Inventory (MBI). Objective data like medical parameters, health status, sick notes or judgements by third persons are extremely seldomly included in the studies. The sample construction is coincidental in the majority of cases, response rates are often low. Almost no longitudinal studies are available. There are insufficient results on the stability and the duration of related symptoms. The ambiguity of the burnout diagnosis is regularly neglected in the studies.
Conclusions
The authors conclude, that (1) further research, particularly high-quality studies are needed, to broaden the understanding of the burnout syndrome. Equally (2) a definition of the burnout syndrome has to be found which goes beyond the published understanding of burnout and is based on common scientific consent. Furthermore, there is a need (3) for finding a standardized, international accepted and valid procedure for the differentiated diagnostics of burnout and for (4) developing a third party assessment tool for the diagnosis of burnout. Finally, (5) the economic effects and implication of burnout diagnostics on the economy, the health insurances and the patients have to be analysed.
Keywords: burnout, burn-out, burning out, burned out, burnout syndrom, burnout syndrome, burn-out syndrom, burnout diagnosis, burn-out diagnosis, burning out diagnosis, burned out diagnosis, burnout differential diagnosis, burn-out differential diagnosis, burning out differential diagnosis, burned out differential diagnosis, categories, burnout categories, burn-out categories, burning out categories, burned out categories, burnout symptoms, burn-out symptoms, burning out symptoms, burned out symptoms, burnout victim, burn-out victim, burning out victim, burn out outcome, burn-out outcome measure, screening, beat, drained from working conditions, MBI, Maslach Burnout Inventory, CBI, Copenhagen Burnout Inventory, SMBM, SMBQ, Shirom Melamed Burnout Measurement, Shirom Melamed Burnout Questionnaire, SBI, School Burnout Inventory, OLBI, Oldenburg Burnout Inventory, ABQ, Athlete Burnout Questionnaire, distress, exhaustion, state of exhaustion, cynicism, depersonalisation, efficiency, personal efficiency, professional efficiency, depression, alexithymia, cutoff, cut-off, comorbidity, predictors
Abstract
Einleitung
Obwohl bisher keine einheitliche Definition des Burnout existiert und Burnout weder in der Internationalen Klassifikation der Krankheiten, 10. Revision (ICD-10) noch im Diagnostischen und Statistischen Handbuch psychischer Störungen (DSM-IV) eine eigenständige Diagnose darstellt, wird Burnout in der klinischen Praxis diagnostiziert. Vor dem Hintergrund der damit verbundenen individuellen, gesellschaftlichen und finanziellen Auswirkungen erklärt sich die hohe Brisanz dieser Thematik.
Fragestellungen
Wie wird Burnout diagnostiziert, welche Kriterien werden für eine Burnout-Diagnose herangezogen und wie valide und reliabel ist dieses Vorgehen?
Welche Störungen sind differentialdiagnostisch relevant bzw. werden gestellt?
Welchen ökonomischen Aufwand verursacht die Differentialdiagnostik in Bezug auf Burnout?
Gibt es negative Effekte von Burnout-Trägern auf Patienten/Klienten und inwieweit kommt es zu einer Stigmatisierung von Burnout-Patienten?
Methoden
Basierend auf einer systematischen Literaturrecherche in 36 Datenbanken werden ab 2004 in deutscher oder englischer Sprache veröffentlichte Studien zur medizinischen Diagnostik und Differentialdiagnostik, zu den ökonomischen Auswirkungen und den ethischen Aspekten des Burnout eingeschlossen und bewertet.
Ergebnisse
Die Literaturrecherche ergibt insgesamt 852 Treffer. Nach der Berücksichtigung aller festgelegten Ein- und Ausschlusskriterien und der Durchsicht der Volltexte werden 25 medizinische Publikationen und eine ethische Studie eingeschlossen. Es kann keine ökonomische Veröffentlichung bewertet werden.
Zentrales Ergebnis des HTA-Berichts ist, dass es bisher kein standardisiertes, allgemeines und international gültiges Vorgehen gibt, um eine Burnout-Diagnose zu stellen. Derzeit liegt es im ärztlichen Ermessen, Burnout zu diagnostizieren. Die Schwierigkeit besteht darin, etwas zu messen, das nicht eindeutig definiert ist. Die bisher diskutierten Burnout-Messinstrumente erfassen größtenteils verlässlich ein dreidimensionales Burnout-Konstrukt. Die bisher gelieferten Cutoff-Punkte erfüllen jedoch nicht den Anspruch der diagnostischen Gültigkeit, da die Generierung dieser Werte nicht der wissenschaftlichen Testkonstruktion entspricht. Die verwendeten Burnout-Messinstrumente sind nicht differentialdiagnostisch validiert.
Von differentialdiagnostischer Bedeutung sind vor allem Depressionen, Alexithymie, Befindlichkeitsstörungen und das Konzept der anhaltenden Erschöpfung. Ein phasenhafter Zusammenhang der Konzepte ist denkbar. Burnout geht zudem mit verschiedenen Beschwerden wie z.B. Schlafstörungen einher und kann sich durch eine Beeinträchtigung der Arbeitsleistung auf andere (z.B. auf Patienten) negativ auswirken. Es liegen keine Anhaltspunkte für eine Stigmatisierung Burnout-Betroffener vor.
Diskussion
Die Evidenz der Studien ist überwiegend als gering zu beurteilen. Die meisten Studien sind deskriptiv und explorativ. Es überwiegt der Einsatz von Selbstbeurteilungsinstrumenten, vor allem des Maslach Burnout-Inventars (MBI). Objektive Daten wie z.B. Gesundheitsparameter, Gesundheitszustand, Krankmeldungen oder Beurteilungen durch Dritte werden extrem selten in die Untersuchungen einbezogen. Die Sample-Auswahl ist meist zufällig und enthält oft niedrige Rücklaufraten. Zudem fließen kaum longitudinale Studien in die Auswertung ein. Hierdurch können keine zeitlichen Zusammenhänge verschiedener Symptome und Konzepte eruiert werden. Die definitorischen Unklarheiten in der Diagnosestellung werden in den Studien weitgehend vernachlässigt.
Schlussfolgerung
Die Autoren kommen zu dem Schluss, dass (1) weitere, vor allem hochwertige Studien notwendig sind, um das Burnout-Phänomen näher zu ergründen. Ebenso muss (2) systematisch und im gegenseitigen wissenschaftlichen Einverständnis eine einheitliche und international valide Definition des Burnout gefunden werden, die sich nicht auf die Gemeinsamkeiten der bisherigen Definitionen beschränkt. Gleichfalls ist es notwendig (3) eine standardisierte, international valide Variante der Burnout-Diagnostik und Differentialdiagnostik zu finden, (4) ein Fremdbeurteilungsinstrument für die Diagnose des Burnout zu entwickeln und (5) die volkswirtschaftlichen Aspekte und die finanziellen Auswirkungen (auf Krankenkassen wie Patienten) zu untersuchen.
Summary
Health political background
According to estimations of company health insurance funds nine million Germans are affected by the so called burnout syndrome. Although there is no existing consistent definition of burnout and it is neither in ICD-10 nor in DSM-IV a self-containing diagnosis, burnout diagnoses are made by reverting to other diagnoses like depression. Burnout goes along with subjective suffering, health problems and a reduced work efficacy. Due to estimations, the work stress related costs are enormous. At the same time a considerable increase in prescriptions of psychotropic drugs and a rise of work incapacity due to psychological disorders can be registered in recent years. Against the background of these indications which point to a rising prevalence of psychiatric disorders, and the adjunctions with individual, social and national economic implications, the health political importance of the diagnostic and differential diagnostic of the burnout syndrome is explained. That is the reason why this issue is picked up in a HTA-report and dealt with systematically.
Scientific background
Up to now, burnout is scientifically often regarded as a work related syndrome which consists of the three dimensions emotional exhaustion, depersonalisation or cynicism and reduced professional efficacy. In fact no consistent valid definition exists. Burnout seems to be more or less a fuzzy set of many definitions. In the literature a multitude of burnout symptoms and theories and explanatory models can be found. Some different burnout measures exist but so far none of these measurements claims general validity and the exclusive right to exist. For differential diagnostic purposes, only symptom catalogues are available. Consequently, psychological and psychobiological mechanisms which underlie the burnout symptoms as well as the connections with other diseases are largely unexplained. Additionally, the psychosocial implications for persons who suffer from burnout and the consequences for others who have contact with the burnout victims (patients, colleagues etc.) are widely unknown.
Medical research questions
How is burnout diagnosed? Which criteria are relevant for it?
Which disorders are relevant for differential diagnoses?
Are differential diagnoses being made?
How valid and reliable are the diagnostic instruments?
Economic research question
Which economic expense is caused by the differential diagnostic concerning burnout?
Ethical and juridical questions
To what extent are burnout patients stigmatized?
Are there negative effects of burnout-victims on patients/clients?
Methods
Several key words are defined and a research strategy is developed. On behalf of the German Institute for Medical Documentation and Information (DIMDI), Art & Data Communication conducts an electronic search in March 25th 2009. 36 databases are included.
The time frame reaches from 2004 until 2009, including German and English literature. Four single searches for medical, health economic, juridical and ethical themes are conducted. Additionally, the authors look for related studies and literature.
The methodological quality of the studies is evaluated by check lists of the German Scientific Working Group Technology Assessment for Health Care (GSWG HTA).
Medical results
25 studies of 826 hits fulfil the medical criteria for inclusion.
The key result of this report is that at present no standardized, general valid procedure to obtain a burnout diagnosis exists. So far, burnout is assessed by self-completion questionnaires, particularly the Maslach Burnout Inventory (MBI). Whether burnout can really be measured with the MBI, cannot be reliably answered. The dimension of emotional exhaustion appears to be a continuous feature. The significance of the dimensions depersonalisation und efficacy remains unclear as the studies achieve quite different results concerning this topic. The so far delivered cutoff points do not meet the demands for valid diagnostic purposes as the original generation process of these values does not correspond with the scientific test construction. In general, there are currently no valid diagnostic criteria available. Thus, it is in the discretion of the doctor to assess a burnout diagnosis and induce a treatment.
A connection between burnout and depression, burnout and the concept of prolonged exhaustion and between burnout and alexithymia is particularly discussed in the studies of this report. An intermittent relation between burnout and other diagnoses is possible. The cohesion of burnout and depression appears to be very important as burnout is potentially a developmental stage of a depressive disorder. Burnout is similarly linked with an increase of inflammatory biomarkers. The connection between burnout and other diseases remains unclear.
Within the prevalent burnout measurements (MBI, Shirom Melamed Burnout Questionnaire (SMBQ), Oldenburg Burnout Inventory (OLBI), Copenhagen Burnout Inventory (CBI), School Burnout Inventory (SBI)) there are no differential diagnostic screening tools integrated. By using the MBI, burnout simulators can be identified. The presently discussed burnout measurements can mostly measure a three dimensional phenomenon, in so far they are modified regarding the work specific, linguistic and cultural concerns of the respective population.
Economic results
None of the 102 economic hits conforms to the defined criteria for inclusion.
Ethical and juridical results
One study out of 852 hits fulfils the inclusion criteria. Some medical explorations can also be used to report about ethical aspects.
Burnout victims clearly suffer from the symptoms of this syndrome. Burnout affects not only the concerned person but also persons in the surroundings of the affected person. One study shows for example that physicians with high burnout levels report more medical treatment errors than their colleagues who do not suffer from burnout. Simultaneously, a treatment error enhances the chance of burn out. No information can be gained about the stigmatization of burnout victims.
Discussion
The evidence of the studies is predominantly low. The studies have mostly a descriptive and explorative character. The sample assortment has mostly coincidently been generated and response rates are low. In most studies (85%) the MBI is used. This self-assessment questionnaire was created for scientific purposes but not as a diagnostic tool. The authors of the MBI do not deliver diagnostically valid cutoff points. Since there is no consistent valid definition of burnout up to now, it remains unclear if the MBI and other burnout measurements really assess burnout. Definitional obscurities are often neglected in the considered studies. Due to the results of this HTA-report, nearly every used burnout measurement (Athlete Burnout Questionnaire (ABQ), CBI, MBI, OLBI, SBI, SMBQ), is able to assess a three dimensional burnout phenomenon in every population if it is adequately modified. But this modification challenges the construct validity and the possibility of a valid generally accepted diagnostic and differential diagnostic. The connection of the three burnout dimensions and predominantly of the dimensions depersonalisation and efficacy remains unclear since the publications produce very differential results regarding that topic. Intermittent connections and the use of an inefficiency dimension instead of an efficacy dimension are discussed. Given that almost no longitudinal studies can be appraised, no chronological context referring to symptoms and other concepts can be reviewed. Objective data like medical parameters, sickness notes and judgements by third persons are extremely seldomly included in the research.
Conclusions
So far, no valid differential diagnostic instrument is available to assign burnout. Simultaneously this phenomenon seems to be of considerable prevalence and cost relevance (health insurances). The authors conclude, that (1) further research, particularly high-quality studies are needed to broaden the understanding of the burnout syndrome. Secondly (2) a systematic and widely accepted, internationally valid definition of the burnout syndrome has to be found which is not delimited by the similarities of the current definitions. There is also a need for (3) finding a standardized and international valid burnout differential diagnostic tool, (4) developing a third party assessment tool for the diagnosis of burnout, and (5) researching the economic aspects and implications of burnout (for health insurances as well as for patients).