This clinical brief is based on a presentation, Battling Burnout: Understanding Mental Health and Suicidality Among Healthcare Providers, by Dr Sidney Visook, MD at the Medscape 2022 Psychiatry Spring Update Conference on June 16, 2022 in Chicago, Illinois.

Mental health challenges continue to increase among healthcare providers (HCPs) and remain a major public health concern. The rising incidence of clinician burnout, depression, and suicide highlights an ongoing need to provide effective education and resources to improve well-being and mental health for all members of the healthcare team.

Defining and Assessing Clinician Burnout

Most clinicians, including psychiatrists and other providers, have experienced burnout at some time during their career. Although the definition of burnout varies between evaluation tools and studies, Maslach et al defines burnout as a psychological syndrome emerging as a prolonged response to chronic stress on the job.^[1]

There are 3 major components of burnout^[1]:

• Overwhelming exhaustion
• Depersonalization (cynicism and detachment from the job)
• A sense of ineffectiveness or lack of accomplishment

Clinicians experiencing burnout often feel like they have nothing left to give, and patient care increasingly becomes associated with a feeling of drudgery instead of fulfillment. It follows then that the antithesis of burnout includes strong engagement and involvement in one’s work, high energy, and a sense of pride and efficacy.^[1] These are the goals for any clinician, allowing increased enjoyment and improving mental health.

In addition to varying definitions of burnout, there is debate as to whether burnout should be considered a category (you are either burned-out or you are not) or a spectrum ranging from mild to extreme burnout. These variations make it difficult to accurately assess the level of burnout among clinicians. A review that included more than 100,000 physicians showed that 182 different studies used a total of 142 unique definitions of burnout and reported a burnout prevalence ranging widely from 0% to 81%.^[2]

Major Drivers of Burnout

Although there is clearly a relationship between high workload and burnout, workload alone is typically not the primary cause of clinician burnout. Burnout often occurs when a high workload is coupled with high responsibility and low autonomy in decision making. In addition, if much of the workday is spent doing paperwork and administrative duties instead of direct patient care, work can become less satisfying and increase the likelihood of burnout.^[3,4]

A study that evaluated physicians for burnout and satisfaction with work-life balance between 2011 and 2017 illustrated the seriousness of this problem. Of more than 5000 physicians surveyed in 2017, 43.9% reported at least one symptom associated with burnout and 41.7% screened positive for depression. Sadly, 31.5% would not choose to become a physician again, suggesting a substantial need to improve satisfaction among clinicians. The rates of burnout and dissatisfaction with work-life balance are slightly lower among psychiatrists compared with other physicians, but burnout still remains an important challenge.^[5]

The emergence of COVID-19 has further increased feelings of burnout among psychiatrists and other clinicians, often related to the increased demands of patient care, personal feelings of loss and trauma, and ongoing challenges in work-life balance. As reported in a survey of more than 13,000 physicians across 29 specialties, the incidence of burnout increased from 42% in 2020 to 47% in 2021, including a rate of 38% among psychiatrists. Not surprisingly, researchers observed the largest increase among emergency physicians, with a burnout rate of 60% in 2021. Survey respondents reported frustration with inadequate staffing, reduced time with patients, and increased demands at home during the COVID-19 era, all of which further contributed to burnout and stress.^[6]

Consequences Associated with Burnout

The consequences of burnout among clinicians are significant, including increased alcohol use, depression, and suicidal ideation. Empathy and compassion often decrease among clinicians experiencing burnout, leading to career regret. Suboptimal professional development for medical students and residents is also a risk when instructors and students are both experiencing high levels of burnout. On an organizational level, increased rates of burnout among healthcare workers leads to lower morale and productivity, as well as increased absenteeism and turnover. Importantly, all of these consequences have a negative effect on patient care.^[7]

How Can We Minimize Burnout Among Clinicians?

Burnout should be addressed with a 2-fold approach: clinicians taking better care of themselves and healthcare institutions implementing wellness-enhancing interventions. The American Medical Association (AMA) provides valuable guidance regarding self-care for clinicians, including the importance of prioritizing their own physical and mental health. This includes adequate rest and exercise, participation in hobbies and recreational activities, and support from trusted friends and family. Setting realistic goals and recognizing when to say "no" to set appropriate boundaries can also improve an individual’s sense of well-being.^[8]

In addition to self-care, healthcare organizations also need to prioritize the mental health of clinicians. The Stanford model created by Shanafelt et al focuses on 3 domains to decrease clinician burnout: a culture of wellness, efficiency of practice, and personal resilience (Table 1). Creating a culture of wellness can include leadership development, increasing clinician autonomy, adequate staffing, showing appreciation for employees, and improving teamwork. Practice efficiency can be increased by simplifying and reducing electronic health record (EHR) tasks when possible and providing adequate time for clinicians to complete necessary documentation during the workday. Personal resilience can be enhanced by providing clinicians with better access to mental health care and appropriate support programs, as it is often challenging for healthcare professionals to access the help they need in a timely manner.^[4]

Table 1. Organizational Strategies to Improve Clinical Well-Being^[4]

Depression Among Healthcare Workers

Major depressive disorder (MDD) is a serious medical condition that can be misdiagnosed as burnout in HCPs. Burnout and depression often coexist, so it can be easy to miss underlying depression in a clinician experiencing substantial burnout; however, major depression goes beyond feelings of sadness or depletion and is instead associated with morbid feelings of worthlessness. Although burnout is primarily associated with the workplace, MDD is persistent and pervasive in many aspects of a person’s life. It greatly diminishes quality of life and can be life threatening if not treated appropriately. Unlike burnout, MDD rarely responds in a sustained way to distraction, rest, exercise, or companionship and instead requires evidence-based treatment such as anti-depressants.^[9]

An important aspect of MDD in healthcare professionals is the associated stigma, which is typically not associated with clinician burnout. Clinicians may also experience fear regarding the potential consequences of disclosure of their depression to medical boards, insurance companies, and their colleagues. This stigma and fear can prevent clinicians from seeking professional help. In a survey of more than 13,000 physicians, 24% reported having clinical depression and another 64% had colloquial depression defined as feeling down or sad; however, only 9% of clinicians were receiving therapy for their mental health.^[6] This illustrates an ongoing need for healthcare institutions and organizations to make changes that can reduce the stigma associated with depression, thereby protecting clinicians and ensuring they get the help they need.

Clinicians may also resist seeking professional mental health because they feel it is not necessary. When asked why they were not seeking help for burnout or depression, 49% of physicians polled felt that they could deal with their mental health on their own without professional help. This highlights the importance of educating healthcare professions on the value of mental health counseling and treatment to prevent prolonged depression.^[6]

Suicidality Among Clinicians

Approximately 300 to 400 physicians in the United States die by suicide every year.^[10] Rates of suicide are higher in male and female nurses compared with the general population; the same is true for female physicians compared with the general population.^[11,12] Suicide is also the leading cause of death among male medical residents and the second leading cause of death among female residents.^[12] Importantly, physicians who died by suicide were less likely to seek mental health treatment compared with nonphysicians who took their lives.^[11] This reinforces the importance of identifying burnout and depression in clinicians and providing easier access to mental health care.

Healthcare institutions and organizations need to proactively address barriers to mental health care, including poor access to care and stigma associated with seeking help. The University of California San Diego has developed the Healer Education Assessment and Referral (HEAR) program, which educates employees about burnout and depression to reduce stigma and increase participation. HEAR provides anonymous mental health screening and access to counseling without associated EHR reporting, which allows clinicians to be more comfortable with seeking help. The program also employs peer support groups and crisis intervention to further expand the reach of the program. Programs such as HEAR can increase participation among healthcare providers and improve overall mental health.^[13,14]

Concluding Thoughts

Distress among HCPs is a significant problem that will not resolve on its own. The healthcare community must work together to remove stigmas associated with depression and seeking treatment for mental health issues. A number of factors contribute to burnout, depression, and suicidality, requiring multifaceted approaches to improve overall well-being among clinicians. Proactive clinician self-care and fundamental changes to the prevailing culture of medicine will be needed to fully address these concerns.

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