Burnout vs Depression

Burnout vs Depression

Differentiating « Burnout » from Depression: the role of cortisol

By Dr. Sonia J. Lupien, Ph.D.

According to the World Health Organization (WHO), major depression will be the second cause of invalidity in humans by 2020, after cardiovascular disease. This constitutes a phenomenal rise over the next years.

Mental health in the workplace

One in two workers who will be absent from work because of mental health troubles will be absent for an average of 13 days or will never return to work. On average, the costs associated with an absence of about forty days, per employee, are at the order of ten thousand dollars. A recent study attributed the costs of depression in the workplace at the order of 4.5 billion Canadian dollars.

The long term effects

This situation entails negative consequences for the four big players of workplaces : the insurance companies, the employers, the mental health system, and the individual.

a- The insurance companies

In 1991, 15% of insurance claims were related to mental health troubles. Ten years later, this number had tripled. Today, about 40% of insurance claims are related to these types of troubles, which costs insurance companies some fifteen to thirty-three million dollars per year. In the long run, there is a risk of lowered insurance coverage, or at the very least, a modification to its nature given the costs which never cease to augment, as would the elevated invalidity coverage, because of the notable rate of absenteeism related to the aforementioned troubles.

b- The employers

1- THE COSTS OF REPLACEMENT AND LEGAL ACTIONS

The costs for employers are enormous as are there different inter-related sources. Firstly, it costs to replace absent employees. Secondly, there are more and more legal actions taken by employees against employers that are related to stress or to mental health. These have doubled over the last years. The best example to illustrate this phenomenon is to take American enterprises as a case study. In effect, these companies are bound to insure the psychological well-being of their employees. Yet, the augmentation of legal cases related to stress and job strain make it such that in the United States, nine out of ten lawsuits are successfully won.

2- THE COSTS OF PRESENTEEISM AND OF ABSENTEEISM

What costs a lot for companies, which we probably underestimate and is beginning to be very important, is what we qualify as « presenteeism » or « the Quidam effect ». This last phenomenon takes into account the fact that the body is at work, but the head is not. Employees that suffer from stress and/or mental health problems present themselves at work, but their performance is diminished considerably.

A study from the United States demonstrated that during a two-week period, absenteeism would cost one hour per employee, for a total of eight billion dollars annually. When it comes to the effects of presenteeism, this equals four hours lost per week, for a total of thirty-six billion dollars annually. This leads us to believe that presenteeism and the potential means for preventing it will become more and more the order of the day for decision-makers and for researchers.

c- The health care system

« Burnout » or professional exhaustion was identified in 1980; it did not exist before. It was characterized as being a mental trouble linked to job strain, the majority coming from types of work that necessitate high empathy on the part of the worker (e.g., professor, nurse, physician, etc.). Today, « burnout » is a very blurry psychiatric entity, which causes a difficulty in differentiating a diagnosis of « burnout » from one of depression. Furthermore, it is very difficult for a treating physician to diagnose « burnout », which leaves place open to the possibility of numerous maltreatments.

In effect, a person who presents a state of psychological distress might be diagnosed a particular illness. This often pushes physicians to pull the person out of their work and to prescribe a psychiatric evaluation and to have a validation of the diagnosis issued by a family doctor. This effectively surcharges already long waiting lists in psychiatry. The more a person is held waiting, however, the more they are in prolonged absence.

For psychiatrists, this causes grumbling. They complain of this surcharge often related to unjustified cases.

A group of psychiatrists from the West Island carried out a study where only 25% of cases examined, which were on their waiting lists showing troubles with « burnout » or of depression (Lalla F, Rosenberg L, Brown R. 2004. ‘Inappropriate Interventions : An examination of how the medical model can complicate recovery and function’, December 3, 2004, Pointe-Claire).

d- The individual

Being diagnosed with a mental health problem is not an easy thing for the individual. In fact, the diagnosis can stick to the skin for a long time. The diagnosis can, in the long run, end by affecting and driving one towards diminished self-esteem. When it comes to the long term consequences, this can translate into a loss of revenues and a negative evaluation from peers and from family. Likewise, pulling back the individual from their workplace while they suffer from mental health problems implies pulling back the social support formed as a result from interactions in the workplace.

In fact, employees spend on average eight hours per day in a social environment which has almost become the only place for relationships and social support. At home, it’s the family that takes the shift. Social support becomes in essence the best means of negotiating mental health problems. Indeed, more and more psychiatrists doubt the efficacy of pulling the worker out of their workplace. In doing so, they are being removed from a social support network that they need to better recover.

In the end, it iss the individual who losses the most, since beyond the suffering, they are at risk of reductions in insurance coverage that they need, as well as an evaluation in mental health once interviewed for a job. If they prove to have genuine suffering from a mental health problem, they should take their pain with patience since the waiting lists are overloaded, without even talking about the costs of a bad diagnosis from all points of view.

The trail to solutions

1- Detection

To prevent, you have to first detect the presence of a problem. Even in a stressful work environment, a portion of people is always at risk of being affected by mental health problems. Such is the importance of detection for determining people at risk, something that is not without its own problems.

Actually, talking about detection with management amounts to what when it is too late?  “We’re interested in problems and we try to control them when an individual already presents symptoms of « burnout » or of depression.” This is what qualifies as the « too late stage », since affected individuals will be pulled out of their workplace. They will be in absence and will need pharmacology or all kinds of other interventions to be remedied. They will be left little choice in terms of prevention.

However, what most employers do not seem to understand is that stress IS the determining factor for developing « burnout » and the most marking factor for the development of depression. Moreover, stress is implicated in 100% of « burnout » cases and 50% of depression cases in the workplace. Thus, detecting people with chronic stress in the workplace would help to prevent emergencies with troubles that are brewing well before they appear.

2- Can we actually detect stress?

After studying stress for seventeen years, we have come to the conclusion that the major problem with stress is that it is an overused term. This is very well illustrated by a New York Times citation : “Stress is a word that is as useful as a Visa card, and as satisfying as a Coke. It’s non-committal and also non-committable” (Richard Schweder, New York Times, 2004).

This overused and misused word has become extremely ambiguous. There are as many definitions of the word stress as there are words in a dictionary. This forces people who are concerned with problems to think that there are few possible avenues for research.

The popular definition of stress is limited to time pressure : a person is stressed when unable to accomplish tasks allocated within a set time frame. This definition of stress is false.

Two big schools of thought

Two big schools of thought have studied stress : the school of psychology and the school of physiology.

1- School of psychology

Numerous studies of stress in the workplace have been carried out using the psychological approach. They have generated two principle models : the first perceives stress as arising mostly from the environment (stress as an environmental stimulus), while the second highlights an disequilibrium between resources and demands.

A- ENVIRONMENTAL STIMULUS

We call it the « fly model », that is, we perceive events coming from outside as the generator of stress. Grief would be a stressor, marriage a stressor, the birth of a child a stressor, which would ultimately lead to pathology. The problem with this model is that it measures only the consequences of stress and brings no attention to the components which might explain why a marriage has become a stressor.

B- DISEQUILIBRIUM BETWEEN RESOURCES AND DEMANDS

This is a model that explains just about everything (which becomes a major problem) but also gives information about the origins of a stressor since it must each time determine what are the resources and the demands. These are very abstract terms.

In these two types of models, psychological stress is measured with the help of questionnaires, where we interrogate the respondent on diverse subjects such as : « Do you often catch a cold? », « Do you feel tense ». Thus, these questionnaires measure the consequences of stress and not the cause. If the respondent obtains a high score on one of these tests, then it is already too late. Taking into account the big weakness of the psychological approach to stress, several researchers turned towards physiology where we have found some very interesting markers with enormous potential.

2- School of physiology

Adrenalin and cortisol are two hormones that the body secretes when a person is stressed. The first is very well known to specialists, so our attention falls more on cortisol.

In 1950, researchers successfully identified a measure of these two hormones in urine. During fifty years, researchers did but one thing : examine the characteristics of a situation that would push the body to secrete these hormones. After fifty years of research, they found four.

So when a person interprets a situation as being stressful, which would lead their body to secrete these two stress hormones, the person must be confronted by situations that are novel, unpredicted or unpredictable. In a more important manner, the person must have the impression that they have no more control over the given situation and finally, this situation must threaten certain aspects of their personality.

Indeed, stress is a personal experience, but also a result of interactions with the environment. If a person always stayed at home and never faced novelty in life, they would have few chances of being stressed, even if this situation would bring about certain disadvantages.

Cortisol can now be measured in saliva. Hence the interesting idea of researchers to use « Salivette®» where the tip is formed from a little piece of cotton imbedded in a polyester coating. Placed in the mouth to gather saliva, it is pulled out once completely saturated and then examined by specialists. It is the level of concentrations of the cortisol hormone measured with the « Salivette® » that determines the degree of the person’s exposure to stress.

A person is said to be exposed to chronic stress once cortisol causes a « domino effect ». That is to say, any variation of the bodies’ normal rate affects other hormones, since hormones act in the interior of a tightly closed system. Thus, once the body finds itself in a situation of increased cortisol secretion for a long time, the long-term effect will be a diminution of insulin, an augmentation of glucose then possibly diabetes, an augmentation of cholesterol leading to cardiovascular problems, and finally a diminution of the immune systems efficiency, causing immune problems.

What is the difference between « burnout » and depression?

Since the 90s, studies conducted at the Centre for Studies on Human Stress have demonstrated that cortisol has some interesting properties. This hormone is secreted by the body to generate changes that affect other hormones and it is particularly rapid at reaching the brain. Previously, researchers had never thought that a hormone could reach the brain.

As a steroid that easily passed through the blood-brain barrier, cortisol assesses the brain in about eight minutes. It begins by affecting the hippocampus implicated in learning and memory.

This allows us to demonstrate that when a person is exposed to cortisol over long periods, this hormone ends up modifying the capacity of the individual to detect and negotiate with novelty, unpredictability, and to have a sense of control.

After fifteen years of study, researchers have successfully found important patho-physiological differences between people who suffer from « burnout » and those who suffer from depression : individuals suffering from « burnout » do not produce enough cortisol, as if the body decided to go on strike. As a reversal, those who suffer from depression produce too much of it.

For specialists, this hormone is actually becoming a « biomarker » capable of detecting very early on people at high risk of developing « burnout » when the rate is decreased, while in a depression, the rate is increased. This « biomarker » could offer a differential diagnosis between « burnout » and depression and could potentially help weed out genuine cases. Here, it is important to note that if specialists are able to detect abuses, this would help people who truly suffer, since, in the long-run, it is them who pay too high a price.

The importance of precise cortisol detection

To determine its importance, researchers have studied a determinant number of individuals over a four-year period. The results they found demonstrated that those who produced too much cortisol have a hippocampus atrophied at 14%. In those who are exposed to this hormone for too long, we have also observed memory deficits.

Cortisol and presenteeism

Stress affects learning, memory, and our capacity to perform. Some attempts at the laboratory have demonstrated a cause and effect relation between cortisol and presenteeism. For example, the brain of a stressed person while they are participating in a clinical study in relation to activation of their brain is inhibited by stress. An inhibited brain evidently becomes unproductive.

Conclusion : How to treat detected cases?

There are three treatment possibilities : pharmacological drugs, social politics, and the power of knowledge.

a- Phamacological drugs

At the Centre for Studies on Human Stress, researchers and specialists are not in favour of using drugs. It is too easy to control this hormone. However, we do not believe that preventing stress should involve medications. Stress is generated by interpretations people make of their environment. Helping people to modify their perception of this environment is much more promising to halt the stress epidemic than is the administration of pharmacological drugs.

b- Social politics

Scientific researchers can attempt to influence social politics by giving convincing arguments. However, the scientific community evidently favors the third voice, the power of knowledge.

c- The power of knowledge

A situation is stressful if it is interpreted as being so. If researchers help a person to recognize what is stress, this will undoubtedly have a positive effect. In fact, in teaching people to detect and to cope with stress, we think we can reduce this problem in individuals. Studies have demonstrated that if a person stays home long enough because they lack control, they will end up producing enough cortisol with long-term effects.

In order to modify the manner in which a person processes information, it must diminish their capacity to secrete too much cortisol. We have calculated that if such a project is efficient in only 10% of people suffering from the effects of stress on mental health, a net economy of one billion dollars per year would be generated.

References

• Making the Case for Investing in Mental Health in Canada – See more at: http://www.mentalhealthcommission.ca/English/node/5020#sthash.aIXuXtDP.dpuf

  Making the case for Investing in Mental Health in Canada

• Évaluation des coûts du stress au travail [PDF]