PERSPECTIVE

published: 10 December 2021

doi: 10.3389/fpubh.2021.796401

From Burnout to Occupational

Depression: Recent Developments in
Research on Job-Related Distress
and Occupational Health
Irvin Sam Schonfeld 1* and Renzo Bianchi 2
1
Department of Psychology, The City College and the Graduate Center of the City University of New York, New York, NY,
United States, 2 Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland

Job-related distress has been a focal concern in occupational health science. Job-related
distress has a well-documented health-damaging and life-threatening character, not to
mention its economic cost. In this article, we review recent developments in research
on job-related distress and examine ongoing changes in how job-related distress is
conceptualized and assessed. By adopting an approach that is theoretically, empirically,
and clinically informed, we demonstrate how the construct of burnout and its measures,
long favored in research on job-related distress, have proved to be problematic. We
Edited by: underline a new recommendation for addressing job-related distress within the long-
Wulf Rössler,
established framework of depression research. In so doing, we present the Occupational
Charité University Medicine
Berlin, Germany Depression Inventory, a recently developed instrument devised to assess depressive
Reviewed by: symptoms that individuals specifically attribute to their work. We close our paper by
Yuan-Pang Wang, laying out the advantages of a paradigm shift from burnout to occupational depression.
University of São Paulo, Brazil
Francesco Chirico, Keywords: depression, anxiety, occupational depression inventory, work stress and burnout, job-related distress,
Catholic University of the Sacred occupational health science, Maslach Burnout Inventory
Heart, Italy

*Correspondence:
Irvin Sam Schonfeld INTRODUCTION
ischonfeld@ccny.cuny.edu
Job-related distress, a focal concern of occupational health science, has well-documented health-
Specialty section: damaging and life-threatening effects, not to mention economic costs. Burnout and depression
This article was submitted to have constituted two key indicators in research on job-related distress over the last decades.
Public Mental Health, Considerable evidence has accumulated to show that chronic exposure to adverse working
a section of the journal conditions contributes to the emergence of depressive symptoms and disorders (1–3). Depression
Frontiers in Public Health
can culminate in suicide, including workplace suicide (4). Burnout is thought to reflect the personal
Received: 16 October 2021 impact of chronic exposure to adverse working conditions. Given the common origins of burnout
Accepted: 12 November 2021 and job-related depressive symptoms and disorders, it is important to examine the evidence bearing
Published: 10 December 2021
on their conceptualization.
Citation: In theory, burnout is a gauge of job-related distress. It consists of three symptom dimensions,
Schonfeld IS and Bianchi R (2021)
the core dimension being (emotional) exhaustion (5). Maslach et al. (6) wrote that “[f]or use in
From Burnout to Occupational
Depression: Recent Developments in
applied settings, a prudent approach when deciding to take action on the basis of burnout scores
Research on Job-Related Distress is to give the most weight to Emotional Exhaustion [EE] scores as they are the most reliable”
and Occupational Health. (p. 3), underlining the dimension’s central position in burnout. EE refers to feeling emotionally
Front. Public Health 9:796401. drained—the result of the worker’s chronic exposure to adverse job conditions. Burnout’s two other
doi: 10.3389/fpubh.2021.796401 dimensions are depersonalization/cynicism (DP) and a reduced sense of personal accomplishment

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Schonfeld and Bianchi From Burnout to Occupational Depression

(rPA), also known as professional inefficacy (6). DP refers to regarding its relation to depression. First, although multiple
the worker being socially distant, disengaged, and possessing a factors can give rise to depression, abundant evidence from well-
cynical attitude toward coworkers and the people the worker is controlled longitudinal studies indicates that workplace stressors
supposed to serve (e.g., patients, students, customers); rPA refers are related to increased levels of depressive symptoms (measured
to the worker feeling that he or she fails to accomplish worthwhile by cause-neutral symptom scales) and elevated risk of depressive
job-related goals. Many researchers have advanced the view that disorders (2, 3, 17, 18). It is unlikely that job stressors increase
burnout is distinct from depression (5, 7). the risk of burnout without commensurately increasing the risk
This paper has a twofold aim. First, we examine sets of depressive symptoms and disorders (19, 20).
of research findings and observations that bear on the Second, burnout’s core dimension, exhaustion, is highly
conceptualization of job-related distress in the context related to depressive symptoms. Although some meta-analytic
of the burnout–depression relationship, approached both evidence suggests an average burnout/exhaustion–depression
dimensionally and categorically. Second, we provide a correlation in the 0.50 s (21, 22), other meta-analytic research (11,
recommendation for assessing job-related distress by way 23) indicates that the burnout/exhaustion–depression correlation
of a new measure that may help occupational health specialists can reach 0.70–0.80 and higher, particularly when measurement
support individuals and organizations more effectively. error is controlled. Meier and Kim (22) observed that a
correlation of 0.50 has been used to advance the view that
(a) burnout and depression do not overlap and (b) burnout
BURNOUT AND DEPRESSION and depression do overlap. Correlation coefficients should be
Burnout has been conceptualized as a set of symptoms, understood in context. The research of Wurm et al. (24)
largely fatigue-related, that are caused by adverse working provides some of that context. These authors obtained a
conditions. An exemplary item from the most frequently burnout–depression correlation of 0.52 in a sample of 5,897
used burnout measure, the Maslach Burnout Inventory (MBI), physicians, and observed that, compared to an almost-symptom-
demonstrates that idea: “I feel emotionally drained from my free reference group, as burnout symptoms increased stepwise
work” (6). The symptom in question is explicitly attributed to from mild to moderate to severe to extremely high levels, the odds
the individual’s job. Burnout scales like the MBI have been ratio for major depression increased dramatically, from 2.99 to
linked to prominent occupational risk factors such as excessive 10.14 to 46.84 to 92.78.
workloads and reduced control over job tasks (8, 9). From a Because fatigue and sleep problems are symptoms of
methodological standpoint, given that burnout items reference depression (25), fatigue-related items are commonly found in
both the dependent variable (the symptoms) and independent depression symptom scales. Maslach and Leiter (7) argued that,
variable (workplace stressors), it is no surprise that burnout scales because depression scales include fatigue-related symptom items,
are related to perceived workplace stressors, particularly when a high burnout–depression correlation may be a methodological
cross-sectional designs are used [see (10)]. artifact. However, empirical research in which fatigue-related
Depression involves a cluster of affective, cognitive, items were stripped out of depressive symptom scales barely
behavioral, and somatic symptoms (e.g., dysphoric mood changed the correlation (23, 26).
and anhedonia). Though depression is nosologically and Exploratory structural equation modeling bifactor analyses
diagnostically defined, there is robust evidence that depression extract a general factor on which all items can, theoretically,
is better conceived of as a dimensional phenomenon—a load and specific factors (bifactors) on which items are allowed
continuum—with only individuals at the highest end of the to cross-load. In several studies (11, 27, 28), depression and
continuum meeting criteria for formal diagnoses of depression exhaustion items primarily loaded on the general factor. The DP
(11–13). Depressive symptom scales differ from burnout and rPA items tended to load more highly on their respective
scales in an important way. Except for the recently developed specific factors than on the general factor with exemplary
Occupational Depression Inventory (14), described later, exceptions. For example, the rPA item “I feel very energetic,”
depressive symptom scales are “cause-neutral.” This is not to say which, understandably, reflects the opposite of exhaustion, has a
that depressive symptoms and disorders are void of causes, only strong negative loading on the general factor and a much weaker
that assessment instruments tend to focus on symptom severity loading on the rPA-specific factor.
rather than symptom causes. Situations involving unresolvable What construct do depression and burnout’s exhaustion
stress, in which individuals feel helpless and trapped in the face (sub)scales measure? Schonfeld et al. (23, 27) advanced the view
of negative events perceived as uncontrollable and impossible that the construct is a dimension of psychopathology that can
to surmount, have long been identified as crucial depressogenic be labeled psychological distress/dysphoria. More than 40 years
factors (15, 16). ago, Dohrenwend et al. (29) found that measures of dread,
sadness, anxiety, helplessness/hopelessness, and poor self-esteem
correlated about as highly as the scales’ reliabilities permitted,
OBSERVATIONS BEARING ON suggesting that the scales reflect the same underlying construct.
BURNOUT’S RELATION TO DEPRESSION The investigators labeled the construct psychological distress.
More recent research on psychopathology has provided evidence
We now examine six sets of observations that bear on for a distress or internalizing dimension reflecting depressive
the problematic nature of the burnout construct, particularly and related (e.g., anxiety) symptoms (12, 27, 30, 31). Structural

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Schonfeld and Bianchi From Burnout to Occupational Depression

equation modeling (SEM) evidence indicates that one cohesive found that 90% of the individuals in the burnout group met
distress factor underlies depressive, anxiety, and exhaustion criteria for a provisional diagnosis of depression. Schonfeld
symptom items (27). and Bianchi (20) obtained similar findings using the Shirom-
Some have argued that burnout (or depression) may mediate Melamed Burnout Measure. Such findings suggest that if “clinical
the impact of job stressors on depression (or burnout). However, burnout” (i.e., burnout as a medical diagnosis) were to be defined
that the discriminant validity of burnout vis-à-vis depression someday, its differential diagnosis vis-à-vis clinical depression
has not been clearly demonstrated undermines the argument. would be impossible, undermining burnout’s clinical validity and
Moreover, such an argument is difficult to articulate when usefulness (38).
approaching both burnout and depression dimensionally (i.e., A related set of findings indicates that as burnout symptoms
as continua). increase, the risk of meeting criteria for a diagnosis of depression
Third, if burnout is a syndrome comprising EE, DP, and rPA— increases. This pattern has been replicated across occupational
as indicated by Maslach and colleagues (5, 6)—one would expect groups, including physician (24), teacher (20, 37), and dentist
the EE, DP, and rPA subscales of the MBI to be more highly (39) samples. Ahola et al. (19) went on to observe that “burnout
correlated with each other than with non-burnout scales. Meta- could be used as an equivalent to depressive symptoms in work
analytic and SEM evidence (11, 23), however, indicates that EE life” (p. 35).
is more highly related to depressive symptoms than to DP and Fifth, “[o]ften insomnia or fatigue is the presenting complaint”
rPA, undermining the idea that burnout is a (distinct) syndrome when a depressed individual seeks help from a clinician [(25);
(11, 23). In other words, if exhaustion is part of a syndrome, it is p. 162]. An experienced clinician recognizes the disorder.
part of a depressive syndrome (10, 11). Freudenberger (40), the first investigator to write about
Interestingly, several methodological factors work against burnout in a research journal, observed that the burned-out
finding the magnitude of the EE–depression correlation to individual “looks, acts and seems depressed” (p. 161). Exhaustion
be stronger than the correlations among the MBI’s subscales, complaints can mask broader depressive syndromes, especially in
suggesting that the EE–depression link is sturdy. First, the male and younger patients. Exhaustion then acts as a metonym
abovementioned “energetic” item on the rPA subscale of the for depression.
MBI likely increases the magnitude of the EE–rPA correlation. Sixth, the nomological networks of burnout’s exhaustion
Second, depression symptom items cover the previous 1 or 2 core and depression parallel each other. Research has, inter
weeks whereas MBI items cover the previous year. Third, the alia, identified parallels in burnout/exhaustion’s and depression’s
wording of the items in the MBI subscales are substantially relationship to the following: cognitive style [e.g., attentional,
similar, each item referencing work, but depression items cover interpretational, and memory biases, rumination, pessimistic
diverse symptoms without a common causal reference. Despite attributions; (41–43)]; anxiety, workplace support, and exposure
the influence of these methodological factors, the magnitude to nonwork stressful life events and job-related adversity (20, 27);
of the EE–depression correlation is greater than that of the and job satisfaction, illegitimate work tasks, and work-nonwork
correlations among the MBI subscales. interference (44).
How are the MBI’s other dimensions, DP and rPA, related In this disquisition on burnout and depression, we do not
to depression? They have non-zero correlations with depressive advance the view that the burnout construct is identical to the
symptoms. DP supposedly reflects a strategy for coping with EE construct of work-related depression. Extensive findings show
(5, 32). It is reflective of “not caring anymore,” a feature associated that burnout’s exhaustion core and fatigue-related symptoms are
with depression (25). rPA is likely to be a long-term consequence important symptoms of work-related depression, but not the only
of exhaustion (5, 33). It parallels the negative evaluations of one’s symptoms of work-related depression. The burnout construct
worth associated with depression (25). captures a depressive phenomenon, but in a truncated manner.
Fourth, there are no clear or consensual diagnostic criteria Some depressed workers may represent themselves as “burned
for burnout. Maslach et al. (6) indicated that the MBI is not out” to reduce stigma. However, the sparse comparative literature
a diagnostic tool. That admonition has not stopped researchers on the issue suggests that both conditions are similarly
from treating burnout diagnostically. Rotenstein et al. (34) found stigmatizing (45). Moreover, the stigma recruiters attach to
142 unique definitions of burnout in the literature on physicians. burnout is a barrier to employment and promotion (46).
When attempting to treat burnout diagnostically, researchers We summarize the reasons for identifying burnout symptoms
generally define a case arbitrarily, as an individual with a as depressive symptoms. First, job stressors elicit both burnout
score above a predetermined cutoff on a burnout (sub)scale. and depressive symptoms. Second, burnout’s core dimension,
Bianchi, Schonfeld, and colleagues (35, 36) observed that many exhaustion, correlates highly with depressive symptoms. Third,
researchers identify individuals as cases of burnout based on exhaustion correlates more highly with depressive symptoms
surprisingly low scale scores. Such case-identification procedures than with burnout’s other putative burnout dimensions,
fail to distinguish an individual experiencing pervasive distress DP and rPA. Fourth, as burnout symptoms increase, the
from an individual confronting a day in which job stress risk of a depressive diagnosis increases. Fifth, often with
increased but was still within the “normal range.” When depression, the presenting complaint is exhaustion, the core
Bianchi et al. (37) used an MBI cutoff corresponding to symptom of burnout. Sixth, the nomological networks of
burnout symptoms experienced at least a few times a week burnout’s exhaustion core and depression closely parallel
(a frequency assumed to represent pervasive distress), they each other.

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Schonfeld and Bianchi From Burnout to Occupational Depression

Finally, we assert that the symptoms burnout scales assess depression in organizations and occupational sectors. Because
are some of the symptoms that characterize depression, but the instrument is brief, it reduces the burden on the respondent
not all the symptoms that characterize depression. Kasl (47) completing it. Unlike the MBI, the ODI is available at no cost.
already observed that a famous burnout scale that “reflects Compared to the ODI, MBI items manifest redundancy (e.g.,
exhaustion (physical, mental, and emotional) . . . can be seen as “Working with people all day is really a strain for me;” “Working
a major component of depression” (p. 396). Burnout scales miss with people directly puts too much stress on me)”, artificially
important depressive symptoms, such as suicidal thoughts. We, inflating the instrument’s reliability. The ODI does not exhibit
next, report on a new instrument that better fills the role that this limitation because each of its nine items focuses on a specific
burnout scales occupy in identifying workers adversely affected DSM-5 symptom of major depression. Item wording shows no
by their jobs. explicit redundancy—yet the ODI has optimal reliability.
Because the ODI deliberately assesses symptoms the
THE OCCUPATIONAL DEPRESSION individual attributes to perceived job stress, we recommend
against using the instrument in cross-sectional research linking
INVENTORY
the ODI to perceived job-stressor measures. We recommend
Depression contributes heavily to the worldwide burden of research that employs longitudinal designs or that links objective
disease (48). Unresolvable stress is a primary depressogenic measures of job adversity to the ODI.
factor. Intractable stressors are often encountered at work. In We created the ODI for two practical purposes: (1) to help
view of the problem of job-related stressors evoking depressive occupational health specialists identify suffering workers and
symptoms in workers, we recently developed the Occupational take the appropriate steps to remediate the problem and (2)
Depression Inventory [ODI; (14, 49, 50)]. The ODI references to aid epidemiologists in estimating the prevalence of job-
the nine symptoms of major depression (25) and incorporates related depression such that appropriate public health policies
causal attributions to work. From a psychometric and structural can be established. A corollary to those two practical purposes
standpoint, the ODI is stronger than burnout scales (14, 49, 50). is that the ODI can help specialists identify depressogenic
In addition, the ODI assesses crucial symptoms such as suicidal organizations. For example, if within a given economic
ideation, a risk factor for work-related suicide. The construct sector, the prevalence of occupational depression is, say, 2.5%
of depression, which is deeply anchored in the ODI, has been but in one organization the prevalence is 25%, problematic
and continues to be highly researched. A diagnosis of depression working conditions are likely to plague that organization.
has consensual criteria, such as the widely employed criteria The ODI would be the sentinel that signals occupational
in the DSM-5, which contrasts sharply with Rotenstein et al.’s health specialists to take action to help troubled workers and
(34) finding that researchers have employed 142 different unique improve workplaces.
categorizations of burnout.
In contrast to other depressive symptom scales (e.g., the CES- DATA AVAILABILITY STATEMENT
D), the ODI explicitly asks respondents whether they attribute
each depressive symptom to their job (e.g., “My experience The original contributions presented in the study are included
at work made me feel like a failure”). The instrument has in the article/Supplementary Material, further inquiries can be
a protocol to help rule out symptoms attributed to nonwork directed to the corresponding author.
sources (e.g., a conflictual spousal relationship) or a source the
respondent cannot identify. The ODI can be used in two different AUTHOR CONTRIBUTIONS
ways. First, it can quantify work-related depressive symptoms
along a continuum of severity. Second, the instrument produces ISS wrote the initial draft of the paper. RB edited the draft and
provisional diagnoses of work-related depression. The ODI is added to it. The draft went back and forth between ISS and RB
currently available in English, French, and Spanish (see the several times during which the two authors iteratively shaped the
Supplemental Material). paper and settled on its final form. Both authors contributed to
Because the ODI can help identify workers with clinically the article and approved the submitted version.
significant job-related distress, occupational health specialists
(e.g., physicians, psychologists) can direct affected workers SUPPLEMENTARY MATERIAL
to treatment. We also recommend that specialists investigate
workplace stressors that contribute to distress and take steps The Supplementary Material for this article can be found
to ameliorate the stressful working conditions. The ODI can online at: https://www.frontiersin.org/articles/10.3389/fpubh.
also help epidemiologists estimate the prevalence of job-related 2021.796401/full#supplementary-material

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Schonfeld and Bianchi From Burnout to Occupational Depression

48. World Health Organization. Depression and Other Common Mental Disorders: Publisher’s Note: All claims expressed in this article are solely those of the authors
Global Health Estimates. Geneva: Author (2017). and do not necessarily represent those of their affiliated organizations, or those of
49. Bianchi R, Schonfeld IS. The occupational depression inventory—a solution the publisher, the editors and the reviewers. Any product that may be evaluated in
for estimating the prevalence of job-related distress. Psychiatry Res. (2021) this article, or claim that may be made by its manufacturer, is not guaranteed or
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endorsed by the publisher.
50. Bianchi R, Schonfeld IS. Is the occupational depression inventory predictive
of cognitive performance? a focus on inhibitory control and effortful
reasoning. Pers Individ Dif. (2022) 184:111213. doi: 10.1016/j.paid.2021. Copyright © 2021 Schonfeld and Bianchi. This is an open-access article distributed
111213 under the terms of the Creative Commons Attribution License (CC BY). The use,
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Frontiers in Public Health | www.frontiersin.org 6 December 2021 | Volume 9 | Article 796401