Doctors are at high risk of burnout, which has far-reaching consequences on an individual and organisational level. Several studies have shown an association between burnout and depression.
This study aimed to determine the rate of burnout and depressive symptoms among doctors, as well as factors associated with both conditions.
Charlotte Maxeke Johannesburg Academic Hospital.
Burnout was measured using the Maslach Burnout Inventory–Human Services Survey and defined as the total score of high emotional exhaustion (≥ 27 points) + high depersonalisation (≥ 13 points). Individual subscales were analysed separately. Depressive symptoms were screened using the Patient-Health Questionnaire-9 (PHQ-9) and a score of ≥ 8 was deemed indicative of depression.
Of the respondents (
A high rate of burnout and depressive symptoms was determined. Although there is an overlap between the two conditions in terms of both symptomatology and risk factors, specific risk factors were determined for each in this population.
This study highlighted the rate of burnout and depressive symptoms experienced by doctors at the state level hospital necessitating individual and institutional interventions to address this.
The term ‘burnout’, first used by Herbert Freudenberger in 1974,
Maslach and Jackson
High emotional exhaustion (EE) – chronic fatigue and low motivation
High depersonalisation (DP) – a feeling of distance from one’s job, cynicism and negativism
Low personal accomplishment (PA)
Further research by Maslach led to the development of the Maslach Burnout Inventory–Human Services Survey (MBI–HSS), which is considered the gold standard measure for assessing burnout.
Many studies explored the risk factors contributing to burnout, which may be divided into three domains:
The consequences of burnout can generally be divided into four domains:
Burnout is often associated with depression with considerable overlap of symptoms
An international systematic review estimated the prevalence of depressive symptoms among registrars as 28.8%
Considering these alarming figures, this study aimed to determine the rate and associated factors for burnout and depressive symptoms among doctors employed at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). We hypothesised that the burnout and depression rate would be elevated (± 50% of doctors) with an overlap of risk factors for each condition.
This cross-sectional analysis of burnout and depression among doctors using the MBI–HSS for Medical Personnel and Patient-Health Questionnaire-9 (PHQ-9) was conducted between 22 November 2019 and 29 February 2020.
Charlotte Maxeke Johannesburg Academic Hospital is a state central level academic institution in Johannesburg, Gauteng, South Africa employing doctors across multiple disciplines and levels of training. All doctors in full-time employment (interns, medical officers, registrars and specialists) were approached to participate in the study.
Once informed consent was obtained, paper-based questionnaires (MBI–HSS and PHQ-9) and a data collection form were self-reported and deposited into sealed, secure collection boxes that were collected by the primary investigator. Data were then recorded in an Excel spreadsheet. The analysed variables included sex, age, ethnicity, relationship status, job position, discipline, number of hours of overtime per week, number of hours remunerated work outside the public service (RWOPS) per week, academic and/or study time per week, hours per week spent on clerical work, psychiatric diagnosis, family history of psychiatric disorder, psychotherapy attendance, psychotropic medication and/or substance use in the past month and lifetime medication and/or substance use. An instrument was not scored if three or more items were missing; therefore, 327 MBI questionnaires and 335 PHQ-9 surveys were scored. Categories with
Burnout is defined as a high range score (≥ 27 points) on the EE subscale, a high range score (≥ 13 points) on the DP subscale and a low range score (≤ 31 points) on the PA subscale.
For the purpose of this study, the ‘Emotional Exhaustion + 1’ principle
The association between risk factors and overall burnout and depressive symptoms was assessed by univariate binomial regression analysis. Factors with
The study was approved by the University of the Witwatersrand, Human Research Ethics Committee. A distress protocol, detailing contact information of available resources for psychological and psychiatric care, was provided to all participants.
Doctors in full-time employment at CMJAH over the study period were 694; 337 doctors for whom either the burnout or depression scale(s) could be scored participated in the study (overall response rate of 48.6%; margin of error 3.8%). The response rate for interns and registrars was significantly higher than other groups. A total of 58.8% (
Response rate according to job position and discipline.
Category | Variable | Responses | Number of employees | Response (%) |
---|---|---|---|---|
Job position | Intern | 40 | 63 | 63.5 |
Medical officer | 39 | 99 | 39.4 | |
Registrar | 156 | 294 | 53.1 | |
Specialist | 102 | 237 | 43.0 | |
Discipline | Anaesthetics | 34 | 78 | 43.6 |
Emergency medicine | 15 | 28 | 53.6 | |
Internal medicine | 59 | 168 | 35.1 | |
Obstetrics and gynaecology | 19 | 44 | 43.2 | |
Paediatrics | 28 | 60 | 46.7 | |
Pathology | 37 | 58 | 63.8 | |
Psychiatry | 17 | 18 | 94.4 | |
Public health | 4 | 7 | 57.1 | |
Radiology and nuclear medicine | 18 | 45 | 40.0 | |
Surgery | 106 | 188 | 56.4 | |
Overall | - | 337 | 694 | 48.6 |
Characteristics of the study participants.
Characteristic | Overall ( |
|
---|---|---|
% | ||
Male | 139 | 41.2 |
Female | 198 | 58.8 |
20–29 | 82 | 24.3 |
30–39 | 183 | 54.3 |
40–49 | 54 | 16.0 |
50 or older | 18 | 5.3 |
93 | 27.6 | |
African people | 119 | 35.3 |
Caucasian people | 115 | 34.1 |
Indian/Asian people | 88 | 26.1 |
Other | 15 | 4.5 |
Intern | 40 | 11.9 |
Medical officer | 39 | 11.6 |
Registrar | 156 | 46.3 |
Consultant | 102 | 30.3 |
0–5 | 82 | 24.3 |
6–8 | 84 | 24.9 |
9–12 | 81 | 24.0 |
13 or more | 90 | 26.7 |
111 | 32.9 | |
Surgery | 106 | 31.5 |
Internal medicine | 59 | 17.5 |
Pathology | 37 | 11.0 |
Anaesthetics | 34 | 10.1 |
Paediatrics | 28 | 8.3 |
Obstetrics and gynaecology | 19 | 5.6 |
Radiology or nuclear medicine | 18 | 5.3 |
Psychiatry | 17 | 5.0 |
Emergency medicine | 15 | 4.5 |
Public health | 4 | 1.2 |
336 | 99.7 | |
4 or less | 22 | 6.6 |
5–12 | 43 | 12.8 |
13–20 | 89 | 26.4 |
More than 20 | 183 | 54.3 |
54 | 16.0 | |
Less than 10 | 221 | 65.6 |
10–30 | 106 | 31.5 |
More than 30 | 10 | 3.0 |
Less than 3 | 61 | 18.1 |
3–5 | 124 | 36.8 |
5–8 | 70 | 20.8 |
More than 8 | 82 | 24.3 |
56 | 16.6 | |
Before internship | 19 | 5.6 |
After internship | 37 | 11.0 |
Depressive disorder | 30 | 8.9 |
Anxiety disorder | 30 | 8.9 |
Bipolar disorder | 3 | 0.9 |
other | 9 | 2.7 |
87 | 25.8 | |
No | 230 | 68.3 |
Yes – ongoing | 23 | 6.8 |
Yes – previous | 84 | 24.9 |
Antidepressant and/or anxiolytic | 50 | 14.8 |
Benzodiazepine | 15 | 4.5 |
Stimulant | 14 | 4.2 |
Illicit substance | 10 | 3.0 |
Mood stabiliser | 4 | 1.2 |
Antipsychotic | 1 | 0.3 |
Other | 4 | 1.2 |
None | 264 | 78.3 |
Antidepressant and/or anxiolytic | 32 | 9.5 |
Benzodiazepine | 14 | 4.2 |
Stimulant | 29 | 8.6 |
Illicit substance | 11 | 3.3 |
Mood stabiliser | 4 | 1.2 |
Antipsychotic | 3 | 0.9 |
Other | 3 | 0.9 |
None | 267 | 79.2 |
High emotional exhaustion (EE ≥ 27) | 199 | 60.9 |
High depersonalisation (DP ≥ 13) | 196 | 59.9 |
Low personal accomplishment (PA ≤ 31) | 181 | 55.4 |
Overall (EE ≥ 27 and DP ≥ 13) | 151 | 46.2 |
Depressive symptoms (score of ≥ 8 on the PHQ-9) | 180 | 53.7 |
EE, emotional exhaustion; DP, depersonalisation; PHQ, patient-health questionnaire; PA, personal accomplishment.
Univariable analysis of risk factors for burnout and depressive symptoms.
Characteristic | High emotional exhaustion (EE ≥ 27) |
High depersonalisation (DP ≥ 13) |
Low personal accomplishment (PA ≤ 31) |
Burnout |
Depressive symptoms |
|||||
---|---|---|---|---|---|---|---|---|---|---|
RR | 95% CI | RR | 95% CI | RR | 95% CI | RR | 95% CI | RR | 95% CI | |
1.31 |
1.08–1.59 |
1.03 | 0.86–1.24 | 1.33 | 1.08–1.65 | 1.17 | 0.92–1.50 | 1.44 | 1.15–1.79 |
|
20–29 | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
30–39 | 0.84 | 0.70–1.00 | 0.76 | 0.64–0.89 |
1.00 | 0.80–1.25 | 0.69 |
0.55–0.86 |
0.86 | 0.70–1.06 |
40–49 | 0.72 |
0.54–0.97 |
0.53 | 0.37–0.75 |
0.89 | 0.64–1.23 | 0.49 |
0.31–0.75 |
0.60 |
0.42–0.87 |
50 or older | 0.26 |
0.09–0.72 |
0.48 | 0.25–0.91 |
0.65 | 0.34–1.27 | 0.29 |
0.10–0.81 |
0.43 |
0.20–0.92 |
1.03 | 0.85–1.25 | 1.08 | 0.89–1.31 | 1.15 | 0.94–1.41 | 1.01 | 0.78–1.32 | 1.03 | 0.83–1.28 | |
African | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
Caucasian | 1.03 | 0.83–1.27 | 1.38 |
1.11–1.71 |
1.02 | 0.80–1.30 | 1.30 | 0.98–1.73 | 1.06 | 0.84–1.34 |
Indian/Asian | 1.05 | 0.84–1.31 | 1.16 | 0.90–1.49 | 1.08 | 0.84–1.38 | 1.18 | 0.86–1.62 | 1.02 | 0.78–1.32 |
Other | 1.08 | 0.71–1.65 | 1.26 | 0.82–1.94 | 1.20 | 0.79–1.84 | 1.26 | 0.71–2.22 | 0.95 | 0.55–1.65 |
Intern | 1.85 |
1.40–2.43 |
2.00 |
1.52–2.64 |
1.27 | 0.91–1.76 | 2.51 |
1.76–3.57 |
1.98 |
1.42–2.76 |
Medical officer | 1.42 |
1.01–1.99 |
1.43 |
1.00–2.04 |
1.19 | 0.84–1.68 | 1.46 | 0.91–2.33 | 1.89 |
1.34–2.66 |
Registrar | 1.54 |
1.20–1.99 |
1.61 |
1.23–2.09 |
1.24 | 0.97–1.59 | 1.66 |
1.18–2.34 |
1.66 |
1.23–2.22 |
Consultant | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
0–5 | 1.54 |
1.18–2.02 |
1.98 |
1.48–2.65 |
1.25 | 0.93–1.68 | 2.20 |
1.51–3.22 |
1.83 |
1.33–2.52 |
6–8 | 1.47 |
1.12–1.94 |
1.77 |
1.31–2.40 |
1.31 | 0.98–1.75 | 1.73 |
1.15–2.59 |
1.72 |
1.25–2.38 |
9–12 | 1.31 | 0.98–1.75 | 1.45 |
1.04–2.01 |
1.28 | 0.95–1.72 | 1.64 |
1.08–2.48 |
1.46 |
1.03–2.07 |
13 or more | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
0.64 |
0.50–0.80 |
0.61 |
0.48–0.78 |
0.90 | 0.72–1.11 | 0.55 |
0.40–0.76 |
0.60 |
0.46–0.77 |
|
Surgery | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
Internal Medicine | 0.83 | 0.60–1.13 | 0.99 | 0.75–1.30 | 1.03 | 0.73–1.45 | 0.93 | 0.64–1.36 | 0.91 | 0.64–1.29 |
Pathology | 1.27 | 98–1.65 | 1.35 |
1.05–1.73 |
1.85 |
1.43–2.40 |
1.38 | 0.97–1.97 | 1.28 | 0.93–1.76 |
Anaesthetics | 1.16 | 0.87–1.53 | 0.97 | 0.69–1.36 | 1.49 |
1.09–2.04 |
1.13 | 0.76–1.68 | 1.39 |
1.03–1.89 |
Paediatrics | 1.30 | 0.99–1.71 | 1.04 | 0.73–1.49 | 1.06 | 0.67–1.68 | 1.08 | 0.68–1.72 | 1.10 | 0.74–1.64 |
O and G | 1.26 | 0.92–1.72 | 1.19 | 0.84–1.68 | 1.39 | 0.93–2.09 | 1.31 | 0.84–2.02 | 1.49 |
1.05–2.10 |
Radiology or Nuclear Medicine | 0.95 | 0.61–1.48 | 0.58 | 0.30–1.14 | 1.23 | 0.77–1.95 | 0.63 | 0.29–1.36 | 1.03 | 0.62–1.70 |
Psychiatry | 0.80 | 0.47–1.37 | 0.92 | 0.57–1.48 | 1.17 | 0.71–1.92 | 0.53 | 0.22–1.28 | 1.09 | 0.67–1.78 |
Emergency Medicine | 1.25 | 0.89–1.77 | 1.62 |
1.31–2.01 |
1.62 |
1.12–2.34 |
1.65 |
1.14–2.40 |
1.24 | 0.78–1.95 |
Public Health | 0.43 | 0.08–2.35 | 0.87 | 0.32–2.35 | 1.66 | 0.91–3.03 | 0.56 | 0.10–3.12 | 1.03 | 0.38–2.80 |
4 or less | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
5–12 | 1.08 | 0.56–2.09 | 0.67 | 0.39–1.16 | 1.08 | 0.69–1.68 | 0.92 | 0.43–1.99 | 1.15 | 0.60–2.22 |
13–20 | 1.67 | 0.94–2.94 | 1.21 | 0.82–1.81 | 1.05 | 0.70–1.58 | 1.48 | 0.78–2.82 | 1.42 | 0.79–2.56 |
More than 20 | 1.75 |
1.00–3.04 |
1.06 | 0.72–1.56 | 0.90 | 0.61–1.34 | 1.48 | 0.80–2.76 | 1.64 | 0.93–2.89 |
RWOPS | 0.66 |
0.48–0.91 |
0.74 |
0.55–0.99 |
0.74 | 0.53–1.02 | 0.64 |
0.42–0.97 |
0.51 |
0.33–0.77 |
Less than 10 | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
10–30 | 0.85 | 0.69–1.05 | 0.78 |
0.63–0.97 |
0.86 | 0.69–1.08 | 0.79 | 0.60–1.04 | 0.87 | 0.69–1.09 |
More than 30 | 1.26 | 0.91–1.75 | 0.61 | 0.29–1.32 | 0.86 | 0.46–1.61 | 0.80 | 0.37–1.74 | 0.71 | 0.33–1.52 |
Less than 3 | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
3–5 | 1.04 | 0.78–1.37 | 1.15 | 0.89–1.50 | 0.99 | 0.78–1.26 | 1.14 | 0.79–1.64 | 0.95 | 0.72–1.27 |
5–8 | 1.11 | 0.82–1.51 | 0.95 | 0.69–1.30 | 0.68 |
0.48–0.95 | 1.12 | 0.75–1.68 | 0.87 | 0.62–1.22 |
More than 8 | 1.35 |
1.03–1.77 |
1.11 | 0.83–1.47 | 0.81 | 0.60–1.08 | 1.24 | 0.85–1.82 | 1.15 | 0.86–1.53 |
1.48 |
1.26–1.73 |
1.22 |
1.00–1.49 |
1.43 |
1.18–1.74 |
1.47 |
1.15–1.88 |
1.70 |
1.43–2.02 |
|
Before internship | 1.38 |
1.05–1.80 |
1.34 |
1.03–1.75 |
1.29 | 0.91–1.82 | 1.43 | 0.96–2.11 | 1.67 |
1.37–2.04 |
After internship | 1.53 |
1.29–1.81 |
1.15 | 0.90–1.48 | 1.51 |
1.22–1.86 |
1.49 |
1.13–1.97 |
1.75 |
- |
Depressive disorder | 1.54 |
1.32–1.81 |
1.30 |
1.04–1.63 |
1.35 |
1.05–1.73 |
1.75 |
1.37–2.23 |
1.64 |
1.35–1.99 |
Anxiety disorder | 1.55 |
1.33–1.81 |
1.38 |
1.13–1.69 |
1.37 |
1.08–1.74 |
1.60 |
1.22–2.09 |
1.62 |
1.33–1.98 |
1.10 | 0.91–1.32 | 1.04 | 0.85–1.26 | 1.16 | 0.95–1.42 | 1.04 | 0.80–1.36 | 1.32 |
1.08–1.61 |
|
No | - | - | - | - | - | - | - | - | - | - |
Yes – ongoing | 1.50 |
1.20–1.87 |
1.22 | 0.91–1.64 | 1.20 | 0.87–1.66 | 1.58 |
1.13–2.21 |
1.93 |
1.56–2.39 |
Yes – previous | 1.28 |
1.06–1.53 |
1.15 | 0.95–1.40 | 1.02 | 0.81–1.29 | 1.32 |
1.02–1.70 |
1.53 |
1.25–1.87 |
Antidepressant and/or anxiolytic | 1.47 |
1.25–1.73 |
1.28 |
1.05–1.55 |
1.51 |
1.25–1.82 |
1.59 |
1.25–2.01 |
1.78 |
1.51–2.10 |
Benzodiazepine | 1.33 |
1.02–1.75 |
1.48 |
1.19–1.84 |
1.48 |
1.12–1.94 | 1.80 |
1.35–2.38 |
1.66 |
1.33–2.08 |
Stimulant | 1.43 |
1.14–1.81 |
1.46 |
1.15–1.84 |
1.17 | 0.78–1.75 | 1.59 |
1.11–2.26 |
1.49 |
1.11–2.00 |
Antidepressant and/or anxiolytic | 1.50 |
1.27–1.77 |
1.15 | 0.88–1.49 | 1.12 | 0.83–1.51 | 1.46 |
1.09–1.95 |
1.53 |
1.23–1.89 |
Benzodiazepine | 1.31 | 0.98–1.74 | 1.33 | 1.00–1.77 | 0.90 | 0.53–1.53 | 1.42 | 0.94–2.13 | 1.49 |
1.11–2.00 |
Stimulant | 0.96 | 0.70–1.32 | 1.23 | 0.97–1.57 | 1.07 | 0.77–1.47 | 1.13 | 0.78–1.65 | 1.32 |
1.01–1.72 |
EE, emotional exhaustion; DP, depersonalisation; RR, relative risk; CI, confidence interval.
, Statistically significant RRs.
Multivariable analysis of risk factors for burnout and depressive symptoms.
Characteristic | High emotional exhaustion (EE ≥ 27) |
High depersonalisation (DP ≥ 13) |
Low personal accomplishment (PA ≤ 31) |
Burnout |
Depressive symptoms |
|||||
---|---|---|---|---|---|---|---|---|---|---|
RR | 95% CI | RR | 95% CI | RR | 95% CI | RR | 95% CI | RR | 95% CI | |
- | - | - | - | 1.31 |
1.06–1.61 |
- | - | 1.18 |
1.01–1.38 |
|
African | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
Caucasian | - | - | 1.43 | 1.17–1.75 |
- | - | 1.32 |
1.00–1.74 |
- | - |
Indian/Asian | - | - | 1.21 | 0.96–1.53 | - | - | 1.16 | 0.84–1.60 | - | - |
Other | - | - | 1.07 | 0.70–1.63 | - | - | 1.09 | 0.63–1.90 | - | - |
Intern | 1.45 |
1.15–1.82 |
1.86 |
1.43–2.42 |
- | - | 2.23 |
1.58–3.16 |
1.43 |
1.12–1.83 |
Medical officer | 1.20 | 0.95–1.52 | 1.45 |
1.03–2.03 |
- | - | 1.43 | 0.91–2.23 | 1.34 |
1.07–1.66 |
Registrar | 1.28 |
1.08–1.53 |
1.78 |
1.38–2.30 |
- | - | 1.66 |
1.19–2.32 |
1.28 |
1.06–1.55 |
Consultant | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
Less than 10 | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- | 1.00 |
- |
10–30 | - | - | 0.82 |
0.67–0.99 |
- | - | - | - | - | - |
More than 30 | - | - | 0.71 | 0.33–1.53 | - | - | - | - | - | - |
1.28 |
1.11–1.47 |
- | - | 1.40 |
1.16–1.69 |
1.32 |
1.05–1.67 |
1.33 |
1.16–1.52 |
EE, emotional exhaustion; DP, depersonalisation; RR, relative risk; CI, confidence interval.
, Statistically significant RRs.
The total number of doctors classified as experiencing burnout (high EE + high DP) was 151 (46.2%). Associations of statistical significance included age, job position, discipline, psychiatric diagnosis, the use of medication and/or substances and not performing RWOPS.
Risk factors for burnout can be divided into three sections:
There was no significant association between burnout and sex, relationship status, ethnicity, overtime hours per week, academic hours per week, clerical hours per week and family history of psychiatric disorder. Multivariate analysis revealed that burnout was associated with Caucasian race; intern and registrar positions and psychiatric diagnosis. Looking at the individual measures of burnout 60.9% (
The number of participants who screened positive for depressive symptoms was 180 (53.73%) (
Summary of significant associations with burnout, burnout subscales and depression.
Variable | Category | Depression | Burnout = high EE + high DP | High EE | High DP | Low PA |
---|---|---|---|---|---|---|
- | x | - | x | - | x | |
- | x | x | x | x | - | |
- | - | - | - | - | - | |
- | - | x | - | x | - | |
Intern | x | x | x | x | - | |
Medical officer | - | - | x | x | - | |
Registrar | x | x | x | x | - | |
Anaesthetics | x | - | - | - | x | |
Emergency medicine | - | x | - | x | x | |
Internal Medicine | - | - | - | - | - | |
Obstetrics and gynaecology | x | - | - | x | - | |
Paediatrics | - | - | - | - | - | |
Pathology | - | - | - | x | x | |
Psychiatry | - | - | - | - | - | |
Public health | - | - | - | - | x | |
Radiology and nuclear medicine | - | - | - | - | - | |
Surgery | - | - | - | - | - | |
- | - | x | x | x | - | |
- | - | - | x | x | - | |
- | - | - | - | - | - | |
More | - | - | x | - | - | |
Less | - | - | - | - | x | |
- | x | x | x | x | x | |
Before internship | x | x | x | x | - | |
After internship | x | x | x | - | x | |
- | x | - | - | - | - | |
Current | x | x | x | x | - | |
Past | x | x | x | x | - | |
Antidepressant and/or anxiolytic | x | x | x | x | x | |
Benzodiazepine | x | x | x | x | x | |
Stimulant | x | x | x | x | - | |
Antidepressant and/or anxiolytic | x | x | x | x | - | |
Benzodiazepine | x | x | - | - | - | |
Stimulant | x | - | - | - | - |
RWOPS, remunerated work outside the public service; EE, emotional exhaustion; DP, depersonalisation PA, personal accomplishment.
Of the participants, 46.2% of doctors employed at CMJAH had burnout. This figure is in keeping with international rates
Those aged 20–39 were more likely to suffer burnout. Internship and registrarship in South Africa mostly commence within this age group and interns were found to be three times more likely to be burnt out than specialists. Common psychiatric disorders also tend to have their onset in this age group
Emergency medicine and pathology doctors were shown to be at a higher risk of burnout, whereas international data show that urology, neurology, internal medicine, surgery and anaesthetics had the highest burnout rates.
Those who performed RWOPS were at a lower risk of burnout. In South Africa (SA), only specialists and medical officers are legally allowed to perform RWOPS. Although RWOPS performance increases work hours in this study, it was not found to increase the risk of burnout. This finding, however, may be confounded by a lower risk of burnout in specialists because of other factors, such as older age and less study time. One could also argue that while RWOPS increases time spent at work, remuneration for this work may decrease financial stress. Institutional factors may need to be examined in greater depth to account for this, for example, a lack of human and infrastructural resources may be more significant in the public versus the private healthcare sector.
Doctors with a psychiatric diagnosis (depression and anxiety) displayed a higher risk of burnout with the risk increasing during and after internship. This could be explained by various risk factors for mental illness during the period of internship, as outlined here. Whilst we observe the association between mental illness and burnout, it is difficult to statistically surmise causality from this finding, that is, if mental illness is an independent risk factor for burnout or if burnout predisposes one to develop mental illness.
Over 60% of doctors assessed as burnt out had never attended psychotherapy. There was a significant association between burnout and having past or present psychotherapy. Doctors may engage with psychotherapy for the management of depressive or anxiety disorders or to improve coping skills related to innate personality factors. It should be observed that the association strengthens with present psychotherapy. We can postulate that the current working environment exposes a need to engage in help-seeking behaviour, whether it is because of burnout itself or other psychiatric illness.
There was a significant association between burnout and the use of recent antidepressants and/or anxiolytics, benzodiazepines and stimulants, as well as for past use of antidepressants and/or anxiolytics and benzodiazepines. This may be because of either: (1) prescribed medication for a depressive and/or anxiety disorder or (2) self-medicating symptoms of either burnout or depression. The latter may be more likely as the association of benzodiazepine use and stimulant use versus antidepressant use is higher. Benzodiazepines are known for their anxiolytic and hypnotic properties, whereas stimulants may be utilised to manage symptoms of fatigue or improve alertness. This finding also implies that stimulant use began or increased after internship. This is an interesting finding, as the number of doctors who, according to our survey, had a diagnosis of ‘other’ was 9 out of 337 (2.7%) (Attention deficit hyperactive disorder [ADHD], the most common condition, for which stimulants such as methylphenidate are prescribed, would be included here).
There was no significant association between burnout and sex, relationship status, ethnicity, overtime per week, academic hours per week, clerical hours per week and family history of psychiatric disorder. Some of these findings differ from what has been reported in the literature; it has been reported that females, clerical work and academic or study time have also been cited as risk factors of burnout. This study showed that females are at increased risk of depressive symptoms (in keeping with accepted risk factors for depression
Multivariate analysis revealed that burnout was associated with Caucasian race. There are little data regarding ethnicity as a risk factor for burnout. South Africa has a unique history regarding racial divides, but it is uncertain whether this is a factor that needs to be considered in the light of this finding.
Three different measures of burnout were analysed individually to determine if particular associations differed from the definition of burnout utilised here (EE + DP). A total of 60.9% of doctors scored high on EE; 59.9% scored high on DP and 55.4% scored low on PA. Global rates of EE range between 43% and 80%, which was comparable to what we found.
Depersonalisation represents the interpersonal element of burnout and it appears that certain disciplines (such as emergency medicine and obstetrics and gynaecology) may be particularly vulnerable in terms of this aspect of burnout but not EE or PA. High levels of DP were found in Caucasians and it is uncertain why this may be a factor in our setting. Those who performed less than 10 h per week of academic duties had the highest risk; this may be linked to interns, medical officers and specialists when compared with registrars (who are enrolled in a training programme), engaging in less academic activities. It also implies that high DP is associated more with other risk factors rather than the academic aspects of medicine. Psychiatric diagnosis made
Females were found to be at higher risk of low PA. One explanation is that females often face more discrimination in the workplace compared with their male counterparts.
Doctors have higher rates of depression and suicide when compared with the general population.
In terms of individual and psychiatric factors, our findings are in keeping with most known risk factors for depression viz. female sex, age of onset (20–30), a past episode of depression and positive family history.
While there are global variances in rates of depression between medical disciplines, in this study, the disciplines of anaesthetics and obstetrics and gynaecology had a significantly elevated risk for depressive symptoms but not for overall burnout. Anaesthetists are more likely to complete suicidal acts and more likely to die by substance-related suicide when compared with the general population.
The current use of medications such as antidepressants, benzodiazepines and stimulants was associated with depression and anxiety. While we can conclude that the use of antidepressants is likely to be for the treatment of depression, we cannot conclusively say the same for the latter two groups of medication. We know that doctors are less likely to seek medical help and are more likely to self-medicate.
The bidirectional relationship between burnout and depression makes it difficult to determine causality over the course of both conditions. A recent systematic review and meta-analysis concluded that job strain may precipitate clinical depression.
High burnout and depression rates were found in this study. There appears to be a bidirectional relationship between the two conditions. Although they have shared risk factors, specific risk factors may be determined for each in this population and confirmed with a longitudinal study looking at the causality between burnout and mental illness. Further studies with semi-structured interviews within the institution may determine organisational and departmental factors, impacting the high rate of burnout and depression, especially within disciplines with significant findings, for example, anaesthetics, emergency medicine and obstetrics and gynaecology.
While this study briefly reflected on the use of medications, the study population is unique because doctors have easier access to medication when compared with the general population. In this regard, it may be interesting to note how many of the physicians self-prescribed medication to manage burnout and depressive symptoms.
It is important to determine the incidence of burnout and factors associated with it to tailor interventions appropriately.
There are several limitations to this study. Firstly, self-reported questionnaires were utilised and these are dependent on participants, who may over- or under-report symptoms. The response rate for interns and registrars was higher, which may indicate responder bias, showing that these groups were more likely to screen positive for burnout and depression. Additionally, findings at a tertiary-level academic institution in an urban setting in South Africa may not be generalisable to other areas of healthcare. This study utilised the PHQ-9, which is a screening tool, and therefore, a formal clinician review would be needed to make a diagnosis of depression. Finally, this study determined associations between risk and certain variables, and therefore, we cannot comment on causality.
The authors acknowledge Data Management and Statistical Analysis for contributing to data assessment.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
All authors contributed to the visualisation, protocol development and final revision of the completed submission for publication of this research.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
The authors confirm that the data supporting the findings of this study are available from the corresponding author, A.N., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.