gms | German Medical Science

In the last years the burnout syndrome received a very high public awareness. There were many reports about the increase of absenteeism, the outing of well-known people of the public life due to burnout and the scientific discussion about the diagnostic of burnout. An increasing number of reports refer to an untamed and unchecked growth of burnout therapies. There is an impression in the public that burnout has become already a widespread disease. By results of a representative survey in 2011, doctors have diagnosed a burnout syndrome already once for 1.9 million people aged 14 to 65 years in Germany. In the light of health care politics 1.8 million sick leaves in 2010 due to a burnout are economically a burden.

Herbert Freudenberger defined burnout as a state of physical and mental exhaustion which develops slowly from continuous stress and use of energy to exhaustion because of excessive demands. Due to unclear diagnostics, the plurality of symptoms and diverse causations of burnout, there are uncertainties in the literature regarding the therapy of burnout. Prevention, intervention and therapy are hardly distinguished from each other. Congenial or similar interventions are differently labelled, that is as burnout intervention, burnout therapy or management of the prevention or relief of stress and stress-induced diseases. The therapy of burnout depends mainly on the understanding of burnout, whether it is regarded as independent disease, as preliminary stage of a depression or as a comorbidity of depression.

Therapies which are used for the treatment of burnout are: psychotherapy, especially cognitive behavioural therapy (CBT), phytotherapy, physiotherapy, adjuvant pharmacotherapy and complementary treatments like music therapy or body-mind therapies.

What is the therapy of a burnout syndrome?

What is the outcome of the different therapies?

What are the costs of the different therapies?

Which juridical aspects have to be considered?

Which groups make use of burnout therapies?

Are there socio-demographic key aspects?

Which ethical implications have been considered in the use of burnout therapies?

The relevant literature has been researched using key words in 31 electronic databases for 2006 until 2011. Important inclusion criteria have been burnout, therapeutic intervention and treatment outcome. 314 abstracts were identified, two independent reviewers sifted through the abstracts and selected 47 studies, considering the Oxford Level of Evidence. After a solid assessment of the study design, especially whether the efficacy of burnout therapies has been examined, 17 studies have been included in the health technology assessment (HTA)-report.

In 14 studies burnout is treated with CBT, stress management training, roots of Rhodiola rosea, physiotherapy, Qigong or music. Self-help groups, interventions at the working place and meditation are further treatment approaches. One study reports the use of a multi-modal psycho-, activity- and relaxation-therapy. Besides that psychotropic drugs are used – primarily antidepressants and anxiolytics.

The evaluation of the efficacy of the therapies is problematic. There is only one study for roots of Rhodiola and one for physiotherapy. The two Qigong studies are published by the same lead author. Even in case that several studies are existent for one therapeutic approach, the specific intervention techniques, the intervention intensity and the intervention duration are different. For the measurement of the therapy outcome the Maslach Burnout Inventory (MBI) is mainly used, but without standardized cut-off-values and without clinical validation. In several studies burnout is reduced without therapy or using standard care. The remarkable occurrence of disturbance variables during the treatment can influence the therapeutic effect as well in positive as in negative ways. Taking into account the different limitations CBT and roots of Rhodiola are the most effective therapies in reducing burnout. The results concerning the other therapies are not consistent.

Two studies deal with cost aspects. One study shows that the combination of CBT with work related interventions results in a faster return to work. The other study argues with the reduction of work incapacity and treatment costs per year and case after psychotherapy. The different costs for each of the mentioned burnout therapies cannot be assessed by the two studies.

Juridical implications of burnout therapies are not covered in the studies.

Within the studies the age focus lies between 40 and 50 years. In most studies the proportion of women is higher. The studies cover different professions – blue collar worker, policemen, teachers, freelancers –, but the majority of the participants are health care professionals (doctors, nurses, caregivers, medical students). The recruitment of the study participants is generally quite selective. It is not possible to give a representative statement regarding the socio-demographics of burnout patients.

Ethical implications are not discussed. The effect of working structure, working climate, work sequence, working process and increased work load is not sufficiently or not at all considered in the therapy studies.

Despite the number of studies with high evidence the results for the efficacy of burnout therapies are preliminary and have only limited reach. The authors of the studies complain about the low number of skilled studies for the therapy of burnout. Furthermore, they point to the insufficient evaluation of the therapy studies and the need for further research. Some authors report the effects of considerable natural recovering.

Numerous limitations affect the quality of the results. Intervention contents and duration, study design and study size are very diverse and do not permit direct comparison. Most of the samples are small by size with low statistical power, long-term follow-ups are missing. Comorbidities and parallel utilized therapies are insufficient documented or controlled. Most of the studies use the MBI as diagnostic or outcome-tool, but with different cut-off-points. It should be noticed that the validity of the MBI as diagnostic tool is not proved.

The efficacy of therapies for the treatment of the burnout syndrome is insufficient investigated. Only for CBT exists an adequate number of studies which prove its efficacy. Big long-term experimental studies are missing which compare the efficacy of the single therapies and evaluate their evidence. The natural recovering without any therapy needs further research. Additionally, it has to be examined to what extent therapies and their possible effects are thwarted by the conditions of the working place and the working conditions.