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- GMS Health Technol Assess
- v.8; 2012
- PMC3434360
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GMS Health Technol Assess. 2012; 8: Doc05.
Published online 2012 Jun 14. doi:10.3205/hta000103
PMCID: PMC3434360
PMID: 22984372
Language: English | German
Dieter Korczak,*,1 Monika Wastian,2 and Michael Schneider3
Author information Copyright and License information PMC Disclaimer
Abstract
Background
The prevalence, diagnostics and therapy of the burnout syndrome are increasingly discussed in the public. The unclear definition and diagnostics of the burnout syndrome are scientifically criticized. There are several therapies with unclear evidence for the treatment of burnout in existence.
Objectives
The health technology assessment (HTA) report deals with the question of usage and efficacy of different burnout therapies.
Methods
For the years 2006 to 2011, a systematic literature research was done in 31 electronic databases (e.g. EMBASE, MEDLINE, PsycINFO). Important inclusion criteria are burnout, therapeutic intervention and treatment outcome.
Results
17 studies meet the inclusion criteria and are regarded for the HTA report. The studies are very heterogeneous (sample size, type of intervention, measuring method, level of evidence). Due to their study design (e.g. four reviews, eight randomized controlled trials) the studies have a comparable high evidence: three times 1A, five times 1B, one time 2A, two times 2B and six times 4. 13 of the 17 studies are dealing with the efficacy of psychotherapy and psychosocial interventions for the reduction of burnout (partly in combination with other techniques). Cognitive behaviour therapy leads to the improvement of emotional exhaustion in the majority of the studies. The evidence is inconsistent for the efficacy of stress management and music therapy. Two studies regarding the efficacy of Qigong therapy do not deliver a distinct result. One study proves the efficacy of roots of Rhodiola rosea (evidence level 1B). Physical therapy is only in one study separately examined and does not show a better result than standard therapy.
Discussion
Despite the number of studies with high evidence the results for the efficacy of burnout therapies are preliminary and do 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 Maslach Burnout Inventory (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. Ethical, juridical and social determining factors are not covered or discussed in the studies.
Conclusion
The efficacy of therapies for the treatment of the burnout syndrome is insufficient investigated. Only for cognitive behavioural therapy (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.
Keywords: burnout, burnout intervention study, burnout, professional, CBT, cognitive behavior therapy, cognitive behavior treatment, cognitive behaviour therapy, cognitive behaviour treatment, cognitive therapy, cognitive-behavioral therapy, cognitive-behavioral treatment, cognitive-behavioural therapy, cognitive-behavioural treatment, depression, depressive disorder, EBM, evidence based medicine, evidence-based medicine, health technology assessment, HTA, HTA report, HTA-report, humans, individual-focused intervention, mind-body therapies, mind-body therapy, music therapy, person-directed intervention, phytotherapy, prognostic instrument, psychotherapy, qigong, relaxation, review, review literature, review literature as topic, rhodiola, rhodiola rosea, stress management training, systematic review, TA, technology assessment, technology assessment, biomedical, therapeutics, therapy, treatment, treatment outcome
Abstract
Hintergrund
Die Prävalenz, Diagnostik und Therapie des Burnout-Syndroms wird in der (Fach)Öffentlichkeit zunehmend diskutiert. Wissenschaftlich wird die unklare Definition und Diagnostik des Burnout-Syndroms kritisiert. Zur Behandlung des Burnout werden verschiedene Therapien mit unklarer Evidenz angeboten.
Fragestellungen
Der Health Technology Assessment (HTA)-Bericht befasst sich mit der Frage, welche Therapien zur Behandlung des Burnout-Syndroms eingesetzt werden und wie wirksam diese sind.
Methodik
Die relevante Studienliteratur ist anhand von Schlagworten in 31 Datenbanken (u.a. EMBASE, MEDLINE, PsycINFO) für den Zeitraum 2006 bis 2011 gesucht worden. Wichtige Einschlusskriterien sind Burnout, therapeutische Intervention und Treatment outcome.
Ergebnisse
17 Studien erfüllen die Einschlusskriterien und werden für den HTA-Bericht berücksichtigt. Die Studien sind sehr heterogen (Fallzahl, Stichprobe, Intervention, Messverfahren, Evidenzlevel). Sie haben aufgrund ihres Studiendesigns (u.a. vier Reviews, acht randomisierte kontrollierte Studien) eine vergleichsweise hohe Evidenz: dreimal 1A, fünfmal 1B, einmal 2A, zweimal 2B und sechsmal 4. 13 der 17 Studien befassen sich mit der Wirkung von Psychotherapie und psychosozialen Interventionen (teilweise in Kombination mit anderen Techniken) auf die Reduktion von Burnout. Der Einsatz kognitiver Verhaltenstherapie (KVT) führt in der Mehrheit der Studien zu Verbesserungen der emotionalen Erschöpfung. Die Evidenz der Wirkung von Stressmanagementtraining auf die Reduktion des Burnout ist ebenso wie die Wirkung von Musiktherapie uneinheitlich. Zwei Studien zur Wirksamkeit der Qigong-Therapie kommen zu keinem eindeutigen Ergebnis. Durch eine Studie mit dem Evidenzgrad 1B wird die Wirksamkeit von Rhodiola rosea (Rosenwurz) belegt. Physiotherapie wird nur in einer Studie isoliert untersucht und ist dort der Standardtherapie nicht überlegen.
Diskussion
Trotz einer Reihe von Studien mit hohen Evidenzleveln haben die Aussagen zur Wirksamkeit von Burnout-Therapien vorläufigen Charakter und sind von begrenzter Reichweite. Die Autoren der Studien beklagen die zu geringe Anzahl qualifizierter Studien zur Therapie des Burnout-Syndroms und weisen auf die unzureichende Evaluation von Therapiestudien sowie auf die Notwendigkeit weiterer Forschung hin. Einige Autoren berichten beträchtliche Effekte natürlicher Erholung.
Zahlreiche Einschränkungen beeinträchtigen die Qualität der Ergebnisse. Interventionsinhalte und -dauer, Studiendesign und Untersuchungspopulationen sind sehr unterschiedlich und lassen direkte Vergleiche nicht zu. Die Stichproben sind überwiegend klein mit geringer statistischer Power, es fehlen längerfristige Follow-up. Komorbiditäten und parallel in Anspruch genommene Therapien sind unzureichend erfasst bzw. kontrolliert worden. Die weit überwiegende Anzahl der Studien verwendet das Maslach Burnout Inventar, dessen klinische Validität nicht bewiesen ist, als Diagnose- und/oder Outcome-Tool, mit jeweils verschiedenen Cut-off-Werten, zur Bestimmung des (schweren) Burnout.
Ethische, soziale und rechtliche Rahmenbedingungen werden in den Studien nicht behandelt.
Schlussfolgerung
Die Wirkung der Therapien, die zur Behandlung des Burnout-Syndroms eingesetzt werden, ist unzureichend erforscht. Es liegt nur zur Wirkung der KVT eine hinreichend große Anzahl von Studien vor, die die Wirksamkeit der KVT belegen. Es fehlen große langfristig angelegte experimentelle Studien, die die einzelnen Therapien in ihrer Wirkung vergleichen und evidenzbasiert evaluieren. Auch die ohne Einfluss einer bestimmten Therapie erreichte „natürliche“ Erholung ist näher zu untersuchen.
Es ist außerdem zu prüfen, inwieweit Therapien und ihre mögliche Wirkung durch die Bedingungen am Arbeitsplatz und die Arbeitsplatzsituation konterkariert werden.
Summary
Health political background
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.
Scientific background
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.
Medical research questions
What is the therapy of a burnout syndrome?
What is the outcome of the different therapies?
Economic research question
What are the costs of the different therapies?
Juridical research question
Which juridical aspects have to be considered?
Social research questions
Which groups make use of burnout therapies?
Are there socio-demographic key aspects?
Ethical research question
Which ethical implications have been considered in the use of burnout therapies?
Methods
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.
Medical results
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.
Economic results
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 results
Juridical implications of burnout therapies are not covered in the studies.
Social results
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 results
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.
Discussion
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.
Conclusion
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.
Articles from GMS Health Technology Assessment are provided here courtesy of German Medical Science
