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/lp/oxford-university-press/burnout-depression-and-paranoid-ideation-a-cluster-analytic-study-TlkZHXzHuX
- Publisher
- Oxford University Press
- Copyright
- © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com
- ISSN
- 0962-7480
- eISSN
- 1471-8405
- DOI
- 10.1093/occmed/kqy150
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- See Article on Publisher Site
Abstract
Abstract Background A link between burnout and paranoid ideation has long been suspected. However, systematic research on the association has been scarce. Aims We investigated the relationship between burnout and paranoid ideation. Because burnout overlaps with depression, depression was also examined. Methods A total of 218 Swiss schoolteachers participated in the study (58% female; mean age: 47). Burnout symptoms were assessed with the emotional exhaustion (EE) and depersonalization (DP) subscales of the Maslach Burnout Inventory-Educators Survey, depressive symptoms with the PHQ-9 and paranoid ideation with the Green et al. Paranoid Thought Scales. Results Burnout, depression and their subdimensions showed raw correlations ranging from 0.42 to 0.55 with paranoid ideation. Burnout, depression and paranoid thoughts were found to cluster together. Lower levels of burnout and depression coexisted with lower levels of paranoid ideation and higher levels of burnout and depression coexisted with higher levels of paranoid ideation. When corrected for measurement error, the correlations of EE with depression and DP were 0.96 and 0.57, respectively. A principal component analysis confirmed that EE was indistinguishable from depression. Conclusions Burnout is substantially associated with paranoid ideation. Interestingly, EE correlated as strongly with paranoid ideation as it correlated with DP. Moreover, if burnout is a syndrome of EE and DP that excludes depression, then the EE-depression correlation should not be close to 1 and EE should not correlate more strongly with depression than with DP. These basic requirements for construct distinctiveness and syndromal unity were not satisfied. Dysphoria, exhaustion, health, mood, paranoia, personality, suicidal ideation, work stress Introduction Burnout has been regarded as a work-related syndrome primarily defined by emotional exhaustion (EE) and depersonalization (DP) [1]. EE constitutes the central characteristic of burnout as well as the entry point into the syndrome; DP refers to a coping strategy regarding EE [2]. DP has been conceived of as an immediate reaction to EE; EE and DP have been claimed to ‘go together’ and ‘mutually reinforce one another’ [1]. From an etiological standpoint, burnout is thought to result from unresolvable work stress. Burnout has become a popular construct among occupational health specialists over the last few decades. However, burnout is not an established diagnostic category, and its overlap with depression is problematic, both at an etiological and a symptom level [3]. The spectrum of paranoid ideation goes from mild distrust and suspiciousness to full-blown persecutory delusions [4,5]. Epidemiological research suggests that paranoid thinking may be a regular experience in one in three individuals in the general population [6]. A growing body of evidence indicates that paranoid ideation is associated with social stress and work stress [6,7]. As an illustration, a recent experimental study involving a non-clinical sample showed that even low-intensity, transient experiences of social stress could trigger paranoid thoughts [7]. Because stress fosters paranoid ideation and burnout is etiologically connected to stress, burnout may be associated with paranoid ideation. Interestingly, in what is generally considered the inaugural article on burnout, Freudenberger [8] claimed that burnout involved ‘a kind of suspicion and paranoia’. This claim, however, was rooted in uncontrolled observations (i.e. observations that did not make use of any standardized techniques and had indeterminable reliability), made in the context of the pioneering phase of burnout research. The link between burnout and paranoid ideation has received little attention in the research literature since then. The aim of this study was to systematically examine the relationship between burnout and paranoid ideation, based on standardized and reliable measures of the variables. Clarifying the extent to which burnout is associated with paranoid ideation may allow for more effective prevention and treatment of burnout. If paranoid thoughts are involved in burnout, then they may constitute therapeutic targets. For instance, reducing paranoid tendencies in burned out individuals may lead them to reappraise their working environment in a less stressful manner. This may contribute to alleviating burnout. In view of the overlap of burnout with depression [3], depression was also examined. Methods The present study involved Swiss schoolteachers. Respondents were recruited through contacts with school administrators in March 2018. Administrators were asked to transmit a web link to an internet survey to the teachers working in their schools. The internet survey contained measures of burnout, paranoid ideation and depression as well as a socio-demographic questionnaire. Participation was voluntary and without compensation. Because we had no information on either the number of school administrators who agreed to relay our invitation or the number of invited schoolteachers who eventually completed the survey, we could not estimate the response rate. Burnout symptoms were assessed with the Maslach Burnout Inventory-Educators Survey (MBI-ES) [1]. The MBI-ES allows the investigator to assess both EE (nine items; e.g. ‘I feel burned out from my work.’) and DP (five items; e.g. ‘I feel I treat some students as if they were impersonal objects.’). Participants reported how they felt over the past 2 weeks using a 4-point rating scale (from 0 for not at all, to 3 for nearly every day). EE and DP correlated 0.48. The two subscales of the MBI-ES were examined both separately and in combination—to obtain a global burnout index. The global burnout index was calculated as the mean of participants’ EE and DP mean scores. Paranoid ideation was assessed with the Green et al. Paranoid Thought Scales (GPTS) [5]. The GPTS consists of two 16-item subscales gauging ideas of social reference (e.g. ‘People definitely laughed at me behind my back.’) and ideas of persecution (e.g. ‘Certain individuals have had it in for me.’). The two subscales correlated 0.92. Participants reported how they felt over the past month using a 5-point rating scale (from 1 for not at all, to 5 for totally). Depressive symptoms were assessed with the Patient Health Questionnaire-9 (PHQ-9) [9]. The PHQ-9 targets the nine symptoms defining major depression (e.g. thoughts about self-harm) [4] and quantifies their severity [9]. Participants responded using a 4-point rating scale (from 0 for not at all, to 3 for nearly every day; 2-week time window). The PHQ-9 can be divided into an affective-cognitive subscale (items 1, 2, 6 and 9) and a somatic subscale (items 3, 4, 5, 7 and 8). The two subscales correlated 0.76 in this study. Data were analysed based on correlational analysis, cluster analysis, the Mann–Whitney U-test, the Pearson χ2 test and principal component analysis (PCA). In our cluster analysis, we used global burnout, paranoid ideation and depression as classifiers and relied on Schwarz’s Bayesian Information Criterion. The number of cluster(s) was not pre-specified. We conducted our analyses with IBM SPSS Statistics 25. Results A total of 218 schoolteachers were enrolled in this study (58% female; mean age: 47, standard deviation [SD] = 9). Participants were employed for 17 years on average (SD = 10). Burnout, depression and their subdimensions markedly correlated with paranoid ideation—rs ranging from 0.42 to 0.55, all Ps < 0.001 (Table 1). Paranoid ideation was increased by 185% in participants experiencing suicidal/self-injurious thoughts nearly every day compared with participants with no suicidal/self-injurious thoughts. Depression correlated moderately with DP (r = 0.42, P < 0.001; correlation corrected for measurement error: 0.50), strongly with global burnout (r = 0.77, P < 0.001; correlation corrected for measurement error: 0.86) and very strongly with EE (r = 0.86, P < 0.001; correlation corrected for measurement error: 0.96). EE correlated with the affective-cognitive and somatic symptoms of depression to a similar extent. Table 1. Means, SDs, Cronbach’s alphas (α) and zero-order correlations among the main study variables (N = 218) Mean SD α 1. 2. 3. 4. 5. 6. 7. 1. PHQ-9—depression (0–3) 0.60 0.58 0.89 – 0.92 0.96 0.77 0.86 0.42 0.52 2. Affective-cognitive depression (0–3) 0.45 0.58 0.82 – 0.76 0.73 0.79 0.42 0.49 3. Somatic depression (0–3) 0.72 0.65 0.82 – 0.72 0.81 0.38 0.49 4. MBI-ES—global burnout (0–3) 0.49 0.46 0.90 – 0.90 0.82 0.55 5. EE (0–3) 0.60 0.60 0.91 – 0.48 0.52 6. DP (0–3) 0.37 0.47 0.78 – 0.42 7. Paranoid ideation (1–5) 1.25 0.55 0.97 – Mean SD α 1. 2. 3. 4. 5. 6. 7. 1. PHQ-9—depression (0–3) 0.60 0.58 0.89 – 0.92 0.96 0.77 0.86 0.42 0.52 2. Affective-cognitive depression (0–3) 0.45 0.58 0.82 – 0.76 0.73 0.79 0.42 0.49 3. Somatic depression (0–3) 0.72 0.65 0.82 – 0.72 0.81 0.38 0.49 4. MBI-ES—global burnout (0–3) 0.49 0.46 0.90 – 0.90 0.82 0.55 5. EE (0–3) 0.60 0.60 0.91 – 0.48 0.52 6. DP (0–3) 0.37 0.47 0.78 – 0.42 7. Paranoid ideation (1–5) 1.25 0.55 0.97 – All correlations are statistically significant at P < 0.001. View Large Table 1. Means, SDs, Cronbach’s alphas (α) and zero-order correlations among the main study variables (N = 218) Mean SD α 1. 2. 3. 4. 5. 6. 7. 1. PHQ-9—depression (0–3) 0.60 0.58 0.89 – 0.92 0.96 0.77 0.86 0.42 0.52 2. Affective-cognitive depression (0–3) 0.45 0.58 0.82 – 0.76 0.73 0.79 0.42 0.49 3. Somatic depression (0–3) 0.72 0.65 0.82 – 0.72 0.81 0.38 0.49 4. MBI-ES—global burnout (0–3) 0.49 0.46 0.90 – 0.90 0.82 0.55 5. EE (0–3) 0.60 0.60 0.91 – 0.48 0.52 6. DP (0–3) 0.37 0.47 0.78 – 0.42 7. Paranoid ideation (1–5) 1.25 0.55 0.97 – Mean SD α 1. 2. 3. 4. 5. 6. 7. 1. PHQ-9—depression (0–3) 0.60 0.58 0.89 – 0.92 0.96 0.77 0.86 0.42 0.52 2. Affective-cognitive depression (0–3) 0.45 0.58 0.82 – 0.76 0.73 0.79 0.42 0.49 3. Somatic depression (0–3) 0.72 0.65 0.82 – 0.72 0.81 0.38 0.49 4. MBI-ES—global burnout (0–3) 0.49 0.46 0.90 – 0.90 0.82 0.55 5. EE (0–3) 0.60 0.60 0.91 – 0.48 0.52 6. DP (0–3) 0.37 0.47 0.78 – 0.42 7. Paranoid ideation (1–5) 1.25 0.55 0.97 – All correlations are statistically significant at P < 0.001. View Large Our cluster analysis revealed two participant profiles (Table 2), corresponding to ‘lower’ (Cluster 1) and ‘higher’ (Cluster 2) levels of symptom severity. The silhouette measure of cluster cohesion and separation was indicative of good cluster quality [10]. The Mann–Whitney U-test revealed an effect of cluster membership on depression and its subdimensions, burnout and its subdimensions and paranoid ideation, all Ps < 0.001. Effect sizes were large (Cohen’s ds ranging from 0.79 to 2.46). The two clusters did not differ in terms of age and length of employment. The Pearson χ2 test indicated that cluster membership was dependent on sex, P = 0.01. Cluster 2 contained a greater proportion of women than Cluster 1. Table 2. Characteristics of the identified clusters—with global burnout, depression and paranoid ideation as classifiers Cluster 1 Cluster 2 ‘Lower’ symptom severity, n = 174 (80%) ‘Higher’ symptom severity, n = 44 (20%) Mean SD Mean SD Mann–Whitney U-test (P-value) Cohen’s d PHQ-9—depression 0.38 0.29 1.47 0.62 *** 2.25 Affective-cognitive depression 0.26 0.30 1.19 0.80 *** 1.54 Somatic depression 0.48 0.37 1.69 0.59 *** 2.46 MBI-ES—global burnout 0.34 0.27 1.09 0.58 *** 1.66 EE 0.39 0.34 1.46 0.67 *** 2.01 DP 0.28 0.35 0.71 0.69 *** 0.79 Paranoid ideation 1.10 0.19 1.83 0.97 *** 1.04 Age 47.09 9.41 45.93 9.60 NS 0.12 Length of employment 17.02 10.73 17.23 9.40 NS 0.02 % % Pearson χ2 (P-value) Phi Female sex 53 75 * 0.18 Cluster 1 Cluster 2 ‘Lower’ symptom severity, n = 174 (80%) ‘Higher’ symptom severity, n = 44 (20%) Mean SD Mean SD Mann–Whitney U-test (P-value) Cohen’s d PHQ-9—depression 0.38 0.29 1.47 0.62 *** 2.25 Affective-cognitive depression 0.26 0.30 1.19 0.80 *** 1.54 Somatic depression 0.48 0.37 1.69 0.59 *** 2.46 MBI-ES—global burnout 0.34 0.27 1.09 0.58 *** 1.66 EE 0.39 0.34 1.46 0.67 *** 2.01 DP 0.28 0.35 0.71 0.69 *** 0.79 Paranoid ideation 1.10 0.19 1.83 0.97 *** 1.04 Age 47.09 9.41 45.93 9.60 NS 0.12 Length of employment 17.02 10.73 17.23 9.40 NS 0.02 % % Pearson χ2 (P-value) Phi Female sex 53 75 * 0.18 NS, non-significant. *P < 0.05, ***P < 0.001. View Large Table 2. Characteristics of the identified clusters—with global burnout, depression and paranoid ideation as classifiers Cluster 1 Cluster 2 ‘Lower’ symptom severity, n = 174 (80%) ‘Higher’ symptom severity, n = 44 (20%) Mean SD Mean SD Mann–Whitney U-test (P-value) Cohen’s d PHQ-9—depression 0.38 0.29 1.47 0.62 *** 2.25 Affective-cognitive depression 0.26 0.30 1.19 0.80 *** 1.54 Somatic depression 0.48 0.37 1.69 0.59 *** 2.46 MBI-ES—global burnout 0.34 0.27 1.09 0.58 *** 1.66 EE 0.39 0.34 1.46 0.67 *** 2.01 DP 0.28 0.35 0.71 0.69 *** 0.79 Paranoid ideation 1.10 0.19 1.83 0.97 *** 1.04 Age 47.09 9.41 45.93 9.60 NS 0.12 Length of employment 17.02 10.73 17.23 9.40 NS 0.02 % % Pearson χ2 (P-value) Phi Female sex 53 75 * 0.18 Cluster 1 Cluster 2 ‘Lower’ symptom severity, n = 174 (80%) ‘Higher’ symptom severity, n = 44 (20%) Mean SD Mean SD Mann–Whitney U-test (P-value) Cohen’s d PHQ-9—depression 0.38 0.29 1.47 0.62 *** 2.25 Affective-cognitive depression 0.26 0.30 1.19 0.80 *** 1.54 Somatic depression 0.48 0.37 1.69 0.59 *** 2.46 MBI-ES—global burnout 0.34 0.27 1.09 0.58 *** 1.66 EE 0.39 0.34 1.46 0.67 *** 2.01 DP 0.28 0.35 0.71 0.69 *** 0.79 Paranoid ideation 1.10 0.19 1.83 0.97 *** 1.04 Age 47.09 9.41 45.93 9.60 NS 0.12 Length of employment 17.02 10.73 17.23 9.40 NS 0.02 % % Pearson χ2 (P-value) Phi Female sex 53 75 * 0.18 NS, non-significant. *P < 0.05, ***P < 0.001. View Large In order to further examine the relationships between burnout, depression and paranoid ideation, we conducted a subscale-level PCA that included EE, DP, affective-cognitive depression, somatic depression, ideas of social reference and ideas of persecution. A promax (oblique) rotation was used. Our PCA resulted in a two-component solution (Kaiser-Meyer-Olkin measure of sampling adequacy = 0.78; Bartlett’s test of sphericity: P < 0.001; explained variance: 80%). The first component included EE, affective-cognitive depression and somatic depression (loading indices > 0.90). The second component included ideas of social reference and ideas of persecution (loading indices > 0.95). DP showed cross-loadings, with a loading index of 0.38 on the first component and a loading index of 0.33 on the second component. The two components correlated 0.54. Discussion A substantial association was found between paranoid ideation and burnout, in keeping with the pioneering work conducted on the syndrome [8]. Interestingly, EE—the core of burnout—correlated about as strongly with paranoid ideation as it correlated with DP, suggesting that paranoid ideation could be considered a component of the burnout syndrome as much as DP. Indeed, by definition, a syndrome refers to a combination of co-occurring symptoms characterizing a given condition [4]. If EE, the central characteristic of burnout, is accompanied by paranoid ideation as often as it is accompanied by DP, then the reason for including DP, and not paranoid ideation, in the definition of burnout is unclear. Consistent with recent research findings [6,11], depressive symptoms—including thoughts of self-harm—were also associated with paranoid ideation. Our study does not support the view that burnout is distinct from depression [1]. Firstly, the correlation of EE with depression was close to 1; EE showed a strong correlation with both the affective-cognitive and somatic symptoms of depression. Consistent with these results, our PCA showed that EE loaded on the same component as the affective-cognitive and somatic subscales of the PHQ-9. Secondly, EE correlated much more strongly with depression than with DP, a finding inconsistent with the claim that EE and DP form a differentiated syndrome that excludes (or does not primarily include) depressive symptoms. Thirdly, burnout and depression were similarly associated with paranoid ideation, a result suggestive of overlapping nomological networks. While our study contributes to burnout research, it is limited by its cross-sectional design, the use of self-reported measures and the indeterminate response rate. There may also be bias due to the ‘healthy worker effect’. Another limitation is that we relied on convenience sampling. Longitudinal studies are needed in order to further clarify the relationships between paranoid ideation, burnout and depression. Diary studies, in which people provide frequent reports on the events and experiences of their daily lives [12], may also be useful in order to better understand how they are interrelated. Because paranoid ideation involves threat overestimation and lower social support [6], it is likely to play a role in the moment-to-moment, ‘micro-level’ dynamics of burnout/depressive symptoms. Key points Burnout is substantially associated with paranoid ideation. Emotional exhaustion is as closely related to paranoid ideation as it is related to depersonalization. The discriminant validity of burnout and depression is unsatisfactory. Competing interests None declared. References 1. Maslach C , Leiter MP . Early predictors of job burnout and engagement . J Appl Psychol 2008 ; 93 : 498 – 512 . Google Scholar Crossref Search ADS PubMed 2. 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Diary methods: capturing life as it is lived . Annu Rev Psychol 2003 ; 54 : 579 – 616 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Journal
Occupational Medicine – Oxford University Press
Published: Feb 7, 2019