Burnout in firefighters: a word on methodology.

Katsavouni et al. [1] examined burnout, post-traumatic stress disorder and work-related injuries in Greek firefighters. The authors found that 20% of the firefighters in their sample met criteria for burnout as treated as a nosological entity. To receive a diagnosis of burnout, scores on the emotional exhaustion, depersonalization and personal accomplishment subscales of the Maslach Burnout Inventory had to be above or below certain thresholds. At least three methodological problems affect the study. First, there are currently no diagnostic criteria for burnout [2], neither in the DSM-5, nor in the ICD-10. Second, although for any study, a critic could assert that a key variable was omitted, we believe that one extremely important variable was indeed omitted from this study, namely, depression. While Katsavouni et al. [1] defined burnout as ‘a long-term reaction to occupational stress’, there is a great deal of evidence that depressive symptoms and disorders develop in response to exposure to occupational stressors [3–8]. Moreover, evidence that depression subsumes burnout has been mounting [9– 12]. Ahola et al. [9] and Bianchi et al. [12] found that burnout and depressive symptoms increase or decline commensurately over time. Ahola et al. [9] concluded that ‘burnout could be used as an equivalent to depressive symptoms in work life’ (p. 35). Bianchi et al. [12] suggested that the burnout-depression distinction is ‘symptomatic of different scientific traditions, rather than of different pathological phenomena’ (p. 1010). Thus, there is no need to multiply constructs when the long-studied construct depression can serve researchers well. It is noteworthy that several firefighters who experienced traumatic events (e.g. death of a child) mentioned experiencing depression regarding their feelings of responsibility. Judging from Table 2, none mentioned burnout. Third, the authors did not control for relevant nonoccupational factors such as stressors occurring outside of work. To be able to conclude that the symptoms under examination were specifically related to work, it is necessary to take into account the stressors experienced in other life domains. For instance, burnout is associated with personal/stressful life events (e.g. a loved one suffering a major illness) [11,13]. In our view, research assessing dispositional (e.g. personality variables) and situational (both occupational and non-occupational) factors is needed in occupational medicine so that clear conclusions can be drawn regarding the influence of work-related exposures in the emergence of burnout/depression.