Burnout in Indian Psychiatrists.

BACKGROUND: Individuals associated with service providing and decision-taking are prone for stress leading to burnout. AIM: The aim of this study is to find out the details of burnout among Psychiatrists in India.
MATERIALS AND METHODS: Copenhagen Burnout Inventory (CBI) with structured biodata sheet was sent to the representative sample of psychiatrists by e-mail. Basic statistical analysis was done to find out prevalence, analyze response pattern, and differences between those with and without burnout.
RESULTS: The number of psychiatrists that responded to survey was 110-81 (74%) male and 29 (26%) female. The number of burnout cases in one or other spheres was 51 in 35 psychiatrists accounting for the prevalence of 46%. 32% of psychiatrists have burnout. Four psychiatrists have burnout in all three dimensions, nine in two dimensions, and 22 in one dimension. Personal burnout topped in the three dimensions (63%) followed by work burnout (24%). Patient burnout was least at 14%.
CONCLUSIONS: Burnout, though not very high, is to be taken seriously by Indian psychiatrists and protective and preventive measures are in order.

INTRODUCTION

There is no profession without stress and tension, which differs from profession to profession and person to person. Professions involving guidance, decision-making, etc., are more prone to it. Even in these professions, it will not be the same and depends on the individual, conditions of work, work environment, socioeconomic background, etc. Depending on numerous factors, occupation can lead to a condition known as Burnout Syndrome (BS) – exhaustion of physical or emotional strength or motivation usually because of prolonged stress or frustration.[1] There is all round feeling of drained-out with the individual becoming mechanical. BS is not depression or anxiety disorder. BS can occur in any profession but most frequently occurs in the caring professions.[2] Among medical specialties, emergency medicine (>50%) tops the list immediately followed by critical care medicine (50%). Psychiatry, ophthalmology, pediatrics, and rheumatology are at the lower end – 33%.[3] Because of universal concern, it was extensively studied. With higher stakes, ambitions, expectations the stress has increased all round in Indian medical profession that can lead to BS in the vulnerable. The toll of BS is heavy not only on the individual but society also. The consequences of BS varies – it effects personal, family, professional, and social life of the individual. The earlier concern toward patient will not be there, interaction with colleagues will be superficial, and marital discord will be common. Relationship with colleagues and staff working under will be strained. Professional performance will not be the same as earlier.

Kristensen et al. presented a new tool for the measurement of burnout in 2005 – the Copenhagen Burnout Inventory (CBI).[4] CBI is a public domain questionnaire measuring the degree of physical and psychological fatigue experienced in three subdimensions of burnout: personal, work-related, and client (patient in the present case)-related burnout. PUMA study[4] (project on burnout, motivation, and job satisfaction) analyses indicate very satisfactory reliability and validity for the CBI instrument. The CBI had acceptable reliability (internal consistency and homogeneity) as well as factorial and criterion-related validity.[5] Personal burnout is defined as the degree of physical and psychological fatigue and exhaustion experienced by the person; work burnout is degree of physical and psychological fatigue, and exhaustion that is perceived by the person as related to his/her own work and Patient burnout is a degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work with patients.[4]

MATERIALS AND METHODS

Data of psychiatrists – name, place, mail ID, and phone numbers were collected from various associations and sources. A questionnaire about details of the doctor was prepared. To avoid mechanical answering, CBI scale was jumbled and additional nonscoring questions were added. The questioner containing details of the psychiatrist and CBI scale was sent as attachment to the representative sample of psychiatrists. When there was no response, reminders by personal phone/mail/SMS/WhatsApp was done. If still there was no response, mails were sent to other persons in the selected list till the target size was achieved and colleagues from the area were approached to get the data from the concerned. A case was considered as BS, if the average score in any dimension is fifty and above. All the responses in CBI were clubbed. Simple statistics were applied to find out characteristics of burnout persons. Comparison was made between those with and without burnout in the variables – gender, age, marital and spouse status, qualification, experience, commitment and support system, habits, exercise, work effect, appreciation, talent utilization, earning mismatch, and satisfaction. The data were entered in Excel Spreadsheet and analysis was done using statistical packages.[67] The three dimensions of burnout were analyzed using basic statistics, ANOVA of burnout – between and within groups and post hoc test of multiple comparisons with personal burnout as dependent variable.

RESULTS

Response rate for the e-mail survey with personal follow-up was 68%. Data from 110 to 81 (74%) male and 29 (26%), psychiatrists were analyzed. The number of burnout cases in one or other spheres was 51 in 35 psychiatrists – 25 (71%) male and ten (29%) female, accounting for 46%. There were no nonresponders (not answering three or more questions in each dimension). Four psychiatrists have burnout in all three dimensions, nine in two dimensions, and 22 in one dimension. Analysis was done with both the sexes combined as there was no difference between sexes in burnout.

Personal burnout topped in three subdimensions of burnout followed by work burnout.

Table 1 gives burnout cases and score details for the three categories – personal, work, and patient Burnout.

Table 1

Burnout cases and score details for the three-dimensions – personal, work, and patient burnout (n=110)

Table 2 gives response pattern to questions in the three dimensions in personal, work, and patient Burnout.

Table 2

Response pattern to questions in the three-dimensions – personal, work, and patient burnout (n=110)

Table 3 gives ANOVA of burnout – between and within groups.

Table 3

ANOVA of burnout – between and within groups (n=110)

Table 4 gives post hoc test of multiple comparisons with personal burnout as dependent variable.

Table 4

Post hoc test of multiple comparisons with personal burnout as dependent variable

Table 5 gives details of variables with no difference with and without Burnout.

Table 5

Details of variables with no difference with and without burnout

Table 6 gives details of variables with difference with and without Burnout.

Table 6

Details of variables with difference with and without burnout

DISCUSSION

It was reported that response from psychiatry was lowest at 27.1% with an overall survey response rate of 35.0% where survey was through the Internet using a well-known and established survey company (www.surveymonkey.com), and multiple methods were used to encourage survey response such as individual personalized e-mail invitations, multiple reminders, and a draw for three gift certificate prizes were used to increase response rate.[8] The present high response rate despite not using incentives may be due to the uncharted topic of BS in Indian Psychiatrists that roused their curiosity prompting them to respond.

It was reported that psychiatrists are at considerable risk for burnout − 25% to 57% of the profession at any given time.[9] Comments gathered in a national survey of community mental health center psychiatrists indicate that many suffer from burnout.[1011] The present study agrees with the report that the least burned-out physicians are dermatologists (37%), psychiatrists (38%), and pathologists (39%),[12] and other studies from Canton of Zurich, Switzerland (18%).[13] Those who have not responded, in spite of assurances of doing so on contact reminders – telephonic, SMS, WhatsApp, or mail might have been cases of burnout not willing to come out.

The ANOVA shows difference in the three dimensions of burnout. In addition, the pair-wise burnout pattern for the three dimensions, tabulated in multiple comparisons, show clear-cut differences pair-wise that are highly significant. This indicates that the three can be mutually inclusive or exclusive giving them individual status.

The present study agrees with the observation that supportive relationships, extracurricular activities by way of exercise, yoga, a positive attitude toward one's work, and high job satisfaction.[1415]

Psychiatrists, as a group are vulnerable to experiencing burnout, and the factors that make psychiatry a stressful profession include factors such as patient violence and suicide, limited resources, crowded inpatient wards, changing culture in mental health services, high work demands, poorly defined roles of consultants, responsibility without authority, inability to effect systemic change, conflict between responsibility toward employers versus toward the patient, and isolation.[16] As psychiatrist, one sees the lowest of human relationships, base behavior, breakdown of relations, etc., which can be thought of as additional contributory factors for BS. Emergency, critical care, terminal care, and oncology doctors (and nursing staff) stare at death almost in every case which can explain high burnout in those branches. Psychiatrists stare at almost living death of patient – figuratively in patients and caregivers, in addition to prolonged misery, stigma, and social ostracizing. These are sure recipes for burnout. Medical practice in India, more so psychiatric practice, is relatively free from patient and family litigation till now. This is fast changing and this could be an additional contributory factor in the future.

The International Classification of Diseases, Tenth Revision (ICD-10) codes burnout under Z73 – problems related to the life-management difficulty that excludes problems related to socioeconomic and psychosocial circumstances. It is coded as Z73.0 burnout include state of vital exhaustion.[17] Nevertheless, it has not come under the net of psychiatry till now.

Psychiatrists working in Mental hospitals or having psychiatric hospitals with many inpatients have different stressors than psychiatrists who see only outpatients. This is a mixed sample as it consists of all types of psychiatrists – consultation, inpatient caring, academic, etc., with different work environment, targets, pressure, etc., and hence the results may be deceptive. The psychiatrists in the former category may be more liable for burnout and no effort was made to analyze from that angle.

There were questions about the diagnosis of burnout as a separate entity.[181920] Irrespective of the arguments for and against the entity and notwithstanding the fact of it being an ICD-10 entity, one should take note of the fact that many psychiatrists have potential for BS as measured by an acknowledged instrument. Two Indian studies relating to medical profession used CBI – one in residents in a tertiary hospital[21] and another in psychiatric nurses.[22] The consequences of BS can be devastating – higher suicide rates than those of the general population and higher rates of divorce and substance abuse compared with other physicians and nonphysicians.[23] These should make the profession alert. Whatever may be the status of the entity, quantum of prevalence, Indian Psychiatrists should be on guard. It is immaterial what exactly is the prevalence of burnout in psychiatry vis-à-vis other branches of medicine as a burnout psychiatrist can cause more long-term damage to the patient than other branches. Looking at it another way nearly a third of patients – assuming that to be the proportion of patients seen by these psychiatrists is at risk. The profile of the BS psychiatrist in India seems to be that of a person with less exercise, vacation, support system, antianxiety, sedative resorting, with work effecting family/social life, unappreciated, unsatisfied, underutilized services, and mismatched earnings.

This is the first-time assessment of burnout in Indian Psychiatrists. The drawbacks of the survey include noninclusion of other variables such as work condition details. Even though representative, the study might have missed burnout cases as severely burnout might not be inclined to respond. Further, there was no way to detect false responses (lie-detect questions were not there).

CONCLUSIONS

Indian psychiatrists need protective measures against burnout.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.