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Job strain, burnout, and depressive

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DOI: 10.1016/j.jad.2007.03.004 Source: PubMed

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Research report
Job strain, burnout, and depressive symptoms:
A prospective study among dentists
Kirsi Ahola , Jari Hakanen
Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A, FI-00250 Helsinki, Finland
Received 30 November 2006; received in revised form 13 March 2007; accepted 13 March 2007
Available online 19 April 2007

Abstract

Background: Burnout has been presented as an antecedent of depression, but longitudinal data are lacking. We investigated
whether burnout mediates the association between job strain and depressive symptoms.
Methods: Two surveys were conducted. In 2003, 71% of Finnish dentists were reached, and the response rate of the 3-year follow-
up was 84% (n = 2555). Burnout was measured with the Maslach Burnout Inventory and depressive symptoms with the Beck
Depression Inventory. The sequences job strainburnoutdepressive symptoms and job straindepressive symptomsburnout
were investigated with logistic regression analyses.
Results: Of the burnout sufferers without depressive symptoms at baseline, 23% reported depressive symptoms at follow-up. The
adjusted odds ratio of burnout for depressive symptoms was 2.6 (95% CI 2.03.5). The effect of job strain on depressive symptoms
had an OR of 3.4 (95% CI 2.05.7), but it disappeared when adjusted for burnout. Of those who had depressive symptoms without
burnout at baseline, 63% had burnout at follow-up. The adjusted odds ratio of depressive symptoms for burnout was 2.2 (95% CI
1.43.4). The effect of job strain on burnout had an OR of 27.9 (95% CI 6.5120.2) for the men and 4.9 (95% CI 2.59.6) for the
women. These effects remained significant after adjustment for depressive symptoms.
Limitations: The study was conducted among one occupational group.
Conclusions: There is a reciprocal relationship between burnout and depressive symptoms. Job strain predisposes to depression
through burnout. In comparison, job strain predisposes to burnout directly and via depression.
2007 Elsevier B.V. All rights reserved.

Keywords: Job strain; Burnout; Depression; Dentists; Prospective study

1. Introduction hausted from excessive demands on energy, strength or

In 1974, psychiatrist Herbert Freudenberger (1974)
described a negative occupational phenomenon among
dedicated volunteers working in a clinic for drug ad-
dicts: Burnout meant that a staff member became ex-
Corresponding author. Tel.: +358 30 474 2492; fax: +358 30 474 2552.
E-mail address: kirsi.ahola@ttl.fi (K. Ahola).
0165-0327/$ - see front matter 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2007.03.004
resources about a year after he or she began working.
Among the physical and behavioural signs, the volun-
teer looked, acted and seemed depressed.
In 1976, Christina Maslach (1976), a researcher in
social psychology, wrote about how professionals in
health and social services can lose all emotional feelings
and concern for their clients after months of listening to
their problems. On the basis of her interviews, burnout
104 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110
occurred when helpers were unable to cope with
continuous emotional stress. Burnout was found to
correlate with mental illness.
Since the development of the Maslach Burnout
Inventory (MBI) (Maslach and Jackson, 1981; Maslach
et al., 1996), occupational burnout has been extensively
studied, and several formulations of the syndrome have
been presented (Shirom, 2003). Even though no final
consensus for the definition of burnout (Cox et al.,
2005) or no binding diagnostic criteria for its assessment
(Weber and Jaekel-Reinhard, 2000) have been estab-
lished, occupational burnout is unanimously regarded as
a consequence of chronic work-related stress (Maslach
et al., 2001). Among researchers, there has been quite
wide consensus of how to measure burnout, since over
90% of all burnout studies have employed the Maslach
Burnout Inventory (Schaufeli and Enzmann, 1998).
Burnout is quite common in developed countries
(Schaufeli and Enzmann, 1998; Maslach et al., 2001;
Ahola et al., 2005; Shirom, 2005). It has been shown to
associate with physical illnesses (Honkonen et al., 2006)
and depressive disorders (Ahola et al., 2005) and to
predict medically certified sickness absences (Toppinen-
Tanner et al., 2005).
The job strain model (Karasek, 1979) is the most
influential conceptualization of work stress in occupa-
tional health research. The dimensions of this model,
psychological job demands and job control, and
especially the combination of high demands and low
control (called job strain) have predicted serious health
consequences (Kivimki et al., 2002; de Lange et al.,
2003; Belkic et al., 2004; Kivimki et al., 2006). High
job demands and low control have also predicted
psychiatric morbidity (Stansfeld et al., 1997, 1999;
Niedhammer et al., 1998; Paterniti et al., 2002), but
evidence on the mental health effects of job strain has
not been consistent (Cropley et al., 1999; de Lange et al.,
2003; Ylipaavalniemi et al., 2005).
Only cross-sectional associations between job strain
and burnout have been tested, and these studies have
lent support to the association (van der Doef and Maes,
1999; Ahola et al., 2006). Burnout has been predicted by
various psychosocial work characteristics (Kalimo et al.,
2003; Borritz et al., 2005) and is thought to result
especially from the combination of high demands and
low resources at work (Schaufeli and Bakker, 2004).
The strong association between burnout and depres-
sion (Glass and McKnight, 1996; Ahola et al., 2005) has
raised questions about their conceptual overlap and
redundancy. When the concepts of burnout and
depression are examined on the basis of appearance,
biomarkers, developmental process and statistical asso-
ciations, both similarities and differences arise (Golem-
biewski et al., 1992; Maslach and Schaufeli, 1993;
Leiter and Durup, 1994; McKnight and Glass, 1995;
Maier and Watkins, 1998; Schaufeli and Enzmann,
1998; Bakker et al., 2000; Brenninkmeyer et al., 2001;
Iacovides et al., 1999, 2003; Toker et al., 2005,
Middeldorp et al., 2006). On the basis of the evidence,
it can be concluded, that even though burnout and
depression are highly related and share common
features, they are not completely redundant.
One possible explanation for the partial overlap be-
tween burnout and depression is that burnout mediates
the relationship between psychosocial work character-
istics and depression. This explanation has been sup-
ported by cross-sectional data among general population
(Ahola et al., 2006). In cross-sectional settings, burnout
has also been shown indirectly to lead to depression
(Leiter and Durup, 1994; Bakker et al., 2000). Fur-
thermore, psychiatric symptoms have been shown to
increase and mental health to deteriorate, as burnout
advances (Golembiewski et al., 1992). In addition, the
more severe burnout was, the closer it was qualitatively
to depression according to the symptoms (Iacovides
et al., 2003). However, to our knowledge, there are no
prospective studies on the temporal relations between
the psychosocial characteristics of work, burnout, and
depression.
The aim of our study was to investigate whether
burnout mediated the relationship between job strain
and depression in a 3-year follow-up study among
Finnish dentists (Fig. 1). A fully mediated effect
between job strain, burnout, and depression can be
established if the following criteria are met (Kenny,
2005): (1) burnout predicts depression, (2) job strain
predicts burnout, and (3) job strain predicts depression,
but not after burnout is adjusted for. Similarly, we also
investigated the possible reversed effect, i.e. whether
depression mediates the relationship between job strain
and burnout (research model B in Fig. 1).
2. Methods
2.1. Participants and procedure
This study was part of a longitudinal research project
that focused on psychosocial working conditions,
workfamily interface, well-being, and health in
dentistry (Hakanen, 2004; Hakanen and Perhoniemi,
2006). In 2003, a questionnaire survey was aimed at
every dentist who was a member of the Finnish Dental
Association (FDA) (n = 4588). About 98% of the
working-aged dentists employed in clinical work in
 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110
Finland belong to the FDA (FDA 2005). Altogether,
3255 (71%) dentists responded to the questionnaire at
baseline, and 2555 of those identified 3 years later
(n = 3035) responded to the follow-up in 2006 (84%). In
2003, the respondents represented all Finnish dentists in
terms of age and sex (Hakanen et al., 2005). The
participants of the follow-up study accounted for 57% of
the dental profession in Finland. The respondents at
baseline and follow-up did not differ from the non-
respondents at follow-up with respect to the level of
burnout or depressive symptoms.
2.2. Measures
Burnout was measured with the Maslach Burnout
Inventory (MBI), which has high reliability and validity
(Maslach et al., 1996). The MBI consists of 22 items in
three subscales: emotional exhaustion (9 items), deper-
sonalization (5 items), and personal accomplishment (8
items). The items were scored on a 7-point frequency
rating scale ranging from 0 (never) to 6 (daily). High
scores on emotional exhaustion and depersonalization
and low scores on personal accomplishment are
indicative of burnout. The items of personal accom-
plishment were reversed. We included persons with a
maximum of two missing values on the emotional
exhaustion scale, one missing value on the cynicism
scale, and two missing values on the personal accom-
plishment scale. The missing values of a respondent
were replaced by the mean of the existing values of the
respondent on the dimension in question. The reliability
(Cronbach's ) of the whole inventory was 0.89.
Fig. 1. The research models to test mediational relationships between job strain, burnout, and depression.
105
In order to assess the level of burnout, we calculated a
weighted sum score of the dimensional scores so that
exhaustion, depersonalization and diminished personal
accomplishment had different weights in the syndrome
(Kalimo et al., 2003). This syndrome indicator was derived
with the help of a discriminant function analysis in which
various health-related indicators were used as dependent
variables (Kalimo and Toppinen, 1997). Coefficients were
formed by weighing each dimension so that the scores
corresponded to the original response scale (0.4 exhaus-
tion + 0.3 depersonalization + 0.3 diminished personal
accomplishment). Burnout was categorized as follows:
no burnout (scores 01.49), mild burnout (scores 1.50
3.49), and severe burnout (scores 3.506). This categori-
zation meant that burnout was severe when symptoms
were experienced approximately once a week or daily,
they were mild when symptoms existed monthly, and there
was no burnout when the symptoms were experienced
only a few times a year or never (Kalimo et al., 2003).
Burnout was dichotomized as no versus mild to severe.
The short form of the Beck Depression Inventory
(BDI) was used to assess depression (Beck and Beck,
1972). It consists of 13 items that are scored from 0 to 3
( = 0.84). An acceptable answer was expected for at
least 11 items. Missing values (2 at the most) were
replaced by the mean of the existing values for that
particular respondent. A sum score for the depressive
symptoms was then calculated. Depressive symptoms
were categorized as no (04 points), mild (57 points),
moderate (815 points), and severe (1639 points)
(Beck and Beck, 1972). Depression was dichotomized
as no versus mild, moderate or severe.
106 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110

Job strain was measured with the Job Content 3. Results

Questionnaire (JCQ) (Karasek et al., 1998). A short
scale of job demands comprised three items ( = 0.79; The dentists were mostly women (74%), married or
e.g. My job requires working very fast), and the scale cohabiting (84%), and in permanent employment
for job control had nine items ( = 0.85) (e.g., My job (94%). Table 1 shows also that a slight majority of
allows me to make a lot of decisions on my own; My participants worked full-time (63%) and in the public
job requires a high level of skills). Responses were sector (62%). Of all participants, 51% were free of
given on a 5-point scale ranging from 1 (strongly agree) burnout and 72% were free of depressive symptoms at
to 5 (strongly disagree). We created an indicator for job baseline (Table 2).
strain as a continuous quotient of job demands distrib-
uted by job control (Landbergis et al., 1994). 3.1. Research model A: job strain burnout depression
Information on age, sex, marital status, professional
sector (private/public), type of employment (permanent/ The dentists who were free of depressive symptoms
fixed-term), job tenure, supervisory position (no/yes), but reported symptoms of burnout at baseline, showed
and working hours were included in the questionnaire. depressive symptoms at follow-up in 23% of the cases
Age was categorized as under 36, 3645, 4655, and
over 55 years. Marital status was categorized as married
or cohabiting, divorced or widowed, and unmarried. Job Table 1
tenure was categorized as under 5, 59, 1019, 2029, Baseline characteristics of the study population (n = 2555)
and over 29 years. Working hours were categorized as
Characteristic n (%)
full-time (at least 35 h a week), shortened (2534 h a
Sex
week), and part-time (no more than 24 h a week).
Women 1883 (74)
Men 672 (26)
2.3. Statistical analysis Age
2635 years 384 (15)
The entire study sample was described with distribu- 3645 years 898 (35)
4655 years 884 (35)
tions of sociodemographic factors, work characteristics,
5673 years 389 (15)
burnout, and depression. Among those who were free of Marital status
depressive symptoms at baseline, binary logistic regression Unmarried 179 (7)
analyses were used to explore the prospective associations Married or cohabiting 2143 (84)
concerning the research model A (Fig. 1): between burnout Divorced or widowed 220 (9)
Missing data 13 (1)
at baseline and depression at follow-up (path 1), between
Professional sector
job strain at baseline and burnout at follow-up (path 2), and Public 1578 (62)
between job strain at baseline and depression at follow-up Private 956 (37)
(path 3). The analyses were adjusted for sex, age and Missing data 21 (1)
marital status. The final adjustment included also burnout at Employment
Permanent 2392 (94)
baseline as a continuous variable in the models with job
Fixed-term 141 (6)
strain. Interaction term was applied in the models to test Missing data 22 (1)
whether job strain had an interaction effect with sex on Job tenure
depression. 04 years 144 (6)
Concerning the research model B among those who 59 years 304 (12)
1019 years 805 (32)
were free of burnout at baseline (Fig. 1), the prospective
2029 years 860 (34)
associations between depression at baseline and burnout 30 years or more 431 (17)
at follow-up (path 4), job strain at baseline and depression Missing data 11 (0)
at follow-up (path 5), and job strain at baseline and Supervisory position
burnout at follow-up (path 6) were also analysed with Yes 677 (26)
No 1790 (70)
binary logistic regression models, which were adjusted for
Missing data 88 (3)
sex, age and marital status. The final adjustment included Working hours
depression at baseline as a continuous variable in the Full-time 1606 (63)
models with job strain. Interaction term was applied to the Shortened 542 (21)
models to test whether job strain had an interaction effect Part-time 386 (15)
Missing data 21 (1)
with sex on burnout.
 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110 107

Table 2 Table 4
Job strain, burnout and depression at baseline and at follow-up Prospective associations of job strain at baseline for burnout at 3-year
(n = 2555) follow-up
Baseline Follow-up Model 1 Model 2
Job strain, mean (S.D.) 0.78 (0.28) 0.81 (0.30) Sex n/cases OR (95% CI) OR (95% CI)
Missing data, n (%) 139 (5) 135 (5)
Men 337/71 27.87 (6.46120.2) 22.31 (5.0898.07)
Burnout, n (%)
Women 861/238 4.87 (2.469.64) 3.99 (1.997.99)
No 1313 (51) 1173 (46)
Mild 1120 (44) 1194 (47) Model 1 adjusted for sex, age and marital status at baseline.
Severe 56 (2) 68 (3) Model 2 adjusted for sex, age, marital status and depression at
Missing data 66 (3) 120 (5) baseline.
Depression, n (%) OR indicates odds ratio.
No 1840 (72) 1774 (69) CI indicates confidence interval.
Mild 350 (14) 382 (15)
Moderate 296 (12) 291 (11)
Severe 28 (1) 28 (1)
Missing data 41 (2) 80 (3) 3.2. Research model B: job strain depression burnout
S.D. indicates standard deviation.
Among the dentists who were free of burnout at
baseline, but reported depressive symptoms, burnout
compared with 10% of those who did not report burnout was present at follow-up in 63% of the cases compared
symptoms at baseline. In this sub-population the with 20% among those who did not show symptoms of
adjusted probability of showing depressive symptoms depression at baseline. In this sub-population the
at follow-up after having burnout at baseline was 2.6- adjusted probability of having burnout at follow-up
fold (95% CI 2.03.5) compared to not having burnout after having experienced depressive symptoms at
at baseline (path 1 in Fig. 1). baseline was 2.2-fold (95% OR 1.43.4) compared to
Job strain predicted burnout among those free of the situation of not having experienced depressive
depression at baseline (path 2 in Fig. 1). The adjusted symptoms at baseline (path 4 in Fig. 1).
probability of having burnout was 11.8-fold (95% CI 7.4 Job strain predicted depression among those free of
18.7) for each one-point increase in job strain score in this burnout at baseline. The adjusted probability of having
group of dentists. When the level of burnout at baseline depression was 7.5-fold (95% CI 3.515.9) for each
was also adjusted for in the final model, the probability of one-point increase in job strain score (path 5 in Fig. 1).
having burnout at follow-up decreased but remained When the level of depression at baseline was adjusted
statistically significant (OR 1.8, 95% CI 1.043.1). for in the final model, the probability of showing de-
Table 3 shows that job strain predicted also pression at follow-up decreased but remained statisti-
depression (path 3 in Fig. 1). When the level of burnout cally significant (OR 4.8, 95% CI 2.111.0).
at baseline was adjusted for in the final model, the effect A significant interaction (p = 0.03) between sex and
of job strain on depression disappeared, thus showing strain was found in the model of strain on burnout in this
that burnout fully mediated the impact of job strain on sub-group. Table 4 shows that job strain predicted
depressive symptoms. There were no significant inter- burnout both among the men and among the women
actions (p N 0.3) between sex and strain in the models for (path 6 in Fig. 1). After adjustment for the level of
depressive symptoms. depression at baseline, these relationships decreased but
remained statistically significant. This result indicates
that job strain had a direct as well as an indirect effect
Table 3 through depressive symptoms on burnout.
Prospective associations of job strain at baseline for new cases of
depression at 3-year follow-up 4. Discussion
Total Model 1 Model 2
n/cases To our knowledge, this is the first study to investigate
OR (95% CI) OR (95% CI)
Job strain 1684/242 3.39 (2.035.66) 1.30 (0.732.30) the temporal relationship between job strain, occupa-
tional burnout and depressive symptoms in a prospective
Model 1 adjusted for sex, age and marital status at baseline.
Model 2 adjusted for sex, age, marital status and burnout at baseline.
setting. We found that the effects between burnout and
OR indicates odds ratio. depression are reciprocal: Occupational burnout pre-
CI indicates confidence interval. dicted new cases of depressive symptoms and depression
108 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110
predicted new cases of burnout. In addition, burnout
mediated fully the relationship between job strain and
depression. This means that after controlling for the
mediating effect of burnout, there was no direct
relationship between job strain and the incidence of
depression; job strain was related to burnout, which in
turn was related to depression. Instead, depression
mediated only partially the relationship between job
strain and burnout indicating both direct and mediated
relationship between job strain and burnout.
On the basis of the present study, it seems possible that
occupational burnout is a phase in the development of
work-related depression. This view has earlier been
supported by cross-sectional data on the general popula-
tion (Ahola et al., 2006). The results of our study agree also
with earlier studies showing burnout to mediate between
psychosocial factors and health. In these studies, health
was indicated by the duration of company-registered
sickness absences (Bakker et al., 2003), psychosomatic
health complaints (Schaufeli and Bakker, 2004), and self-
rated health and work ability (Hakanen et al., 2006).
In addition to burnout leading to depression, depres-
sion also predisposed to burnout. There are at least two
main mechanisms to explain this reversed effect (de
Lange et al., 2004). Firstly, those who are depressed
probably have lower resources to meet the demands of
their work, and this situation predisposes them to burn-
out. Secondly, it is possible that those who are depressed
perceive and evaluate their situation at work more nega-
tively than those who are free of depression. On the basis
of the present study, the path of job strain predisposing to
depression through experienced burnout appear stronger
than the path of job strain predisposing to burnout via
depression.
The extent to which burnout differs from depressive
symptomatology has been debated in the past (Taris,
2006). In studies conducted to rule out the possibility of
redundancy, it has been recommended to include well-
validated measures of burnout and depressive symptoms
to ascertain that burnout and its correlates are not due to the
effects of depression (Shirom, 2005). The present longitu-
dinal study supports the distinction between burnout and
depression phenomena. Furthermore, it contradicts the
suggestion of burnout and depression developing from the
same risk factors simultaneously, in tandem, as
McKnight and Glass (1995) have suggested on the basis
of their small sample (n = 100) of nurses. However, further
research is needed to fully understand the cross-lagged
reciprocal associations between burnout and depression.
As a risk factor for burnout, job strain was emphasized
especially among healthy men in our study. The impact of
chronic stressors and psychosocial factors on health has
generally been stronger for women than for men (Denton
et al., 2004). However, work-related factors such as high
job strain and occupational burnout have associated with
mental disorders especially among men (Ahola et al.,
2005; Virtanen et al. 2007). This finding may reflect the
significance work has in men's lives.
At least two limitations of this study are noteworthy.
Firstly, this study was based on survey data that present
problems of self-report bias and common method var-
iance (Lindell and Whitney, 2001). However, variance in
self-report measures of job conditions has been largely
attributed to variations in the objective work environ-
ment (Spector, 1992). Subjective evaluation of work
characteristics has also been shown to be more strongly
related to mental well-being than objective evaluation is
(Stansfeld et al., 1999). Still, it is well-known that com-
mon method variance may artificially inflate associa-
tions through factors such as negative affectivity and
social desirability (Parkes, 1990; Heinisch and Jex,
1997). Ahola et al. (2006) found that a relationship
between high job strain and depression, as well as be-
tween burnout and depression, appeared regardless of
the depression measure used, although the associations
were stronger with self-reported variables than with the
use of a structured psychiatric interview. Thus we argue
that it is unlikely that common method variance has
caused major confounding in our study, which employed
a prospective design, included only healthy workers at
baseline concerning the outcome variable, and con-
trolled for the baseline values with respect to the med-
iating variable. Nevertheless, the impact of common
method variance should be further examined in future
research by combining other measures with self-report
inventories in a prospective setting.
Secondly, the study population comprised only one
occupational group, the dentists. Our sample was large
and representatively comprised the majority of working
dentists in Finland. Dentists practice human service
work and, as for socioeconomic status, belong to the
group of upper white-collar workers. Therefore, the
results must be generalized with caution outside this
reference group. On the other hand, the results of our
study agree with the findings of a previous cross-
sectional population-based study on the relationship
between job strain, burnout and depression, which
included 30- to 64-year-old employees from all types of
occupations (Ahola et al., 2006). Because our study
included dentists who were working and who responded
to both questionnaires, it is possible that this procedure
excluded the dentists with the worst situations and thus
resulted in weakened associations. However, we were
able to reach 71% of the whole profession in the first
 K. Ahola, J. Hakanen / Journal of Affective Disorders 104 (2007) 103110
phase of the study, and at follow-up the respondents and
the non-respondents did not differ in relation to burnout
or depressive symptoms.
Sickness absence and disability pensions granted on
the basis of depressive disorders have increased in
Finland during the present millennium (Salminen, 2004).
Among intensive human service work, like dentistry, the
importance of mental well-being at work is evident. If
human service professionals are to perform well and
keep working until statutory retirement age, their
working conditions should be continuously evaluated.
In primary health care, and especially in occupational
health services, burnout could be considered a serious
alarm signal of an unfavourably developing working
situation. Among employed clients, assessment proce-
dures and early intervention practices concerning work-
related well-being should be further developed.
In conclusion, job strain predisposes to depression
through burnout. In comparison, job strain predisposes
to burnout directly and via depression. Even though the
relationship between burnout and depression is recipro-
cal, the path from burnout to depression appears to be
stronger than the path from depression to burnout.
5. Contributors
K. Ahola and J. Hakanen together planned the design,
J. Hakanen gathered the data, K. Ahola analysed the data
and wrote the first version of the manuscript, and K.
Ahola and J. Hakanen together refined the manuscript.
Acknowledgements
This study was supported by the Finnish Work
Environment Fund (project no. 105325) and the Finnish
Dental Association. The Finnish Work Environment
Fund and The Finnish Dental Association had no further
role in the study design, the analysis and interpretation
of the data, writing or submitting the manuscript.
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