Journal of Psychosomatic Research 131 (2020) 109954

Contents lists available at ScienceDirect

Journal of Psychosomatic Research

journal homepage: www.elsevier.com/locate/jpsychores

Do burnout and depressive symptoms form a single syndrome? Confirmatory T

factor analysis and exploratory structural equation modeling bifactor
analysis
⁎
Renzo Bianchi
Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, NE, Switzerland

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: The issue of burnout-depression overlap remains contentious. In this study, the question of whether
Bifactor analysis burnout symptoms form a syndrome that is distinct from depression was reexamined.
Burnout Methods: The study involved 332 employed individuals (65% female; mean age: 34). Burnout symptoms were
Confirmatory factor analysis assessed with the Shirom-Melamed Burnout Measure (SMBM). The SMBM operationalizes burnout based on
Fatigue
three interconnected components, namely, physical fatigue, cognitive weariness, and emotional exhaustion.
Occupational health
Depressive symptoms were assessed with the PHQ-9, a scale that covers the main manifestations of major de-
pression. Confirmatory factor analysis (CFA) and exploratory structural equation modeling (ESEM) bifactor
analysis were conducted.
Results: On average, the factors underlying burnout's components correlated more strongly with the Depressive
Symptom factor than with each other. Remarkably, such results were obtained even when fatigue-related items
were excluded from the depression scale. Second-order CFA revealed that the factors underlying burnout's
components and the Depressive Symptom factor were reflective of the same higher-order factor. ESEM bifactor
analysis indicated that the general factor accounted for about 2/3 of the common variance extracted.
Conclusion: Consistent with a growing corpus of research, this study suggests that the burnout-depression dis-
tinction is untenable. Because the burnout-depression distinction tends to convey the idea that burnout is not as
serious a problem as depression, many people struggling with depression might underestimate the gravity of
their condition and not seek help when self-identifying as “burned out.” Maintaining a line of demarcation
between burnout and depression may thus be problematic from both a scientific and a health management
standpoint.

1. Introduction complaints in affected patients [5]. At an etiological level, depressive

Burnout has been regarded as a syndrome in which the individual is
left exhausted and demotivated by a long-term confrontation with in-
surmountable job stress [1,2]. Although burnout has elicited growing
interest among occupational health specialists over the last decades, the
nature of the syndrome and (discriminant) validity of the construct
remain strongly debated [3,4]. To date, there is no established diag-
nosis for burnout and burnout is not nosologically recognized by either
the American Psychiatric Association or the World Health Organization
[5,6]. A major object of controversy in burnout research concerns the
extent to which burnout refers to anything other than a depressive
condition [3,4].
Depression is primarily characterized by anhedonia and dysphoric
mood, with fatigue and loss of energy constituting common presenting
symptoms have been identified as basic responses to unresolvable stress
in human beings (and mammals in general) and are considered basic
signals of a discrepancy between positive, rewarding experiences on the
one hand, and negative, punitive experiences on the other hand [7–9].
Depressive symptoms vary in severity along a continuum, with de-
pressive disorders representing the high end of that continuum
[3,10,11].
Theoretically speaking, because (a) depressive symptoms constitute
basic responses to unresolvable stress (either job-related or not) and (b)
burnout is supposed to result from insurmountable job stress, the reason
for expecting burnout to fall outside, rather than inside, the spectrum of
depression is unclear [3]. On a related note, when burnout and de-
pression are both approached dimensionally, the continua of the two
entities mirror one another (Fig. 1), rendering the burnout-depression

⁎
Corresponding author at: Institute of Work and Organizational Psychology, University of Neuchâtel, Émile-Argand 11, 2000 Neuchâtel, NE, Switzerland.
E-mail address: renzo.bianchi@unine.ch.

https://doi.org/10.1016/j.jpsychores.2020.109954
Received 29 December 2019; Received in revised form 23 January 2020; Accepted 3 February 2020
0022-3999/ © 2020 Elsevier Inc. All rights reserved.
R. Bianchi Journal of Psychosomatic Research 131 (2020) 109954

Fig. 1. Schematic representation of the theoretically expected overlap of burnout with depression. Unresolvable stress constitutes the common etiological de-
nominator of the burnout and depression processes. The burnout process overlaps with the depression process, rendering a between-process distinction founda-
tionless. The clinical stage of the depression process, at which a depressive disorder can potentially be diagnosed (categorial approach), is an integral part of the
continuum of depression (dimensional approach); it corresponds to the high end of the depression continuum. It is noteworthy that the clinical stage of burnout has
not been characterized in either a clear or a consensual manner to date. Burnout has remained nosologically and diagnostically undefined—notably because of its
similarities with depression, an entity that has been nosologically and diagnostically defined long before the emergence of the burnout construct. Importantly, the
conception of burnout and depression illustrated here reconciles dimensional and categorical approaches to (psycho)pathology; such a conception allows us to
overcome the classic, yet problematic, opposition between dimensions and categories.

distinction—including the distinction between full-blown burnout and
clinical depression—difficult to articulate [3,11,12]. It is worth un-
derlining that the job-related character of burnout has often been re-
garded as a distinctive feature of the phenomenon [2,4]. However,
because burnout could be both job-related and depressive in nature, the
pertinence of the “job-relatedness” argument is open to question [3,13].
Depressive symptoms can emerge in the work context—in response to
unmanageable occupational stressors—before potentially impregnating
other areas of life [12].
Substantiating the abovementioned concerns, the burnout-depres-
sion distinction has been increasingly called into question on empirical
grounds [3]. Burnout has been found to overlap with depression in
terms of: (a) primary symptoms and causes [13–15]; (b) cognitive
processing of emotional information (e.g., biased memorizing in favor
of negative information, negative interpretation of ambiguous in-
formation) [16–19]; (c) dispositional correlates and risk factors (e.g.,
neuroticism, history of anxiety and depressive disorders) [20–22]; and
(d) prescribed treatments (e.g., antidepressant medication) [23–25]. A
recent meta-analytic study, however, concluded that while burnout and
depression were substantially associated with one another, the size of
the association remained compatible with the view that the two con-
structs are distinct [26]. In addition, it has been argued that the pre-
sence of fatigue-related items in both burnout and depression scales
may have “inflated” the burnout-depression association [4,26]. Al-
though the validity of this argument is not beyond question [27], the
extent to which the strength of the burnout-depression association can
be imputed to content overlap at the level of fatigue-related items re-
quires further clarification [14]. Overall, more research has been called
for before definite conclusions can be envisaged regarding the distinc-
tiveness of burnout vis-à-vis depression [4].
In the present study, the issue of burnout-depression overlap was
addressed through an examination of the unity of burnout as a syn-
drome. By definition, a syndrome refers to a combination of co-occur-
ring symptoms characterizing a given entity [5,28]. On this basis, it was
reasoned that, if burnout constitutes a syndrome that is distinct from
depression, then burnout symptoms should combine with each other
rather than with depressive symptoms. That burnout's components be
more strongly linked to each other than to any aspect of depression has
been considered crucial to establishing the discriminant validity of the
burnout construct [29]. Despite its importance, this aspect of burnout's
distinctiveness has received insufficient attention thus far. The earlier
mentioned meta-analysis, for instance, did not compare the correlations
between burnout and depression to the correlations among burnout's
components [26]. Clarifying whether burnout is well characterized
when separated from depression is key to our ability to assess, prevent,
and treat burnout effectively.
2. Methods
2.1. Study sample and recruitment procedure
Participants were recruited in Switzerland in June and July 2016
through contacts with Swiss organizations in both the public and the
private sector as well as through advertisements in social media. Our
participation request contained a brief description of the study (e.g.,
general context, targeted population, expected duration) and a weblink
allowing individuals to complete the study. The organizations were free
to forward our request to their employees or to ignore it. The only
eligibility criterion for participating in the study was to be currently
employed. Employed individuals were thus invited to participate
whether experiencing job stress or not. Participation was voluntary.
Confidentiality was guaranteed to each respondent. Individual consent
was requested. The study was conducted in accordance with the ethical
standards of the institutional review board of the University of
Neuchâtel.
2.2. Measures of interest
Burnout symptoms were assessed with the Shirom-Melamed
Burnout Measure (SMBM) [1,2]. The SMBM is an explicitly work-con-
textualized questionnaire. The SMBM divides burnout into three com-
ponents, namely, physical fatigue (six items; e.g., “I feel physically
drained”; Cronbach's α = 0.90), cognitive weariness (five items; e.g., “I
feel I am not focused in my thinking”; Cronbach's α = 0.90), and
emotional exhaustion (three items; e.g., “I feel I am not capable of in-
vesting emotionally in coworkers and recipients”; Cronbach's
α = 0.81). It is noteworthy that the physical fatigue subscale of the
SMBM refers to a general kind of ill-being at work (e.g., “I feel fed up”;
“I feel burned out”) as much as it refers to actual physical fatigue. The
cognitive weariness subscale of the SMBM homogeneously gauges
cognitive impairment (e.g., attentional problems, difficulties in rea-
soning). The emotional exhaustion subscale of the SMBM deals with
burnout symptoms at an interpersonal level. Participants were asked to
indicate how they felt over the previous two weeks. They responded

2
R. Bianchi
using a 4-point rating scale, from 0 for not at all to 3 for nearly every day.
The SMBM is a measure of reference in burnout research [1,2]. Scores
on the SMBM correlate almost perfectly (disattenuated correlations
around 0.90) with scores on the core dimension of the Maslach Burnout
Inventory (MBI)-General Survey, another popular measure of burnout
[1,29]. By contrast with the MBI, however, the SMBM is in the public
domain and reflects a theory-driven approach to burnout [1].
Depressive symptoms were assessed with the PHQ-9 [30], a scale
that covers the main manifestations of major depression as referenced
in the latest edition of the Diagnostic and Statistical Manual of Mental
Disorders [5]. The PHQ-9 thus allows for a quantification of anhedonia,
depressed mood, sleep disturbance, fatigue/loss of energy, appetite
alteration, guilt/worthlessness, concentration impairment, psycho-
motor malfunction, and thoughts of self-harm. In addition, the PHQ-9
enables the investigator to establish a provisional diagnosis of major
depression based on a dedicated algorithm [30]. The response frame
used with the PHQ-9 was identical to the response frame used with the
SMBM. Cronbach's α for the PHQ-9 was 0.83.
2.3. Data analyses
Data were analyzed principally within a factor analytic framework,
using Mplus 8 [31]. The items were treated as ordinal. The weighted
least squares—mean and variance adjusted—(WLSMV) method was
employed. Goodness of fit was assessed based on five complementary
indices: The Root Mean Square Error of Approximation (RMSEA), the
Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), the Stan-
dardized Root Mean Square Residual (SRMR), and the Weighted Root
Mean Square Residual (WRMR).
First, a four-factor confirmatory factor analysis (CFA) was con-
ducted. Latent Physical Fatigue, Cognitive Weariness, and Emotional
Exhaustion factors were created based on the items belonging to the
original subscales of the SMBM and a latent Depressive Symptom factor
was created based on the items belonging to the PHQ-9. The aim of this
CFA was to examine the correlations among the latent factors attached
to the measures of burnout and depression.
A second-order model was then tested, in which the latent Physical
Fatigue, Cognitive Weariness, Emotional Exhaustion, and Depressive
Symptom factors were defined as first-order factors. The goal was to
examine whether the latent factors attached to the measures of burnout
and depression could be considered reflective of the same overarching
factor.
Third, an exploratory structural equation modeling (ESEM) bifactor
analysis with partially specified target rotation (PSTR) was conducted
[32]. The logic of PSTR is highly similar to that of CFA. However, by
contrast with CFA, in which loadings are forced to equal zero, PSTR
extracts factors and then attempts to match the target as well as pos-
sible. In the specification employed, all items were allowed to load on
the general factor and each item was allowed to load on a bifactor that
was specific to the scale or subscale to which the item belonged. For
instance, a PHQ-9 item would load on the general factor as well as on a
PHQ-9 bifactor. Because four (sub)scales were submitted to examina-
tion (the PHQ-9 and the three SMBM subscales), four bifactors were
considered in addition to the general factor. The mean item loading on
the general factor as well as the explained common variance (ECV) and
Table 1
Correlations among the latent depressive symptom factor and the latent factors linked to burnout's components (N = 332).
Depressive Symptom factor Physical Fatigue factor
Depressive Symptom factor – 0.77
Physical Fatigue factor 0.89 – 0.70
Cognitive Weariness factor 0.81 0.70
Emotional Exhaustion factor 0.59 0.62
Notes. Entries above the diagonal concern the confirmatory factor analysis from which fatigue-related items 3, 4, and 7 were excluded from the PHQ-9; entries below
the diagonal concern the confirmatory factor analysis in which all the items of the PHQ-9 were included.
3
Journal of Psychosomatic Research 131 (2020) 109954
omega hierarchical (omegaH) indices were computed. ECV is an index of
the proportion of the common variance extracted that is explained by
the general factor [33,34]. OmegaH is an index of total score reliability
[34]. The state of the art suggests that “when omegaH is high (> .80),
total scores can be considered essentially unidimensional, in the sense
that the vast majority of reliable variance is attributable to a single
common source” [33].
In view of the claim, made by some investigators [4,26], that the
burnout-depression association may be driven by content overlap at the
level of fatigue-related items, the CFAs were re-run with three fatigue-
related items deliberately excluded from the PHQ-9 (items 3 [sleep
disturbance], 4 [fatigue/loss of energy], and 7 [concentration impair-
ment]). Such a procedure allowed for a more “conservative” approach
to the burnout-depression association.
3. Results
A total of 332 participants, employed in various occupational do-
mains (e.g., human resources, education, healthcare), were enrolled in
the present study (65% female; mean age: 34). Participants' mean
length of employment in their current occupation was 7 years.
Descriptive statistics pertaining to the PHQ-9 and SMBM items (e.g.,
range, skewness, kurtosis) are available as supplementary materials.
About 9% of the participants (n = 31) met the criteria for a provisional
diagnosis of major depression. This sample has not been involved in any
other published study.
The first CFA, in which the nine items of the PHQ-9 were allowed to
load on a Depressive Symptom factor, the six items of the SMBM's
physical fatigue subscale were allowed to load on a Physical Fatigue
factor, the five items of the SMBM's cognitive weariness subscale were
allowed to load on a Cognitive Weariness factor, and the three items of
the SMBM's emotional exhaustion subscale were allowed to load on an
Emotional Exhaustion factor showed an acceptable fit: RMSEA = 0.073
(90% confidence interval [CI]: 0.066–0.079); CFI = 0.959;
TLI = 0.954; SRMR = 0.074. The four factors strongly correlated with
each other (from 0.59 to 0.89; see Table 1). The three latent burnout
factors correlated less strongly with each other—0.63 on average—than
with the Depressive Symptom factor—0.76 on average.
The second-order model involving the Physical Fatigue, Cognitive
Weariness, Emotional Exhaustion, and Depressive Symptom factors as
first-order factors fit the data satisfactorily: RMSEA = 0.072 (90% CI:
0.065–0.079); CFI = 0.960; TLI = 0.955; SRMR = 0.075. All first-
order factors loaded substantially on the higher-order factor—from
0.66 for the Emotional Exhaustion factor to 0.98 for the Depressive
Symptom factor (0.84 on average; Fig. 2).
The bifactor model (Table 2) showed an excellent fit:
RMSEA = 0.036 (90% CI: 0.025–0.047); CFI = 0.993; TLI = 0.988;
WRMR = 0.460. All PHQ-9 and SMBM items loaded substantially on
the general factor—from 0.50 to 0.87 (M = 0.67). OmegaH was 0.86.
The items of the PHQ-9 and physical fatigue and cognitive weariness
subscales of the SMBM loaded on average more strongly on the general
factor than on their respective bifactors; this was not true for the items
of the SMBM's emotional exhaustion subscale. The ECV index showed
that the general factor accounted for well over half the common var-
iance extracted (66%). When excluding the items of the emotional
Cognitive Weariness factor Emotional Exhaustion factor
0.77 0.56
0.62
– 0.57
0.57 –
R. Bianchi Journal of Psychosomatic Research 131 (2020) 109954

Fig. 2. Graphical summary of the second-order factor analysis that included the full version of the PHQ-9 (N = 332). “ds”: Depressive Symptom factor; “pf”: Physical
Fatigue factor; “cw”: Cognitive Weariness factor; “ee”: Emotional Exhaustion factor; “dep”: Depression factor.

exhaustion subscale of the SMBM, the ECV index reached 0.70.
The additional CFA, which only differed from the first CFA by the
exclusion of three fatigue-related items from the PHQ-9 (items 3, 4, and
7), showed a good fit: RMSEA = 0.060 (90% CI: 0.051–0.068);
CFI = 0.977; TLI = 0.973; SRMR = 0.061. Again, the four factors
strongly correlated with each other (from 0.56 to 0.77; see Table 1).
Despite the removal of three fatigue-related items from the PHQ-9, the
three burnout factors still correlated more strongly with the Depressive
Symptom factor—0.70 on average—than with each other—0.63 on
average.
The second-order model involving the Physical Fatigue, Cognitive
Weariness, Emotional Exhaustion, and Depressive Symptom factors as
first-order factors fit the data well: RMSEA = 0.058 (90% CI:
0.050–0.067); CFI = 0.978; TLI = 0.974; SRMR = 0.062. All first-
order factors loaded substantially on the higher-order factor—from
0.69 for the Emotional Exhaustion factor to 0.90 for the Depressive
Symptom factor (0.82 on average; Fig. 3).
In ancillary analyses, burnout scores were compared in participants

Table 2
Summary of the exploratory structural equation bifactor analysis with partially specified target rotation (N = 332).
General factor Bifactors

Scale Subscale Item Distress PHQ-9 PF CW EE Communality I-ECV S-ECV ECV

PHQ-9 – 1 0.58 0.35 0.17 0.05 0.07 0.52 0.66 0.73 0.66
2 0.69 0.60 0.16 −0.16 −0.15 0.84 0.57
3 0.61 0.04 0.00 −0.20 −0.02 0.41 0.90
4 0.84 −0.12 0.17 −0.09 −0.07 0.78 0.91
5 0.68 0.03 −0.08 −0.08 0.07 0.47 0.97
6 0.62 0.45 −0.07 0.02 −0.05 0.59 0.64
7 0.66 −0.10 −0.25 0.26 0.01 0.58 0.75
8 0.63 0.27 −0.07 0.15 0.00 0.52 0.76
9 0.55 0.68 −0.18 0.02 0.06 0.81 0.37
SMBM PF 1 0.73 −0.14 0.32 −0.05 −0.02 0.67 0.80 0.73
2 0.65 0.04 0.32 −0.08 0.09 0.55 0.77
3 0.82 −0.01 0.38 −0.04 −0.08 0.82 0.82
4 0.55 0.15 0.53 0.24 0.19 0.74 0.40
5 0.81 −0.07 0.43 0.04 −0.08 0.84 0.78
6 0.87 −0.05 0.42 0.05 −0.01 0.93 0.81
CW 1 0.65 −0.10 −0.04 0.59 0.02 0.76 0.55 0.60
2 0.65 −0.03 0.13 0.57 −0.02 0.73 0.57
3 0.74 0.16 0.01 0.47 −0.06 0.82 0.67
4 0.71 0.11 0.01 0.53 0.00 0.81 0.61
5 0.72 −0.01 0.06 0.57 0.04 0.84 0.61
EE 1 0.58 0.03 −0.04 0.07 0.50 0.61 0.56 0.40
2 0.54 −0.04 0.06 −0.06 0.73 0.82 0.36
3 0.50 −0.01 0.06 −0.07 0.80 0.89 0.28

4
R. Bianchi
Fig. 3. Graphical summary of the second-order factor analysis in which three fatigue-related items were deliberately excluded from the PHQ-9 (N = 332). “ds”:
Depressive Symptom factor; “pf”: Physical Fatigue factor; “cw”: Cognitive Weariness factor; “ee”: Emotional Exhaustion factor; “dep”: Depression factor.
who met the criteria for a provisional diagnosis of major depression and
participants who did not meet such criteria. Welch's analysis of variance
revealed that depressed participants had higher burnout scores
(M = 1.42, SD = 0.68) than their non-depressed counterparts
(M = 0.54, SD = 0.46), p < .001. The effect size was large, d = 1.52.
4. Discussion
This study does not support the view that burnout symptoms form a
unified, non-depressive syndrome. First, contrary to what would be
expected if burnout indeed constituted a distinct syndrome [3,28,29],
the mean correlation among the burnout factors did not exceed the
mean correlation of the burnout factors with the Depressive Symptom
factor. Remarkably, such results were obtained even when fatigue-re-
lated items were excluded from the depression scale under scrutiny,
suggesting that the overlap of burnout with depression is much more
profound than assumed by some investigators [4,26]. Second, the
burnout factors and the Depressive Symptom factor were found to re-
flect the same higher-order factor. Third, ESEM bifactor analysis
showed that all burnout and depression items loaded substantially on
the general factor, which accounted for about 2/3 of the common
variance extracted. In keeping with our factor analytic findings, parti-
cipants who met the criteria for a provisional diagnosis of major de-
pression exhibited much higher levels of burnout symptoms than par-
ticipants who did not meet such criteria. Overall, these results suggest
that the symptoms assessed by burnout and depression scales can be
viewed as the constituents of a single syndrome, consistent with the
mounting evidence that burnout problematically overlaps with de-
pression [3,14,35].
It is of note that this study's findings apparently contrast with the
findings of factor analytic studies conducted in the mid-1990s and early
2000s [36,37]. However, important shortcomings were identified in the
studies in question [14], including model misspecification and proble-
matic item exclusion [37], or the assessment of burnout and depressive
symptoms within highly different time windows [36,37]. Furthermore,
5
Journal of Psychosomatic Research 131 (2020) 109954
these studies were conducted in an era when fitting ordinal structural
equation models was challenging [14,35].
Interestingly, the overlap of burnout with depression was dis-
cernible in the initial descriptions of the burnout syndrome.
Freudenberger, who introduced the burnout construct in psychology,
already indicated that the burned-out professional “looks, acts and
seems depressed” [38]. In addition to exhaustion, this author en-
umerated depressive symptoms such as sadness, crying spells, resigna-
tion, discouragement, hopelessness, irritability, frustration, and
changes in sleep and weight as components of burnout [38,39]. A
burnout scale published by Freudenberger and Richelson included
items such as “Are you often invaded by a sadness you can't explain?” or
“Is joy elusive?” [40]. Such items are strongly evocative of depressed
mood and anhedonia—the two main characteristics of depressive con-
ditions [3,5]. Similar items are commonly employed in depression
scales [30,41]. Other items found in Freudenberger and Richelson's
scale [40], such as “Are you seeing close friends and family members
less frequently?” or “Do you have very little to say to people?”, refer to
social withdrawal, a well-known aspect of depression [42]. From an
etiological standpoint, Freudenberger and Richelson considered
burnout to result from an investment (cost) that was devoid of the
expected return on investment (benefit), that is to say, from the ex-
perience of a loss [40]. The etiology of depression has been described
along the same lines [7,8,43]. Loss of gratification is reportedly the
most frequent complaint among depressed patients [42]. A close ex-
amination of how the burnout construct emerged in the research lit-
erature may help us understand why burnout was approached as a new
phenomenon despite the striking similarity between the characteristics
ascribed to burnout and the long-identified characteristics of depres-
sion.
The present study has several strengths, such as the use of advanced
statistical analyses or the control for content overlap at the level of
fatigue-related items. However, the study also has limitations. First, the
recruited sample was a convenience sample, the representativeness of
which (e.g., in terms of sex or age) cannot be clearly established. This
R. Bianchi
being mentioned, it should be underlined that the implementation of
methods promoting sample representativeness such as random sam-
pling is problematic when the populations of interest cannot be accu-
rately circumscribed or exhaustively contacted, which was the case in
this study. Second, only one measure of burnout, the SMBM, and one
measure of depression, the PHQ-9, were employed. Although these two
scales are measures of reference in burnout and depression research, the
inclusion of additional measures of burnout and depression would have
been a plus.
Consistent with a growing body of research [3,13,14,35,44], this
study suggests that urging practitioners and researchers to draw a de-
marcation line between burnout and depression is unwarranted. Dis-
quietingly, a “separatist” approach to burnout and depression may be
detrimental to worker health protection. Indeed, reducing burnout to
feelings of exhaustion and demotivation when the syndrome appears to
entail all “classical” symptoms of depression is likely to result in mis-
guided assessment, prevention, and treatment strategies. Moreover,
because the burnout-depression distinction tends to convey the idea
that burnout is not as serious a problem as depression, many people
struggling with depression might underestimate the gravity of their
condition and not seek help when self-identifying as “burned out.”
Sources of funding
None declared.
Declaration of Competing Interest
None declared.
Acknowledgements
The author thanks Noémie Pasquier for her help with data collec-
tion.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jpsychores.2020.109954.
References
[1] A. Shirom, S. Melamed, A comparison of the construct validity of two burnout
measures in two groups of professionals, Int. J. Stress. Manag. 13 (2006) 176–200,
https://doi.org/10.1037/1072-5245.13.2.176.
[2] S. Toker, S. Melamed, S. Berliner, D. Zeltser, I. Shapira, Burnout and risk of cor-
onary heart disease: a prospective study of 8838 employees, Psychosom. Med. 74
(2012) 840–847, https://doi.org/10.1097/PSY.0b013e31826c3174.
[3] R. Bianchi, I.S. Schonfeld, E. Laurent, Burnout: moving beyond the status quo, Int. J.
Stress. Manag. 26 (2019) 36–45, https://doi.org/10.1037/str0000088.
[4] C. Maslach, M.P. Leiter, Understanding the burnout experience: recent research and
its implications for psychiatry, World Psychiatry 15 (2016) 103–111, https://doi.
org/10.1002/wps.20311.
[5] American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, 5th ed., American Psychiatric Publishing, Washington, DC, 2013.
[6] World Health Organization, The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines, World Health
Organization, Geneva, Switzerland, 2016.
[7] C.R. Pryce, D. Azzinnari, S. Spinelli, E. Seifritz, M. Tegethoff, G. Meinlschmidt,
Helplessness: a systematic translational review of theory and evidence for its re-
levance to understanding and treating depression, Pharmacol. Ther. 132 (2011)
242–267, https://doi.org/10.1016/j.pharmthera.2011.06.006.
[8] E.T. Rolls, A non-reward attractor theory of depression, Neurosci. Biobehav. Rev. 68
(2016) 47–58, https://doi.org/10.1016/j.neubiorev.2016.05.007.
[9] P. Willner, J. Scheel-Krüger, C. Belzung, The neurobiology of depression and anti-
depressant action, Neurosci. Biobehav. Rev. 37 (2013) 2331–2371, https://doi.org/
10.1016/j.neubiorev.2012.12.007.
[10] N. Haslam, E. Holland, P. Kuppens, Categories versus dimensions in personality and
psychopathology: a quantitative review of taxometric research, Psychol. Med. 42
(2012) 903–920, https://doi.org/10.1017/s0033291711001966.
[11] M. Wichers, The dynamic nature of depression: a new micro-level perspective of
mental disorder that meets current challenges, Psychol. Med. 44 (2014) 1349–1360,
https://doi.org/10.1017/S0033291713001979.
6
Journal of Psychosomatic Research 131 (2020) 109954
[12] R. Bianchi, I.S. Schonfeld, E. Laurent, Burnout syndrome and depression, in: Y.-
K. Kim (Ed.), Understanding Depression, 2 Springer Nature, Clinical manifestations,
diagnosis and treatment. Singapore, 2018, pp. 187–202.
[13] K. Ahola, J. Hakanen, R. Perhoniemi, P. Mutanen, Relationship between burnout
and depressive symptoms: a study using the person-centred approach, Burn. Res. 1
(2014) 29–37, https://doi.org/10.1016/j.burn.2014.03.003.
[14] I.S. Schonfeld, J. Verkuilen, R. Bianchi, Inquiry into the correlation between
burnout and depression, J. Occup. Health Psychol. 24 (2019) 603–616, https://doi.
org/10.1037/ocp0000151.
[15] M. Melchior, A. Caspi, B.J. Milne, A. Danese, R. Poulton, T.E. Moffitt, Work stress
precipitates depression and anxiety in young, working women and men, Psychol.
Med. 37 (2007) 1119–1129, https://doi.org/10.1017/S0033291707000414.
[16] R. Bianchi, D. da Silva Nogueira, Burnout is associated with a depressive inter-
pretation style, Stress. Health 35 (2019) 642–649, https://doi.org/10.1002/smi.
2897.
[17] R. Bianchi, E. Laurent, Emotional information processing in depression and
burnout: an eye-tracking study, Eur. Arch. Psychiatry Clin. Neurosci. 265 (2015)
27–34, https://doi.org/10.1007/s00406-014-0549-x.
[18] R. Bianchi, E. Laurent, I.S. Schonfeld, J. Verkuilen, C. Berna, Interpretation bias
toward ambiguous information in burnout and depression, Personal. Individ. Differ.
135 (2018) 216–221, https://doi.org/10.1016/j.paid.2018.07.028.
[19] R. Bianchi, E. Laurent, I.S. Schonfeld, L.M. Bietti, E. Mayor, Memory bias toward
emotional information in burnout and depression, J. Health Psychol. (2018),
https://doi.org/10.1177/1359105318765621 advance online publication.
[20] I.C. McManus, A. Keeling, E. Paice, Stress, burnout and doctors’ attitudes to work
are determined by personality and learning style: a twelve-year longitudinal study
of UK medical graduates, BMC Med. 2 (2004) 29, , https://doi.org/10.1186/1741-
7015-2-29.
[21] W. Rössler, M. Hengartner, V. Ajdacic-Gross, J. Angst, Predictors of burnout: results
from a prospective community study, Eur. Arch. Psychiatry Clin. Neurosci. 265
(2015) 19–25, https://doi.org/10.1007/s00406-014-0512-x.
[22] B.W. Swider, R.D. Zimmerman, Born to burnout: a meta-analytic path model of
personality, job burnout, and work outcomes, J. Vocat. Behav. 76 (2010) 487–506,
https://doi.org/10.1016/j.jvb.2010.01.003.
[23] K. Ahola, T. Honkonen, M. Virtanen, et al., Interventions in relation to occupational
burnout: the population-based health 2000 study, J. Occup. Environ. Med. 49
(2007) 943–952, https://doi.org/10.1097/JOM.0b013e31813736e3.
[24] M.P. Leiter, J.J. Hakanen, K. Ahola, S. Toppinen-Tanner, A. Koskinen, A. Väänänen,
Organizational predictors and health consequences of changes in burnout: a 12-year
cohort study, J. Organ. Behav. 34 (2013) 959–973, https://doi.org/10.1002/job.
1830.
[25] I.E.H. Madsen, T. Lange, M. Borritz, R. Rugulies, Burnout as a risk factor for anti-
depressant treatment—a repeated measures time-to-event analysis of 2936 Danish
human service workers, J. Psychiatr. Res. 65 (2015) 47–52, https://doi.org/10.
1016/j.jpsychires.2015.04.004.
[26] P. Koutsimani, A. Montgomery, K. Georganta, The relationship between burnout,
depression, and anxiety: a systematic review and meta-analysis, Front. Psychol. 10
(2019) 284, https://doi.org/10.3389/fpsyg.2019.00284.
[27] R. Bianchi, I.S. Schonfeld, Burnout-depression overlap: nomological network ex-
amination and factor-analytic approach, Scand. J. Psychol. 59 (2018) 532–539,
https://doi.org/10.1111/sjop.12460.
[28] A. Shirom, Reflections on the study of burnout, Work Stress. 19 (2005) 263–270,
https://doi.org/10.1080/02678370500376649.
[29] C. Maslach, S.E. Jackson, M.P. Leiter, Maslach Burnout Inventory Manual, 4th ed.,
Consulting Psychologists Press, Palo Alto, CA, 2016.
[30] K. Kroenke, R.L. Spitzer, The PHQ-9: a new depression diagnostic and severity
measure, Psychiatr. Ann. 32 (2002) 509–515, https://doi.org/10.3928/0048-5713-
20020901-06.
[31] L.K. Muthén, B.O. Muthén, Mplus user’s guide, 8th ed., Los Angeles, CA, Muthén &
Muthén, 1998-2017.
[32] H.W. Marsh, A.J. Morin, P.D. Parker, G. Kaur, Exploratory structural equation
modeling: an integration of the best features of exploratory and confirmatory factor
analysis, Annu. Rev. Clin. Psychol. 10 (2014) 85–110, https://doi.org/10.1146/
annurev-clinpsy-032813-153700.
[33] A. Rodriguez, S.P. Reise, M.G. Haviland, Applying bifactor statistical indices in the
evaluation of psychological measures, J. Pers. Assess. 98 (2016) 223–237, https://
doi.org/10.1080/00223891.2015.1089249.
[34] A. Rodriguez, S.P. Reise, M.G. Haviland, Evaluating bifactor models: calculating
and interpreting statistical indices, Psychol. Methods 21 (2016) 137–150, https://
doi.org/10.1037/met0000045.
[35] I.S. Schonfeld, J. Verkuilen, R. Bianchi, An exploratory structural equation mod-
eling bifactor analytic approach to uncovering what burnout, depression, and an-
xiety scales measure, Psychol. Assess. 31 (2019) 1073–1079, https://doi.org/10.
1037/pas0000721.
[36] A.B. Bakker, W.B. Schaufeli, E. Demerouti, P.P.M. Janssen, R. Van Der Hulst,
J. Brouwer, Using equity theory to examine the difference between burnout and
depression, Anxiety Stress Coping 13 (2000) 247–268, https://doi.org/10.1080/
10615800008549265.
[37] M.P. Leiter, J. Durup, The discriminant validity of burnout and depression: a con-
firmatory factor analytic study, Anxiety Stress Coping 7 (1994) 357–373, https://
doi.org/10.1080/10615809408249357.
[38] H.J. Freudenberger, Staff burnout, J. Soc. Issues 30 (1974) 159–165, https://doi.
org/10.1111/j.1540-4560.1974.tb00706.x.
[39] H.J. Freudenberger, The staff burn-out syndrome in alternative institutions,
Psychotherapy: Theory Res Practice 12 (1975) 73–82, https://doi.org/10.1037/
h0086411.
R. Bianchi
[40] H.J. Freudenberger, G. Richelson, Burn-out: The High Cost of High Achievement,
Bantam Books, New York, NY, 1980.
[41] A.T. Beck, C.H. Ward, M.M. Mendelson, J.J. Mock, J.J. Erbaugh, An inventory for
measuring depression, Arch. Gen. Psychiatry 4 (1961) 561–571, https://doi.org/10.
1001/archpsyc.1961.01710120031004.
[42] A.T. Beck, B.A. Alford, Depression: Causes and Treatment, 2nd ed., University of
Pennsylvania Press, Philadelphia, PA, 2009.
Journal of Psychosomatic Research 131 (2020) 109954
[43] A.T. Beck, K. Bredemeier, A unified model of depression: integrating clinical, cog-
nitive, biological, and evolutionary perspectives, Clin. Psychol. Sci. 4 (2016)
596–619, https://doi.org/10.1177/2167702616628523.
[44] R. Bianchi, I.S. Schonfeld, J. Verkuilen, A five-sample confirmatory factor analytic
study of burnout-depression overlap, J. Clin. Psychol. (2020), https://doi.org/10.
1002/jclp.22927 advance online publication.