ORIGINAL ARTICLE INTERNATIONAL JOURNAL OF aumento) WILEY Occupational burnout and depression among paediatric dentists in the United States Leena Chohan' | Carolyn S.Dewa? | WafaEl-Badrawy’ | S.M. Hashim Nainar* "Private Practice, Toronto, Ontario, Canada Department of Peyhitry and Behavioral Sciences, University of California, Das, Davis, California “Paculy of Dentistry, Unversity of Toronto, Toronto, Ontario, Canada Correspondence S.M. Hashim Naina, Faculty of Dentistry. University of Toromo, 124 Edward Suet I5G 166, Canad, Eni hash ainar@utorono.ca Toronto, Otro TRODUCTION Freudenberger in 1974 first described burnout as a Abstract Background: Paediatric demtists in the United States may be at greater risk for oc- cupational burnout and/or depression hecause of chronic stress associated with provi- sion of paediatric dental care and inereasing prevalence of females in the workforce. Aims: To determine the prevalence of occupational burnout and/or depression atric dentists ‘administered online anonymous survey was sent to members of the American Academy of Pediatrie Dentistry (n = 4735). The questionnaire consisted of seven demographic items, 22 items of Maslach Burnout Inventory (Three sub- scales: Emotional exhaustion, Depersonalization, and Personal accomplishment), and eight items of Patient Health Questionnaire-8, Results: The survey had a response rate of 11.4% (females = 53%). Twenty-three per cent of respondents had high emotional exhaustion while fewer respondents had high depersonatization (12%) or low personal accomplishment (10%). Nine per cent fulfilled the study's definition of occupational burnout (high emotional exhaustion + high depersonalization} re were no gender differences in prevalence of burnout or depression, Conclusions: Few paediatric dentists had occupational burnout and/or depression. KEYWORDS «depression, occupational burnout, pediatric dentist, United States Practitioners who are emotionally exhausted and can- not provide necessary psychological support to their patients, ive job-related psychological state manifested as physical fatigue, ‘emotional exhaustion and loss of motivation,’ Occupational ‘burnout results from response to chronic emotional and in- {erpersonal stressors in a human services setting.” Negative sequelae of occupational burnout include: «© Practitioners with depersonalization manifest cynical neg- ative attitudes towards their patients thereby dehumani them «© Practitioners with reduced personal accomplishment lack professional satisfaction.” ‘iene confralipd Pepin fa wastage rangi) ire som pepeonisod or ‘0202 MEPESIEL rate sanay ead Jo} ileoxe pany you Aine Uonneuep PUR SEO -€202 9p BEAU 9 EL Uo HEARN 20(CHOHAN In summary, emotional exhaustion leads to negative, eyn- attitudes and depersonalization, which in turn results in negative self-assessment and decreased well-being’? Burnout is specific 10 the work environment but is a risk factor for depression:** Some signs and. symptoms overlap between burnout and depression, but the two con- ditions are discrete entities categorized in the World Health Organization's International Classification of Diseases (ICD- 115 Depression is characterized by anxiety, loneliness, sadness, changes in appetite or sleep, decreased cognitive functioning, and loss of interest in enjoyable activities.” Occupational burnout and depression have implications both for individual practitioners and health care system. Occupational burnout can adversely affect the physical health of practitioners including cardiovascular diseases among men and musculoskeletal diseases among, women. Clinical practitioners afflicted with burnout and/or de- pression have increased potential for self-harm and suicide ideation.” Burnout and depression were independently as- sociated with suicide ideation in practitioners.” While some studies do not find higher suicide rates among dentists oth- ers noted 4.45-5.43 times higher rates than in the general population,’ Burnout is associated with decreased practitioner pro- ductivity and increased risk of patient safety incidents.!™!? Burnout and depression are independent predictors of report- ing a recent major medical error and reduced quality of care by health care providers." Dentists experience a variety of stressors in their work environment including time-related pressures, heavy work- Toads, anxious or dificult patients, staffing issues, equipment failures, defective materials and the routine aspect of their job that place them at risk for chronic occupational stress and oc- cupational burnout.*' Eight per cent of dentists in the United Kingdom had occupational burnout." A seven-year prospee- tive study of dentists in Finland found burnout predicted de pressive symptoms lending support to “the assumption that ‘burnout might be a phase in the development of depression.’* ‘A study conducted in 2000 reported that nine per cent of randomly sampled US dentists had depression,"” More re- cently, American Dental Association's (ADA) 2015 Dentist Well-Being Survey found much higher prevalence of depres- sion in US dentists with seven per cent using antidepressants (om a regular basis.'® Male US dentists reported elevated cho- lesterol 28%) and heart disease (11%) as their most common ‘medical conditions while female dentists reported headaches (22%) and depression (13%). Female dentists may be more ‘vulnerable to stress-related suicide." ‘The prevalence of occupational burnout among paediatric dentists remains unknown, Provision of dental care to children can be stressful having to deal regularly with anxious children and their protective parents.'*"” A systematic review identi- fied younger age as a risk factor for occupational burnout in INTRRUTONALIOUWALOFY yy) py | Why this paper is important to paediatric dentists, ‘A small but noble number (9.1%) of US paedi- atric dentists had occupational burnout (high emo- tional exhaustion + high depersonalization). One Jn four paediatric dentists (25.2%) had either high emotional exhaustion or high depersonalization. ‘© Based upon PHO criteria, 7.2% of paediatric dentists had moderate-to-severe depression. + Two out of five paediatric dentists (40.8%) with occupational burnout (high emotional exhaus- tion + high depersonalization) also had moderate- to-severe depression dentists” The average age of US paediatric demtiss has been declining due to increasing numbers of new paediatric den- tists?! A random sample of US dentists (n = 559 including 104 paediatric dentists) found depression was more likely 0 occur among female paediatric dentists rather than males."7 Increasing numbers of female practitioners in US paediatric dentist workforce (22001 = 18%; 2016 = 52%) make it timely to field broad-based information regarding depression among paediatric dentists.” The objectives of the present study were {0 determine prevalence of occupational burnout and/or de- pression among US paediatric dentists and associated select ‘demographic characteristics. 2 | METHODS ‘An online survey questionnaire (Survey Monkey® website) ‘was sent to all active members of the American Academy of Pediatrie Dentistry (AAPD) residing in the United States. The survey was conducted over a six-week petiod (2 February 2015-16 March 2015). A personalized introductory e-mail message reviewing informed consent along with an enclosed hyperlink to survey webpage was initially sent by LC followed afterwards by two reminder e-mail messages sent two weeks and four weeks later. All survey responses ‘were anonymous without the use of any identification com- puter cookies, and respondent IP addresses were blocked for confidentiality. Participation was voluntary; survey respond- ents did not receive any remuneration for their participation in the study. Based upon 5200 active AAPD members, an anticipated response rate of 15%, expected effect size of 15% with 5% margin of error and 95% confidence intervals, the sample size required was estimated to be 189. University of Toronto, Health Sciences Research Ethics Board reviewed and ap- proved the study (Reference # 30722). a pepiianun fe wonfoyuienpauto//sdhy wo papeonmon ‘0202 XES2S9EL ‘spss esny vado 19} done ‘pad you Apa = Uonnagiap pu B94 -£202 BP ONE 9p UO- EMEAEN 202 |Wiev Maslach Burnout Inventory (MBI) is a validated and ‘widely used instrument for identifying occupational burnout based upon three dimensions: emotional exhaustion (key as- pect), depersonalization and reduced personal accomplish- ment.?*""69 Patient Health Questionnaite-8 (PHQ-8) has been used for identifying depression. ‘The 37-item survey questionnaire consisted of the follow- ing three domains: ‘+ Demographic variables (n = 7): Gender (male/female), Marital status (singlefcommon law/married/divorced), ‘Age in years (Intervals in decades), Number of years in clinical practice (Imervals in decades), Number of hours ‘worked per week (10-hour intervals), Clinical practice ype (solo/group practice/nsttutional) and US Census region of clinical practice (West/Northeas/South/Midwes) ‘* MBI Human Services Survey: Response to 22 statements was fielded using a seven-point Likert-type frequency scale (0—Never; I—A few times a year or less; 2—Once a month or less; 3—A few times a month; 4—Once a week; SA few times a week; and 6—Every day) (To illustrate, the first of 22 statements was: ‘I feel emotionally drained from my work’)! # PHQ8: Response to 8 statements were fielded using a four-point Likert-type frequency scale (0 — Not at all; I— Several days; 2—More than half the days; and 3—Nearly every day) [To illustrate, the PHQ primary question was “Over the last 2 weeks, how often have you been bothered by any of the following problems?” and the fist of 8 state- ‘ments was: ‘Lite interest or pleasure in doing things”? avoid response sensitization to burnout/depression, at the outset, survey respondents were informed the study was examining job-related attitudes of paediatric dentists with MBI items presented as Human Services Survey and depres- sion items presented as Patient Health Questionnaire-8. The first survey page investigated demographics, second MBI, third PHQ-8 with the fourth and final debriefing page. The questionnaire was single directional and respondents could not view/change answers from previous pages. Upon com pletion of the 37-item questionnaire, respondents were taken to the debriefing letter explicitly informing respondents that the survey examined occupational burnout and depression, Respondents were provided at this juncture with the opportu- nity to withdraw their data from the study. Only survey questionnaires completed in their entirety (all 37 items) without any missing data were included for analyses in the study, The MBI scoring key was used for sorting and aggregating individual responses to the 22 MBI statements for determination of three subscales: Emotional exhaustion by summation of nine statement scores, depersonalization by summation of five statement scores and personal accom- plishment by summation of eight statement scores." The (CHOWAN er. MBI manual provides a table of norm scores (occupational subgroup—medicine) and cut-off points for categorization of each subscale score into high, moderate and low levels.* Cccupational burnout in the present study was defined as high scores in wo dimensions: Emotional exhaustion and depersonalization.!° Responses to PHQ-8 statements were summed up, and {otal scores interpreted as follows: O-4 points = No significant depressive symptoms; 5-9 points = Mild depression; 10-14 points = Moderate depression; 15-19 points = Moderately severe depression; and 20-24 points = Severe depression. Depression inthe present study was defined as PHQ-8 score 6f 10 points or higher”? The data set was downloaded from the Survey Monkey® website and exported {0 Microsoft Excel and Statistical Package for Social Sciences (SPSS) version 17.0 for data analyses. Descriptive statistics (including frequency dist bution analyses) and binary logistic regression were used with statistical significance set at P < 05. For tests with multiple comparisons, a Bonferroni corrected p-value was used. 3. | RESULTS ‘The survey was distributed to 4735 active AAPD members residing in the United States [NB OF the 5200 AAPD mem- bers those who had opted out of receiving any survey from Survey Monkey® (n = 456) and those with incorrect e-mail addresses (n = 9) were excluded from survey distribution} Based on the total number (4735) for survey distribution, the _gr0ss response rate was 17% (n = 805) with median time of 4.58 minutes for survey completion. From the gross response number of 805, the following 265 respondents were excluded from the study: « Individuals who responded to all seven demographic items but did not complete any other survey questionnaire item (n= 118). © Individuals with incomplete survey questionnaires, with data missing from any of the three survey domains (n= 136). « Individuals who asked to have their data withdrawn from, the study at the debriefing page (n = 11) Following the exclusion of the above-noted respondents, the finalized response rate was lowered to 11.4% (n = 540) for survey questionnaires completed with all 37 items (no missing data) and this culled data set was used for analyses, described hereafter. Respondent demographics were similar by gender (fe- males = 53%), 82% were married, two-thirds were in their Ihirties/forties by age, largest number were from the South a pepiianun fg wonfoyuvenpauto//edhy wo papeonian ‘oe ‘0202 *ES2S9Et ‘spsue ony vado 19} done ‘paaod you Apa = Uonngep ue SE-94 £202 3p ONE 9p €1 UO EURAEN 20eon SS = uo, 0 a wicey 2 TABLE 1 Usdin ae, ropes = 50) nga cntng ele (otc Burt cay (BD on Poona see Repandet xopry _tchauton 8) Depereaiaton () _scomplkhment (6) vow En or rm Noses 24 119 ns ry ms us 7 TABLE 2 Binary logistic regression: high emotional exhaustion vs demographie variables 95% CIforOR 95% CIfor OR a psiawun Ke wofayuieqpauuo//sdiy Woy papeonioc ‘0202 *ES2S9EL Demographic Variable 5 Se Wald df Prvae, OR (Lowerlimit). (Upper imi) Age in years (<30 axe 48s rece) 3039 oar woes Lie os7 ssi 409 asa on wes 12038 536 50.59 oa os seh 180 740 5 coe ost 028 1 gs ist 03s vow g Marital Status 0.059) 0.043 1 836, 1.06 061 1.85 i Miueconnon ; ta (Singllverced 5 eal 8 Cina exprone in wn 3am : yen (0 towne) i 20 oo 0368 ost as ast as : 2130 pe corte ree) te ean os ae lat & ayt ou9 0760. 1 470 058 13 256 [ Practice Tne am 2 om : (Prive patie - Slo i remieortr g Group Piva Paice 048102 aT 097 : InsituionlPrcice 0499037041 ost 029 as F eee trea EE i Worked (220 : reeenes) i 2029 19193287 sora i 30-39 1.896 1.035 3.355 1 067 6.66, 088 50.62 E 20 2300 1055010331059, 138 133 : Constant aol 1210647 1m 05 z Omnibus tests of model coefficients z Chi-square ge Sig. g Step 1 ‘Step 2.005 13 0.055 E Block 22.05 B oss Mot 2.005 8 05s ea Nagetherke —2 Log likelihood Cox & Snell R® R Step 557498 aun ue os,(36%) [West = 25%; Northeast = 21%; Midwest = 18%), many were new practitioners (<10 years in clinical prac 1%) or had been in clinical practice for 11-20 years ). Most respondents worked in a private practice set- ting either as solo practitioners (36%) or in a group practice (51%), and 59% worked between 30-39 hours per week Based upon the MBI scoring key, respondent scores for MBI subscales were as follows: ‘* Emotional exhaustion: 22.8% of respondents had! high emotional exhaustion (Median score = 15.0, Mean score = 18.2; Range = 0-54). (Table 1) # Depersonalization: 11.5% of respondents had high de- personalization (Median score = 4.0; Mean score = 5.6; Range = 0-26). Table 1) + Personal accomplishment: 9.8% of respondents had low personal accomplishment (Median score = 42.0; Mean score = 40.4; Range: 1-48), (Table 1) Based upon study's dual criteria (high emotional exhaus- tion + high depersonatization), the prevalence of occupa- al burnout was 9.1% Respondents with either high emotional exhaustion or high depersonalization numbered 25.2%. Based upon any of three MBI dimensional strata (high emotional exhaus- tion, high depersonalization, low personal accomplishment) 1.1% of respondents scored positive for any two of the three criteria while 2.2% of respondents scored positive for all three criteria Mean MBI subscale scores of respondents in the present study were compared using t tests with established norms for ‘overall population sample and for medical professionals.* ‘Mean emotional exhaustion score (18.2) of respondents was significantly lower (P <..001) than for overall sample (21.0) ‘or medicine (22.2), Mean depersonalization score (5.6) of re- spondents was significantly lower (P < .001) than for overall sample (8.7) or medicine (7.1). Mean personal accomplish ‘ment score (40.4) of respondents was significantly higher (P< 001) than for overall sample (34.6) or medicine (36.5) Binary logistic regression showed significant associations with those working in a group private practice setting 38% Jess likely to experience high emotional exhaustion as com- pared to those working in a solo private practice (P = .037; Table 2). Respondents who worked 40 hours or more per ‘week were 10.59 times more likely to experience high emo- tional exhaustion (P = .023) in comparison to those working <20 hours per week (Table 2. Respondents with 11-20 years of clinical experience were 2.99 times more likely to have high depersonalization as compared to those with 10 or less years of experience (P = 026; Table 3). Respondents in the present study had a median PHQ-8 score of 2.0 points [Mean = 3.3 points; Range = 0-24 points} ‘Most respondents had no depressive symptoms (72.6%) or (CHOWAN er. had mild depression (20.2%). Respondents scoring greater than the studs cut-off for depression (210 points) numbered 7.2% (Moderate depression = 4.4%; Moderately severe de- pression = 2.0%; and Severe depression = 0.7%). There was no association noted between prevalence of moderate-t0-se- vere depression and various demographic factors in the pres- cent stud 4 | DISCUSSION ‘The present study surveyed the prevalence of occupa tional burnout (utilizing Mastach Burnout Inventory: MBI) and the prevalence of depression (utilizing Patient Health Questionnaire — 8: PHQ-8) among paediatric dentists in the United States.* At the outset of the study, it was hypothe sized that paediatric dentists may be at greater risk for oceu- pational burnout in comparison with general dentists because provision of paediatric dental care can be stressful with prac- titioners having to deal with anxious children and protective parents.'*"” Findings from the present study however belied that notion over multiple MBI assessments. Mean emotional exhaustion and! mean depersonalization scores of study re- spondents were significantly lower while mean personal accomplishment scores were significantly higher than estab- lished MBI norms for overall population sample or medical professionals * The prevalence of occupational burnout (high emotional exhaustion + high depersonalization) in present sample of US paediatric dentists was 9.1% and much lower than for Irish dentists (26%) or dentists (15%) in the United Kingdom (UK)."S* High emotional exhaustion is a key aspect of occu- pational burnout.” A longitudinal study among Dutch dentists found that emotional exhaustion was an early sign of burnout preceding the development of depersonalizationas well as per- sonal accomplishment. As compared to UK dentists, fewer pediatric dentists in the present study had high emotional ex- haustion (23% vs 42%), high depersonalization (12% vs 20%) (or low personal accomplishment (10% vs 32%; Table 1)."° Only 2.2% of paediatric dentists in the present study scored positive for all three MBI dimensions for burnout (High emotional exhaustion + High depersonalization + Low petsonal accomplishment), a number much lower than previ- ously reported for dentists (UK—8%-11%; Dutch—13%, and, Irish—16%), 16252425 a pepiianun fe wonfoyuienpauto//edhy wo papeonion ‘oe ‘0202 *ES2S9EL ‘pais ony vado 19} done ‘pao you Apa Uonngep pe SE-n4 £202 3p ON api UO- EMRAEN 20CHOHAN ea. INTENATONALIOONACOR! yy ey | TABLE 3 Binary losis regression high dperonalizaton vs demographic variables 98% Clfor OR 98% CLfor OR Demographevarible Een oe ee) ‘Age (<4Dy reference) 23 SB 40499 “030 049105061 aT om at as 50.59 “04% 0638153 255 cays =13% 10071867105, oo a2 Moria Staus Maricdor —0980=« 0493-37081 MSE 28) x0 ‘Common in (Single oe Divorced referee) eee eereerera 6023 we reese) Los 04st 491 mae 29) 783 om 0716 0868131958 793 ye isi) 0983 ash a as? 2060 Prac Type Solo pracce ais 2310 a Group Private Pra “048 0302 -22% = «1088 Lis Instutional Practice “0120 0475001008908 22s Hours Worked per week (<20h om 3a reference) 2029 06 ORK ose1ae Ts woot 2039 ose 07s sss 1868 sot one om 07 ose 138) oka 90 Contant “3585 098 4460100003 ‘Omnibas test of model coeticens a Chisguare Sie at Sie step 1 Sep 18203 2 109 Blok 8223 B 109 Mode! 2 0109 Model Summary 2 Log likelihood ‘Cox & Snell R? ‘Nagelkerke R? Step! 306.759 0.033 6s ros. Binary logistic regression showed three significant as- sociations in the present study between demographic char- acteristics and burnout. First, paediatric dentists working in group private practice setting were 38% less likely to experi- ence high emotional exhaustion compared with those in solo private practice (Table 2). This finding was similar to UK dentists who had less emotional exhaustion when working in group practices (24 dentists) ** Second, paediatric dentists who worked 40 hours and more per week were 10.59 times more likely to expe- rience high emotional exhaustion compared with those working <20 hours per week (Table 2). This finding \was similar to UK dentists who showed high emotional exhaustion when working long hours while those who worked fewer than three days per week had low emo- tional exhaustion." Finally, paediatric dentists with 11-20 years of clinical experience were 2.99 times more likely to have high de- personalization compared to those with 10 or less years of ‘experience (Table 3). A study of Dutch dentists observed that ‘the male dentist in his forties appears to be most vul- nerable to burnout” but the present study found no gender predilection.» “There were no gender differences observed in the pres- ent study for emotional exhaustion, depersonalization, or personal accomplishment, Gender differences reported in Pepin fa wastage agnigia/ sry som pepeonaod OE ‘O202 MEPESIEL a : i ' : : i i : 1 i i = i*|Wiev as literature have been equivocal. There were no gender dif- ferences for any of the MBI burnout dimensions among UK dentists."* Among Dutch dentists, males had higher deper- sonalization scores than females.” One in five paediatric dentists in the present study had mild depression while those scoring greater than the PHQ-S cut-off (210 points) for measuring moderate-to-severe de- pression numbered 7.2%. Prevalence of depression in this study of paediatrie dentists was therefore lower than among US dentists (Moderate level = 22%; High level = 4%).° ‘There was no association noted between prevalence of moderate-o-severe depression and various demographic factors in the present study. In the general US population (National Health and Nutrition Examination Survey 2009- 2012), females had higher rates of depression at all ages.”* ‘The present study found no gender differences regarding prevalence of depression contrary toa random sample of US dentists wherein female paediatric dentists were more de- pressed than males.'” American Dental Association's 2015 Dentist Well-Being Survey also reported greater prevalence of depression among female US dentists," There were no differences in prevalence of burnouv/de- pression in the present study based upon marital status while married UK dentists had lower levels of depersonalization than single dentists.* There was a higher prevalence of de- pression among US dentists who were single than those who were married.” ‘There were Significant correlations in the present study between moderate-to-severe depression and high emotional exhaustion, high depersonalization and low personal accom- plishment, Two out of five paediatric dentists in the present study with high MBI scores in both emotional exhaustion and depersonalization also had moderate-to-severe depres- sion, These correlations confirmed other reports of the link between occupational burnout and depression in dentists and the two conditions are diserete entities.® Burnout preceded depressive symptoms among dentists in Finland, [As noted above, the present study found the number of US paediatric dentists suffering from occupational burnout and! or depression was low. This finding may be due to personal outlook as well as unique personality traits of paediatric den- tists” Personality type of dentists have been associated with prevalence of occupational burnout.” Two-thinds of paedi atric dentists in the present study reported high personal ac- ccomplishment concurring with the report that most paediatric dentists were satisfied with their profession (Table 1). Given potential ramifications, raising awareness of men- tal health issues among paediatric dentists may be salutary even if benefit accrues only to a few. It has been remarked, “the effort to improve health care professional well-being is an ongoing journey, analogous to efforts to improve quality and safety’. Practitioners who were burned outdepressed ‘were at greater risk for suicide ideation.” Individuals with (CHOWAN er. depressive symptoms may have reluctance to seek treatment AA small number (15%) of US dentists with depression were receiving treatment.” Among the general US population (National Health and Nutrition Examination Survey, 2009- 2012) two-thirds of those with severe depressive symptoms hhad not seen s mental health professional in the past yeat.”* US surgeons indicated reluctance to seek care for mental health issues “due to concern that it could affect their licence to practise medicine’. The present study may have underestimated prevalence of occupational burnout and/or depression among US pac atric dentists since two groups of individuals (who together comprised 16% of the study's gross response rate) showed reticence: © 118 individuals completed the first seven demographic items but did not complete any of the remaining 30 main survey (MBI + PHQ-8) items, # 11 other individuals withdrew their data from the study at the debriefing page. Tt has been sugg likely to respond to surveys than non-depressed people’. Limitations of present study include low response rate. However, with regard to the key study demographic of gender distribution, the study sample was similar to US paediatric dentist workforce,”! ested that “depressed people may be less ACKNOWLEDGMENTS. This manuscript is based upon a thesis submitted by Dr Leena Chohan for Master of Science in Pediatric Dentistry at the University of Toronto, hutps:/tspace.library.utoronto.c hnandle/1807/74563 REFERENCES 1. 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Changes in burnout and satisfaction with wore integration in physicians and the general US working population between 201] and 2017. Mayo Clin Pro 2019:94: 1681-1694, How to cite this article: Choban L, Dewa CS, Ek Badrawy W, Nainar SMH. Occupational bumout and depression among paediatric dentists in the United States. Int J Paediatr Dent, 2020;30:570-577. hiipslf doi.org/10.11 1 ipa. 12634 a pepiianun fe wosfoyuienpaute//edhy wo papeonman ‘0202 XES2S9Et ‘pais ny vado 19} one ‘paaiod you Apa Uonnagep pe SE-94 £202 3p Oe 9p UO- EMRAEN 20