Mental exhaustion / burnout (P78)

March 3, 2023
Clinical course of mental exhaustion / burnout

Mental exhaustion, neurasthenia (‘surmenage’) and burnout are terms that have been used interchangeably throughout the years, with variations in their definition and use. Generally, these terms refer to the inability to cope with chronic psychological stress, mainly at work (but not limited to work) because of insufficient resources to meet (work) demands.

The diagnosis is not part of the DSM classification and there are no strict diagnostic criteria. Treatment recommendations are mainly based on practical experience.

The 2018 Dutch NHG guideline states that being ‘overworked’ or ‘mentally exhausted’ (in Dutch, ‘Overspanning’) can be diagnosed when four criteria are met. The first (1) is having at least three of the following stress symptoms: fatigue, disturbed sleep, irritability, lability, not being able to deal with busy environments, excessive worrying, feeling pushed, concentration problems and forgetfulness. This may lead to (2) (feelings of) loss of control in daily living and (3) malfunctioning. Furthermore (4), these symptoms cannot be attributed to a psychiatric disease.

Burnout is considered a severe form of mental exhaustion / overwork when these symptoms persist for at least six months and feelings of fatigue / exhaustion are in the forefront. We refer to all diagnoses with ‘mental exhaustion’ because it’s not possible to distinguish mental exhaustion from burnout within the FaMe-Net data.

In the course of mental exhaustion / burnout, three phases are distinguished. In the first (crisis) phase, rest and acceptance are important, with practical advice on how to structure the day. In the second phase, the problem and possible solutions are defined and discussed, followed by the third phase in which the patient can try to implement possible solutions and find a new balance. In the treatment phase, the GP can collaborate with the mental health nurse in general practice (in Dutch, ‘poh-ggz’) and an occupational health physician. Interventions such as mindfulness or coaching may help. In complex cases, the help of a psychologist might be needed or, in occasional cases, a referral to secondary care is warranted.

How is mental exhaustion / burnout recorded in FaMe-Net?

In ICPC-2, Neurasthenia (‘surmenage’) / mental exhaustion is coded P78, which includes (the more severe) burnout. However, ‘burnout’ can alternatively be coded P29 (‘other psychological symptoms / complaints’) with an ICD-10 code specifying burnout (Z73.0, ‘Problems related to life-management difficulty’). This means that using only ICPC-2 data is insufficiently specific for studying all episodes (and / or only episodes) of ‘burnout’. Additional data extractions using ICD-10 subclasses would be possible.

Symptom diagnoses such as P01, ‘feeling anxious, nervous, tense’, or P02, ‘acute stress reaction’, may be recorded if the problems cannot be classified as ‘mental exhaustion’ (P78). If problems are (only) related to the workplace but cannot be classified as ‘mental exhaustion’ (P78), the symptom diagnosis Z05 (‘work problem’) can be coded.

Epidemiology of mental exhaustion / burnout in FaMe-Net

The incidence of neurasthenia / mental exhaustion (P78) is 7.2 per 1000 patient years, meaning that out of 1000 patients in a year, seven patients contact their GP with a new episode of mental exhaustion. New diagnoses are made more often in women (9.3) than in men (5.0 per 1000 patient years) and the incidence is highest between 15 and 64 years (which corresponds with those ages at which people are engaged in a ‘working life’), with the peak between 25 and 44 years (13.3 per 1000 patient years), followed by the 45-64 age group. The incidence increases slightly over time and is more pronounced in women than in men. Link/Figure 1

‘Other psychological symptoms / complaints’ (P29), which may include burnout, have an incidence of 4.9 per 1000 patient years, again higher in women than in men with the highest incidence in the 15-24 and 25-44 age groups. Link/Figure 2

The incidence of P01 (Feeling anxious, nervous, tense) is 12.6 per 1000 patient years which presents also more often in women (16.7) than in men (8.5 per 1000 patient years). Link/Figure 3 For an ‘acute stress reaction’ (P02) the incidence is 2.4 per 1000 patient years (3.1 in women and 1.8 in men).

Link/Figure 4 The incidence of work problems (Z05) is also 2.4, but with smaller differences between men (2.2) and women (2.7 per 1000 patient years) and mainly occurring in the 25-64 age group. Link/Figure 5

Neurasthenia / mental exhaustion (P78) has a prevalence of 14.5 per 1000 patient years, meaning that out of 1000 patients in a year, 15 individuals seek help from their GP for this problem. Again, there is a clear sex difference: women are twice as likely to seek help for P78 as men. Link/Figure 6

The prevalence of ‘other psychological symptoms / complaints’ (P29) is 8.2 per 1000 patient years.

The higher prevalence number compared to incidence number of mental exhaustion (P78) indicates that this episode often requires GP attention for a longer period than one calendar year. The same applies to P29.

Which initial RFEs do patients with mental exhaustion / burnout present to their GP?

The most common initial reason for encounter (RFE) for mental exhaustion / burnout is RFE P78 (‘neurasthenia / mental exhaustion’, in 34%), meaning that many patients recognise and name ‘mental exhaustion’ as the problem on initial presentation. This implies that a proportion of patients (or their family members / colleagues) are well capable of defining the (origin of the) problem at the moment they visit their doctor – a problem that often evolves over months or years. However, the majority of patients initially present with other (mental or physical) problems. In 14%, feeling anxious (P01) is the initial RFE, followed by fatigue (A04), depressive feelings (P03) and acute stress reaction (P02). Link/Table 7 In the remaining cases, a variety of problems (e.g. sleep problems (P06), headache (N01), palpitations (K04), chest symptoms (L04) and dizziness (N17)) are recorded as RFEs.

How do FaMe-Net GPs act?

In many episodes of mental exhaustion / burnout (P78, in 43%) the GP records the intervention ‘therapeutic counselling’ (*58), meaning that the GP takes time to listen to, coach and advise the patient. Other common interventions include medical examination (*31, in 38% per year), which can involve both psychiatric and somatic examination (auscultation of heart or lungs, pulse and blood pressure measurement) and providing education and advice (*45, in 31%) (i.e. less extensive compared to ‘therapeutic counselling’). Link/Table 8 In about a quarter of the episodes per year medication is prescribed (*50), mostly enzodiazepines and SSRIs. Link/Table 9 Referrals to primary care professionals (*66, in 23% of episodes) are more common than referrals to secondary care (*67, in 6% per year). Referrals to primary care mainly involve psychology (in 16%) or physical therapy (in 4%) (Link/Table 10), and referrals to secondary care involve psychiatry (in 2%) or psychotherapy (in 2%). Link/Table 11