Stress and Health
Stress and Health 25: 281–285 (2009)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/smi.1283
Editorial
Burnout and health: expanding
our knowledge
Burnout is often conceptualized as an affective
reaction to ongoing stresses at work. Burnout’s
core content is the gradual depletion over time of
individuals’ intrinsic energetic resources; it is
reflected primarily in emotional exhaustion, phys-
ical fatigue and cognitive weariness (cf. Shirom,
2003). This Special Issue focuses on employee
burnout and its relationship with the different
facets of physical health. The major objective of
this essay is to provide readers with an overview
of the specific ways in which the papers included
in the Special Issue augmented our knowledge on
the relationship between employee burnout and
health.
There are several reasons justifying the focus of
this Special Issue on burnout and health. In some
countries, burnout is a legitimate base for a com-
pensation claim (Schaufeli, 2003) and represents
a major reason for sickness absences and work
disability (Bekker, Croon, & Bressers, 2005). For
example, in a series of prospective studies con-
ducted in Finland, based on large and representa-
tive samples and on longitudinal designs, baseline
levels of burnout (assessed based on the Maslach
Burnout Inventory—General Survey; MBI) were
found to predict medically certified sickness
absences for both men and women (Ahola et al.,
2008) and disability pensions in two independent
samples (Ahola et al., 2009; Ahola, Toppinen-
Tanner, Huuhtanen, Koskinen, & Väänänen,
2009). Yet another contribution to the previously
mentioned series of studies appears in the Special
Issue (Toppinen-Tanner, Ahola, Koskinen, &
Väänänen, 2009) and found that the MBI’s facet
of emotional exhaustion predicted subsequent
* Correspondence to: A. Shirom, Faculty of Manage-
ment, Tel Aviv University Ramat Aviv, Tel Aviv 69978,
ISRAEL.
†
E-mail: ashirom@post.tau.ac.il
Copyright © 2009 John Wiley & Sons, Ltd.
hospital admissions because of cardiovascular
disease (CVD) and mental disorders. In Sweden,
‘burnout’ is used as a diagnosis on medical
certificates (Hallsten, 2005). In The Netherlands,
about 30% of work disability recipients are clas-
sified as occupationally disabled on mental
grounds, reflecting primarily cases of advanced
burnout (Michielsen, Croon, Willemsen, De Vries,
& Van Heck, 2007).
In several large-scale studies conducted in dif-
ferent countries, burnout was found to be associ-
ated with a variety of physical health impairments
(Honkonen et al., 2006; Peterson et al., 2008).
Burnout may transfer from one employee to
another, either directly or indirectly, and may
thereby adversely impact the health and well-
being of one’s partner (Bakker, 2009). Thus,
accumulated evidence supports the proposition
that burnout at work can be regarded as a major
public health problem and a cause for concern for
health-care policy-makers. Complementing and
extending a recent review of the aforementioned
body of knowledge (Melamed, Shirom, Toker,
Berliner, & Shapira, 2006), the Special Issue on
burnout and health covers additional health end
points, including hospitalization, insomnia and
back pain, and several possible physiological
mediators and moderators of the linkages between
burnout and physical health.
Burnout and self-rated health (SRH)
Burnout reflects a process of deteriorating ener-
getic resources, and therefore, it is reasonable to
assume that it will predict decrements in indi-
viduals’ perceived health status. I start my review
of the papers included in the Special Issue with
the two contributions that focused on burnout
and SRH (Bakker, 2009; Vinokur, Pierce, &
Lewandowski-Romps, 2009) because this crite-
rion probably represents one’s general (albeit
 Editorial
subjective) assessment of one’s overall health
status. Several meta-analytic studies concluded
that SRH predicted mortality and survival after
adjusting for traditional risk factors, socio-demo-
graphic characteristics and objective measures of
health status (Benyamini & Idler, 1999; DeSalvo,
Bloser, Reynolds, He, & Muntner, 2006). The
predictive power of SRH with respect to subse-
quent survival possibly reflects its ability to cover
a wide spectrum of health conditions and
attests to its validity as a global health status
measure (McGee, Liao, Cao, & Cooper, 1999).
Corresponding to the literature (e.g. DeSalvo
et al., 2006), SRH is often conceptualized to
reflect a person’s global assessment of his or her
general state of health. Qualitative (Benyamini,
Leventhal, & Leventhal, 2000) and quantitative
(Singh-Manoux et al., 2006) studies have found
that SRH represents a holistic summary of how
individuals perceive their overall health status.
The paper by Vinokur et al. in this issue (2009)
makes a unique contribution to the study of the
effects of burnout on health by viewing SRH as
a health-related outcome impacted by burnout.
Vinokur et al. (2009) assessed burnout based
on the Conservation of Resources theory as refer-
ring to individuals’ affective reaction to the
gradual depletion of their energetic resources (cf.
Shirom, 2003). These energetic resources repre-
sent important and basic coping resources; there-
fore, one’s feeling that one’s physical, cognitive
and emotional or interpersonal resources have
been depleted is likely to impact one’s SRH. The
obverse may also be correct: one’s perceived state
of health is an important coping resource influ-
encing one’s coping effectiveness and recovery
process following temporarily lost energetic
resources (Hobfoll, 2002). Therefore, a change in
SRH is likely to have an impact on one’s level of
burnout. Based on a longitudinal design and using
structural equation modelling, Vinokur et al.
(2009) were able to demonstrate that across time,
perceived health predicted a decrease in burnout
and burnout predicted a decrease in perceived
health, providing support to the coexistence of
both types of effects. However, they were also
able to find considerable support to their expecta-
tion that the effect of perceived health on burnout
is stronger than the effects of burnout on per-
ceived health. A major conclusion that could be
formulated based on Vinokur et al. (2009) is that
in studies examining burnout’s linkages with
physical health, the reverse causation hypothesis,
namely that individuals’ initial health status
282 Copyright © 2009 John Wiley & Sons, Ltd.
impact their feelings of burnout, should always
be investigated.
In yet another study included in the Special
Issue, Bakker (2009) was able to establish a bridge
between two fields of research on burnout:
burnout and health, and burnout’s transfer or
spillover among employees in the same unit or
between intimate partners. Bakker’s (2009) major
finding that burnout may transfer from employ-
ees to their intimate partners thereby indirectly
impacting their partners’ SRH establishes the
potential contribution of making the theoretical
and empirical tie-in between the previously men-
tioned two subfields of burnout research.
Burnout and insomnia
Earlier, I referred to the accumulated evidence
documenting that burnout is implicated in the
incidence of CVD (cf. Melamed et al., 2006).
Analogously, the Job Demands–Control–Support
(JDC–S) model proposed by Karasek and Theo-
rell (1990) has been found in a meta-analytic
study (Kivimaki et al., 2006) to predict CVD, and
a qualitative review (Belkic, Landsbergis, Schnall,
& Baker, 2004) also found it to predict CVD. As
Armon’s (2009) contribution to the Special Issue
points out, the same pattern is correct regarding
insomnia, such as burnout; it was found to be a
precursor of CVD. Additionally, the JDC–S model
was found in many studies (cf. Armon, 2009) to
predict burnout and insomnia. However, the rela-
tionship between burnout and the JDC–S model
in the prediction of insomnia have not yet been
investigated. Following the rationale mentioned
earlier, Armon’s paper (2009) focused on the
incremental additive effects of the initial levels of
burnout to the prediction of subsequent changes
in the levels of insomnia over and above those of
the JDC–S model.
Armon’s paper (2009) adds to our understand-
ing of the impact of the work nexus on employee
health in the following way. Burnout could be
viewed as a proxy variable representing the accu-
mulated effects of a variety of work-related
stresses on health outcomes. These stresses include
chronic stresses, hassles and critical job events. It
follows that burnout is regarded as a proxy vari-
able of these types of stresses because it reflects
the extent to which one’s energetic coping
resources have been depleted because of one’s
exposure to them (cf. Melamed et al., 2006). Yet,
there are several theoretical models, including the
Stress and Health 25: 281–285 (2009)
DOI: 10.1002/smi

JDC–S model (Karasek & Theorell, 1990) and
the effort–reward imbalance model (Siegrist et al.,
2004), which seek to explain psychological and
physiological strain by demands and resource.
Therefore, one could argue that burnout is redun-
dant over job demands as embodied in the two
models mentioned earlier. Armon’s study (2009)
points out that burnout predict insomnia even
after controlling for the components of the JDC–
S model because this model focus on only a subset
of work-related stresses. Therefore, it could be
argued on theoretical grounds that burnout is
going to have additional predictive power of rel-
evant strains and health outcomes over and above
either of the aforementioned models.
Burnout and musculoskeletal (MS) pain
Two papers in this issue (Grossi, Thomten,
Fandino-Losada, Soares, & Sundin, 2009;
Melamed, 2009) investigated the relationships
between MS pain and burnout. MS pain is highly
prevalent among workers in most countries. Fur-
thermore, as documented in the two papers men-
tioned earlier, it represents a major cause of
absenteeism, chronic disability, frequent utiliza-
tion of health services and early retirement. The
few past studies that found burnout and MS pain
to be associated were all based on a cross-
sectional design (e.g. Honkonen et al., 2006),
whereas Melamed (2009) and Grossi et al. (2009)
used longitudinal design studies conducted in two
different countries independently.
As noted by Melamed (2009), several reviews
of the area have suggested that psychosocial
factors are powerful predictors of MS pain;
however, most past studies used a variety of psy-
chosocial stresses in relation to MS pain, such as
those included in the JDC–S model. Additionally,
the findings of some past cross-sectional studies,
based on the MBI (e.g. Miranda, Viikari-Juntura,
Heistaro, Heliövaara, & Riihimäki, 2005), are
ambiguous because they used the total score of
the MBI to represent the construct of burnout;
this issue is further elaborated in the epilogue to
the Special Issue. In contrast, Melamed (2009)
and Grossi et al. (2009) used the Shirom–Melamed
Burnout Measure, an instrument whose total
score is theoretically meaningful and has been
empirically verified (cf. Shirom, Vinokur, & Nirel,
in press). The two studies support the view that
burnout is implicated in the aetiology of MS pain.
Because their longitudinal design better support
Copyright © 2009 John Wiley & Sons, Ltd.
Editorial
causal assertions, and because they controlled a
variety of confounders representing alternative
explanatory factors of MS pain (for example,
Grossi et al., 2009, controlled for psychological
distress and the components of the JDC–S model
in addition to baseline levels of burnout), the two
studies add an important new facet to the burnout
and health literature.
Grossi et al. (2009) also found that burnout
exerts an effect on changes over time in MS pain
over and above the effects of the JDC–S model.
Therefore, their study (Grossi et al., 2009) joins
hands with the Armon (2009) study reviewed
earlier in providing considerable support to this
hypothesis that burnout, rather than the popular
JDC–S model, could be regarded as a representa-
tive of one’s overall exposure to a variety of
work-related stresses at work.
Burnout and fatigue
I will use the term fatigue to refer to chronic or
prolonged fatigue because these terms are used
interchangeably in the relevant literature. Fatigue
is a common patient complaint in a variety of
medical settings, but when it appears without a
known co-morbidity (such as anaemia, joint pains
or any of the malignant diseases), it is very diffi-
cult to identify an organic condition explaining
it. The prevalence rates of fatigue bear consider-
able similarity to those of burnout.
There are several major similarities between the
fields of study of burnout and of fatigue. Concep-
tually, the core content of both has been noted to
be the depletion of a person’s energetic resources
(Shirom, 2003). Additionally, both are consid-
ered persistent and stable across time (Leone,
Huibers, Knottnerus, & Kant, 2008), possibly
because of the similar physiological processes
underlying them (cf. Melamed et al., 2006). Most
past studies on the relationships between burnout
and fatigue have been based on a cross-sectional
design.
The major findings presented by Leone,
Huibers, Knottnerus and Kant (2009) advance
our understanding of the relationships between
burnout and fatigue in several ways, most notably
by finding that burnout and prolonged fatigue
predict each other in time. Moreover, there seems
to be a dose-response relationship between the
two conditions. Taken together, the results by
Leone et al. (2009) suggest that burnout and pro-
longed fatigue influence each other in the manner
Stress and Health 25: 281–285 (2009) 283
DOI: 10.1002/smi
 Editorial
of a downward spiral. This implies that early
intervention is important to prevent the condi-
tions from co-occurring and the outcome from
worsening.
Concluding note
The series of studies on burnout and health in the
Special Issue are characterized by higher levels of
research rigour relative to past studies in this
area, particularly in that most of them are based
on longitudinal designs, systematically controlled
for confounders and use advanced statistical tech-
niques such as structural equation modelling to
analyse their data. Additionally, some of them
(van Doornen et al., 2009) directly addressed the
underlying biological mechanisms linking burnout
and health. Hopefully, they will pave the way to
additional studies in this area because many major
research questions, such as the extent to which
burnout has an impact on subsequent mortality
after controlling for other negative affective states
(e.g. depressive symptoms), remain unanswered.
Collectively, the papers included in the Spe-
cial Issue offer policy-makers and practitioners in
the area of occupational health evidence-based
avenues of action to minimize the deleterious
impact of burnout on several key aspects of
employee physical health, including hospitaliza-
tion for CVD and mental disorders, insomnia and
MS pain.
Acknowledgments
The authors acknowledge the support of the Israel
Science Foundation for the project on which this study
is based (Grant 962/02–1).
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ARIE SHIROM*,†, Ph.D
Professor (emeritus)
Faculty of Management, Tel Aviv University
Ramat Aviv, Tel Aviv 69978, ISRAEL
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