Burnout

According to the World Health Organization (WHO), occupational burnout is a result of chronic work-related stress, with symptoms characterized by “feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy”.^[1]
While burnout may influence health, it is not itself classified by the WHO as a medical condition or mental disorder.^[1]
The WHO additionally states that “Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life”.

However psychology today avers that burnout, though most often caused by problems at work, can also appear in other areas of life, such as parenting, caretaking or romantic relationships. [2]

The definition and circumstances notwithstanding, burnout is a stress-related state of chronic, high-grade hypothyroid symptoms, including reduced cognition and at least mild depression.
The psychological state is viewed, with significant resentment by the affected person, as the end result of intolerable volume of work, unpleasant colleagues or supervisors and/or unsatisfactory conditions of employment.

Metabolic Pathogenesis

The metabolic changes involved in burnout are easily explained:

• Stress leads to an increase in cortisol production.
• Cortisol blocks deiodinase 1 and promotes deiodinase 3, thereby preventing the synthesis of T3 (from T4) and encouraging its destruction.
• Intracellular T3 starvation (https://cbhrt.ca/2023/04/27/intracellular-hypothyroidism-ih/ . [3] *CAVEAT: the accepted “normal range” of rT3 (5 – 25) is skewed, due to inclusion of subjects with undiagnosed IH in the population from which the range was calculated – the “optimal range” for rT3 is 5 – 13 [3]. Treatment As with IH from whatever cause, burnout should be managed by • “Sick leave”, of sufficient duration (recovery time plus one week), • Counselling, • Appropriate recreation, • Correction of intracellular triiodothyronine starvation, utilizing orally administered T3: the dose is started at 5 – 10 µg/day. The serum T3 is estimated once weekly and the dose of triiodothyronine is titrated upward, until serum T3 is between 4.5 and 6.0 pmol/Litre. • When serum T3 exceeds 4.5, reverse T3 is re-checked: a rT3 of <13 is evidence that deiodinase 3 is no longer up-regulated and the “burnout” syndrome is under control. At this point, the daily dose of triiodothyronine may be reduced slowly and discontinued if serum T3 is auto-maintained at greater than 4.5. The TSH will usually be low, or subnormal in most cases, because prescribed T3 entering the pituitary satisfies its need for thyroid hormone; however in a small percentage, entry of T3 into the pituitary is blocked and the TSH rises: this is easily managed by addition of Eltroxin or Synthroid, to the prescription. • The employer’s human-resources department should discuss the situation with the subject, analysing the work circumstances and workload and initiating steps toward stress reduction. CAVEAT: addition of T4 to the prescription does not usually result in increased rT3. Relapse When oral triiodothyronine is discontinued, relapse of IH may occur, with recurrence of symptoms, following significant stress of whatever origin. The first diagnostic sign of relapse is suppression of the serum T3, and elevation of reverse T3. Symptoms recur when the T3/rT3 ratio falls to less than 20. If this happens, prescription of oral T3 at the previously successful dosage, should be reinstated. Caveat Burnout is hardly ever an isolated phenomenon. Every HR professional and all employees should be educated regarding the signs, symptoms, diagnosis and management of IH “burnout” and prophylactically, any worker presenting with hypothyroid symptoms should be referred to a company physician who is aware of, and prepared to test and treat, IH. References [1] Burn-out, an "occupational phenomenon": International Classification of Diseases. 28 May 2019, https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases [2] https://www.psychologytoday.com/ca/basics/burnout [3] INTRACELLULAR HYPOTHYROIDISM, Gervais Angelo Harry, May, 2023, https://www.researchgate.net/publication/370772568_INTRACELLULAR_HYPOTHYROIDISM">Intracellular Hypothyroidism, “IH”) ensues.

The metabolic, cognitive and psychological symptoms of IH are identical, except in fine detail, with those associated with the low T3 syndrome (a.k.a. euthyroid sick syndrome, nonthyroidal illness, etc.). The symptoms also parallel those of chronic fatigue syndrome and other conditions in which intracellular T3 starvation occurs.

Diagnosis

IH can be confidently diagnosed via a complete panel of thyroid tests, as follows:
TSH: TSH may be elevated if the patient has an underlying true hypothyroidism, but is usually normal.
T4: T4 is usually normal, but may be low if the patient has an underlying true hypothyroidism, or high if there is pre-existing hyperthyroidism.
T3: T3 is low, because it is not being generated peripherally: the only source of T3 is the thyroid gland itself and the thyroid’s output of T3 is minimal.
Reverse T3 (rT3) is high, because deiodinase 3 produces it preferentially, from available T4 in the cells.*
The T3/reverse T3 ratio will be low (by consensus, “low” means <20, while “optimal” means >23). This (the T3/rT3 ratio)is the diagnostic calculation: there is no need to consider whether or not reverse T3 is “normal”.
A table of T3/r T3 calculations is available: see “intracellular hypothyroidism”, at https://cbhrt.ca/2023/04/27/intracellular-hypothyroidism-ih/ . [3]

*CAVEAT:

The accepted “normal range” of rT3 (5 – 25) is skewed, due to inclusion of subjects with undiagnosed IH in the population from which the range was calculated – the “optimal range” for rT3 is 5 – 13 [3].

Treatment

As with IH from whatever cause, burnout should be managed by

• “Sick leave”, of sufficient duration (recovery time plus one week), with pay.
• Counselling, for both the “burnout” subject and the employer’s human-resources department: the situation should be discussed frankly with the subject, analysing the work circumstances and workload and initiating steps toward stress reduction. Other similarly employed colleagues should be approached, with a view to optimizing workload and assessing coworkers for signs of burnout, ad hoc.
• Appropriate recreation, exercise programs, etc.
• Correction of intracellular triiodothyronine starvation, utilizing orally administered, slow-release T3, at a starting dose of 5–10 µg/day (rapid release liothyronine produces a post-dose “spike” of T3 and a late day “crash”: it should therefore not be prescribed.
• The serum T3 is estimated once weekly* and the dose of triiodothyronine is titrated upward, until serum T3 is between 4.5 and 6.0 pmol/Litre. When serum T3 exceeds 4.5, reverse T3 is re-checked: a rT3 of <13 is evidence that deiodinase 3 is no longer up-regulated and the “burnout” syndrome is under metabolic (if not psychological) control.
• The T3/rT3 ratio is the arbiter, with regard to the maintenance dose of oral T3. However the serum FT3 reliably represents the net effect of exogenous T3 dosage, plus T3 generated in the peripheral cells.
  Therefore there is no need to Check the rT3 level and estimate the T3/rT3 ratio until FT3 reaches the therapeutic target (4.5–6.1)
• When FT3 attains 4.5 (ideally, 5.0–6.1) pmol/litre, the daily dose of triiodothyronine may be reduced slowly and discontinued if serum T3 is auto-maintained at greater than 4.5.
• TSH and T4 are usually low, or subnormal, because prescribed T3 entering the pituitary satisfies its need for thyroid hormone. A low TSH and/or T4 is not a concern in the context of IH therapy.
  However in a small percentage of cases, entry of T3 into the pituitary is blocked: in this situation, TSH rises and T4 tends to follow suit. This finding indicates a suboptimal supply of T4 for the pituitary, which is easily managed by addition of Eltroxin or Synthroid, to the prescription.

CAVEAT:

(1) There is no need to reassess reverse T3 until the serum T3 has risen to the desired range (4.5 – 6.1 picomoles/litre) and the physician wishes to “prove cure”.
(2) Once deiodinase 3 has been downregulated, addition of T4 to the prescription does not usually result in significantly increased rT3. If the IH has not been completely reversed, rT3 may rise slightly; but is unlikely to exceed 13 nmol/DL (optimal rT3 = 5.0 – 13).
(3) When all hypothyroid symptoms have subsided, oral administration of slow-release triiodothyronine may be weaned slowly, with weekly monitoring of serum T3 levels: maintaining serum T3 above 4.5 pmol/litre will prevent relapse.

Relapse

When oral triiodothyronine is discontinued, relapse of IH may occur, with recurrence of symptoms, in response to significant stress of whatever origin.
The first laboratory sign is suppression of the serum T3, and elevation of reverse T3.
Symptoms recur when the T3/rT3 ratio falls to less than 20: if this happens, prescription of oral T3 at the previously successful dosage, should be reinstated.

Caveat

Burnout is hardly ever an isolated phenomenon. Every HR professional and all employees should be educated regarding the signs, symptoms, diagnosis and management of IH “burnout” and prophylactically, any worker presenting with hypothyroid symptoms should be referred to a company physician who is aware of, and prepared to test and treat, IH.

References

[1] Burn-out, an “occupational phenomenon”: International Classification of Diseases. 28 May 2019,
https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

[2] https://www.psychologytoday.com/ca/basics/burnout

[3] INTRACELLULAR HYPOTHYROIDISM, Gervais Angelo Harry, May, 2023, https://www.researchgate.net/publication/370772568_INTRACELLULAR_HYPOTHYROIDISM

[4] Table for calculation of T3/rT3 ratio: https://cbhrt.ca/2023/06/05/t3-rt3-ratio/