The solution to life’s enigma is to be found not outside oneself but within, in one’s mind.

Introduction to

Japanese Death Poems

A senior physician seeks help from a psychiatrist at the insistence of her sibling, also a senior physician*. The apparent problem is an impulsive suicide attempt that almost succeeded. After some initial reluctance to talk, she discloses that she has been sad and unhappy. Her unrelenting workload with demanding patients and families, administrative headaches at the hospital, household matters, teenage children and elderly in-laws, have been grating on her nerves for a while. Her husband, solicitous and caring, accompanies her for the visit and seems genuinely worried. After a couple of visits to a psychiatrist, she seems better. At a follow up visit a month later, she seems to be doing well.

As a distinct phenomenon, burnout was first reported in the 1970s by American psychologist, Herbert Freudenberger, who initially used the term to describe a constellation of symptoms found within the “helping professions” - in his case, doctors and nurses. Another American psychologist, Christina Maslach, helped develop one of the earliest tools for measuring burnout, the Maslach Burnout Inventory. Their pioneering work led to the concept of burnout being broadened beyond just healthcare practitioners. It is now widely known that burnout, with its associated effects on work efficiency, productivity, life satisfaction and mental health in general, affects just about everyone.

Since the onset of Covid-19, there has been an enormous amount of research conducted on burnout, which has added to the already voluminous scientific literature on the topic. Scientific studies have demonstrated burnout in all professions, even in housewives and those not working outside their homes. From teachers and lawyers to doctors and nurses, from administrators to soldiers and even politicians, it seems that burnout is the new “psychological Covid-19”, except that there is no vaccine for it.

But what is a “burnout” exactly? According to Maslach and other researchers, the easiest way to understand burnout is to see it as a sort of general unhappiness; an inability to find pleasure in day-to-day activities; an emotional detachment (from work, family or other important things); a feeling that one is irritated, anxious or angry all the time and that feelings of contentment, happiness and satisfaction (with life, work, family, leisure activities etc) are either few and far between or absent altogether. One can see how this state of unhappiness, if prolonged with no resolution forthcoming, can easily lead to more serious mental health issues such as clinical depression, disabling anxiety symptoms, substance use or abuse or even suicide ideation.

So, what is going on? Why are we so stressed out and unhappy all of a sudden? States of feeling analogous to burnout have been around ever since humans started thinking and reflecting on themselves and the world around them. Shakespeare seems to be writing about something suspiciously close to burnout when Macbeth says to the doctor: “Canst thou not minister to a mind diseas’d/ Pluck from the memory a rooted sorrow/ Raze out the written troubles of the brain/ And with some sweet oblivious antidote/ Cleanse the stuff’d bosom of that perilous stuff/ Which weighs upon the heart”.

Let us not forget that going forward, we will all refer to our lives as “pre-Covid” and “post-Covid” given how it has visited economic and social destruction upon the world or at least substantial parts of the Western world. China and its surrounding countries have done a much better job of containing the pandemic and its impact by implementing simple, scientifically proven strategies that prioritise human life and well-being over economic activity.

In Pakistan (as also in India, the US, UK and many other countries that have tried to minimise the impact of Covid-19 by various “half measures”), the repeated dislocations of the economy and its consequences (including soaring unemployment and pervasive economic insecurity) have led to tremendous levels of burnout in workers as well as their families. Large numbers of people were laid off work when Covid-19 first hit. Those that remained on the job were made to work harder. We experienced this first hand in our large public hospital in Lahore over the last year, an Odyssey I wrote about in these pages.

And there is no end in sight.

A welcome development after Covid-19 has been the push it has given to online activities, including work. Virtual work has been around for at least the last couple of decades. When I worked full time in the US, back in the early 2000s, we had already developed a telepsychiatry network to connect several of our clinics located over a large geographic area. Online learning and teaching have also been around for a while as have conferencing, online meetings and financial transactions. But Covid-19 forced all of us to transition online, and in some cases to online leisure and socialising. While in Pakistan, we continue to grapple with basic technological issues (power cuts, poor internet connectivity, lack of access to computer and mobile devices), Covid-19 has helped spur the development of online work here as well. Schools, colleges and universities are now mostly equipped for online learning (the quality of education thus provided varies widely but that is another discussion). Telehealth has taken a huge leap forward in Pakistan with many doctors and healthcare professionals now offering online services and, thankfully, online financial transactions and business are beginning to mature.

But there is a downside to all this. Simply put, the line between work and leisure has been completely erased. Most of us are now working all hours of the day and night with little or no respite. Coupled with the financial insecurity which everyone in a country like Pakistan faces all the time, it is no wonder that we are all feeling the strain. And the constant hanging sword of new “waves” of Covid-19 (the Omicron variant being the latest example) is adding to the mix.

What can be done? The remedies are not complicated. We need to make time for sleep, leisure, exercise and (in-person) socialising with family and friends. Disconnecting from work, social media and screens regularly (including at least 2 hours before bedtime) is essential. Better yet, designate specific times to check email (especially, work emails) and social media. Don’t obsessively follow news about Covid, natural disasters etc. Find time to be alone, reflect, pray or meditate and just have some downtime. Take time off and go somewhere relaxing. A change of scenery can be an amazing recharge for burnout. And if nothing else seems to work, consider getting professional help from a certified, properly qualified psychiatrist or psychologist/ therapist.

The world will not stop spinning and, in fact, will continue to spin faster and faster but it is important to step off the treadmill regularly to take a breath and refocus on what matters most to you. Your body and mind will thank you for it.

*Personal details have been changed to protect privacy

The writer is a psychiatrist and faculty member at King Edward Medical University and a member of the Government of Pakistan’s HEC National COVID19 Committee for Psychosocial Wellbeing. He taught and practised psychiatry in the United States for 16 years. He tweets @Ali_Madeeh