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Four Perspectives: Burnout: Beyond workplace stress

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Four Perspectives: Burnout: Beyond workplace

The latest Four Perspectives with Professor Lesley Braun and the fx Medicine Ambassadors provides healthcare practitioners with a concise overview of the landscape of burnout - beyond the workplace and its management with key nutrients, herbs and psychosocial strategies. 

They begin by clarifying our understanding of what burnout is and the important distinction between anxiety and stress. They highlight the normalisation of stress in society and the need to understand burnout. There is discussion around the pros and cons of diagnostic criteria of burnout, covering two diagnostic surveys along with the use of salivary cortisol testing.. 

An important perspective shift is introduced on the concept of ‘adrenal fatigue’, and the need to reconsider this concept and move towards HPA dysfunction and cortisol dysregulation. This reframing better supports the practitioner's approach to managing burnout andemphasises the significance of rest and recovery, with a unique perspective on tissue healing and the time needed for nerve tissue recovery. 

Key herbal and nutritional therapeutics are discussed with the ambassadors providing an overview of nutritional interventions, focusing on magnesium, deficiency states, specialized pro-resolving mediators, B vitamins, and CoQ10. The value of herbal remedies are also explored with a focus on effective utilisation of key herbs including withania, holy basil, kava, and saffron. 

This Four Perspectives episode provides a valuable insight to address this prevalent issue within the healthcare community and your patients. 

Covered in this episode

[00:48] Welcoming the Ambassadors and introducing the topic of burnout
[03:14] Gradient burnout
[07:19] Recognising burnout in our patients
[09:15] Is there a diagnostic criteria for burnout?
[11:40] Pros and cons of the Maslach Burnout Inventory and Sydney Burnout Measure
[15:13] Salivary cortisol as a measure of stress
[17:31] Triggers of burnout outside the workplace
[20:34] Adrenal fatigue vs HPA axis dysfunction vs cortisol dysregulation
[24:45] Post-pandemic stress disorder
[27:41] Neuroplasticicty - a dead match
[32:51] Magnesium
[38:02] Withania 
[43:51] Saffron
[47:38] Kava
[48:46] Holy basil
[50:50] CoQ10 and SPMs
[56:16] B group vitamins
[59:49] Managing expectations and experiencing setbacks
[1:05:15] Preventing burnout before it begins
[1:08:36] Thanking the Ambassadors and final remarks

Key takeaways

  • Clear definition of burnout - chronic stress and frustration that leads to both physical and emotional exhaustion , feelings of cynicism and detachment, and a sense of ineffectiveness, lack of accomplishment or productivity.  Linked to workplaces, people who are primary carers and parents (unpaid work). 
  • Anxiety VS burnout. At its roots anxiety: 
    • Is characterised with excessive fear 
    • Results in a change in behaviour  
    • Has significant impacts one’s social, professional and personal relationships 
  • Stress VS burnout. At its roots stress: 
    • Covers a broad scope and is more general in nature 
  • Diagnosing and “naming” the condition may be helpful for some patients.
  • Scientifically validated tools and their pros (+) and cons (-): 
    •  Maslach Burnout Index (22 questions) 
      • + Globally recognised, well validated for assessing workplace burnout 
      • + Strictly related to the workplace 
      • + Quick completion 
      • - Does not consider cognitive impairment 
      • - Does not consider personality traits and change 
      • - Seems dated because of these limitations 
    • Sydney Burnout Measure (34 questions) 
      • + covers a wider range of parameters: exhaustion, cognitive impairment, social withdrawal, compromised work performance, and empathy loss 
      • + useful for clinicians  
      • + considers personality types 
      • + more recent 
      • + Quick completion 
      • - newer, research base not as robust 
  • Salivary cortisol testing is useful to determine when someone has normalised their stress and may be unable to recognise the physiological responses as detrimental. 
  • HPA axis dysfunction or cortisol dysregulation, a technically accurate naming for the term “adrenal fatigue”, is the flatlining of cortisol. A cortisol pattern that doesn’t follow a diurnal rhythm is a common sign in burnout. 
  • Recovering from burnout takes time and involves restoring nervous system dysfunction, and changes to neuroplasticity. Developing a habit can take 20 to 250 days depending on complexity and chronicity of the burnout. Rest is the most important aspect to recovery. 
  • Managing setbacks is important in supporting someone through their journey. Self-compassion is a priority along with considering a team of healthcare professionals as support structures. Enjoying and prioritising rest, relaxation, and reflection. 
  • Burnout Therapeutic Considerations:
    • Herbal 
      • Withania 
        • Mechanisms of action
          • Adaptogen
          • HPA axis modulator
          • Upregulates GABA receptors
          • Anti-inflammatory actions
          • Appetite regulator 
        • Dosage: 225 or 400 mg/d
      • Saffron 
        • Mechanisms of action: Anti-depressant; Sleep support 
        • Dosage: 14 mg BD
        • Time to effect: 2 weeks with most improvement at 8 weeks 
      • Kava 
        • Mechanism of action: Anxiolytic 
      • Holy Basil
        • Mechanisms of action: Anxiolytic; Stress support (trialled to support lowering cortisol) 
    • Nutritionals
      • Magnesium 
        • Mechanisms of action
          • Enhances GABA receptor activity
          • Reduces TNF-a expression
          • HPA axis modulator 
        • Dosage
          • Citrate: 400 mg/d
          • Glycinate: 600 mg/d
          • Threonate: 25 mg/kg p/d, divided dosing 
        • Time to effect: 3 days
      • Specialised pr-resolving mediators (SPMs)
        • Mechanisms of action: Resolves chronic (low-grade) inflammation 
        • Dosage: 100-200mg/d 
      • CoQ10/Ubiquinol 
        • Mechanisms of action: Antioxidant; Mitochondrial support 
        • Dosage: 100-600 mg/d 
      • B vitamins 
        • Mechanisms of action: Stress support; Energy support 

Resources discussed and further reading


Report: Australian WHS Survey (Centre for Work Health and Safety, 2023)
Article: Burn-out an "occupational phenomenon": International Classification of Diseases (World Health Organization, 2019)
Article: Experiencing burnout? Here’s what to do about it (Black Dog Institute)
Research: Burnout: Re-examining its key constructs (Psychiatry Research, 2020)
Research: Modifiable risk factors related to burnout levels in the medical workplace in Taiwan: cross-sectional study (BMJ Open, 2019)
Podcast: Workplace Wellness: Preventing Practitioner Burnout with Dr. Michelle Woolhouse and Sharee Johnson

Resources for Practitioners

Gordon Parker's Book: Burnout: A guide to identifying burnout and pathways to recovery

Dr. Michelle Woolhouse's Book: The Wonder Within

(fx Medicine listeners get 20% off with code FXMED20) 

Self Care Plan (Black Dog Institute)
The Rest Test: Preliminary Findings from a Large-Scale International Survey on Rest

Maslach Burnout Inventory (MBI)

MBI-HSS (MP): for Medical Personnel 
MBI-HSS: for Human Services workers 
MBI-ES: for Educators 
MBI-GS: for General use 
MBI-GS (S): for Students

Sydney Burnout Measure 


Cortisol and HPA axis dysfunction

Research: We are tired of 'adrenal fatigue' (South African Medical Journal, 2018)


Research: An investigation into an evening intake of a saffron extract (affron®) on sleep quality, cortisol, and melatonin concentrations in adults with poor sleep: a randomised, double-blind, placebo-controlled, multi-dose study (Sleep Med., 2021)
Research: Efficacy of a standardised saffron extract (affron®) as an add-on to antidepressant medication for the treatment of persistent depressive symptoms in adults: A randomised, double-blind, placebo-controlled study (J Psychopharmacol., 2019)
Research: Saffron (Crocus sativus) for depression: a systematic review of clinical studies and examination of underlying antidepressant mechanisms of action (Hum Psychopharmacol., 2014)

Holy Basil

fx Medicine Article: Holy Basil: The story of Ocimum Sanctum
Research: A randomized, double-blind, placebo-controlled trial investigating the effects of an Ocimum tenuiflorum (Holy Basil) extract (HolixerTM) on stress, mood, and sleep in adults experiencing stress (Front Nutr. 2022)

Prof. Julia Rucklidge's research

Podcast: Stress Resilience & Practical Prescribing with Dr. Adrian Lopresti and Professor Julia Rucklidge
Research: ‘Broad spectrum micronutrient formulas for the treatment of symptoms of depression, stress, and/or anxiety: a systematic review’, Expert Review of Neurotherapeutics, 2019
Research: Psychological functioning 1 year after a brief intervention using micronutrients to treat stress and anxiety related to the 2011 Christchurch earthquakes: a naturalistic follow-up (Rucklidge, et al., 2011)
Research: Shaken but unstirred? Effects of micronutrients on stress and trauma after an earthquake: RCT evidence comparing formulas and doses (Rucklidge, et al., 2011)
Research: ‘Database Analysis of Depression and Anxiety in a Community Sample—Response to a Micronutrient Intervention’, Nutrients, 2018
Research: A randomised trial of nutrient supplements to minimise psychological stress after a natural disaster (Kaplan, Rucklidge, Romjin, & Dolph, 2015)
Research: Massacre, earthquake, flood: Translational science evidence that the use of micronutrients postdisaster reduces the risk of post-traumatic stress in survivors of disasters. (Rucklidge, et al., 2021)



Lesley: Hi, I'm Dr Lesley Braun. On behalf of the fx team and our four ambassadors, Adrian, Emma, Lisa, and Michelle, welcome to fx Medicine where we bring you the latest in evidence-based integrative functional and complementary medicine. 

fx Medicine acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Our four ambassadors are joining us, and that's Adrian, Emma, Lisa, and Michelle. Welcome, everybody.

Everyone: Hi, Lesley.

Lesley: An Australian work health and safety survey that was conducted in January 2023 reported that 64% of workers are feeling burnt out. Now, depending on the study, the burnout rates amongst healthcare practitioners are actually high, and they remained high over the last three years, and they're sitting at over 80%. 

But it isn't only healthcare professionals at risk. Many have had patients who are all screaming for more support, and we need more evidence-based tools to help people suffering the widespread impacts of burnout. So, why the sudden rise? Is the burnout epidemic real or is it just unveiling a previously hidden issue in our society? And what even is burnout and are we using the term too casually?

Today we're going to answer those questions and more. We're going to look at burnout throughout the lens of our four ambassadors. So, our psychologist, Dr. Adrian Lopresti, our two naturopaths, Emma Sutherland and Lisa Costa-Bir, and our integrative GP, Dr. Michelle Woolhouse. 

We'll take you through the difference between anxiety, stress, and burnout, and hopefully you'll learn a whole new perspective and way of approaching burnout as we discuss the following five aspects: what burnout is and what it isn't, what are the risk factors for developing burnout, how it presents, and what can we do holistically to support people with burnout. Importantly we're going to talk about how to work collaboratively and manage the sometimes inevitable setbacks which will occur because healing never progresses in a straight line. And finally we're going to do a deep dive and focus on some key nutrients and herbs that are useful, including some prescription protocols so clinicians can understand what, when, and how to prescribe them.

Let’s get started, and I'm going to kick off the discussion with you, Michelle. There is a debate in some of the psychological literature and quite honestly even amongst the public about whether burnout is a real thing. The other thing I want to learn about is something called the gradient to burnout, and how they're intertwined, and how we differentiate this. So, can you tell us more?

Michelle: Sure. So, it was interesting to me that the World Health Organization a couple of years ago came out with the statement about burnout being a real and genuine condition. They defined burnout as a “state of chronic stress and frustration that leads to both physical and emotional exhaustion, feelings of cynicism and detachment and a sense of ineffectiveness or lack of accomplishment or loss of productivity.” And so it actually started to be included in the 11th revision of the international classification of diseases, but it's recognised as an occupational phenomena and not actually classified as a medical condition, so that's where some of the confusion lies. But a lot of people in the literature are now talking about what classifies the workplace, and a lot of people are extending burnout into the areas of carer stress, or parenthood, or those that are working in multiple different and non-paid areas.

And so anxiety is very different to burnout, although it's common to feel anxious through the burnout experience. And it's likely that burnout and anxiety go together the other way around as well. So, anxiety and fear-related disorders are characterised by excessive fear. And it's related to a behavioural disturbance with symptoms sort of severe enough to result in significant impact on one's life, a significant impairment perhaps in their personal situations or family, social, workplace, or educational areas in their life.

And stress is, kind of, more broad. So, the theory of stress is that stress can be much more ubiquitous, and it can be experienced in a whole raft of different ways. And I think the difference between something like burnout and anxiety is that stress is a very broad way of describing something.

I particularly love this theory of stress by a researcher called Lazarus, which came out in the 1960s. And I don't think that there's a better one. And he states that stress is experienced when a person perceives that the demands on them exceeds the resources that they have or their coping strategies.

But there is some really fantastic research that's coming out. And the leader of that research is Prof Gordon Parker, and he's a psychiatrist and founder of the Black Dog Institute. And he recently released a book on burnout. And the beautiful thing about that, and I really concur, is that he extended this idea of the workplace to encompass a much broader area than that paid work element. And he believes that burnout is actually particular in a certain group of people that is overrepresented and really dutiful people, really reliable, really caring, really empathic people.

Lesley: You know, Michelle, one of the things I think about when I hear your answer is we've done a Four Perspectives on mental wellbeing, and we talked about stress and how psychological stress is very much about how you perceive something, but burnout seems to be different because there's a physical element to it. It seems to have many more dimensions.

The other thing I found interesting is when you're talking about workplace and since COVID, and lockdowns, and pandemic, I mean, what is the workplace now anyway? People are working all over the place. I'm sitting in a bedroom right now. So I think there's a fuzzy line that's happened now between workplace as well, and it's tipping over into other parts of our lives.

I’m going to bring Emma and Lisa in here for a minute because, as practitioners. I can only imagine that you're seeing people that come through the door and say, "I've got burnout," or maybe they don't even realise it and you've got to help them identify that. 

Let's start with Emma. what are you seeing in your practice?

Emma: For me, I definitely see people that are in burnout, but a lot of the time they don't recognise it because they are so incredibly overwhelmed and in their little microcosm that they don't see the bigger picture, but they'll come in and they'll say things like, "I don't have energy. I don't have any motivation. I'm feeling anxious," or they've got these negative coping patterns like drinking too much alcohol or, "I can't stop eating sugar." So, for me, it's something that I see quite clearly, but most of the time, my patients don't.

Lesley: That's interesting. Lisa, are you finding the same thing? Are you seeing the same patterns in your clinics?

Lisa: I am. And in terms of building upon what Emma's already said, I'm seeing a lot of fatigue, a lot of mood issues, more so than I ever have done actually. So, a lot of flat mood, not necessarily depression, but melancholy, just not feeling like themselves is often how they describe it. And clients also experiencing increasing frustration, irritability, impatience. Just if they're waiting for their coffee and it's taking longer than expected, they feel like they go from zero to 10 very quickly. And just feeling more cynical about the world in general. And then of course things like libido can be affected, and they don't make that connection. And of course when we're feeling fatigued and overwhelmed, the last kind of thing anyone wants to do is the libido sort of stuff. So, I think burnout is really interesting because it's not just the mental state as you said, but it also manifests physically in every aspect of a person's life.

Lesley: And from what you're both saying, it's not something that someone feels for a day or two or a week. It's more longer-lasting than that, isn't it?

Lisa: Yes, definitely.

Lesley: Great. Look, I think it's time to ask Adrian, surely there's an official diagnostic criteria for burnout? I was reading that I think it's the University of New South Wales School of Psychiatry and obviously Black Dog Institute have recently carried out two Australian first studies looking into burnout.

I know that they used, I think, over a thousand volunteers to develop a method to try and understand this and have some kind of criteria so everyone's, again, singing off the same song sheet. I'd love for you to explain a bit more about this because I'm sure a lot of practitioners are seeing people coming in with signs and symptoms, and we need something to help us understand this.

But, Adrian, you are the expert. So, what's the latest here?

Adrian: Yeah, I mean, certainly. I think we can get into the issue of diagnoses and trying to identify whether somebody's suffering from burnout or not. And there's pros and cons to whether you come up with a label for somebody. And sometimes it's helpful. Sometimes having a diagnosis can help motivate people. They've now got a name to the conditions or the symptoms they're experiencing.

But the reality is that there's a significant heterogeneity when it comes to burnout and any condition in general mainly. And many people will suffer, as Michelle mentioned from anxiety. Many people also have sleep disturbances. I think some of the researchers saying at least a third of people will have sleep disturbances who suffer from burnouts. Many of them will have depression and, again, 30% to 50% of people who experience depressive symptoms.

So, we do need to do a really good assessment and try to identify symptoms people are experiencing. Are they sleeping well? Are they sleeping not enough? Are they sleeping too much? Are they experiencing depressive symptoms? Are they experiencing anxiety symptoms? What's their social connections like? Are they withdrawing? Because that's another common symptom that occurs with people with burnouts, that there's a social withdrawal. There's less engagement at work, obviously that occurs.

So, I think they're the things that we really need to be asking for, and asking even when it comes to ourselves as practitioners. Are we experiencing some of these symptoms and what are some of the risk factors? What are the causes? What are the things that are contributing to these symptoms in myself or in the clients that I'm seeing? I think they're really, really important questions that people need to be asking.

Lesley: Mm, I agree. 

Emma, from a naturopathic perspective, I know you've worked with various tools in practice. And one of the ones that I see a lot reported in the research is something called the Maslach Burnout Inventory.

Emma: Yes, yes.

Lesley: I know it's got limitations. It's got strengths. Do you use it? And how helpful is it?

Emma: I don't use it. I think it's good to understand it though, because it was the first scientifically developed measure of burnout. And realistically, it's used in about 88% of burnout literature, so we do need to understand it. And it is validated for workplace use. So, what I think is important about this is that it's very specific for health professionals, government employees, teachers, and the actual index itself comprises of 22 questions, and the person has to rate them on a frequency scale.

And there's questions like, "I feel emotionally drained by my work," or, "I feel like I'm at the end of my rope." And when you look at the pros, it is considered gold standard for measuring burnout. It's globally recognised, which is good. It's very well researched. It's well validated for screening workplace burnout. And it's pretty easily done with a patient in about five minutes. 

But when you look at the cons, it is workplace-related only. I think it's outdated. It doesn't include cognitive impairment. It considers burnout an occupational phenomenon and not a medical or a physical condition. And it also doesn't take into account personality traits. So, I think when you weigh it up, it's not something that I would use clinically.

Lesley: Okay. Well, then that begs the obvious question. What are you using clinically and how useful is that?

Emma: Yeah, I use the Sydney Burnout Measure, which was developed by Gordon Parker as Michelle mentioned earlier. And I feel it is way more relevant for us. It takes into account the personality types. And when you're looking at that, people in people professions such as us, we're more likely to suffer from burnout. And I feel his reframed index is way more relevant in current times. I feel it's more holistic in nature. It covers a wider symptoms sets, so it includes the five burnout factors, which is exhaustion, cognitive impairment, compromised work performance, empathy loss, and social withdrawal.

So, looking at the pros, it's way more recent, 2021. It's Australian-based. It takes into account more factors of burnout, and it doesn't consider burnout just a workplace phenomenon. And it is actually really easily done in about five minutes. But looking at the cons, validity is still being researched. It is new, so we don't have the long-term validity. And if the scores do come up high, you've got to ensure that you refer back to a GP to look for conditions such as anxiety, or anaemia, or depression, or hypothyroidism. So, it's not perfect but I think it's way more relevant.

Lesley: Wow. I really like the fact that it's beyond workplace but also the fact that it only takes five minutes. How many questions in this measure?

Emma: It's 34. So, there are more questions, and it is a little bit more holistic, but it's often something that I will put in front of a patient or send them afterwards and say, "Look, don't think too much about it. Just gut feeling, first answer, and send it back to me." And it's a really good insight for me just to get a baseline with patients.

Lesley: It sounds really easy, really easy to use and really easy to interpret.

Emma: Yeah.

Lesley: Yeah, thank you. Now, Michelle, what do you do when people come in and they say, "I think I have burnout," or maybe they don't recognise it, but like we've talked about, you're starting to think that this might be the case? How do you assess people?

Michelle: I think it's really important to listen really deeply to their story. I have a full hour with my new patients and I think a lot can be had by the way you listen to a person tell their story. And they'll often, kind of, you’ll hear things about, "I've had enough," and irritability is worse than ever, and there's a lot of self-doubt. And even to the point of imposter syndrome and perfectionism. And you can pick up a lot of these nuances along the way. So, as you're listening deeply, you're looking for the quality of how people are telling their story.

And I usually see female patients, and so there's a prevalence within the female population in terms of that, particularly if you're looking at the group of people that are previously very passionate about their work. And so often that loss of passion is quite disturbing for them. I also like Gordon Parker's assessment, and I don't use Maslow’s measure quite so much. But I think generally a good history taking can really pinpoint what burnout is.

The other thing that I often tend to do for people that have almost normalised stress in their life... So, they're used to such high levels of stress that their coping strategies have become lessened. But in fact, they feel like they are not coping even though they're coping with more, and more, and more. And so I like to do a saliva cortisol test throughout the day so that people can actually see the response of their cortisol to certain stressors. And I think that that's a really nice way that it’s — I guess it's a stress test — but it's actually helping people to understand the level of impact on their physicality of their body in a burnout situation.

Lesley: I found it really interesting how you also use salivary cortisol. I think that's so smart. There’s the analogy of the frog in the pot, and you slowly warm the water, and the frog doesn't realise.

Michelle: Mm, that's right. Exactly.

Lesley: I'm going to want to talk to Lisa for a minute because we've talked about the fact that this was once considered a work-related issue, but we know that actually burnout is happening to people outside the traditional workplace. It's basically possible anywhere. And I'd imagine you probably have seen people that might have had burnout related to work, but you've seen a shift in your practice. What are you seeing as some of the causes or triggers? And have you seen this shift as well?

Lisa: I have. I have seen a lot of burnout in patients that it's coming not from a work-related area but from caring for a chronically ill parent, or a spouse that maybe has dementia, or something along those lines, or people caring for a child that has special needs. And definitely lots of clients in my dynamic that have a history of relationships where maybe there's been domestic violence, financial abuse, that sort of thing, and now they're single parenting. And then you throw in financial stress, the pandemic, watching political unrest unfold, and you can kind of really understand how that burnout picture might arise.

So, in terms of common causes and triggers, I feel like it's never just one thing. We've talked about some of the triggers already, but definitely from that microscopic level, personality factors certainly do play a large part, and we often see individuals' own expectations of themselves and their extreme commitment to a situation. So, that might be a relationship or a workplace situation, then results in them neglecting their own needs. And if stress intolerance and a little bit of lacking in resiliency are often already a little bit low, then they often find that they're more prone to that burnout. I think especially if they've got that type A personality, which many of us do.

Lesley: Expectations are a funny thing, aren't they? Because, funny, in our family, we sometimes talk about if you lower your expectations, you're more likely to be delighted, but sometimes you can't help yourself. You have high expectations of yourself, and it helps you to rise to a challenge and stretch yourself in ways that maybe you didn't always know you could. So, yeah, the balance of expectations, it's a hard one, isn't it?

Lisa: Yeah, I also think it's really interesting if we look at societal factors like technology too. I'm a huge fan of technology. I love the connectivity that it brings, but definitely research is showing us, too, that digital burnout is a huge contributor to burnout too. There's lots of research on this. We’re switched on a lot more, but as a result, we could find it really difficult to switch off.

So, I think we have to consider things like that as well. And I often think about my patients. They're running on this empty tank, and they're like a little car that's missed their service, and they're expecting that they're going to be able to do all the things and go around the track really efficiently, but the engine's starting to stutter. The wheels are starting to fall off and I kind of think of burnout like that.

Lesley: Yeah. Now, that's a good point. We all need a bit of maintenance and an oil change.

Lisa: Yeah.

Lesley: And we need to remember to do it before there's a problem.

One of the things I hear about is this concept, it's used a lot in the naturopathic community, of adrenal fatigue. And I think it's a really good thing to talk about. What is adrenal fatigue? Is it real? And how can your adrenals get tired? It's a very simplistic way of describing something that, of course, is going to be more complex. So, can you tell us a little bit more about this?

Lisa: Sure.

Lesley: And I'll bring Michelle into this conversation as well.

Lisa: Yeah, so I think as naturopaths, we all got taught the concept of adrenal fatigue, and it made a lot of sense at the time. But then in 2018, Ross, et al. wrote this great and somewhat controversial journal article stating that adrenal fatigue does not exist and, to an extent, he was right. If the adrenals stopped working, that would be Addison's disease. And so I think it comes down to using the correct terminology.

So, we see clients that obviously don't have Cushing's, which is too much cortisol, and they don't have Addison's, which is not enough, but we see them in this halfway place where they're definitely exhibiting issues with their cortisol rhythm. And so the more correct term is actually HPA axis dysfunction. And what we're describing is this communication between the hypothalamus, the pituitary, and the adrenal axis, so the brain structures communicating to the adrenals. And I think obviously we know this becomes dysfunctional where there is this prolonged sustained stress, and we see this abnormal rhythm of cortisol.

So, cortisol has a diurnal rhythm. It's highest about half an hour after we wake up, and then it slowly decreases throughout the day. But I think in burnout, with a lot of my patients that I see and Michelle would probably be able to see this too with the salivary cortisol that she's doing, we see a dysfunctional cortisol rhythm. And often with burnout patients, it's flatlining, which is why they feel fatigued and brain foggy. They're hitting snooze on the alarm multiple times. They're very reliant on caffeine to get them going.

Michelle: Yeah. I mean, I too read that article about adrenal fatigue a couple of years back, and certainly the mainstream medical community really jumped on that and was a little bit disparaging about that communication. But I've always found looking at the HPA axis just incredibly revealing, particularly when you look at modern social stressors. I mean, we don't really have to look very far to look at the extreme difference in the level of stress that we experience on a day to day function now as compared to, say, 40 years ago. Just the pace of life is so extraordinary. I loved Lisa's contribution about the digital burnout because I hadn't heard that term before but I know exactly what she means when she talks about that.

With adrenal fatigue, what I like the terminology is cortisol dysregulation. And I think when you look at the science of psychoneuroimmunology, we're always looking at the difference between, say, homeostasis and this pressure on what balance is to the body. And every time we have extra pressure, the body has to respond in which to maintain a certain level of balance. And we see that with insulin, and insulin resistance, and insulin sensitivity. And cortisol is much the same. We probably have elements to the cells functioning about how sensitive we are to cortisol. So, it's not just about the amount that we secrete but it's also how we respond to it as well.

And then there's the impacts of cortisol on sleep and the impacts of cortisol on sex hormone regulation and insulin, all of which are neurosteroids and all of which have impacts on brain function as well. So, it's a very holistic concept to bring cortisol and stress response into helping patients to understand, or helping people with burnout understand the physiological implications of when the body is under extraordinary levels of stress.

Lesley: Yeah, that makes so much sense. Well, I'm glad we cleared that up. So, adrenals getting tired is a bit simplistic, and we've got some new ways of thinking about it. So, that's really helpful.

Adrian, you mentioned labels. So, one I've heard about recently is post-pandemic stress disorder. Is that a real thing, or is it just burnout, which happens to happen after the pandemic? You know, what do you think?

Adrian: Look, to be honest, I hadn't heard of that term before, that disorder, and there's always new ones. And if we think about post-pandemic stress disorder, I assume that means that they've experienced the stress following post-pandemic, but why hasn't everybody experienced post-pandemic stress disorder because we've all experienced this stressor? But some of us have experienced exhaustion after that, and some of us haven't. Some of us experienced depression, some of us experienced anxiety, but the reality is not all of us have. And what the disorders don't allow us to do is to identify the factors that might be contributing to the symptoms that people are experiencing. And I think sometimes disorders are there to keep psychologists and psychiatrists and so on in jobs and keep us relevant.

Lesley: No, no. Really?

Adrian: So, I think we just got to be careful around that, but if it's helpful for people, if a label helps them to understand it... But ultimately we need to really look at the person and not the disorder when you treat the person and not the disorder, and we need to identify the risk factors that were going on for that individual before the pandemic and after. 

I just recently read a Taiwanese study where they looked at burnout, and what they found was that people who had an abnormal meal time, there was 140% increased risk of having burnout, and people who are frequently eating out had a 50% increase of burnout. And lack of sleep was a five-time increased risk of experiencing burnout. So, those are the things that we need to be assessing for. And then from there, developing a treatment plan with our patients to help them overcome some of those symptoms.

Lesley: What I found really interesting about that is I'm sure there's a lot of people that can relate to those things. And they do go out a lot, they might travel a lot, they might eat at different times, and they're perfectly fine. But yet the next person having all of those same factors in their life may not respond the same way. So, that individualisation is so important.

Adrian: Yeah. I mean, we've spoken about personality playing a part, and that can predispose somebody to an increased risk of experiencing burnout. But, again, it doesn't guarantee that somebody's going to experience that burnout. If somebody has that perfectionistic style but they have good social connections, and they have good self-care, and they have a job that suits their personality, then certainly they're not necessarily going to result in burnout. But if somebody's working 40, 50, 60 hours a week, and they have that predisposition, then that's going to trigger symptoms for them.

Lesley: Yeah, it'll put them at higher risk for sure.

Adrian: Absolutely.

Lesley: So, one of the things I'd like to go into now is looking at some of the tools of trade that we have. We've got so many different nutrients, so vitamins, minerals, herbs as well. There's a lot that we've got that we can draw from. So, let's start moving a little bit more into some of the tools that we have to help people with. 

So, I'm going to start with Michelle. How long does it take before you see tangible changes in someone, regardless of whatever mix of things that you're giving them? And what are some of those factors you look out for that help to avoid people slipping backwards? Because we know that healing is never a straight line forward. There's always going to be a couple of steps forward and a step back.

Michelle: I absolutely love this question, by the way, because I think this is probably one of the most important questions about burnout in my clinical practice that I talk to people about. And I think it all comes down to the science of neuroplasticity. And that is the science that the neurons have the ability to grow and reconnect. 

So, the way that I look at burnout on a clinical and really practical level is that it is a state where the nervous system is exhausted. It's kind of gone too far. And I'll often say to my patients burnout is like a dead match. So, you can't relight a dead match. So, that's the first thing that I tell them. And so some of them are really happy to hear that, and other people are really a bit shocked to hear that. But in fact, it's actually quite a profound thing to hear because the fact that they can't just keep going on and doing what they're doing when they're in a state of burnout is a really, really important critical factor in the healing.

The second thing that I tell them is what we do with the dead match is that we have to put it into the compost and they have to learn to rest. And we work with Einstein’s famous quote which I’m going to paraphrase, is that you can’t solve a problem with the same thinking that you created the problem with in the first place. And I think that’s the critical element of burnout, is that people have to learn and relearn new and sustainable ways in which to then either return to the job they’re in, or develop new strategies or new workplaces changes, whatever they end up deciding to do.

So, this change in adaptation pathways occurs in the mind and takes a lot more time, unfortunately, than people realise. The reason for that is the brain uses 25% of our energy. It's a very hungry beast. So, when we want to change our thinking and our behaviour and find new sustainable ways in which to be ourselves, it takes a lot more time. So, some research actually says that a new habit will take anywhere between 21 days and 254 days. And that pretty much is depending upon the complexity of the habit that you're trying to change. And repetition and practice is seriously important for neurogenesis. So, I like to tell people that starting a new pathway of change is like starting on a little rickety walking track through a bush and hoping to form new pathways into a super highway. So, it's going to take time.

And the other thing that I tell people is that different cells in the human body have different healing rates. So, the fastest healing of any cell is in the cornea. That takes about 24 to 48 hours to heal. And then you've got your skin, which is anywhere between 5 and 10 days. Then you've got your ligaments and muscles, and that's usually between about two and six weeks. And then you've got bones, which may be 12 weeks for a big fracture. And then nerve tissue, and they wait for it, and they're like, "How long does it take?" And I say, "Well, nerve tissue takes about 2 to 5 years to change."

But what we find is that, in the early days, that rest is really, really important. The power of resting the mind we know scientifically helps to increase productivity. But what's happened in our modern day community is we don't rest anymore. So, we don't recreate. Our whole idea of rest is binging on Netflix. And that's a kind of physical resting state, but it's not a mental resting state. And so mentally resting requires a whole new commitment to change that neuroplasticity and remodel the brain. 

Finding new ways to rest even like... I like to instruct myself and also my patients just to lie on the grass because that connection to the earth is really beautiful. And if it's a cloudy day, to just watch the clouds go by or watch a little ant crawl up a blade of grass. And these really microfocused new ways of resting can be incredibly profound. It's very underrated, rest in our community for helping the brain to unwire itself and to rewire.

Lesley: For someone who has been called a perfectionist and very work-focused, it's taken a long time to realise that rest is productive but not in the traditional sense of productive. But rest is restorative, and that's being productive on a cellular level. But it's taken a while to reframe that.

Well, let's move on to some herbs and nutrients because I know that there's some powerful things out there that can really help to nudge the body a little bit faster in these ways and really support through this. 
So, Emma, I know magnesium is your go-to. It is for so many people. It must have a place here. Can you tell us a bit about how it works in these cases and how to prescribe it? How often? How much? How long? How do you use it?

Emma: Yeah, I'd love to. So, when we're looking at the mechanism of action, magnesium agonises GABA receptors, and that inhibits the neuronal excitation, and that results in a calmer nervous system. If someone is magnesium deficient, GABA receptor activity is actually reduced, and that results in glutamate excitation and results in nervous system over excitability. Magnesium also inhibits the production of the inflammatory cytokine, TNF alpha. And as Lisa discussed, the HPA axis, magnesium helps to modulate this beautifully, and I really love it for that effect.

What I wanna think about is highlighting the risk factors for a magnesium deficiency. If you look at these, I think the burnout patient is going to be top of the list. So, it's people with excessive intakes of caffeine, alcohol, or salt. It's people with prolonged stress or elevated cortisol. It's people with gastrointestinal disorders, super common in those burnout patients. And also thinking about the impact of medications like proton pump inhibitors, laxatives, and the oral contraceptive pill.

Now all of those are going to lead to a hypomagnesemic state, which research has been shown to reduce resilience and increase the risk of burnout. So, essentially this creates a chicken and the egg situation as higher stress levels deplete magnesium and low magnesium levels predispose to anxiety and burnout, which I feel our patients get trapped in this cycle and where magnesium can be so powerful in implementing.
But it's also about using the correct form of magnesium. I avoid the oxide and sulfate forms because of their poor bioavailability. We want to be prescribing highly bioavailable forms such as citrate, glycinate, and threonate. And also don't forget that food is medicine approach. Foods like nuts, legumes, whole grains, raw cacao, avocado, and leafy greens are really good for their magnesium content. So, don't overlook the food side of things.

And then when we're looking at the doses that you want to use, look, the RDIs are between 320 to 420. I would go around that as a supplement, depending on the form you're using. So, if you're using a citrate form, I would go with 400 milligrams a day. If you're using a glycinate, I would go a little bit higher at about 600 milligrams a day. And with threonate, which I love as it crosses the blood-brain barrier, and it works really nicely on cognitive function and anxiety, I work on the basis of 25 milligrams per kilogram of body weight per day, and then I do that in a divided dose. So, for someone like me, that's about 2 grams a day, 1 gram morning, 1 gram night.

So, I think you can be really flexible in your dosing with magnesium because we've got different forms to use. The glycinate form is so beautiful at night because the glycine can help reduce sleep onset insomnia. So, for example, for myself personally, I take 400 milligrams of citrate in the morning and then I take another 200 milligrams of the glycinate form at night, but you can really tailor it to the patient sitting in front of you, which I think is the beauty of magnesium.

Lesley: The thing I like about magnesium is it's so safe. And not only are you getting all of these effects cognitively, like you say, and you're repleting the body as well, because it's being depleted but also it has that really nice effect on muscles and that tightness with muscles that you can get with this whole picture as well, I'd imagine.

Emma: Yeah, exactly. I like the citrate form for that. And also for sluggish bowels, the citrate form can be really nice. It's a very gentle osmotic laxative. So, for those burnout patients that just have very sluggish digestion, it could be one to think of.

Lesley: And so, when you start a patient on magnesium like you've described it, how long before they start to feel something different? We're talking days or weeks here? What are you seeing?

Emma: I typically see this quite quickly within three days. I have patients that will email me and say, "Oh, my goodness, I can't believe my headache's gone. My eye twitch has gone. I'm sleeping." Magnesium is one of those ones that I think does get a pretty rapid response.

Lesley: That's really quick. That has to feel good and be so motivating for someone to continue.

Emma: Well, it's good for people to get a quick win in that way and to start the ball rolling so that they can then start implementing the next layer of self care.

Lesley: Couldn't agree more. We have to move to one of my all time favourite herbs, and that's withania. I mean, what can't this herb do really?

Emma: I know.

Lesley: It has to have a role here. Please tell me you use it and how do you use it.

Emma: I use it extensively. So, as we all know, it's an adaptogenic herb, and that essentially means it improves resilience to stress. The active constituents are mainly the withanolides, specifically withaferin A. But interestingly, when I was researching for this episode, many papers said that there was evidence for as yet unidentified active constituents in withania. So, that means while we have identified withanolides, there's whole-plant medicine here where we could also keep in mind, it's the synergy of the whole plant.

But looking at the mechanisms of action, once again like magnesium, it works beautifully on the HPA axis and results in that sort of healthier expression of hormones. Research has also shown that withania has an upregulating effect on GABA receptors. And I do have to say clinically, I use magnesium and withania a lot because their actions are so similar. And interestingly, withania has also shown to have an anti-inflammatory action by increasing interleukin-10 and decreasing NFkappaB. So, beautiful when those patients are also inflamed and burnt out.

Lesley: I think what you've described about herbs is so common. Herbs are...they're so complex. It's not like a drug with a single molecule and a mechanism of action. When you have a herb, there's so many actives in there. And I think, for so many herbs like this one, there's a lot we still don't understand.

Emma: Yeah, I would agree. And it is confusing, I have to say, when you're looking at the forms and you're looking at the research. And what we've got to take and note is that mainly it's the root and leaf extracts that are used, but a lot of them are standardised with varying amounts of withanolides in them, but more doesn't mean better either. Don't discount that impact of the whole plant extract.
There was a 2022 study in adults with perceived stress, and they used doses of 400 milligrams, 225 milligrams or placebo for 30 days. And in both treatment groups, there were improvements in cognitive function and self-reported measures of stress, anxiety, and food cravings. But interestingly, the 225-milligram dose showed the best reductions in serum cortisol. So, it's not always the fact that more is better, as is the case usually with herbal medicine.

Lesley: Yeah, very good point. Now, Lisa, I'm sure you used withania as well. What's been your clinical experience with this and how quickly are you getting results with withania?

Lisa: I love withania too, so indicated for that burnout picture due to its restorative, almost grounding action. I like to use withania for a lot of the other concerns that come up with burnout like the appetite that Emma just mentioned in terms of eating behaviour. So, I often find, when there's that burnout picture, we see changes with the way people are eating, that some people don't want to eat at all. They lose their appetite. And then more commonly in my clinic, I see a lot of women kind of binge eating, mindlessly eating as a form of self-soothing because they're feeling so fatigued and unmotivated.

So, supplementation with withania has led to less controlled eating in clinical studies, less emotional eating, and that then leads to better weight management and better sense of self essentially. So, I love with withania for this sort of picture for burnout but all the symptoms and things that come along with that burnout picture. And it combines so beautifully with herbs like holy basil, Siberian ginseng. I tend to find that patients get a result within a week. They start to notice improvement in their energy levels and their motivation.

Lesley: That's also pretty quick, isn't it? A week. That's really good. 

Now, Adrian, I know that you've done some research here. Can you tell us what you've seen?

Adrian: Yeah, I mean, certainly Emma and Lisa have covered it quite well. So, I suppose the thing we need to really think about is where you're going to use a withania extract, I think it's important that it's a clinically trialled one. There's several out there that have had extensive research on their quality and efficacy. And so I'd really encourage people to use ones that have been clinically trialled, so that's probably one thing I'd recommend.

Then I suppose the other thing, too, is in the research studies, we're generally, kind of, dosing once in the morning and once in the evening. But in clinical practice, I think you do need to individualise it a bit. So, if you think you need to, kind of, go heavier in the morning or maybe have a dose in the afternoon, so you can certainly individualise it because we don't know what the optimal dosage is. Every time, it's one in the morning, one in the evening, but I've tried to use it with my clients, maybe for some people, they have a double dose in the morning, for example or a dose in the afternoon as opposed to an evening dose. So, just really try out the different combinations and see how that works for your patients.

Lesley: So, it sounds like there's an opportunity to titrate the doses with your patients for them to start to notice how they're responding and then make a few changes accordingly.

Adrian: Yeah, and that's where really a lot more research needs to be done around titration, also around its acute administration and chronic administration. And unfortunately you don't have that opportunity to do that in clinical trials. In a trial, you'd use the same dose for 4 to 8 weeks and you'd keep them on that same dose. But in clinical practice, you might start lower and then increase the dose if you're not seeing a response over time. So, I would certainly use the research to guide the extract types and the dosages and give you some guidance on the dosages but really try out the different trials and combinations.

Lesley: Makes sense. There's so many other herbal therapeutics that would be beneficial in burnout. I know there's another star herb here, saffron, of course. There's kava, holy basil. I think Lisa mentioned that.

Adrian, I know you've done some research on saffron. It is also one of my favourites, although I've got to say I haven't got much clinical experience with it. Can you tell us how this herb might fit in?

Adrian: Yeah, the dosage for saffron, people kind of freak out because it's so expensive, but you're only using a very, very small dose. So, whereas with withania, you're using 300, 600 milligrams a day. With saffron, you're only using 14 to... Well, in the trials that I'm using, we're using 14 milligrams twice a day, so it's a very tiny dose. And, again, when it comes to saffron, I would use clinically trialled saffron extracts. All the trials that I've done have been on an extract called Affron, and we use 14 milligrams twice a day in most of the trials that we've done.

And particularly if people are experiencing more depressive symptoms, that's when I think saffron is when you should be, kind of, using that as a treatment option for people who are experiencing those depressive symptoms. And we've also done trials for saffron with regards to sleep, and in those studies, we gave 14 to 28 milligrams of saffron or Affron at one hour before bed. And it showed some really positive effects in sleep.
And the reason why we did that trial was because, with the depression trials that we're doing, one of the comments or feedback we're getting was that many of the people were experiencing improved sleep. So, we thought, okay, maybe one of the mechanisms is through its impact on sleep, and that's how mood improves. And so we've done two trials now showing that saffron can help with sleep.

Lesley: So, if someone was to use saffron because they had the mood effects that happened with burnout and also some sleep disturbance with this, how quickly are they going to see some kind of response?

Adrian: One of the benefits I have with doing clinical trials is half of the participants are on a placebo and half are on the real stuff. And the reality is that, through placebo controlled studies, you always get a benefit. So, the answer to that question is part of it also depends on their expectations. So, if they have really positive expectations about the supplement you're going to give them, they're more likely to have rapid effects. That doesn't mean it's not from the herb, but I think how you present it, the psychoeducation you provide, the information you provide about the herb is going to impact on how quickly it works. Because if you believe something's going to help you, it's going to work very quickly.

But saying that, we again are seeing improvements within about two weeks, improvements in mood. We're seeing generally it stabilises about four weeks and then it continues to, kind of, mood improves after eight weeks. So, most of our trials have been about eight weeks. Again, as I mentioned earlier, if it was in clinical practice, after four weeks, if I was getting a moderate improvement in symptoms, I would then increase the dose a little bit for people and see whether that would be a greater treatment response, which we don't do in clinical trials. So, that's something for people to think about there.

Lesley: So, you'd do a four-week trial with a patient and see how they respond. And if they're not getting maximal response, you'd up the dose. But if they're getting maximal response, at that point, you'd just maintain the dose?

Adrian: Even two weeks. Even after two weeks, you've seen them and they're saying they're not experiencing any improvements or if you're giving them a questionnaire, you're not seeing any improvement in their symptoms or in their scores on the questionnaire. Then even after two weeks, you can just increase the dose a little bit and go to, say, 28 milligrams maybe during the day in the morning, and then you could potentially go to 14 milligrams at night.

Lesley: Okay. And we've heard a lot about kava. I know there's a meta-analysis for kava in generalised anxiety disorder, and it's been used quite a lot for more of that anxiety-type picture. Do you think it's got a role here too?

Adrian: Yeah, again this is where you can, kind of, certainly choose the herb based upon the symptom presentation. So, if you have somebody coming in with burnouts who are experiencing your depressive symptoms, that's where your saffron can play a part. If you have people with anxiety or have a history of anxiety, then certainly kava can be a good option there. And kava's certainly been mostly used for more your generalised anxiety, but the research is sometimes positive, sometimes not so positive. And, again, the reasons for the differences in the studies might be because of the different extracts that people were using. So, there's different variations in kavas, and the dosages, and so forth. So, again, I think kava's a really good option for people who are experiencing anxiety and, again, trying that for several weeks and seeing if you get some improvement from kava there, too.

Lesley: Okay. A couple of years ago, I had some friends who went to a...I think it was like a longevity wellness conference, and they all came back wanting to plant tulsi in their back garden, holy basil. So, I don't know who was talking about it, but clearly got them all very excited. Adrian, do you know much about the research on holy basil in burnout? And what do you think?

Adrian: Well, for burnout, not a lot of research, but for anxiety, there is. In actual fact, we did a study last year or the year before on holy basil for people who are experiencing stress, and anxiety, and poor sleep. So, it was an eight-week trial, and we used a particular extract there called Holixer. And we found some really positive improvements. We used the perceived stress scales and outcome measure. We saw some nice improvements in the perceived stress scale.

One of the interesting things that we also did... I know Michelle talked about salivary cortisol where you can certainly measure it throughout the day, but on this occasion, we actually stressed people out in the study. So, we actually got people...

Lesley: How do you recruit for a study like that? Do you want to get stressed out? How does that happen?

Adrian: Well, yeah, it was a mild stress. We didn't create too much stress. So, what we basically did is we got them to put their hand in cold, freezing water, and then after that, we'd get them to count backwards by sevens, and we say we were also filming them. And so throughout that, we would measure their cortisol before the stressor, then immediately after the stressor, and then for 30 to 40 minutes after the stressor. And so we wanted to see what impact the stressor had on their their cortisol levels and their perceived stress before the test and after.

And what we found was that people who were on the holy basil, they had a more blunted stress response, which was really, really positive. So, certainly I think that if people are experiencing stress, and they've got that hyperactive kind of HPA axis activity or high cortisol, then holy basil could really be a good option for them.

Lesley: Okay. All right. Well, I want to shift gears into nutrients because there's so many nutrients out there. And, Lisa, I know you've been talking about SPMs for a while now. I think you even mentioned it at our last four perspectives. Has it got a role to play here? And the other one I'm really keen on is CoQ10, which is another one of my favourites. And do you have much experience using that as well?

Lisa: Yeah, definitely. So, when it comes to burnout, I think we go straight as practitioners to trying to improve energy, supporting the stress response and dealing with some of that brain fog and the mood stuff that comes up. But I do think we need to consider what's happening at that more microscopic level. And I think this often gets forgotten. But as practitioners that are into preventative care, it's definitely something we need to be factoring in.

So, the research shows that when there's that prolonged sustained stress, as there is in most of those burnout pictures, there will always be low-grade or that microinflammation. So, essentially we could think of that microinflammation as being those lightly smouldering embers causing big problems in the background.

Now, as we know, left unchecked over time, that low-grade inflammation has been implicated in the pathogenesis of pretty much every chronic health condition, including metabolic syndrome, cardiovascular disease. And I don't think patients with burnout realise that this could be happening in the background.

So, for practitioners, it's really worth considering trying to resolve microinflammation when there's a patient that's coming in with burnout, even though they're not really presenting with overt inflammation. And this is where the SPMs come in. So, SPMs or specialized pro-resolving mediators, which is what they stand for, are essentially substances that help to resolve inflammation. So, we're familiar with omega-3s reducing inflammation, but the SPMs take it one step further and actually help to resolve that inflammation. And we know that production can be impaired of SPMs where there is chronic inflammation, which there is in burnout.

So, some of my clients with burnout can't actually leave that scenario. Ideally, as practitioners, I think when someone comes in with burnout, we want to resolve it really quickly and get them out of that situation. But if they're caring for an elderly parent, or if they're in a job they don't like and they financially can't leave, then that microinflammation just kind of festers. So, I think the impact of microinflammation is a lot more extensive than we think and using something like the SPMs can be very helpful just to help offset that.

So, we're looking at about 100 to 200 micrograms of SPMs daily. You could go higher if there was a lot of inflammation, if the patient was presenting with a lot of brain fog and really bad symptoms. But I'd start off kind of gently and then increase if required. And then you can also taper down if they're getting the results that you want pretty quickly.

And then the coenzyme Q10 that you mentioned, we all love CoQ10. We all know it's a fat-soluble antioxidant. Just so important for the energy production in the mitochondria, which we know those little powerhouses in ourselves. Now, low serum levels of CoQ10 are found in people that have fatigue. And these levels of CoQ10 often correlate with levels of fatigue. So, the lower the CoQ10, the worse the fatigue that is experienced.
So, being in a constant state of SNS dominance in burnout results in mitochondrial dysfunction. We know this. And this is because it's the actual stress that causes the oxidative stress and inflammation, and that then results in the fatigue and burnout. So, CoQ10 functions as an antioxidant to help protect our neurons, and that improves the neural pathways connecting the brain to the muscle.

So, in meta-analysis, CoQ10 has been shown to produce a statistically significant reduction in fatigue, which then also results in less brain fog. So, it's a no-brainer when it comes to burnout, I think, but not necessarily one we think of straight away but one we should be thinking about.

And ubiquinol is the active form of CoQ10. It's more bioavailable compared with the oxidised form, which is the ubiquinone. They're both good, but the ubiquinol is the better form because it's more bioavailable, so it's going to produce more bang for your buck, essentially. And as we age, our production of CoQ10 decreases, so we probably need to go for something like the ubiquinol over the oxidised form, I would say, and definitely for someone that has burnout.

Dosage-wise, we're looking at benefit from 100 milligrams, but you can go much higher up to 500, 600. But I think anything, even a small dose is going to be beneficial in patients that have burnout. Most of the studies usually go for about two months, but of course with burnout, we know there is sometimes no, kind of, ending point in sight. So, I think continuous use is important for a lot of our patients, and I usually team it with some B vitamins.

Lesley: Yeah, that makes a lot of sense. I know that there's research that's been conducted with CoQ10 with people with chronic fatigue, a whole lot of mitochondrial disorders as well, and it's just one of those things super safe. You can take it long term, and it really makes a difference in that mitochondrial  cellular energy piece. So, it makes sense that it will fit here too.

Michelle, we know that when people are stressed, they go through vitamin C and some of the B group vitamins more quickly. The requirements just increase so quickly and in a very significant way. What do you do? Do you use this and how do you use this?

Michelle: I like to put it back to basics. The body has a response to stress if it is nutritionally deplete. So, even looking at where a person's nutritional level is at. So, if they're iron deficient, we like to make sure that they've got enough iron, because otherwise that's obviously a really clear source of fatigue. Zinc is a major one. It's really quite similar to magnesium in the sense that it gets used up excessively at times of stress and can be really profound for settling down that overwhelm of the brain.

But B group vitamins are a total go-to for me as well. We know in the literature that people use up their B-group vitamins at times of stress, but also Multi-B was equally as effective as counselling in some research by Julia Rucklidge from Christchurch in New Zealand after a period of time where counselling wasn't available. So, the research on using B-group vitamins when a person is stressed is really quite strong. And I think in terms of safety and efficacy, it's a total go-to.

It's really important to go back to basics sometimes. So, I do use these quite a lot. And there's some really great formulas that have been developed with that stress and burnout in mind. So, they also contain vitamin C and maybe a higher amount of B5 and maybe some zinc and some other really complimentary nutrients that actually really support brain healing and neurogenesis as well.

Lesley: I'm really glad you mentioned Julia Rucklidge's work. The way you described it was like this is cancelling benefits in a bottle. I can't imagine it's that simple, but that's how you said it. 

Michelle: Well, yeah. I mean we know that these nutrients are super important. And as Lisa mentioned before, sometimes in burnout, people are excessively using alcohol, caffeine to stimulate them in the morning, excessive sugar breaks in the afternoon or all throughout the day. And these are the kind of stressors of the body that actually use up key nutrients like Em mentioned, like magnesium, zinc, and B-group vitamins, and create that underlying subclinical chronic inflammation. We don't think as well when the brain is inflamed. We don't behave as well. We don't relate as well. We don't communicate as well. And these are all factors in burnout that are really worth considering.

And so because it's so safe, it's water-soluble, it's really quite a cheap intervention. Really I think it's essential for people experiencing burnout in most cases. And its impact on neurogenesis is probably assumed. I mean, when we look at neurogenesis, we know that nutrition actually helps to support brain development. We know that in a developmental case, we know that in adolescence, and we know that in adulthood as well.
So, you kind of have to put the pieces together because we probably don't have a study yet on B-group vitamins and burnout, but we will in the future. And I'm sure that we'll probably...those conclusions will concur with Julia's research from New Zealand.

Lesley: Yes, highly likely.

Michelle: Highly likely.

Lesley: Now, Michelle, I know that you have recently launched your first book, so congratulations.

Michelle: Thank you.

Lesley: Very exciting. But you talked in your book about managing setbacks, and I think one of the things we have to be is realistic. But like we also said, recovery is never in a straight line forward. There's always little setbacks along the way. So, can you share with us some of the key strategies that you talked about in your book about when people are experiencing a setback?
Michelle: Well, you mentioned before expectations, and I think that probably setting people's expectations right from the start is really important. And depending upon the depths of burnout and their current life situation, making sure that they don't expect to feel better within a week, two weeks, three weeks, four weeks is really quite important because what we don't want to add to their current situation is another sense of failure, because failure and not feeling good enough is almost pathognomonic of a burnout kind of scenario.

And I always think burnout is like an invitation to self-compassion because when we talk about personality types of people being, kind of, driven, and passionate, and empathic, often they're putting a lot of their energy into supporting other people, and they tend to forget the need to look after themselves.

And so looking at your inner critic and getting to know your inner critic is a really powerful strategy in helping to permanently unravel the tendencies towards burnout, and self-compassion is the antidote to the inner critic. And then through practice and repetitive experience, this level of self-compassion, just like you do bicep curls at a gym, it starts to become stronger and it starts to become a go-to method of self-soothing but also self-encouragement that is, as I said before, a total game changer.

And making sure that you've got one or two really important healthcare professionals that you can turn to at times of setback is really important as well, not doing this alone, because what we want to achieve after burnout is a much more sustainable ability to look after oneself. But for many people, it's a part of their style of working this tendency to work really hard, tendency to get really passionately involved, puts them at risk of burnout. 

And really embracing the power of rest, as you mentioned before, Lesley, really bringing it into your every day, into your every week, into your every month, and into your every year. So, it's kind of beyond the holidays as well. It's like really embracing leisure time, recreation time, hobbies, and that non-striving aspect of life, managing social media and making sure you don't have excessive, kind of, comparison-itis that can be really difficult particularly at the early stages.

Lesley: I like that. That's a good word.

Michelle: Yeah, at the early stages of burnout too, and really becoming quite reflective and understanding the tenderness that's required, particularly in the early stages of neural change. And learning an effective relaxation tool, some really good yogic or prana breathing exercises that you can try and work for you. Simple yoga nidras that you might practice every night. Mindfulness exercises are profound, and some of the ones you don't need to sit on a mat for.

So, even for example, washing the dishes with a mindfulness-based perspective can just be a beautiful way of slowing down. Some people have turned, I think I spoke to you last time about this, Lesley, of using ice bathing. People are jumping into icy cold water.

Lesley: Sounds stressful to me, I'm sorry.

Michelle: But that's become quite popular as a way of developing a habit where you're kind of engaged in nature, you're learning to really relax the parasympathetic nervous system. And then developing what works you to commit. So, not to overcommit to too many of these things but to really find the one that works for you, and develop that, and put that into your daily life can really help with setbacks as well.

Lesley: So, one of the things that I've learned from what you've said, there's so many things, but one of the things that... I think it's really important for people to remember is, if your burnout is a workplace-related burnout, and that is fairly clear from all the people that you talk to and your professionals and your understanding of yourself, just moving to a new job doesn't mean that suddenly you're going to cure this because what everyone's been saying today is that your body's depleted. Your brain is undergoing some kind of change that needs to be reset. Your attitudes and expectations need to be reset. Your routines, your attitude to rest and relaxation needs to be reset. So, it sounds to me like you can't just change your job and go, "Right, I'm good now. All good." It has to be more than that.

Michelle: Yeah, I think it's a real invitation to really looking within, and learning and trusting the body's innate healing, because the body has this beautiful innate mechanisms inside us. And what many people forget is that the mind's natural state is one of calmness. And so what we have to do is often remove the stressors to get to that calmness. We often do the opposite way around. We kind of seek calmness by doing more and more, and often calmness comes by doing less and less. 

And that's a really profound kind of change for people. But trusting your body and learning new ways to relate to yourself is really important for burnout, because it's likely that, as Gordon Parker spoke about, part of it is the personality, and the drive, and the passion, and the enthusiasm, which actually puts you at risk of burnout.

Lesley: So, Emma, I want to just finish with you and talk about prevention because Michelle and I have been talking about people who have had burnout that they're going through it, recovery, and all the changes required there. But what about helping everybody not get into that place in the first place? What are some of those early signs or just healthy things we can put in place so we don't even get to early signs because we're maintaining ourselves really well, we're well-sustained, and all those other things? So, I'm just curious for you as well what are the red flags you look for or how do you help your clients to understand how to put all the good things in place so they don't get to burn out in the first place.

Emma: It's a really interesting thing. I mean, first of all, we as health practitioners are, I believe, the lowest hanging fruit for burnout. So, we really do need to be on the front foot. In Gordon Parker's book, he had this interesting expression, and he said our view is that burnout is unfortunately much more likely to be experienced by caring people, people who are diligent, dutiful, reliable, and perfectionistic. They work longer hours. They don't want to renege on anything. They're dedicated. They're conscientious. They take their work home.

Now, to me, that sounds like every single health practitioner I know. We are the universal carers. I think it's critical that you talk to your patients about these personality traits and help them identify if they are more at risk of burnout. I would always err on the side of caution and screen patients rather than wait until they tell me that they have burnout, because we need to be as proactive in avoiding burnout as possible rather than trying to mop up later. You could do the Sydney Burnout Index. As we've talked about, it's really easy to do. If the scores come up high, refer them to their GP to rule out conditions like anaemia, or depression, or hypothyroidism, and employ the strategies we've outlined in this episode such as the therapeutic doses of withania, magnesium, saffron, CoQ10, B vitamins.

But I want to put a caveat here. Remember to take a personalised approach rather than a prescriptive approach to this, because not everyone is the same. And we have many tools in our toolkit that can be so easily personalised for our patients and ourselves. And I often discuss something called the Rest Test with patients which was a global survey involving over 18,000 people. And they ask them what activities they felt were the most restful. And the top five were things that are so easy like reading, napping, being in nature, spending time on their own, and listening to music. So, just adding in one single one of those could be all that's needed to just prevent burnout. And from a patient perspective as well, the Black Dog Institute have developed a self-care planning template that I use, and I find it really, really helpful to work through with patients.

Lesley: That's really practical. And I'd like to believe all of you, all of the fx Medicine ambassadors are looking after yourself really well, because we've heard how it's higher in healthcare practitioners, and I think a lot of us also relate to those personality characteristics, too.

So, I just want to say a big thank you to everybody here. You know, we've covered a lot of ground. We've talked about definitions and diagnostics, herbs, and nutrients, some of my favourites: withania, CoQ10, B-group vitamins, magnesium for just about all aspects of this as well. And we touched on quality diet, regular physical exercise, sleep, spending time in green spaces. We haven't done a deep dive in those, but I think a lot of our listeners already understand the importance of these things as well. And, Emma, I really like the fact that we ended with that prevention and knowing where you are and putting in place those things that make you feel restful and realising that's actually really important.

So, I just want to thank you all for sharing your thoughts and expertise today and your stories. And I'm sure our listeners will love hearing this episode and all the practical strategies that you've outlined today. Thank you.

Together: Thanks, Lesley.


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