Burnout and job satisfaction of psychiatrists in China: a nationwide survey

With an estimated 173 million people living with mental disorders currently in China [1], China accounts for the largest percentage (17%) of the global mental, neurological, and substance use disorder burden [2]. According to the latest nationwide survey of mental disorders in China, the lifetime prevalence of any mental disorder has increased significantly from 1.3% in 1982 to 16.6% in 2015 [3]. Moreover, since the outbreak of the COVID-19 epidemic, it was suggested that Chinese mental health burden has further escalated [4, 5]. One nationally representative study showed that the prevalence of anxiety or depression or both was as high as 20.4% among the general adult population in China at the peak of the COVID-19 epidemic [6]. Not only do mental disorders have high personal costs for patients and caregivers, but they also have high social and economic costs for the entire society. It was estimated that the year 2013 witnessed a total annual cost of $88.8 billion attributed to mental disorders in China, which was nearly four times that in 2005 [7].

Evidently, China is now faced with a surging demand for mental health service provision among the general population. However, a severe shortage of psychiatrists poses a major challenge to China’s mental health care system. Nowadays, the total number of psychiatrists in China is just above 40,000 [8], indicating that there are less than 3 psychiatrists per 100,000 population. Moreover, most of these psychiatrists are working in the more socioeconomically developed eastern coastal region of China, leaving the treatment gap for mental disorders in China’s western and central regions strikingly huge [8‐10]. In order to develop and strengthen the mental health workforce in China, the General Office of China’s State Council issued the 2015–2020 National Mental Health Work Plan [11] in 2015 which proposed a package of measures to develop and strengthen the mental health workforce in China, including encouraging regions and higher education institutions to provide medical bachelor’s degrees specializing in psychiatry, allowing non-psychiatrist physicians to switch their clinical specialties to psychiatry after receiving training in psychiatry, and improving the level of remuneration for mental health professionals. However, the effectiveness of these measures has been inadequately evaluated and the number of psychiatrists in China is still far less than needed [10]. In addition, most of these efforts till now have been focused on recruiting more psychiatrists, with the retention issues of psychiatrists largely neglected. In fact, it was reported that an ever-increasing amount of psychiatrists in China are experiencing occupational burnout which further leads to job dissatisfaction [12] and intent to leave their jobs [13].

As defined by the World Health Organization [14], burnout is “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” It is characterized by three dimensions: emotional exhaustion (EE), depersonalization (DP), and reduced personal accomplishment (PA) [15]. Numerous studies have reported a high rate of burnout among physicians [16‐18]. A number of socio-demographic and occupational factors appear to relate to physician burnout. For example, high workloads, lack of job control, poor work-life balance, and loss of support from colleagues have each been associated with physician burnout [19‐24]. Some studies have reported an increased risk of burnout among younger physicians [24‐26]. Female physicians also seem to be more likely to experience burnout than their male counterparts [27‐29]. It is indicated that burnout has grave repercussions on physicians’ physical and mental health and well-being [19, 30], as well as their job performance [31‐33]. More importantly, physicians experiencing burnout are more likely to be dissatisfied with their jobs and to consider leaving [34‐36], which in turn threatens health workforce retention particularly in low- and middle-income countries (LMICs) with limited human resources for health. Burnout among psychiatrists has also been documented in many countries [37‐41]. For example, 36.9% of psychiatrists in the US showed burnout symptoms in 2017 [17]; the prevalence rate of burnout among psychiatrists in Japan was 40% in 2016 [42]. However, most studies of burnout among psychiatrists to date were conducted in high-income countries (HICs) [43], leaving an evidence gap with regards to burnout among psychiatrists in LMICs.

In China, a vast majority (~ 80%) of psychiatrists are working at psychiatric hospitals, whereas those working at other mental health service providers, such as general hospitals, rehabilitation hospitals, and community health centers, account for only a small percentage [8]. Psychiatric hospitals in China can be further classified into two tiers: secondary psychiatric hospitals (SPHs), which tend to be affiliated with a medium size city, county or district; and tertiary psychiatric hospitals (TPHs), which are often situated in provincial capitals or major cities. In the absence of a well-developed referral system, people with mental health conditions in China have the freedom to choose where they want to obtain specialist mental health services from, and most of them prefer TPHs [44]. Moreover, in addition to providing specialist mental health services for larger geographical areas than SPHs, TPHs are also responsible for providing guidance and support to all other mental health service providers, including SPHs, in the corresponding areas [45]. Therefore, Chinese psychiatrists working at TPHs are often burdened with much heavier workloads and faced with an even grimmer crisis of burnout [46, 47].

Given the importance of burnout and job dissatisfaction to workforce retention and the central role that TPHs play in China’s mental health care system, there is a strong imperative to investigate the prevalence of burnout and job dissatisfaction among psychiatrists at TPHs in China, as well as the risk factors for burnout and job dissatisfaction. Yet, to our knowledge, there have been no nationwide studies in China to date that have achieved these purposes. Therefore, this nationwide study aimed to investigate the prevalence of burnout and job dissatisfaction among psychiatrists at TPHs in China, to identify socio-demographic and occupational factors associated with burnout and job dissatisfaction, and to examine the relationship between burnout and job dissatisfaction among psychiatrists.

Our study was the first nationwide survey that comprehensively investigated the prevalence of burnout and job satisfaction among psychiatrists in China. The sample of > 4000 psychiatrists, covering all the TPHs in China, represents the largest study of psychiatrist burnout in the literature.

We found a high rate of burnout (38.4%) among psychiatrists working at TPHs in China. This rate was concordant with those reported in HICs such as the US (36.9%) [17] and Japan (40.0%) [42]. More specifically, our study found that 25.4% of psychiatrists in China had high levels of EE, 32.9% had high levels of DP, and 20.7% had low levels of PA. These rates were also consistent with the overall estimated pooled prevalence for high levels of EE, higher levels of DP, and low levels of PA among mental health professionals [43]. There are many causes that may lead to burnout among psychiatrists in China, such as widespread stigma towards mental illness [60], heavy workload [61], low salary [62], and poor physician-patient relationships [63‐66]. Interestingly, although the prevalence of burnout among psychiatrists in China is comparable to those in HICs, the percentage of job satisfaction among psychiatrists in China is much lower than those reported in HICs [67‐69]. For example, 88% of Australian psychiatrists were satisfied with their work and proud of their profession [69]. In contrast, only 64.4% of respondents in our study were satisfied with their jobs in general. For those experiencing burnout, the percentage of psychiatrists reporting job satisfaction was even lower (43.2%). Despite the fact that burnout and job dissatisfaction are closely interrelated, this finding supports the view that burnout and job dissatisfaction are two distinct indicators of job morale with different etiologies [70].

Our study suggests that male psychiatrists in China seem to be at higher risk of burnout and job dissatisfaction. This is inconsistent with the findings from HICs, e.g., the US [39], Austria [71], and France [72]. One possible interpretation is that psychiatrists in China often have to live with unsatisfactory payment [62] and deep-rooted stigmatization towards mental health professionals [60], which conflicts with the expectations attached to males in China to gain more wealth and higher status. We also found that early-career psychiatrists reported lower rates of burnout and job dissatisfaction, which was again inconsistent with the findings in North American psychiatrists [39] and European psychiatrists [73]. There may be two explanations. Firstly, because of relatively low tuition costs, medical students in China rarely reply on student loans to finish their medical schools. So, unlike many early-career psychiatrists in HICs, their counterparts in China are often not burdened with medical school debts after graduation and are therefore faced with less financial stress. Indeed, several studies have found strong associations between medical school debts and burnout among early-career physicians [29, 74]. Secondly, most psychiatrists in China start residency training immediately after receiving medical bachelor’s degrees, as demonstrated in Table 1. Therefore, early-career psychiatrists in China are usually much younger than those in many HICs, which makes them to some extent freed from household debts, as well as other family responsibilities.

Till now, there have been an enormous body of evidence suggesting that longer working hours [72, 73, 75, 76] and less control over one’s job [39] can lead to burnout and job dissatisfaction. Similarly, our study also reported that longer working hours were significantly associated with both burnout and job dissatisfaction. Regarding job control, it should be noted that our study asked its respondents whether they had leadership roles in their workplaces instead of asking directly how much control they had over their jobs. However, team leaders are often considered to have more control over their jobs. Accordingly, our data suggest that having leadership roles in the workplace was significantly associated with less burnout and more job satisfaction among psychiatrists in China.

It is often reported that psychiatrists have a lower rate of burnout compared with other specialists [16, 17, 20]. Our study also showed a lower rate of burnout (38.4%) among psychiatrists than those among other specialists, such as neurologists (53.2%) [77], anesthesiologists (69%) [49], and oncologists (51%) [50], in China. There are several possible explanations for this finding. Firstly, psychiatrists may be more aware of their own emotional and psychological needs than other specialists. Also, psychiatrists may be more skilled at stress relieving and have better access to mental health services.

A large body of research has suggested that burnout and job dissatisfaction among health workers is associated with an increased likelihood of leaving their jobs [34‐36]. Therefore, a high rate of burnout and job dissatisfaction that we found among psychiatrists in China will evidently complicate the current challenges of workforce development in mental health. In order to mitigate burnout and job dissatisfaction among psychiatrists in China, a systemic strategy attempting to tackle with various factors on different levels is needed [78]. First, on the organizational level, staff care and wellbeing programs, such as mindfulness, stress management, and small group discussions [79], should be developed and provided for psychiatrists. A culture of mutual support should also be created and advocated in mental health care facilities [80]. Second, on the national level, new investments should be encouraged in mental health care and particularly for mental health workforce retention. With low salary as an important contributor to job dissatisfaction, the salary and compensation system at psychiatric hospitals needs to be reformed. To better remunerate Chinese psychiatrists, a workload-based salary scheme should be adopted [62]. Finally, on the societal level, it is also of great importance to destigmatize mental health problems and to improve public attitudes towards psychiatry and psychiatrists [81].

Our study had several limitations. First, we utilized self-report measures of burnout and job satisfaction. Although both MBI and MSQ were well validated in China and in other countries, their self-report nature makes their validity still questionable. Second, our study included psychiatrists working in psychiatric hospitals but not those working in other health care settings such as primary care facilities. However, according to the official data from China’s National Health Commission, 80.2% of mental health professionals in China worked in psychiatric hospitals [8]. Therefore, our study can still stand out as being of crucial importance to landscape and investigate burnout and job satisfaction among psychiatrists in China. Third, the cross-sectional survey method does not allow assessment of the direction of effect for the associations described in this study. Future studies are needed to investigate prospectively the effects of relevant factors on psychiatrists’ burnout and job dissatisfaction.