Depression, anxiety, and burnout among psychiatrists during the COVID-19 pandemic: a cross-sectional study in Beijing, China

Mental health issues have been one of the top ten leading causes of global disease burden, with no evidence of a reduction in the burden since 1990 [1]. There was a high prevalence of symptoms of depression, anxiety, insomnia, and acute stress during the COVID-19 pandemic [2]. Psychiatrists are needed more than ever to optimize the population’s mental health by providing interventions for outbreak-related distress responses [3]. Increased work hours and workloads are common to meet the increasing mental health service demand during the COVID-19 pandemic. During this period, all healthcare workers, including psychiatrists, were affected by various challenges. Besides the routine work, they must educate health care and community leaders about effective ways to support the population’s mental health during the COVID-19 outbreak. They have to respond to the challenges of the epidemic prevention and control requirements and the pressure of increased numbers of patients. Some mental hospitals must implement weekly or even monthly shift duty, meaning the psychiatrists must stay there for a week or even a month. In addition, due to a shortage of medical staff, they have to be rotated to the epidemic area to support large-scale nucleic acid testing work. However, there are not enough psychiatrists to meet this demand [4], and this shortage is more severe in China [5, 6].

In recent years, China has gradually strengthened the construction of the mental health prevention and control system, forming progressively a national, provincial, prefecture-level city, county (district), township (street), village (community) mental health prevention and control service system that is mainly composed of specialized psychiatric hospitals, supplemented by comprehensive hospitals, supported by primary medical and health institutions and mental disease rehabilitation institutions, and supplemented by disease prevention and control centers [7]. The National Health Commission of the People’s Republic of China has set standards for different levels of psychiatric hospitals (http://​www.​nhc.​gov.​cn), and the standard considered several aspects, such as the number of beds and medical workers. Psychiatrists play the most crucial role in guiding the diagnosis and treatment of mental illnesses, but cultivating a psychiatrist is a long process. In China, to train as a psychiatrist, you will start training as a medical doctor (4–6 years), then receive standardized training for resident physicians, according to different majors, including psychiatry. After a year of “24-hour resident physician” training, you can become a psychiatrist, but completing the training requires at least three years. There is a national psychiatrist certification system, and every psychiatrist has to pass this qualification to practice psychiatry. This process usually takes at least 6 years from receiving medical education. Numerous studies have addressed the escalating shortage of psychiatrists, and several programs have tried recruiting future psychiatrists [8, 9]. To increase the supply of the psychiatric workforce, 31 medical colleges across China have established psychiatry programs for medical students with vigorous promotion by the National Health Commission and the Ministry of Education. These are specialized programs with a curriculum focusing on psychiatry-related teaching, to fast-track graduates to psychiatry residency directly. Compared to increasing the number of future psychiatrists, the more urgent problem is investigating the mental health and work burnout status of practicing psychiatrists to improve their health status and better serve patients.

Psychiatrists have basic similarities with other professional doctors but may also have some unique characteristics. For example, a study proposed that good psychiatrists were defined as “a good communicator and listener with a professional manner, who respects confidentiality and has good doctor-patient relationships“ [10]. In addition, long-term contact with people with mental health conditions has great mental pressure and practicing risk [11]. The economic income of psychiatrists is relatively low [12], the social appreciation is unrecognized, and there is a certain sense of practicing shame, etc., which may cause high emotional burdens [13]. Besides, the high probability of experiencing patient suicide may be a common source of distress for psychiatrists [14]. A previous study reported that 5% of psychiatry trainees in the United States experienced a patient suicide within one year and estimated that 20% would experience it at least once over their traineeship [15]. Compared with doctors from other specialties, psychiatrists are more likely to suffer from various mental health problems [16]. Longitudinal studies in the UK also suggest that psychiatrists suffer from exceptionally high levels of stress and the highest levels of depression [17].

The symptoms of depression and anxiety are the most frequently reported mental health issues in health careers, including psychiatrists. The definition of depression is based on symptoms forming a syndrome, including depressed mood, anhedonia, feelings of worthlessness or guilt, suicidal ideation, plan, or attempt, fatigue or loss of energy, insomnia or increased sleep, loss or increase in appetite or weight and so on [18]. Anxiety often has a series of symptoms, such as “feeling keyed up or tense”, “being unusually restless”, “having trouble concentrating because of worry”, “having a fear that something awful may happen”, and “feeling of that one might lose control of oneself” [19].Anxiety is common in the context of depression, and almost two-thirds of individuals with major depressive disorder have clinical anxiety [20].Another severe condition of a psychiatrist is work burnout [21], which threatens the psychiatrist’s health and leads to performance inefficiency and despair. Burnout is a psychological syndrome in response to chronic occupational stressors, consisting of three key dimensions: overwhelming exhaustion, depersonalization, and low personal accomplishment [22]. Burnout is closely related to depression and anxiety in previous study [23], and these symptoms often co-occur among medical staff [24, 25]. However, burnout and clinical symptoms of depression and anxiety were empirically distinct, highlighting the importance of screening for burnout and clinical symptoms to allow fast access to adequate support and treatment in health professionals [26]. Before the COVID-19 pandemic, a study investigated the prevalence of anxiety and depression among hospital psychiatrists and reported that the prevalence of depression and anxiety was 22.5% and 28.1% in 285 psychiatrists [27]. A systematic review and meta-analysis reported a pooled prevalence of 23.2% for anxiety and 22.8% for depression in healthcare workers during the outbreak of COVID-19 [28]. A later meta-analysis only included data from China revealed a higher prevalence of anxiety (31.5%) and depression (23.7%) in healthcare workers [29]. While the psychiatrists’ career carries a high emotional burden and stressful demands, there is a lack of studies estimating the prevalence and evaluating the risk factors related to the mental health of psychiatrists in China. A recent study reported that the anxiety level in psychiatrists is lower than in physicians [27]. A recent study in healthcare reported no significant increase in anxiety symptoms after the COVID-19 pandemic [30]. Previous studies have shown that the overall burnout among physicians during the outbreak of the COVID-19 pandemic ranged from 14.7–90.4% [31], and the introduction of COVID-19 has heightened existing challenges that physicians face, such as increased workload, which is directly correlated with increased burnout [32].

This study aims to investigate the prevalence and risk factors of depression, anxiety, and work burnout among psychiatrists in Beijing during the COVID-19 pandemic.The present study surveyed psychiatrists’ mental health for several reasons. First, the psychiatrist-patient relationship is unique among medical specialties, as psychiatrists become “tools” in their profession. Second, most psychiatrists experience stressful adversities such as attacks by violent patients or hostile relatives of patients and experiencing patient suicide. These conditions increased the emotional burdens of psychiatrists. Furthermore, the shortage of psychiatrists may cause them to neglect their personal care by saturating their time with multiple consultations. The need for psychiatric care in China rapidly increases due to economic and social development and population aging, especially during the COVID-19 epidemic. Besides recruiting more future psychiatrists, the retention issues of currently practicing psychiatrists are more urgent in China. Considering the lingering effect of COVID-19 on people’s mental health and the importance of psychiatrists in this process, the survey was conducted in January 2022, two years after COVID-19 was declared a global pandemic. In this particular month, 31 province-level regions in China have reported 3634 new confirmed COVID-19 cases, and Beijing has reported 135 new confirmed COVID-19 cases (http://​www.​nhc.​gov.​cn/​; http://​wjw.​beijing.​gov.​cn/​).

To the best of our knowledge, this is the first study that systematically investigated the prevalence of and risk factors associated with mental health symptoms (i.e., symptoms of depression, anxiety, and burnout) by standardized rating scales among psychiatrists during the COVID-19 pandemic in China. We found that approximately one-third of the psychiatrists exhibited depression, one-quarter showed anxiety symptoms, and more than 40% experienced burnout. We also identified several risk factors. Having a medium annual income was associated with a lower risk for the symptoms of depression and anxiety. Levels of the medical institution and working duration in psychiatry were related to depression symptoms. Having children was a risk factor for anxiety symptoms. Psychiatrists with lower professional titles were more likely to suffer from burnout. Specifically, perceived stress and social support were associated with these three mental health issues. These findings provide a comprehensive profile of the psychological status of the psychiatrist in Beijing, China, during the period when the COVID-19 epidemic continues to affect and call for action in delivering appropriate training to protect mental health and developing appropriate interventions for psychiatrists.

The present survey shows that during the prevalence of COVID-19, a considerable proportion of psychiatrists is experiencing mental health conditions, which is similar to previous studies on healthcare worker’s [41, 42]. In contrast to previous studies, we detected a higher prevalence of depressive symptoms than anxiety. A recent survey also found similar results that the prevalence of depressive symptoms is higher than anxiety in Mexican psychiatrists [43]. One of the important reasons may be that in the early stage of the COVID-19 epidemic, physicians often showed anxiety-related behaviors, such as tension, worry, and uneasiness. With the persistence of the epidemic, the awareness of the epidemic gradually improved. However, the work pressure related to the epidemic persists, such as being unable to visit relatives for a long time. The initial worry gradually decreased and was internalized into a continuous depressive reaction, including depression emotion, pessimism, and despair [44]. Another reason may be due to the self-diagnosis process, as a previous study suggested that physicians tend to under- or over-react to their symptoms, switching from diagnosing diseases with the worst prognosis to ruling out a disorder altogether [45]. A similar problem may happen to the psychiatrist as well. However, data on anxiety and depression in psychiatrists are very insufficient, making it impossible to conclude the impact of the pandemic on the mental health conditions in psychiatrists [28]. The burnout rate in our study is consistent with a recently published report, which showed that 42% of psychiatrists reported burnout in the last year [46]. Plenty of studies have investigated burnout in doctors, including the psychiatrist [47]. It is often reported that psychiatrists have a lower burnout rate than other specialists [48, 49]. A previous study also reported a lower burnout rate (38.4%) among psychiatrists than other specialists in China [12]. According to the newly released Medscape Psychiatrist Lifestyle, Happiness & Burnout Report 2022, about half of psychiatrists (52%) reported that they were more burned out now than during the initial quarantine months of the pandemic [46].

In the present study, we found that having a medium annual income was associated with a lower risk for the symptoms of depression and anxiety. This is to some extent consistent with Western research, which suggest that lower-income Americans are less likely to report being in good health and are more likely to have high-stress levels [50]. Depression and anxiety may affect people’s cognitive function, affecting workability and thus economic income [51]. Conversely, poverty itself can influence cognitive function by capturing attention and taxing mental bandwidth [52] In addition, depression and anxiety may affect an individual’s economic level by influencing their beliefs, preferences, creativity, work hours, efficiency, creativity, etc. [51]. We also found that working in a Secondary hospital, and working longer in the psychiatry field increases the risk of depressive symptoms. This may be related to the shortage of medical staff in secondary hospitals, higher work pressure, and relatively low income. On the other hand, the longer the working experience, the more work tasks one needs to undertake, such as undertaking routine medical work, administrative management work, organizing and attending various academic conferences, and so on. These often occupy many psychiatrists’ spare time, consume a lot of energy, and increase occupational stress, which may affect depression [46]. In the present survey, having children increase the risk of anxiety symptoms. It is consistent with a recently published study which suggested that having children increased daily stress in the general population [53], and parents experience greater anxiety, depression, and marriage dissatisfaction than spouses without children [54]. Many studies have shown that parents’ anxiety levels increase from preparation for pregnancy to birth and during the care of the baby [54, 55]. Additionally, we found that psychiatrists with lower professional titles were more likely to suffer from burnout. A recently published meta-analysis also reported a negative effect of lower professional levels on mental health in healthcare workers [56]. Lower professional titles often mean less experience in treating patients and facing complex situations, undertake more detailed, specific, and trivial tasks, which may increase individual exhaustion.

High perceived stress, which scored more than 25 in CPSS, was an independent risk factor for depression, anxiety, and burnout. Consistent with previous studies, perceived stress also increased the risk of depressive symptoms in interns during medical internships [57]. An extensive survey of psychiatrists identified “out-of-hours of duty, dealing with difficult and hostile relatives of patients, arranging admissions, paperwork, balancing personal and professional lives, and managing suicidal or homicidal patients” as particularly stressful experiences [46]. After the outbreak of COVID-19, the Chinese government adopted strict prevention and control measures different from those of most countries in the world so that the development of the epidemic in China did not get out of control. These measures put forward higher requirements for medical staff, encouraging them to adopt the two-dot and one-line lifestyle (only going to and from the hospital and residence, not going to other places, especially not participating in gathering social activities), irregular support for epidemic prevention and control in different regions, and support for large-scale nucleic acid testing of a novel coronavirus, which may make Chinese doctors face higher work pressure, and make their mental health status different from other countries during this period. It is worth noting that about 91% of the psychiatrist have been assaulted at least once in the present study, which suggests that psychiatrists have more work-related emotional exhaustion [58], and their work is more emotionally difficult than that of other doctors. A previous study showed that insomnia mediated the association between perceived stress and depression [59]. Another study showed that alexithymia moderated the perceived stress-mediated relations between the pandemic events and the changes in depressive and anxiety symptoms by enhancing the detrimental effect of perceived stress on mental health [60]. Effective and acceptable programs should be implemented to reduce the perceived stress in the psychiatrist. Tai Chi/Yoga could be an alternative method for stress reduction for individuals who live under high stress or negative emotions [61].

High social support scores of more than 49 in SSRS were an independent protective factor for depression, anxiety, and burnout. The existing empirical literature proposes that social support directly influences the well-being of medical staff [62, 63]. A recently published study reported a moderating effect of social support on the relationship between burnout and anxiety symptoms among intensive care unit staff [64]. It has been well-documented that social support can protect people from mental health problems [65]. A recent meta-analysis revealed that in Asia, good social support is related to decreased depression [66]. Social support, particularly family support, is an important social factor in geriatric depression in China [67]. Seeking social support as a means of coping with adversity has been categorized as a problem-focused coping strategy and has been found to effectively reduce stress [68]. During the pandemic, when stress and anxiety are elevated, adequate social support may help healthcare workers maintain healthy emotional states [69]. Considering the significant protective effect of social support, formal support systems are needed to provide extra support for psychiatrists during life events to decrease the risk of mental problems and burnout.

To the best of our knowledge, this is the first study that systematically investigated the prevalence and risk factors associated with mental health symptoms by standardized rating scales among psychiatrists during the COVID-19 pandemic in China. The present study has several limitations. First, measures were obtained from self-reports rather than clinical diagnoses and may reflect bias in reporting. Second, this was a cross-sectional study. Therefore, associations between mental health symptoms and risk factors cannot necessarily be considered causal relationships. Third, The results may only reflect the mental health status of psychiatrists in Beijing when the COVID-19 epidemic continued for two years. However, due to the lack of data in the early stage of the pandemic, we cannot obtain the exact impact of different stages of the COVID-19 epidemic on the mental health of psychiatrists. Follow-up nationwide studies are needed to determine the possible long-term mental health outcomes in psychiatrists associated with the COVID-19 pandemic in China.

The prevalence of symptoms of depression, anxiety, and burnout was worth noting in this sample of psychiatrists from Beijing, China, during the COVID-19 pandemic. Perceiving more stress and receiving lower social support were independent risk factors for these three mental health issues. Besides recruiting more future psychiatrists, the retention issues of currently practicing psychiatrists are more urgent in the shortage of psychiatrists. Our findings may provide helpful information for policymakers to help them make strategies to protect mental health and develop appropriate interventions for psychiatrists, and we proposed that effective and acceptable programs to reduce stress and increase social support are important for psychiatrists’ mental health and well-being.