Physicians, including psychiatrists, are particularly vulnerable to a range of psychological symptoms such as depression, anxiety, stress, and insomnia (1–3). The COVID-19 pandemic has exacerbated these issues due to an increased workload and other stressors. Facing this global public health crisis, medical professionals must deal with immense work pressure, a higher risk of infection, and continuous emotional and psychological stress. A recent nationwide survey conducted by Yao et al. (4) revealed that Chinese psychiatrists experienced high levels of burnout during the pandemic, highlighting the significant impact of these pressures on their job satisfaction and overall mental health.

In addition to the heavy workload, medical professionals also face social stigma. Social stigma refers to the negative perceptions and discriminatory attitudes directed towards healthcare workers, stemming from their close associations with infectious diseases (5). This stigma can lead to social ostracization and emotional distress, further compounding the challenges these professionals face (6). According to Malik and Annabi (7), such psychological pressures, combined with professional burnout, can have a lasting effect on the mental well-being of healthcare workers, suggesting that intervention is critical. Summers et al. (8) further emphasized the global scope of this issue, noting that psychiatrists in North America also experienced elevated levels of depression, anxiety, and burnout during the pandemic. Kang et al. (9) noted that medical professionals who directly managed COVID-19 cases and were exposed to high-pressure environments were more susceptible to mental health issues such as depression, anxiety, and stress.

The COVID-19 pandemic has underscored the critical need for effective mental health interventions (10). During this period, psychiatrists have played an essential role in providing mental health support while facing unique challenges and pressures (11, 12). There has been an unprecedented surge in demand for psychiatrists that significantly increase their workload and stress levels since the COVID-19 pandemic (13). Especially in China, the mental health support system is facing a dual challenge of resource scarcity and uneven distribution, making it difficult to meet the public’s growing demands for mental health services. According to government staffing guidelines, fewer than one-third of hospitals (31.7%) meet the minimum ratio of psychiatrists per bed, highlighting the insufficiency of resource allocation (14). They frequently manage complex cases involving severe psychological disorders and intense emotional fluctuations (15, 16), substantially increasing their work-related stress.

Moreover, widespread physician burnout, emotional exhaustion, and psychological distress underscore the challenges faced by medical professionals (17). Physician burnout is defined as a psychological syndrome stemming from enduring interpersonal stressors in medical practice (18). It is characterized by emotional exhaustion—described as a condition in which individuals feel emotionally overstretched and drained of emotional resources (19), depersonalization, and a diminished sense of personal achievement. Previous research predominantly viewed burnout as just another manifestation of depressive symptoms (20, 21). However, this perspective was challenged by Maslach and Leiter (22) in their study, suggesting that the link between burnout and depression might not be straightforward. Despite this re-evaluation, physician burnout remains to be linked to a broad spectrum of psychiatric conditions and risky behaviors. For instance, West et al. (23) revealed that doctors experiencing physician burnout were at an increased risk of emotional disorders, substance and alcohol use disorder, and motor vehicle accidents, illustrating the complex implications of physician burnout beyond its connection with depression.

A recent study increasingly demonstrated the intricate connections between depression, and anxiety across the three dimensions of physician burnout: emotional exhaustion, depersonalization, and reduced personal accomplishment (24). While these investigations provided a broad overview of the associations among various symptoms, they did not delve into any specific links. Network analysis (NA) techniques offer a novel approach to moving beyond the traditional categorical definitions of mental disorders, focusing on the interplay among individual symptoms rather than broader syndromes, thereby uncovering the underlying associations within psychopathology (25, 26). NA enables the modeling of interactions between psychological structures at the symptom level. This method employs “nodes” to represent various psychological symptoms and “edges” to depict the connections between them. Previous research often concentrated on the structural relationships between depression and anxiety (27), potentially overlooking the unique links between the three dimensions of burnout and various mental health symptoms. By leveraging NA, especially through the use of partial correlations and regularization techniques, we can unveil the subtle connections among physician burnout, depression, anxiety, and stress. Moreover, by calculating the bridge expected influence (BEI) index, which sums the edges connecting a node to nodes in other clusters, we can better understand the protective role of various physician burnout dimensions on mental health, providing fresh insights for potential intervention strategies.

Through the utilization of NA, this study aims to achieve two objectives: (1) examine the associations between physician burnout symptoms (emotional exhaustion, depersonalization, and personal accomplishment), and the common psychological symptoms of depression, anxiety, and stress; (2) employ EI and BEI metrics to identify the most influential nodes within physician burnout and other psychological symptoms network. Given previous research suggesting emotional exhaustion has a stronger association with depression than it with anxiety (27), we hypothesize that emotional exhaustion in physician burnout will exhibit the strongest positive correlation with depressive symptoms. Additionally, earlier studies have indicated that alleviating burnout symptoms, especially emotional exhaustion, effectively improves depressive symptoms. As a result, we propose that interventions targeting emotional exhaustion in physician burnout may act as bridge nodes within the psychological symptom cluster, opening new avenues for enhancing overall psychological well-being.

This study highlights the significant mental health challenges faced by Chinese psychiatrists, revealing that approximately 25.1% experienced symptoms of burnout. This finding is consistent with a meta-analysis by Bykov et al. (46), which reported an overall prevalence of physician burnout at 25.9% across 36 studies. Such alignment emphasizes that physician burnout is a widespread issue in healthcare systems across different cultures and institutions. However, unlike previous studies that mainly focus on prevalence rates, our study provides deeper insights by utilizing network analysis to explore the intricate relationships between different dimensions of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and psychological symptoms such as depression, anxiety, and stress.

Around one in four Chinese psychiatrists also reported symptoms of depression and anxiety, a finding consistent with Sahebi et al. (47), who observed similar rates among internists. Although Yao et al. (5) reported similar prevalence figures, our network analysis revealed stronger associations between depression and emotional exhaustion, highlighting the critical importance of addressing emotional well-being in high-pressure environments, particularly during crises like the COVID-19 pandemic.

This study also revealed that approximately one in four Chinese psychiatrists reported symptoms of depression and anxiety, aligning with findings from a meta-analysis among internists, which showed prevalence rates of depression and anxiety at 24.83 and 24.94%, respectively (47). The 11% prevalence rate of stress symptoms among Chinese psychiatrists also mirrors findings among psychiatric residents in Bangladesh (48). It is important to note that different assessment tools can yield varying results, as demonstrated by a study that used a single-item measure for stress symptoms and reported a significantly higher prevalence rate of 35.3% (49).

These findings are consistent with prior literature emphasizing the prevalence of burnout and psychological symptoms among healthcare workers globally, especially during crises like the COVID-19 pandemic (50, 51). For example, Dalmasso et al. (52) evaluated the impact of individualized psychological support in the Bambino Gesù Paediatric Hospital in Rome and found that such interventions significantly improved healthcare workers’ mental health by reducing anxiety and stress levels. This suggests that similar psychological support interventions could be highly beneficial for Chinese psychiatrists, particularly in addressing the psychological distress highlighted in our study.

The dense regularized network offers a deep dive into the complex associations between the three dimensions of physician burnout—emotional exhaustion, depersonalization, and personal accomplishment—and the other mental health variables in this study –depression, anxiety, and stress, unveiling notable differences among them. Emotional exhaustion was strongly linked to multiple mental health symptoms within the DASS (Depression, Anxiety, and Stress Scales) community, particularly within the depression spectrum. This is evident in three key indicators: DASS-21_10 (“I felt that I had nothing to look forward to”), DASS-21_05 (“I found it difficult to work up the initiative to do things”), and DASS-21_03(“I could not seem to experience any positive feeling at all”). These connections highlight how closely emotional exhaustion is related to an individual’s motivation and the ability to experience joy and positivity. Previous research has indicated that feelings of despair and an absence of pleasure contribute to the exacerbation of emotional exhaustion (53, 54).

In previous network analyses, emotional exhaustion has also been identified as a key component of burnout, often serving as a central link between burnout and other psychological symptoms, such as depression and anxiety (22, 55). Our findings expand on this by identifying emotional exhaustion as a critical bridge symptom in the burnout network, suggesting that interventions targeting emotional exhaustion could help prevent the progression of burnout into more severe mental health issues. This is in line with research by Maslach and Leiter (22), who emphasized emotional exhaustion as one of the first indicators of burnout. Therefore, targeted interventions focusing on reducing emotional exhaustion could have far-reaching effects on preventing other mental health complications (56).

Depersonalization, characterized by an indifferent attitude towards work and feeling like an outside observer of oneself, was found to be correlated with DASS-21_18 (“I felt that I was rather touchy”) and DASS-21_06 (“I tended to over-react to situations”) within the stress community. These associations suggest that depersonalization may lead to an increased sensitivity and overreaction to everyday situations (57), where enhanced reactivity could heighten tensions in interpersonal relationships and exacerbate the symptoms of depersonalization.

The central role of stress in our network model aligns with previous findings, where stress was found to play a pivotal role in mental health deterioration, particularly under high-pressure conditions (58–60). Our findings further support the assertion that stress can serve as a precursor to psychological disorders, including depression, anxiety, and burnout. Previous studies have also shown that stress can predict depression over time (59). Given the high stress levels reported during the COVID-19 pandemic, these findings underscore the importance of early interventions to manage stress in healthcare professionals.

Additionally, stress was shown to have the highest EI (Expected Influence) index in our network, reflecting its centrality in the burnout-depression-anxiety-stress network. This finding is supported by the work of Mihić et al. (61), who found that stress played a core role in the depression-anxiety-stress network in healthcare workers. Similarly, previous research has found that relaxation techniques such as mindfulness and yoga can be effective in reducing stress and its associated symptoms (62, 63). Therefore, implementing effective intervention strategies such as these becomes crucial when stress symptoms appear.

This study also unveils the pivotal role of emotional exhaustion as a bridge symptom in the nexus of physician burnout and other mental health symptoms, including stress, depression, and anxiety. Bridge symptoms are vitally important in network analyses, as they act as essential conduits for the interaction of different mental health issues, potentially leading to comorbidity or exacerbation of existing conditions (55). Emotional exhaustion has been recognized as a core symptom of physician burnout in numerous studies (22). It often signals the commencement of physician burnout. By targeting bridge symptoms, clinicians can more effectively treat or prevent complications (56). This indicates that interventions designed to alleviate emotional exhaustion could have wider implications for promoting psychological well-being. Organization-based interventions, mindfulness-based stress reduction, and cognitive-behavioral therapy suggested by previous studies should be widely used in healthcare settings to mitigate emotional exhaustion (51, 64).

Our findings also highlighted emotional exhaustion and depersonalization had the strongest link. This further confirms that physician burnout is not merely a manifestation of depression (22). However, empirical findings showed that emotional exhaustion and depression had a stronger association when compared to the link between depersonalization and personal accomplishment (21). When facing this controversial debate, it seems more appropriate to consider the two core symptoms of physician burnout, emotional exhaustion and depersonalization, are separate from symptoms of depression. Physician burnout, stemming directly from prolonged work-related stress, affects not just an individual’s mental well-being but can also result in a detached approach to the workplace and responsibilities, or in other words, depersonalization. Additionally, while physician burnout and depression exhibit overlapping characteristics, physician burnout is intricately linked to the work environment, contrasting with depression, whose symptoms persist regardless of changes in the work setting (65).

Consistent with empirical findings, our research also confirmed that personal accomplishment had a minimal impact across the entire network, suggesting a limited association with the physician burnout-depression network dynamics. Emotional exhaustion (22) and depersonalization (66, 67) have been empirically considered as the primary domains of physician burnout measured by Maslach Burnout Inventory-Human Services (MBIHSS), which is also the statistical tool applied in this study to assess physician burnout (23). Additionally, a previous study indicated that more than half of the individuals in the high burnout group experienced at least a moderate level of personal accomplishment (20).

While the current study highlighted important findings, it is crucial to acknowledge its limitations. First, as a cross-sectional study, it does not capture the dynamic changes in burnout and psychological symptoms over time. This design limits our understanding of the long-term psychological impact. Future research should consider employing a longitudinal design to track changes in mental health and burnout over time, offering a more comprehensive understanding of the pandemic’s lasting effects on psychiatrists.

Second, this study did not include a control group of non-psychiatric healthcare professionals, making it difficult to differentiate the specific factors contributing to burnout among psychiatrists compared to other healthcare workers. Including a control group in future research would help to better identify the unique stressors faced by psychiatrists and provide more targeted intervention strategies.

Third, the study did not assess the use of psychotherapy or counseling interventions, which may serve as protective factors in alleviating burnout and associated symptoms. The absence of data on these interventions is a limitation, and future research should evaluate their potential role in preventing and mitigating mental health issues among psychiatrists.

Lastly, while this study underscores the need for psychological support, it did not assess the effectiveness of specific interventions. Future studies could focus on evaluating the impact of psychological support programs on reducing burnout and improving mental health outcomes for psychiatrists, especially in the context of the post-pandemic recovery.

To our knowledge, this is the first study to investigate the network of physician burnout and symptoms of depression, anxiety, and stress among Chinese psychiatrists during the COVID-19 pandemic. By employing innovative methodologies to quantify the strength and centrality of connections among various symptoms, this research offers a more holistic approach to comprehending mental health disorders and identifies highly centralized symptoms in networks, such as stress, which may shed light on targeted therapeutic interventions.