This study investigated anxiety disorder and associated risk factors among Chinese doctors. A survey was conducted of 1,134 doctors from 7 teaching hospitals in China. The doctors completed questionnaires assessing anxiety using the Zung Self-Rating Anxiety Scale (SAS), as well as information on demographics, health, lifestyle, work conditions, and work-related psychological factors. Statistical analysis found that 46.8% of male doctors and 46.7% of female doctors had anxiety levels indicating disorder. Work-related psychological status was the strongest predictor of anxiety. Specifically, job burnout, lack of work efficacy, and sleep problems were linked to higher anxiety scores, especially for male doctors.
This study investigated anxiety disorder and associated risk factors among Chinese doctors. A survey was conducted of 1,134 doctors from 7 teaching hospitals in China. The doctors completed questionnaires assessing anxiety using the Zung Self-Rating Anxiety Scale (SAS), as well as information on demographics, health, lifestyle, work conditions, and work-related psychological factors. Statistical analysis found that 46.8% of male doctors and 46.7% of female doctors had anxiety levels indicating disorder. Work-related psychological status was the strongest predictor of anxiety. Specifically, job burnout, lack of work efficacy, and sleep problems were linked to higher anxiety scores, especially for male doctors.
This study investigated anxiety disorder and associated risk factors among Chinese doctors. A survey was conducted of 1,134 doctors from 7 teaching hospitals in China. The doctors completed questionnaires assessing anxiety using the Zung Self-Rating Anxiety Scale (SAS), as well as information on demographics, health, lifestyle, work conditions, and work-related psychological factors. Statistical analysis found that 46.8% of male doctors and 46.7% of female doctors had anxiety levels indicating disorder. Work-related psychological status was the strongest predictor of anxiety. Specifically, job burnout, lack of work efficacy, and sleep problems were linked to higher anxiety scores, especially for male doctors.
This study investigated anxiety disorder and associated risk factors among Chinese doctors. A survey was conducted of 1,134 doctors from 7 teaching hospitals in China. The doctors completed questionnaires assessing anxiety using the Zung Self-Rating Anxiety Scale (SAS), as well as information on demographics, health, lifestyle, work conditions, and work-related psychological factors. Statistical analysis found that 46.8% of male doctors and 46.7% of female doctors had anxiety levels indicating disorder. Work-related psychological status was the strongest predictor of anxiety. Specifically, job burnout, lack of work efficacy, and sleep problems were linked to higher anxiety scores, especially for male doctors.
: Cross-Sectional Study of Anxiety Disorder among Doctors
ing sleep quality should be given attention during health care system reform with the aim of lessening anxiety disorder in doctors in China. (J Occup Health 2012; 54: 18) Key words: Anxiety disorder, China, Doctors, Job burnout, Sleeping problem Anxiety is a basic human emotion, an uncomfort- able feeling related to uneasiness, apprehension or worry. At the beginning of 21st century, anxiety disor- ders became the most prevalent mental health problem affecting the quality of life around the globe 1, 2) . Its lifetime prevalence ranged from 13.6 to 28.8% in the general population 3, 4) . Moreover, anxiety disorders have high comorbidity rates with other psychiatric disorders 5) . Thus, their impact has become compa- rable to that of chronic somatic disorders 6) . Doctors, as a particular occupational population coping with the cure of illness and directly confront- ing suffering, disease and death everyday, tend to have a high risk of mental health disorders 7, 8) . Unfortunately, mental disorders in doctors can lead to medical mistakes and adversely affect their atti- tude towards patient care 9, 10) . Therefore, how to improve the mental health of doctors has become an accelerating social concern for the quality of lives of not only doctors themselves but also the whole general population. This issue seems to be particu- larly serious in China because of the heavy patient load resulting from the huge population. The ratio of doctors to the general population is 1 : 735 in China, considerably lower than that in western countries (1 : 2801 : 640) 11) . As a result, medical disputes occur more frequently than before. Moreover, China is undertaking health care system reform in which the focus is transforming from disease to health and from sustaining life to quality of life. The tradi- tional disease-centered care model had been gradually replaced by the patient-centered care model. This Abstract: Epidemiological Study on Risk Factors for Anxiety Disorder among Chinese Doctors: Wei SUN, et al. Department of Social Medicine, School of Public Health, China Medical University, P.R. ChinaObjectives: Anxiety disorders are the most prevalent mental health problem. However, few studies are available pertaining to this problem among Chinese doctors, a special occupational population exposed to high stress, especially during the implementation of health system reform. The aim of this study was to assess anxiety disorder among Chinese doctors and clarify its risk factors. Methods: A cross-sectional study was conducted in 7 teaching hospitals of China Medical University. Questionnaires pertaining to anxiety disorder indicated by the Zung Self-Rating Anxiety Scale (SAS) and demographic characteristics, health status, lifestyle factors, work conditions and work-related psychological status were distributed to all registered doctors during April-June 2009. There were 1,134 effective respon- dents (effective response rate 71.2%), and these respondents became our subjects (539 male doctors and 595 female doctors). Results: The average stan- dard scores of SAS for the male and female doctors were 46.8 and 46.7. General linear model analysis indicated that SAS was associated with, in standardized estimate () sequence, cynicism, emotional exhaustion, professional efficacy, sleeping problem, chronic diseases and physical exercise in men and with profes- sional efcacy, emotional exhaustion, cynicism, sleeping problem, chronic diseases, job satisfaction, alcohol consumption and meals in women. Work-related psychological status contributed the most to the model R-square. Conclusion: Chinese doctors were at considerably high risk of anxiety disorder and job burn- out and sleeping problem had prominent roles. Interven- tions such as preventing exhaustion at work and improv- Epidemiological Study on Risk Factors for Anxiety Disorder among Chinese Doctors Wei Sun 1, 2 , Jialiang Fu 1 , Ying Chang 1 and Lie Wang 1 1 Department of Social Medicine, School of Public Health, China Medical University and 2 Department of Environmental Health, School of Public Health, China Medical University, P.R. China J Occup Health 2012; 54: 18 Journal of Occupational Health Received Aug 10, 2011; Accepted Oct 12, 2011 Published online in J-STAGE Dec 10, 2011 Correspondence to: L. Wang, Department of Social Medicine, School of Public Health, China Medical University, 92 Beier Road, Heping District, Shenyang, 110001, P.R. China (e-mail: liewang@mail. cmu.edu.cn) 2 J Occup Health, Vol. 54, 2012 China-specific reform is expected to inevitably dete- riorate the mental health problems of doctors. It has been reported that, at present, most Chinese doctors suffer from depressive symptom 12) . However, anxiety disorder, the most prevalent mental health problem affecting quality of life, has been few studied among Chinese doctors up to now. The purpose of the present study was to assess anxiety disorder among Chinese doctors and explore its risk factors. Since most situations that trigger anxiety are work-related 13) , work conditions (admin- istrative leadership, professional rank, work arrange- ment, night shift, prepost training and on-the-job training) and work-related psychological status (bored with patient, effort-reward imbalance, job satisfaction and job burnout) were considered to clarify the factors associated with anxiety disorder among Chinese doctors. In view of the fact that health status is the basis of any disorder and illness, chronic diseases and sleeping problems that had been reported to be a common disturbance in the work population 14) were taken into account. Also, lifestyle factors such as nutrition, food intake and alcohol consumption have been revealed to be the main determinants of anxiety disorder 15) . Thus, work conditions and work-related psychological status, health status and lifestyle factors along with demographic characteristics were inves- tigated in the present study to clarify the factors in relation to anxiety disorder among Chinese doctors. Materials and Methods Study population China Medical University was the first medical school established by the Chinese Communist Party and has been the prominent medical institution in northeast China. It has 7 teaching hospitals dispersed throughout Liaoning Province which has almost same income level as the average level and a proportion of health workers who are doctors (34.5%) comparable to that of the whole nation (35.4%) according to the China Yearbook. These teaching hospitals, 6 grade one hospitals (>500 beds) and 1 grade two hospital (101500 beds), became our approaches to access- ing to doctors. All registered doctors in these teach- ing hospitals composed our study population, a total of 1,593 registered doctors. After obtaining written consent to conduct this survey, questionnaires were distributed to these participants during AprilJune 2009. We received effective responses from 1,134 doctors (effective response rate 71.2%). These doctors became our study subjects. Assessment of anxiety disorder Anxiety covers a variety of anxiety disorders. Somatic complaints represent a core feature of anxiety pathology and have been implicated in some kinds of anxiety disorder 16) . Thus, the Zung Self-Rating Anxiety Scale (SAS) that was designed by William WK Zung with focus on somatic complaints 17)
was used as the indicator of anxiety disorder in the present study. It composed 20 questions with 4 possible responses: (1) never, (2) rarely/sometimes, (3) frequently and (4) always. Each item was scored from 1 to 4 according to severity. The raw score was standardized according to the formula: standard score=int (1.25*raw score). A higher score denoted more serious anxiety disorder. Measurements of demographic characteristics, health status, lifestyle factors, work conditions and work- related psychological status Demographic characteristics included age, sex, marital status, education and monthly income. In China, health workers who graduated from junior college are able to obtain a doctors license after they have become a licensed assistant doctor and expe- rienced years of medical practice. Thus, education was categorized as junior college, undergraduate and graduate 18) . As for marital status, only 10 men (1.90%) and 20 women (3.47%) belonged to the widow/ divorced/separated group. Thus, they were combined with the single group as others. Monthly income (dollars) was divided into <292.8, 292.8439.2 and >439.2 groups. Health status was assessed on the basis of 2 items: 1) chronic diseases and 2) sleeping problem. Chronic diseases were defined as present if any disease such as hypertension, cardiovascular disease, diabetes, stoke or peptic ulcers had ever been diagnosed 19) . Sleeping problem was determined by asking the question Do you have difficulty in sleeping (no/slight/serious)?. Lifestyle factors included smoking, alcohol consumption, meals and physical exercise. Physical exercise was examined according to the frequency of doing exercise as none, once a week and twice or more a week (2 times/wk). Work conditions included 6 items: 1) administra- tive leadership, 2) professional rank, 3) work arrange- ment, 4) night shift, 5) prepost training and 6) on-the- job training. Administrative leadership was assessed with the question Are you the administrative leader in your department (yes/no)? Professional rank was categorized as primary, middle and senior. Work arrangement was categorized as fixed and shift groups. Night shift, prepost training and on-the-job training were determined by asking the questions Do you work night shift (yes/no)?, Had you ever attended prepost training before taking this job (yes/no)? and Have you ever participated in any professional train- ing program while working (yes/no)? respectively. 3 Wei SUN, et al.: Cross-Sectional Study of Anxiety Disorder among Doctors Work-related psychological status referred to 4 items: 1) bored with patients, 2) effort-reward imbalance (ERI), 3) job satisfaction and 4) job burn- out. Bored with patients was measured by asking the question How often do you feel bored dealing with relationships with patients? with 5 possible answers (never, rarely, sometimes, frequently and always). The answers were categorized into never, general and serious groups by combining the response rarely with the response sometimes and the response frequently with the response always. ERI was tested by the Chinese version of the ERI questionnaire 20, 21)
to claim the failed reciprocity in terms of high efforts spent and low rewards received in turn. It contained extrinsic effort (6 items), reward (11 items) and overcommitment (6 items). Each response for extrinsic effort and reward was scored from 1 to 5, and higher total scores indicated higher demands of efforts and higher rewards. The effort/reward ratio calculated according to the formula ratio=extrinsic effort / (reward*0.5454) indicated stressful if the ratio was over 1. Responses for overcommitment were scored on a scale of 1, representing complete disagreement, to 4, representing complete agreement. A higher score suggested higher demands character- ized by excessive work-related commitment. Job satisfaction was assessed by the short form of the Minnesota Satisfaction Questionnaire (MSQ), which has been used widely in the Chinese population 22) . It comprised 20 items with 5 possible responses scored on a scale of 1, representing completely dissatisfied, to 5, representing completely satisfied. The total score was used as the indicator of job satisfaction. Job burnout was measured with the Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS), which has been well applied in health workers 23, 24) . It included three scales: emotional exhaustion (5 items), cynicism (4 items) and profes- sional efficacy (6 items). Each item has 7 possible answers: (1) never, (2) rarely (several times per year), (3) sometimes (once a month), (4) often (several times per month), (5) frequently (once a week), (6) always (several times per week) and (7) everyday. These responses were scored from 0 to 6. A higher score implicated serious exhaustion and cynicism and higher professional efficacy. Statistical analysis Among all categorical independent variables, items to which over 95% of individuals had the same responses were not included in the data analysis. Smoking in women (2.1%) was thereby excluded. Data analyses were performed separately for men and women. The standard score of SAS was used to conduct statistical analysis. Distributions of anxi- ety disorder in categorical items were tested by the Students t-test and one-way ANOVA. Correlations of anxiety disorder with continuous variables were tested by Pearson correlation. The different characteristics between male and female doctors were examined by the Students t-test and chi-square test for continu- ous variables and categorical variables respectively. General linear model analysis was used to clarify the risk factors for anxiety disorder. All variables that were significant at the 0.25 level in univariate analysis were entered in the model. With adjustment for age, items with p>0.15 were eliminated one at a time in the sequence of p value. When an item was eliminated, if the change in any remaining parameter estimate was greater than 20%, this item would be remained in the model as a confounder. In this study, no confounder was found during elimination. SAS for Windows, Ver. 8.2, was used for all statistical analyses. Results The characteristics of the participants and the corre- lations of anxiety disorder with continuous variables are shown in Table 1. The standard score of SAS was 46.8 11.09 (mean SD) in male doctors and 46.7 10.85 in female doctors respectively. Male doctors had significantly higher scores of cynicism, extrinsic effort and reward than female doctors. In both male and female doctors, the standard score of SAS was significantly correlated with extrinsic effort, reward, overcommitment, job satisfaction and all scales of job burnout. The subject characteristics and the distributions of anxiety disorder in categorical items are shown in Table 2. In comparison with female doctors, male doctors had significantly lower education but significantly higher levels of chronic diseases, alco- hol consumption, irregular meals and physical exer- cise. In male doctors, the standard score of SAS had significant relations with education, chronic diseases, sleeping problem, meals, physical exercise, work arrangement and bored with patients; whereas, it was significantly related to chronic diseases, sleeping problem, alcohol consumption, meals, administrative leadership, bored with patients, and effort/reward ratio in female doctors. The results of the general linear model analysis for clarifying the major risk factors for anxiety disorder are shown in Table 3. With adjustment for age, the standard score of SAS was significantly associated with, in the sequence of standardized estimate (), cynicism, emotional exhaustion, professional efficacy, sleeping problem, chronic diseases and physical exer- cise in male doctors and with professional efficacy, emotional exhaustion, cynicism, sleeping problem, chronic diseases, job satisfaction, alcohol consumption 4 J Occup Health, Vol. 54, 2012 and meals in female doctors. The contributions of risk factors to the model R-square are shown in Table 4. Among all clarified risk factors, the contribution to the model R-square attributed to work-related factors (R-square) was 0.2240 in male doctors and 0.2575 in female doctors. Health status contributed 0.1206 to the model R-square in male doctors and 0.1265 in female doctors. The model R-square value contributed by lifestyle factors (R-square) was 0.0345 for both male and female doctors. Discussion Anxiety is one of the most common conditions impairing quality of life. Our results revealed that the standard SAS scores were 46.8 in male doctors and 46.7 in female doctors respectively. In compari- son with studies using the same anxiety indicator, our raw scores (37.8 in male doctors and 37.7 in female doctors) were close to the levels among survivors of severe acute respiratory syndrome, which were in the range of 37.243.0 at 2, 7, 10, 20 and 46 months after discharge from medical hospitalization 25) , but lower than that among airplane pilots (44.56) 26) ; on the other hand, the standard scores were much higher than the anxiety status among university teachers (37.3 in male and 34.8 in female) 27) , and even a little higher than the level (45.36) among inhabitants in Wenchuan County after the 5.12 Sichuan earthquake 28) . All these findings revealed that Chinese doctors were suffering from a considerably serious anxiety disorder at pres- ent. Unfortunately, comparison with the anxiety level before implementation of health care system reform could not be performed due to the lack of previous related assessments. But, according to our results, anxiety disorder among Chinese doctors requires urgent attention during the China-specific health care system reform for the quality of lives of the doctors and thereby the general population. As for the risk factors, work-related psychological status was found to be crucial for anxiety disorder among Chinese doctors, coinciding with a previous conclusion 13) . Moreover, job burnout was found to have the strongest association with anxiety disor- der among both male doctors and female doctors. It made up the major contribution to the model R-Square. Job burnout is an experience of physical, emotional and mental exhaustion caused by stress from work 29) and is characterized as emotional exhaus- tion, cynicism and reduced professional efficacy. The exhausted feeling produced by working seems to be a kind of personal erosion that makes an individual prone to anxiety disorder. Interestingly, among the three scales of job burnout, cynicism was revealed to have the strongest association with anxiety disorder in male doctors, whereas professional efficacy was the most crucial risk factor in female doctors. The reason for this sex-related difference is unclear. It might due to the higher education level of our female individuals than that of the male individuals. In China, women share the working burden and compete with men. For those women with a higher education, the accomplish- ment in work particularly represents the fulfillment of their lives and shows that they have value. This posi- tive thinking certainly is able to help prevent anxiety disorder. As for men, they are accustomed to the task role assumed by traditional viewpoint. Comparably, interest in and passion for work seem to affect their attitude towards their career. Thus, attention regard- ing job burnout should be sex-specifically focused at improvement of anxiety disorder among Chinese doctors. In addition, job satisfaction was found to affect anxiety disorder among female doctors. This might result from women being more emotional than Table 1. The characteristics of the participants and the correlations of anxiety disorder with continuous variables Variables Male (n=539) Female (n=595) Mean SD r Mean SD r Standard SAS score 46.8 11.09 46.7 10.85 Age (yr) 38.5 9.25 0.05 37.5 8.31 0.05 Overcommitment 13.7 2.08 0.21** 13.6 2.00 0.27** Job satisfaction 63.9 12.57 0.35** 63.7 11.10 0.38** Emotional exhaustion 11.8 7.94 0.46** 11.7 7.18 0.46** Cynicism 6.2 6.05* a 0.49** 5.4 5.53 0.51** Extrinsic effort 19.1 6.05* a 0.32** 18.3 6.18 0.32** Reward 28.1 7.51** a 0.40** 26.4 6.83 0.35** Effort/reward ratio 1.28 0.38 0.02 1.30 0.41 0.08 Professional efficacy 23.5 9.48 0.22** 24.5 9.44 0.33** *: p<0.05. **: p<0.01. a: Comparison between men and women. 5 Wei SUN, et al.: Cross-Sectional Study of Anxiety Disorder among Doctors men. With respect to health status, chronic diseases have been well documented as the basis for disorders 12, 19) , and having a sleeping problem was found to be a risk factor for psychological disorders such as depression, anxiety disorder and suicide 30, 31) . Among our partici- pants, their impacts on anxiety disorder were also found in both male and female doctors. Interestingly, sleeping problem showed the second strongest asso- ciation with anxiety disorder. Its contribution to the model R-Square accounted for 17.8% in male doctors and 23.6% in female doctors respectively, even if it was assessed by a single question. Having a sleeping problem will inevitably lead to tiredness and thereby Table 2. The subject characteristics and the distributions of anxiety disorder in categorical items Variables Male (n=539) Female (n=595) n Mean SD n Mean SD Marital status Others Married Education Junior college Undergraduate Graduate Monthly income (dollars) <292.8 292.8439.2 >439.2 Chronic diseases Absent Present Sleeping problem No Slight Serious Smoking No Yes Alcohol consumption No Yes Meals Regular Irregular Physical exercise None Once a week 2 times/wk Administrative leadership No Yes Professional rank Senior Middle Primary Work arrangement Fixed Shift Night shift No Yes Prepost training Yes No On-the-job training Yes No Bored with patients Never General Serious Effort/reward ratio 1 >1 111 415 125 374 36 361 124 53 360 179* a 196 283 47 314 220 191 348** a 266 273** a 212 178 121** a 430 109 157 195 174 209 326 184 355 419 103 493 34 74 338 122 107 432 46.5 11.69 46.7 11.00 44.0 10.75 47.7 11.24 45.9 9.58** 46.9 11.44 47.1 10.71 45.4 9.56 45.2 10.95 50.0 10.70** 42.9 10.66 48.2 10.71 53.4 10.67** 46.6 11.24 47.0 10.94 46.0 11.90 47.2 10.61 44.4 10.43 49.1 11.24** 48.1 11.26 46.9 10.81 43.4 11.04** 47.1 11.38 45.3 9.80 46.4 9.99 47.1 11.14 46.8 12.15 45.4 10.77 47.6 11.26* 45.8 10.28 47.3 11.47 46.7 11.24 47.4 10.63 46.7 11.10 47.6 11.17 40.9 11.20 46.1 10.42 52.1 10.53** 45.6 11.37 47.1 11.01 106 470 97 452 43* a 404 150 40 438 157 233 276 69 542 41 416 179 319 178 67 500 95 191 221 178 244 350 228 367 466 104 537 43 64 403 118 126 469 44.8 9.54 47.0 11.05 46.3 11.12 46.9 10.84 45.3 10.31 46.8 10.78 47.1 11.01 44.0 10.81 45.5 10.53 50.1 11.04** 42.6 10.03 48.2 10.03 54.3 10.96** 46.4 10.76 50.4 12.12* 45.0 10.41 50.5 10.91** 47.2 10.92 45.7 10.48 45.0 11.40 47.2 10.87 44.0 10.36** 46.8 11.19 47.7 10.79 45.4 10.55 45.8 10.96 47.4 10.74 46.1 10.66 47.0 10.96 46.4 10.94 47.9 10.48 46.6 10.74 46.1 11.94 43.4 10.58 46.0 10.41 50.5 11.45** 44.2 10.20 47.4 10.93** *: p<0.05. **: p<0.01. a: Comparison between men and women by chi-square test. 6 J Occup Health, Vol. 54, 2012 Table 3. The general linear model analysis for clarifying the major risk factors for anxiety disorder Variables Parameter estimate (B) Standardized estimate () Model R-Square Male Intercept Age (yr) Cynicism Emotional exhaustion Professional efficacy Sleeping problem (serious vs. no) Sleeping problem (slight vs. no) Chronic diseases (present vs. absent) Physical exercise (2 times/wk vs. no) Physical exercise (once a week vs. no) 40.46 0.03 0.51*** 0.35*** 0.23*** 4.36*** 3.77*** 2.31** 1.82* 0.39 0.03 0.27 0.25 0.19 0.11 0.17 0.10 0.07 0.02 0.3814*** Female Intercept Age (yr) Professional efficacy Emotional exhaustion Cynicism Sleeping problem (serious vs. no) Sleeping problem (slight vs. no) Chronic diseases (present vs. absent) Job satisfaction Alcohol consumption (yes vs. no) Meals (irregular vs. regular) 48.57 0.06 0.29*** 0.32*** 0.37*** 4.32*** 2.97*** 2.36*** 0.10*** 3.60** 1.45* 0.05 0.25 0.22 0.19 0.13 0.14 0.10 0.10 0.08 0.06 0.4208*** *: p<0.15. **: p<0.05. ***: p<0.01. Age was fixed in the model. Table 4. The contributions of risk factors to the model R-square Demographic characteristics Health status Lifestyle factors Work-related psychological status Male F R 2 R 2 Age 1.21 0.0023 0.0023 Chronic diseases Sleeping problem 17.68** 0.1229 0.1206 Physical exercise 14.91** 0.1574 0.0345 Job burnout 32.61** 0.3814 0.2240 Female F R 2 R 2 Age 1.32 0.0023 0.0023 Chronic diseases Sleeping problem 20.81** 0.1288 0.1265 Alcohol consumption Meals 17.93** 0.1633 0.0345 Job satisfaction Job burnout 39.74** 0.4208 0.2575 **: p<0.01. 7 Wei SUN, et al.: Cross-Sectional Study of Anxiety Disorder among Doctors weaken working ability and deteriorate work perfor- mance, which seems to be considerably harmful for doctors, a particular occupational population engag- ing in high stressful profession. This impairment seems to be especially serious in China due to the great number of patients yielded by the huge popula- tion. On the basis of this great patient load, having a sleeping problem tends to place an additional stressful burden on doctors and make them prone to anxiety disorder. Thus, the improvement of sleep quality seems to have an important role in lessening anxiety disorder for Chinese doctors. Lifestyle factors have been revealed to be another main determinant of anxiety disorder 15) . Their effects on anxiety disorder were also observed in the present study. Among our assessed lifestyle factors, physi- cal exercise, especially doing exercise twice or more a week, exerted an effect on anxiety disorder among male doctors, whereas alcohol consumption and irreg- ular meals were risks for female doctors. Physical exercise has been considered important for restoration of personal resources 32) . The performance of physi- cal exercise seems also to be a kind of personal stress relief. Thus, it plays an important role in preventing anxiety disorder. Unfortunately, only 11.9% of female doctors performed physical exercise twice or more a week in comparison to our male individuals (23.7%). Consequently, its effect on anxiety disorder might be weakened among female doctors. In contrast, the prevalence of alcohol consumption in these female doctors was 7.0%, 2.7 times the average level among female health workers in general hospitals 33) , and 30.1% of them could not have regular meals. Even if these levels were much higher in male doctors, men usually have a much higher ability than women to adapt to or even to become accustomed to an irregular life style and thus cannot be affected easily. There are two limitations to the present study. First, all individuals were drawn from the teaching hospitals of China Medical University. Although these hospitals are dispersed in all sizes of cities in Liaoning Province, which is located in northeastern China, the representation of our study population might be weakened. Second, our study was limited by its cross-sectional design. We were unable to draw any causal conclusion between anxiety disorder and its risk factors. All findings obtained in the present study need to be confirmed in future prospective stud- ies. In conclusion, the present study assessed anxiety disorder and explored its risk factors among Chinese doctors during China-specific reform of the health care system. Our findings revealed that both male and female doctors in China were at high risk of anxiety disorder. Work-related psychological status, especially job burnout, was a prominent risk factor for anxiety disorder for both male and female Chinese doctors. Health status such as having a sleeping problem seemed to have a considerable effect on anxi- ety disorder among Chinese doctors. Lifestyle factors were also able to affect anxiety disorder. Attention on preventing exhaustion from work and improving sleep quality should be focused on, especially during reform of the health care system, with the purpose of lessen- ing anxiety disorder among doctors in China. Competing Interests: The authors declare that they have no competing interests. Acknowledgments: The authors would like to thank all the administrators in all teaching hospitals who helped to get the written informed consent about the conduct of this survey and to distribute the question- naires to the subjects. References 1) Pearson P. A brief history of anxiety (yours and mine). Toronto (ON): Random House Canada; 2007, p.13. 2) Tone A. Looking to the past: history, psychiatry, and anxiety. Can J Psychiatry 2005; 50: 37380. 3) Kessl er RC, Bergl und P, Deml er O, Ji n R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 593602. 4) Alonso J, Angermeyer MC, Bernert S, et al. Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand 2004; Suppl. 420: 217. 5) Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbid- ity of 12 month DSM-IV disorders in the National Comorbi di t y Survey Repl i cat i on. Arch Gen Psychiatry 2005; 62: 61727. 6) Merikangas KR, Zhang H, Avenevoli S, Acharyya S, Neuenschwander M, Angst J. Longitudinal trajec- tories of depression and anxiety in a prospective community study: the Zurich cohort study. Arch Gen Psychiatry 2003; 60: 9931000. 7) Stansfeld S, Candy B. Psychosocial work environ- ment and mental healtha meta-analytic review. Scand J Work Environ Health 2006; 32: 44362. 8) Tyssen R, Vaglum P. Mental health problems among young doctors: an updated review of prospective studies. Harv Rev Psychiatry 2002; 10: 15465. 9) Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351: 183848. 10) Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns weekly work hours on sleep 8 J Occup Health, Vol. 54, 2012 and attentional failures. N Engl J Med 2004; 351: 182937. 11) Li J, Yang W, Cho SI. Gender differences in job strain, effort-reward imbalance, and health function- ing among Chinese physicians. Soc Sci Med 2006; 62: 106677. 12) Wang JN, Sun W, Chi TS, Wu H, Wang L. Prevalence and associated factors of depressive symptoms among Chinese doctors: a cross-sectional survey. Int Arch Occup Environ Health 2010; 83: 90511. 13) Dowbiggin IR. High anxieties: the social construc- tion of anxiety disorders. Can J Psychiatry 2009; 54: 42936. 14) Sateia MJ, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia. An American acad- emy of sleep medicine review. Sleep 2000; 23: 243308. 15) Aver i na M, Ni l ssen O, Br enn T, Br ox J, Arkhipovsky VL, Kalinin AG. Social and lifestyle determinants of depression, anxiety, sleeping disor- ders and self-evaluated quality of life in Russia- -a population-based study in Arkhangelsk. Soc Psychiatry Psychiatr Epidemiol 2005; 40: 5118. 16) Olatunji BO, Deacon BJ, Abramowitz JS, Tolin DF. Dimensionality of somatic complaints: factor struc- ture and psychometric properties of the Self-Rating Anxiety Scale. J Anxiety Disord 2006; 20: 54361. 17) Zung WWk. A rating instrument for anxiety disor- ders. Psychosomatics 1971; 12: 3719. 18) Wu H, Zhao Y, Wang JN, Wang L. Factors associat- ed with occupational stress among Chinese doctors: a cross-sectional survey. Int Arch Occup Environ Health 2010; 83: 15564. 19) Sun W, Watanabe M, Tanimoto Y, et al. Factors associ- ated with good self-rated health of non-disabled elderly living alone in Japan: a cross-sectional study. BMC Public Health 2007; 7: 297. 20) Li J, Yang W, Cheng Y, Siegrist J, Cho SI. Effort- reward imbalance at work and job dissatisfaction in Chinese healthcare workers: a validation study. Int Arch Occup Environ Health 2005; 78: 198204. 21) Yang W, Li J. Measurement of psychosocial factors in work environment: application of two models of occupational stress. Chin J Ind Hyg Occup Dis 2004; 22: 4226 (in Chinese). 22) Shao H, Yan S, Hu L. The work satisfaction degree of nurses in longgang district of Shenzhen city. J Nursing (China) 2007; 14: 124 (in Chinese). 23) Zhu W, Wang Z, Wang M, Lan Y, Wu S. Occupational stress and job burnout in doctors. J Sichuan Univ (Med Sci Edi) 2006; 37: 2813 (in Chinese). 24) Zhu W, Wang Z, Wang M, Lan Y, Wu S. Job Burnout and Contributing Factors for Nurses. J Sichuan Univ (Med Sci Edi) 2006; 37: 6325 (in Chinese). 25) Hong X, Currier GW, Zhao X, Jiang Y, Zhou W, Wei J. Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow- up study. Gen Hosp Psychiatry 2009; 31: 54654. 26) Liang Z, Wang Y, Li J, Yu Y. Anxiety and influenc- ing factors of civil air pilots. Int Medicine & Health Guidance News 2005; 11: 202 (in Chinese). 27) Zhang D, Wang P, Gao F. Relationship between job satisfaction and anxiety: mediated by job burn- out. Chin J Health Psychol 2011; 19: 9435 (in Chinese). 28) Guo M, Gao Y, Wang X, Jiang X. Survey of anxi- ety and depression of people during Wenchuan earthquake. Chin Tropical Med 2009; 19: 3834, 75 (in Chinese). 29) Maslach C, Goldberg J. Prevention of burnout: new perspectives. Applied Prevent Psychol 1998; 7: 6374. 30) Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behav Sleep Med 2003; 1: 22747. 31) Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, depression, and anxiety. Sleep 2005; 28: 145764. 32) Osipow SH. Occupational stress inventory revised edition. Odessa (FL): Psychological Assessment Resources Inc; 1998. p.110. 33) Zu Q, Zhu Q, Zhu X, Shen H, You H, Yu R. Investigation of the relationship between smok- ing, drinking and mental health status of medical staff in comprehensive hospitals. Acta Universitatis Medicinalis Nanjing (Natural Science) 2008; 28: 12147 (in Chinese).