Stress, Burnout, Anxiety and Depression among Teachers: A Scoping Review

Background: Worldwide, stress and burnout continue to be a problem among teachers, leading to anxiety and depression. Burnout may adversely affect teachers’ health and is a risk factor for poor physical and mental well-being. Determining the prevalence and correlates of stress, burnout, anxiety, and depression among teachers is essential for addressing this public health concern. Objective: To determine the extent of the current literature on the prevalence and correlates of stress, burnout, anxiety, and depression among teachers. Method: This scoping review was performed using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Relevant search terms were used to determine the prevalence and correlates of teachers’ stress, burnout, anxiety, and depression. Articles were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica Data Base), APA PsycINFO, CINAHL Plus (Cumulative Index of Nursing and Allied Health Literature), Scopus Elsevier and ERIC (Education Resources Information Center). The articles were extracted, reviewed, collated, and thematically analyzed, and the results were summarized and reported. Results: When only clinically meaningful (moderate to severe) psychological conditions among teachers were considered, the prevalence of burnout ranged from 25.12% to 74%, stress ranged from 8.3% to 87.1%, anxiety ranged from 38% to 41.2% and depression ranged from 4% to 77%. The correlates of stress, burnout, anxiety, and depression identified in this review include socio-demographic factors such as sex, age, marital status, and school (organizational) and work-related factors including the years of teaching, class size, job satisfaction, and the subject taught. Conclusion: Teaching is challenging and yet one of the most rewarding professions, but several factors correlate with stress, burnout, anxiety, and depression among teachers. Highlighting these factors is the first step in recognizing the magnitude of the issues encountered by those in the teaching profession. Implementation of a school-based awareness and intervention program is crucial to resolve the early signs of teacher stress and burnout to avoid future deterioration.


Introduction
The teaching profession can be highly stressful, and this stress may lead to reduced job satisfaction, burnout, and poor work performance. Stress is a normal response to upsetting or threatening events and becomes pathological when chronic [1]. Chronic stress can impede day-to-day functioning and emotional balance, and it is a risk factor for developing other psychiatric illnesses, such as anxiety and depression [1][2][3]. Prolonged teacher stress negatively correlates with job satisfaction and positively correlates with intending to leave the teaching profession. It may also result in withdrawal behaviour, including physically or psychologically leaving the work setting [4,5]. Chronic stress may also lead to inappropriate anger and increased alcohol and drug consumption [6,7], and it can cause an individual to experience excessive anxiety, mental fatigue, and burnout, while also predicting increased depression [8][9][10]. According to Maslach, stress occurs when a person perceives an external demand as exceeding their capability to deal with it [11]. Teacher stress can be associated

Data Charting and Extraction Process
The research team extracted data for each selected article according to the following domains: author(s) name, year of publication, country of study, study design, assessment tools used, sample size (N), age, main findings, and conclusion.

Data Charting and Extraction Process
The research team extracted data for each selected article according to the following domains: author(s) name, year of publication, country of study, study design, assessment tools used, sample size (N), age, main findings, and conclusion.

Collating, Summarizing, and Reporting the Results
This study presents an overview of existing evidence relating to the prevalence and the correlates of stress, burnout, anxiety, and depression among teachers. All the relevant data were organized into tables and validated by at least two team members. The characteristics and results reported in each included article were summarized. In addition, the prevalence range for the psychological conditions in high-quality studies were determined after identifying the high-quality studies for each psychological condition in this scoping review using the Joanna Briggs Institute's (JBI) critical appraisal checklist for prevalence studies [37]. The JBI checklist includes: studies with an adequate sample size, studies which provided an appropriate sample frame to address the target population, studies with an adequate response rate, studies which had a high response rate, studies in which a systematic approach was used for the data capture to ensure the study sample was representative of the study population, and studies with an adequate statistical analysis.

Study Characteristics
The search strategy identified 10,493 citations. Covidence software [38] was used to automatically remove 5711 duplicates. One hundred and ninety articles remained for a full-text screening, and seventy of these were eligible for inclusion. Overall, 67 articles were quantitative cross-sectional studies. One study was a mixed quantitative and qualitative study, and two studies were randomized controlled trials. The seventy articles included a total of 143,288 participants, who were all teachers. The sample size for an individual article ranged from 50 to 51,782 participants, with an age range from 18 years to 75 years. The minimum response rate was 13% and the maximum was 97.4% with the median response rate of 77%. The articles included studies from 1974 to 2022. Most studies (79%) were published between 2007 and 2022, and 21% were from 1974 to 2006. Most of the studies were conducted in Europe (40%), followed by Asia (30%) and North America (19%). In contrast, African, South America and Oceanian studies represented 6%, 1% and 4%, respectively, as shown in Figure 2. One study [39] was conducted across multiple continents.
teristics and results reported in each included article were summarized. In addition, the prevalence range for the psychological conditions in high-quality studies were determined after identifying the high-quality studies for each psychological condition in this scoping review using the Joanna Briggs Institute's (JBI) critical appraisal checklist for prevalence studies [37]. The JBI checklist includes: studies with an adequate sample size, studies which provided an appropriate sample frame to address the target population, studies with an adequate response rate, studies which had a high response rate, studies in which a systematic approach was used for the data capture to ensure the study sample was representative of the study population, and studies with an adequate statistical analysis.

Study Characteristics
The search strategy identified 10,493 citations. Covidence software [38] was used to automatically remove 5711 duplicates. One hundred and ninety articles remained for a full-text screening, and seventy of these were eligible for inclusion. Overall, 67 articles were quantitative cross-sectional studies. One study was a mixed quantitative and qualitative study, and two studies were randomized controlled trials. The seventy articles included a total of 143,288 participants, who were all teachers. The sample size for an individual article ranged from 50 to 51,782 participants, with an age range from 18 years to 75 years. The minimum response rate was 13% and the maximum was 97.4% with the median response rate of 77%. The articles included studies from 1974 to 2022. Most studies (79%) were published between 2007 and 2022, and 21% were from 1974 to 2006. Most of the studies were conducted in Europe (40%), followed by Asia (30%) and North America (19%). In contrast, African, South America and Oceanian studies represented 6%, 1% and 4%, respectively, as shown in Figure 2. One study [39] was conducted across multiple continents. From Figure 3: Most studies reported on multiple outcomes, indicating the interrelatedness of stress, burnout, anxiety, and depression. Some articles reported on a single outcome, such as stress (N = 9), burnout (N = 8), or depression (N = 6). Burnout and depression (N = 15), stress and depression (N = 5), burnout and anxiety (N = 2), anxiety and depression (N = 4), and stress and anxiety (N = 4), were commonly paired outcomes. One study (N = 1) specifically examined the paired outcomes of burnout and stress. In addition, the outcome of the interaction between three or four of these psychological problems were explored by some studies: anxiety, depression, and stress (N = 10); anxiety, burnout and depression (N = 1); stress, burnout and anxiety (N = 1); stress, burnout, and outcome, such as stress (N = 9), burnout (N = 8), or depression (N = 6). Burnout and depression (N = 15), stress and depression (N = 5), burnout and anxiety (N = 2), anxiety and depression (N = 4), and stress and anxiety (N = 4), were commonly paired outcomes. One study (N = 1) specifically examined the paired outcomes of burnout and stress. In addition, the outcome of the interaction between three or four of these psychological problems were explored by some studies: anxiety, depression, and stress (N = 10); anxiety, burnout and depression (N = 1); stress, burnout and anxiety (N = 1); stress, burnout, and depression (N = 2). Finally, two articles reported the interaction between stress, burnout, anxiety, and depression.    Figure 4 shows that depression was the most reported psychological problem among the included studies and the least reported was anxiety.

Prevalence and Correlates of Burnout, Stress, Anxiety and Depression
The prevalence and correlates of stress, burnout, anxiety, and depression as identified in the literature search are summarized in Tables A1 and A2 in Appendix A.

Prevalence of Stress
The reported stress prevalence rates were heterogenous, which may reflect, in part, the use of different stress measures. The prevalence of stress in all forms ranged from 6.0% to 100% [28,40], with a median of about 32.5%. In addition, the lowest, highest and median stress prevalence ranges from 2020 to 2022 (after the pandemic and lockdown) were, respectively, 6.0% [40], 66.0% [41] and 10.7%. Similarly, the lowest, highest and median stress prevalence up until 2019 (prior to the pandemic and lockdown) were, respectively, 7.0% [42], 100% [28] and 33.9%.
Early studies of teacher stress found a relatively high degree of stress. For example, 76% [43] and 87.1% [44] of teachers described their stress levels at their school as moderate or significant, respectively. In some studies, 45.6% reported "much stress" [44] or "almost unbearable" stress (20%) [43]. Another study echoed these findings, reporting 32%

Prevalence and Correlates of Burnout, Stress, Anxiety and Depression
The prevalence and correlates of stress, burnout, anxiety, and depression as identified in the literature search are summarized in Tables A1 and A2 in Appendix A.

Prevalence of Stress
The reported stress prevalence rates were heterogenous, which may reflect, in part, the use of different stress measures. The prevalence of stress in all forms ranged from 6.0% to 100% [28,40], with a median of about 32.5%. In addition, the lowest, highest and median stress prevalence ranges from 2020 to 2022 (after the pandemic and lockdown) were, respectively, 6.0% [40], 66.0% [41] and 10.7%. Similarly, the lowest, highest and median stress prevalence up until 2019 (prior to the pandemic and lockdown) were, respectively, 7.0% [42], 100% [28] and 33.9%.
Earlier studies on teacher stress are consistent with more recent findings, indicating teacher stress is a long-standing issue and is challenging to tackle. A 2021 study completed during the COVID-19 pandemic reported a 6.0% prevalence of severe to highly severe stress among teachers [40]. This is similar to another recent but pre-pandemic study which reported a 7.0% prevalence of "severe to extremely severe" stress, a 32.3% prevalence of stress, and 25.3% prevalence of mild to moderate stress [42].

Prevalence of Burnout
Published studies have identified three different burnout profiles among teachers with the prevalence ranging from 25.12% to 48.37% [11,46]. These are, (1) groups of teachers with predominantly low levels of emotional exhaustion and high levels of personal accomplishment, (2) teachers with high levels of emotional exhaustion and depersonalization, and (3) teachers with low levels of depersonalization and personal accomplishment [46]. These groups show the combination of the three interrelated components of burnout reported by Maslach et al. [6,7,11,16].
Variable prevalence of burnout and psychological distress have been reported among teachers [47], with the burnout prevalence at all levels ranging from a low of 2.81% [7] to a high of 70.9% [48], with a median of 28.8% (Table A1). The lowest, highest and median burnout prevalences from 2020 to 2022 (after the pandemic and lockdown) were, respectively, 3.1% [48], 70.9% [48] and 27.6%. Similarly, the lowest, highest and median burnout prevalences up until 2019 (prior to the pandemic and lockdown) were, respectively, 2.81%, 63.43% [7] and 25.09%.
In an early study, only 11% of the teachers were classified as burnt out, and more than half (68.5%) of the teachers reported they did not experience any burnout [49]. Some studies reported burnout prevalence in the three subdimensions [50]. For instance, four studies reported a burnout prevalence of 11% to 40% for emotional exhaustion, depersonalization and for reduced personal accomplishment [3,46,49,50]. Studies have also reported that 18.3% to 34.9% of teachers may be at risk of or are threatened by burnout syndrome [3,25,51]. Higher burnout scores and subdimensions such as emotional exhaustion and depersonalization burnout were significantly higher among female teachers than male teachers [51][52][53]. Likewise, a higher percentage of males (59.38%) showed low burnout than did females (53%) [54]; however, other studies have reported contradictory results where males had a slightly higher burnout prevalence of 56.0% than females of 53.0% [55] and 31.88% of males and fewer females (25%) reported a lack of personal accomplishment [54].
There are also studies reporting various levels of burnout ranging from low/no burnout (58.12%) to moderate (2.81% to 70.9%) and severe levels of burnout (3.1% to 33.3%) [7,25,47]. Regarding the subjects taught by teachers, science stream and science teachers reported experiencing slightly more burnout (14.38% to 26.26%) than arts stream and art teachers, who reported an average burnout prevalence of 12.5% to 25% [7].
Early studies indicated that teachers' anxiety prevalence ranged from 26% for borderline anxiety, 36% for minimal or no anxiety, and 38% for clinically significant anxiety [45]. Recent studies have reported a similar prevalence for low anxiety at 17.6%, mild at 23.2% [28] and 7.0% to 23.3% for severe to extremely severe anxiety [28,39,41]. Another study reported an anxiety prevalence of 43% among teachers. The prevalence of anxiety did not change significantly during the COVID-19 pandemic, with most teachers (56.2%) reporting no change in their anxiety during the pandemic compared with before the pandemic, and only 4.9% of teachers reported an increase in anxiety levels from the baseline during the first week of the 2020-2021 school year [58].
Early studies showed a highly varied prevalence of depression, with 79% of teachers scoring at the low or no depression levels in one study. This study also reported that 17% of teachers had borderline depression scores, and 4% had scores that indicated clinical depression [45]. Studies from 2008 onwards identified that the prevalence of depression ranged from 17.86% to 49.1% [3,41,55,60,61] and the prevalence of severe to extremely severe depression ranged from 0.7 to 9.9% [42], whilst the prevalence of mild depression ranged from 20 to 43.9% [41,42,60,62]. Soria-Saucedo et al. reported a particularly high prevalence (16%) of severe depression symptoms among teachers [61]. Depression was also found to range from 45% to 84.6%, depending on the educational level and teaching experience, and was highest among those with a lower education level, followed by teachers with more teaching experience [42].
Studies during the pandemic demonstrated higher rates of mild depression but similar rates of severe depression symptoms among teachers. In one study, 58.9% of teachers had mild depression, 3.5% had moderate, and 0.6% had severe depression. [48]. Another study reported that 3.2% of teachers had severe to extremely severe depression [40]. According to Keyes, 'flourishing' denotes being filled with positive emotion and functioning well psychologically and socially while 'languishing' in life signifies the individual has poor mental health with low well-being [59,62]. Capone and Petrillo reported that 38.7% of 'flourishing' teachers reported a lower prevalence of depression but higher levels of job satisfaction. A severe rating of depression was also reported by 85.7% of 'languishing' teachers [59].

Prevalence Range and Median for Stress, Burnout, Anxiety and Depression Reported in High Quality Studies
After applying the JBI checklist [37] to identify high-quality studies, the clinically meaningful (moderate to severe) burnout among teachers recorded by three studies ranged from 25.12% to 74% [25,46,47]. Similarly, three studies reported stress at clinically meaningful levels which included severe, extremely severe, moderate to high or very stressful, and a great deal of stress, with a prevalence ranging from 8.3% to 87.1% [43,44,57]. Likewise, two studies reported the prevalence of clinically meaningful anxiety among teachers ranging from 38% to 41.2% [45,57]. Furthermore, five studies [44,47,57,63,64] reported the prevalence of depression in clinically significant levels, which included terminologies such as major, moderate, moderate to severe, and extremely severe depression symptoms. The lowest prevalence in this category was 4% [45] and the highest category was 77% [65]. Finally, the median prevalence of stress, burnout, anxiety, and depression among these studies were, respectively, 67.0%, 60.9%, 39.6%, and 14.%.

Correlates of Stress, Burnout, Anxiety and Depression
The correlates of stress, burnout, anxiety, and depression, as extracted from Tables A1 and A2, are summarized in Table 1. A wide range of variables are significantly associated with teachers' stress, burnout, anxiety and depression and can be divided into socio-demographics, school, organizational and professional factors, and social and other factors, including intrapersonal factors. The most reported correlates were sex, age, gender, marital status, job satisfaction, subject taught and years of teaching [28,40,57,63,66,67]. Socio-demographic factors, such as age and sex, and work-related factors correlate with depression, anxiety and stress [42]. Emotional exhaustion is correlated with age, gender and marital status. [39,52,53,68]. Other studies, however, refute these, indicating that no significant demographic variable correlations were found between burnout and depression, and that depressive symptoms in men and women were similar [64,69]. Capone et al. also noted that all the school climate factors, such as social support, were negatively related to depression [70]. Higher levels of co-worker support were related to lower levels of anxiety and depression [71]. Educational Level [42] Family economics status and income [40] [40] [40] Teachers' weight [55] Spirituality [83] Number of children [63] Country of participant [39] School and professional correlates Lack of students' Progress [78,85] Violence/Verbal Abuse from Students [82] Dealing with parent [45] Class Management [45] High job demands and workload [73,86]  Interpersonal conflict and organizational constraints [73] Job seniority [73] High sense of coherence among colleagues [91] [91] Student Attendance [81] Social and other correlates Dysfunctional attitudes, ruminative responses, and pessimistic attributions. [92] [92] Exercise [40] [61] Relationship quality [40] [40] Presenteeism [81] Absenteeism [65] [31] Non-restorative sleep [80] Effort-reward imbalance [42,50,51,80] Quality of life [31] Psychological distress [74] Communication [58] Overcommitment [50] [85] Flourishing/Languishing [59]  Confidence levels [54,69] Motivation to quit [18] General lifestyle [54,69] Organizational factors associated with anxiety included: work overload, time pressures causing teachers to work during their free time, and role conflict. There were significant correlations between the reported anxiety and those stressors relating to pupils and parents [45]. In addition, interpersonal conflict, organizational constraints and workload were reported to result in depression through increasing job burnout [73]. Furthermore, depressive symptoms correlated with teaching special needs students and had a significant and robust relationship with the general burnout factor [50]. Self-perceived accomplishment was also positively associated with autonomy and negatively associated with low student motivation [18]. Personal accomplishment had a significant positive relationship with the number of teaching hours per week [40]. On the contrary, a cross-sectional study by Baka reported that increased work hours are usually accompanied by job demands, job burnout, and depression [73]. Job strain, job demand and job insecurity all showed positive associations with depressive symptoms [80,94]. Work-related factors, such as workload, were also correlated with stress, burnout, depression, and anxiety [42,73].
Furthermore, the educational level and teaching experience also predict depression. Depression was highest among teachers with a lower education followed by teachers with the most teaching experience [42]. Teacher stress was reported to be significantly associated with psychological distress, and social support could moderate the influence of stress; hence, the high-stress and the low-support group were most vulnerable to anxiety [74]. Studies have also reported that 55% of teachers without spousal support had depression [42]. In addition, stress was reported to be associated with missed work days, high anxiety and high role conflict [43,89] and 53.2% of teachers identified work as a source of long-term stress, leading to burnout [55]. According to Fei Liu et al. resilience significantly correlated with job burnout and turnover intention, and low resilience could result in a high job burnout [86]. The research also showed that personality trait neuroticism was the best predictor of burnout (28-34%) [67].

Association between Stress, Burnout, Anxiety and Depression
A significant overlap was reported between stress, burnout, anxiety and depression. Eighteen articles reported a correlation between burnout and depression, with differences in depressive symptomatology depending on the prevalence of burnout [3,18,25,41,42,48,50,52,54,60,64,69,84,86,92,95]. Three articles reported a correlation between burnout and anxiety symptoms [52,64]. Seven articles reported a correlation between stress and anxiety [28,58,65,71]. Six articles reported a correlation between stress and depression [28,31,43,61,68,71]. A correlation exists between moderate depressive disorder and anxiety disorder as well as stress [31,96]. Negative affectivity (a tendency to feel depression, anxiety, or stress) plays a role in the development of burnout among teachers. Teachers who developed a more markedly negative affectivity also felt more burnt out, and the opposite was true [41]. This may be related to rumination. According to Nolen-Hoeksema, rumination is a pain response which entails a recurrent and passive focus on the symptoms of pain and their likely causes and outcomes [97]. Ruminative responses may prolong depression by overly focusing on negative thinking and may affect one's behaviour and problem-solving [97]. Liu et al. reported that rumination moderated the association between job burnout and depression and that burnout was a stronger predictor of depression in teachers who experienced low rumination rather than high rumination [98]. This was explained by the importance of rumination for depression; with an improvement in the rumination level, job burnout had less ability to predict depression for those with high rumination levels.
There is a strong association between burnout and depression, as reported in several studies. High frequencies of burnout symptoms were identified among clinically depressed teachers [92], with 86% to 90% of the teachers identified as burnt out meeting the diagnostic criteria for a depressive disorder [60,64], mainly for major depression (85%) [60]. In 25% to 85% of teachers with no burnout, depression ranged from 1% to 15% of the study sample. Specifically, only 1% to 3% of the participants in the no-burnout group were identified as having minor depression or depression not otherwise specified (2%) [60,64]. A history of depression was reported by about 63% of the teachers with burnout and 15% of the burnout-free teachers [60]. The high overlap between depression and burnout was emphasized in one study, which categorized depression as "low burnout-depression" (30%), "medium burnout-depression" (45%), and "high burnout-depression" (25%) [92]. Notably, the report suggests that although teacher burnout leads to subsequent depressive symptoms, it is not true vice versa [95]. Furthermore, burnout symptoms at 'time one' did not necessarily predict depressive symptoms at 'time two' [99]. Another study reported a positive relationship between burnout and depression [84]. This was confirmed by a study which suggested that depressive symptoms had a significant and robust association with the general burnout factor [50].
Anxiety disorder is also associated with higher perceived stress and major depression [65]. In one study, higher ongoing stressors were positively associated with higher anxiety levels. Continuous and episodic stressors were significantly and positively associated with anxiety and depression. They accounted for 28% (adjusted 25%) of the variability in anxiety and 27% (adjusted 24%) of the variability in depression. [71]. In contrast, higher levels of co-worker support were related to lower levels of anxiety and depression [71]. Teachers reported a high prevalence of depressive symptomatology relating to subjective and school-related stress [43].

Discussion
This scoping review included 70 articles. The prevalences of stress, burnout, anxiety and depression reported in this scoping review are similar to those reported in two systematic reviews and meta-analysis conducted among teachers during the pandemic. For example, the prevalence of stress reported by Ma et al., from a meta-analysis of 54 studies was 62.6%, whereas the prevalence of anxiety was 36.3% and depression was 59.9% among teachers during the pandemic [100]. In another meta-analysis, the prevalence range of anxiety was 10% to 49.4%; depression was 15.9% to 28.9%; and stress was 12.6% to 50.6% [101], which all fall within the range reported in this scoping review for stress [28,40], anxiety [42,56], and depression [48,59]. However, the minimum in all cases was higher during the pandemic, suggesting an increase in psychological problems during the pandemic.
The varying prevalence for stress, burnout, anxiety and depression reported by different studies in this review may be attributable to heterogeneous study designs, including the sample size, location, period of data collection, diversity in the standardized scales used for the assessment, and other factors such as the class size and grade taught [102,103]. In this scoping review, the studies used combinations of terminologies such as "none," "slightly," "significant," "much," "extremely," "considerably", "almost unbearable", "quite a bit" or "a great deal" to describe the level of stress experienced by teachers according to the measures utilized" such as the Teachers Stress Inventory [44,77] or the Bruno Teachers Inventory [43]. The prevalence rates also varied with population, for example, in the case of Fimian, the teachers were teaching special needs students, and this may explain the relatively high prevalence (87.1%) recorded [44]. More recent studies which used other scales, such as the Perceived Stress Scale (PSS), and the Depression Anxiety Stress Scales (DASS), used terminologies such as "symptoms of stress", ranging from "mild," "moderate," "mild to moderate" or "extremely severe", to describe the stress levels. For burnout, although most studies used a combination of the three interrelated components of burnout reported by Maslach et al. [6,7,11,16], some studies focused on reporting the sub-dimensions of burnout, whilst others reported general burnout. Varying expressions such as "low burnout", "high burnout, "severe burnout", and moderate were used to describe burnout, making it difficult to make an effective comparison. It was also not clear whether the stress and burnout experienced by the participants were everyday existential life experiences that everyone faces or chronic ones that needed intervention, as these were not specifically stated in the studies. It is essential that future research clarifies this to estimate their prevalence rates more accurately. Secondly, as indicated in the review, the studies applied various scales to measure the prevalence of psychological disorders; however, there was a lack of consensus. This scoping review provides a comprehensive picture of the prevalence of the target outcomes and sets up a foundation for future systematic reviews and meta-analysis to accurately estimate the prevalence of these outcomes among teachers.
The essential correlates of stress, burnout, anxiety, and depression identified in this review include socio-demographic factors such as sex, age, gender, marital status, school (organizational) factors and work-related factors (years of teaching, class size, job satisfaction, subject taught and absenteeism). Most studies were published in the last fifteen years (2007-2022), indicating a recent increase in interest in this area of research.

Socio-Demographic, School and Work-Related Factors as Determinants of Stress
Socio-demographic factors such as sex, age and marital status significantly influence teacher stress [54]. Sex correlates with stress although there are some conflicting reports [42,53,76], especially between the levels of stress experienced by males and females. Some studies suggest that female teachers experience more stress than their male counterparts [28,75,77]. Working women often have additional demands at home, and trying to accomplish both roles may increase their stress levels [104] compared to males who may have less demand from home. However, this may be context-dependent, as no sex difference in occupational stress was reported among police officers [105], for example. The demand from female teachers' personal lives, including marital issues and home, may be a source of increased stress levels [104]. Among the general workforce, work-family conflict has been reported to be significantly associated with work stress [106], and this is not confined only to females. This argument is confirmed in three separate studies, which reported that gender, per se, was not a significant predictor of perceived stress [39,85,89]; thus, it is possible that these differences may, rather, be due to differences in the scales used or the effect of organizational factors. For example, the organisational effect experienced by female teachers in a female only elementary or high school may differ from that experienced in a male only or mixed sex teaching environment; however, further research is needed in this area of gender influencing stress factors. Findings from the Canadian Community Health Survey data nonetheless endorsed a difference between males and females regarding work stress, in particular supervisor support. Higher levels of supervisor support seemed to lower work stress amongst women but not men [107]. Among the general population, social support at work could be more strongly related to a stress reduction in women than in their male counterparts [108] Sex difference was also observed in relation to student behaviour, with women experiencing increased stress [42,77]. In particular, female teachers' collective efficacy and beliefs about their school staff group capabilities may lower their stress from student behaviour. Findings from the study by Klassen support the hypothesis that teachers' collective efficacy serves as a job resource that mediates the effect of stress from student behaviour [77]. Interventions addressing gender/sex differences may also be considered in supporting female educators' mental health and work productivity.
A study among refugee teachers also endorsed sex differences in stress [42,57]; however this was in relation to self-care and the association was moderated by age [57]. Higher occupational stress scores were observed among teachers over 40 years [28]; nonetheless, among the general population, the published literature reports that the ageing process can worsen or counter the effects of stress [109], indicating that age does not necessarily increase stress. The cause of increased stress, hence, shifts to other factors such as the poor academic performance of students, or a lack of assistance [78], which may be influencing an increase in stress.
The class size, grade level taught, workload, poor student performance or lack of progress and other work and school-related factors contribute to teachers' stress. According to Fimian et al., when stressful events or the perception of them are not ultimately resolved or improved, this may result in several physiological manifestations [44]. There is clear data indicating that teacher stress was intensified among primary school teachers, special needs teachers, and teachers in private schools who provided more support and input to students than other teachers [28,78,85,110]. The additional time and energy teachers may invest in primary school kids, who are usually much younger and may require more support, may explain the increased stress among primary school teachers. Again, teaching special needs students may require significant teacher input and assistance, depending on the nature and degree of the disabilities. There is also an increased expectation from teachers in private schools regarding the students' performances, leading to increased stress [28]. A study conducted among primary and secondary school teachers in Pakistan concluded that government school teachers were more satisfied with their working conditions than private school teachers [110], and thus, may experience less stress. In addition, the school location (rural vs. urban), teacher role ambiguity and coherence further exacerbated teacher stress [3,75,89,111]. An excessive use of technological devices, such as mobile phones, has also been associated with social disruption [112] and may result in a lack of concentration or poor student performance at school [112,113], leading to teacher stress. Teachers experiencing more significant stress were also burnt out [68]. For example, during the pandemic, teachers had to adopt and adjust to teaching online, and virtual instruction teachers had the most increased anxiety [58]. Nonetheless, a rapid systematic review with a meta-analysis reported that teacher stress during the pandemic was still comparatively lower in school teachers with a prevalence of 13% ([95% CI: 7-22%]) in comparison to studies with university teachers as the participants of 35% ([95% CI: 12-66%]) [114].
While there are complex interactions among several factors which contribute to teacher stress, there have been limited evidence-based interventions to help teachers alleviate these stress sources despite some self-reported coping strategies. This research gap started to receive attention during the COVID-19 pandemic through the application of mindfulnessbased interventions [115], warranting more advanced research on how to best address these challenges in education.

Socio-Demographic, Years of Teaching, School and Work-Related Factors as Determinants of Burnout
Burnout continues to pose problems within the teaching profession, and factors such as gender, sex, age, marital status and the number of years teaching correlated with the degree of burnout [40,47,[51][52][53][54][55]63,67,68,72,73], although conflicting results were reported with potentially different explanations. Differences in the study design, particularly the scales used to assess burnout as well as geographical and organizational factors, may account for some of the conflicting results. In addition, there could be an interplay between some personal and professional factors. For example, younger teachers are more likely to be enthusiastic about their new teaching careers, whilst older teachers may experience boredom leading to increased exhaustion. Consistent with this hypothesis, one study reported that teachers who had taught for the fewest (0-5) years experienced the lowest burnout prevalence [54]. On the contrary, more experienced teachers were likely to have gained exposure, learnt students' characteristics and classroom management skills and the necessary tools to help them prevent and address burnout. Additionally, teachers who lacked self-fulfilment may have been mostly younger and lacked personal accomplishments [47], leading to more burnout.
Significantly higher burnout scores, including for emotional exhaustion, depersonalization, and intellectual burnout were found among female teachers than among male teachers in some studies [51][52][53], whilst other studies reported that burnout was higher among male teachers. These results are contrary to findings reported among police officers, which indicated no significant difference in the levels of occupational burnout reported by male and female police officers [105]. Further studies are needed to investigate the contradictory gender differences in teachers' burnout by different studies. In addition, research is needed on innovative gender-neutral ways of addressing burnout in teachers. Other structural factors, such as the number of children teachers have and class sizes which are associated with increased teacher burnout, require an increased investment in teachers and schools to address them. Governments providing teachers with affordable childcare and other supports for their own children, and building more schools to reduce the class sizes, may lead to a reduced burnout among teachers.
There is also a relationship between burnout and school or work-related factors. The subjects and grades taught and the medium of instruction all contribute to teachers' burnout [7,51]. Teachers' perceptions of the difficulty of a subject taught appears to determine their degree of burnout experienced; however, no particular subject seems to be the leading cause of burnout. High school teachers may perceive an increased workload in terms of the amount of time attributed to class preparation due to the difficulty of a subject taught. A cross-sectional study among nurses also found that role overload contributed to higher levels of emotional exhaustion [116] and this was also endorsed among healthcare managers where prolonged job strain resulted in burnout and an increased turnover intention [117]. This suggests there is a complex interaction between self-perception and burnout, which makes burnout in teachers a complex problem to address. Differences were also noted in the prevalence of burnout among teachers working in different countries [84]. For example, 58% of the variance in burnout in Cyprus could be explained by job satisfaction and anxiety, whereas 57.5% of the variance in burnout in Germany was explained by job satisfaction alone [84]. Different countries have different working conditions which may explain the differences in job satisfaction and associated burnout prevalence among teachers in different countries.

Effect of Resilience on Burnout
Resilience involves adapting well in the face of stress, difficulty, trauma, disaster, and threats. Resilient people use positive emotions to rebound and find positive meaning even in stressful circumstances [118]. Resilience had a significantinverse correlation with job burnout and turnover intention, and resilience could negatively predict job burnout [86]. Resilience was also reported to have an inverse association with burnout symptoms [119]; thus, increased resilience is linked to decreased burnout and, hence, the tendency for a teacher to remain in their job and thrive no matter what they encounter. Job burnout had a significant positive predictive effect and correlation with turnover intention, which suggests that the more severe the job burnout is, the higher the turnover intention [86]. Teachers require positive emotions and an increased resilience to remain in the profession and succeed without quitting. Conversely, among physicians, a survey indicated that the burnout prevalence was still significant even among the most resilient physicians; however, West et al. suggested that physicians exhibited higher levels of resilience than the general working population [119], including teachers. Additionally, resilience was also a significant predictor of depression and anxiety [88]; thus, the higher the resilience, the less likely teachers will experience depression or anxiety.

Socio-Demographic, School and Work-Related Factors as Determinants of Depression and Anxiety
Socio-demographic, school and work-related factors are all associated with both anxiety and depression [42,50,51,80]. This association is consistent with what was reported in a systematic review and meta-analysis by Ma et al., which suggested that teachers' experiences of psychological issues were associated with various socio-demographic factors such as gender, institutional factors, teaching experience, and workload volume [100]. In this scoping review, conflicting results were found in relation to the association between teacher gender and depression. Whilst some studies reported that female teachers have higher depression levels than male teachers [42,51,70,79,81,82], other studies have reported no gender differences in teacher depression levels [53]. Contradictory results were also reported for the association between the age of teachers and depression, with some studies reporting higher depression levels in younger teachers [42] and others reporting higher depression in older teachers [51]. As discussed previously, it is likely that the use of different scales, coupled with organizational factors, contributed to these contradictory findings among the different studies. The findings also indicated that most female teachers who suffered from depression had been working for about 11 to 15 years [120].
A poor workplace environment has also been associated with increased anxiety and depressive symptoms [121] and school-related stress may transition to depressive symptoms among teachers [80,94]. As teachers' workloads increase, their working hours will invariably increase, resulting in a rise in job demand and ultimately a surge in stress, leading to anxiety and depression. A systematic review reported similar findings where the main risk factors associated with anxiety and depression included job overload and job demands. [122]. The research also shows that teachers are not the only exception regarding experiencing a poor workplace environment which may lead to increased anxiety and depression [122,123]. Improving teachers' workplace environments may, therefore, reduce the prevalence of anxiety and depression among teachers. Anxiety has also been linked to stressors relating to pupils and parents. For example, the possibility of a parental complaint increased anxiety scores [45]. Generally, parents want their children to succeed academically, which sometimes creates friction between teachers and parents. The underperformance of students or failure may be blamed on teachers or construed as the responsibility of schools and teachers [124], which may result in increased stress and subsequently anxiety and depression for teachers.
Social support was also reported to predict anxiety and depression symptoms, with high support levels indicating fewer symptoms related to anxiety and severe depression [121,125]; thus, teachers who perceived social support at school (e.g., the personnel relation dimension) expressed a lower stress level than those who did not [75]. According to Peele and Wolf 2020, anxiety and depressive symptoms increase for all teachers over the school year, and poor social support plays a significant role in the development of anxiety and depression symptoms [121]. Organizational policies that include the provision of adequate social support for teachers may, therefore, be a useful strategy to prevent and mitigate anxiety and depressive symptoms among teachers.

Limitations
The scoping review is not without limitations. This scoping review searched for articles in the English language only. Though every effort was made to identify all relevant studies for this review considering our eligibility criteria, we may have left out some relevant studies, particularly those published in other languages. Our search included six databases, yet the overall search strategy may have been biased toward health and sciences. Searching other bibliographic databases may have yielded additional published articles. Furthermore, different studies included in this scoping review used various screening tools and worldwide diagnostic classifications to determine stress, burnout, anxiety, and depression, leading to variations in the prevalence estimates. The scoping review included studies from 1974 till date; therefore, it is possible that the theoretical approaches to the concept of burnout may have changed. Notwithstanding these potential changes in the theoretical approaches to the concept of burnout, the burnout prevalence among teachers has appeared to have remained stable over the years. There was also no evaluation of the risk of bias for the included studies. Despite these limitations, this scoping review provides an excellent perspective on the prevalence and correlates of stress, burnout, anxiety and depression among teachers.

Conclusions
Teachers' psychological and mental health is of utmost importance as it indirectly affects the students they teach. The stress associated with the teaching profession can be linked to three major overlapping issues: burnout, anxiety, and depression, which have a myriad of effects, including an impact on teachers' health, well-being, and productivity. A wide range of prevalences and correlates were reported for stress, burnout, anxiety, and depression. Differences in the severity were observed in different articles resulting in the diverse prevalence reported among the various studies. The differences in the measurement instruments creates critical knowledge gaps, making it difficult for researchers to make effective comparisons between the different studies. Future research should focus on addressing these research gaps arising from methodological issues, especially the use of different scales to allow for a meaningful comparison. Researchers, educators, and policy makers could benefit from an international consensus meeting and agree on common scales to be used when assessing stress, burnout, anxiety, and depression in teachers. Such an international consensus meeting can also help to streamline the definition of stress and can be used as a forum for addressing other methodological issues related to research and innovations involving elementary and high school teachers. Future research can also focus on exploring the gender differences in these psychological issues further, especially, defining the various subsets of gender being referred to and the specific prevalence in each case. In addition, the high prevalence of stress, burnout, anxiety, and depression reported particularly by several high-quality studies suggests that these psychological problems are widespread among teachers and deserves special attention both at the level of policy and practice.
This scoping review also highlights the risk factors associated with stress, burnout, anxiety, and depression. Identifying these risk factors is a significant step toward addressing these issues among teachers. Schools need to prioritize and promote interventions aimed at teachers' personal wellbeing. Testing and implementing the interventions aiming to improve teachers' well-being and ability to cope are important to address stress and burnout, with the expectation that this will prevent or reduce anxiety and depression. This may include school-based awareness and intervention programs to detect the early signs of teacher stress and burnout, or programs that incorporate meditation techniques or text-based support. Meditation techniques have been proposed to be effective in improving psychological distress, fatigue and burnout [126]. For example, mindfulness practice has been suggested as beneficial in coping with job-related stress, improving the sense of efficacy and reducing burnout in the teaching profession [127]. Interventions such as mobile text technology are an evidence-based, unique, and innovative way that offers a convenient, low cost and easily accessible form of delivering psychological interventions to the public with mental health problems [128][129][130]. Mobile text-based programs can be easily implemented at the school level to support teachers' psychological needs. Future studies need to explore the development, implementation, monitoring, and evaluation of intervention programs for improving mental health outcomes among teachers. For instance, the Wellness4Teachers program which is planned for implementation in Alberta and Nova Scotia, Canada [34], is expected to provide evidence of effectiveness for the use of daily supportive text messaging to combat stress, burnout, anxiety, and depression among teachers. Finally, governments, school boards and policymakers need to collaborate with researchers on the design and implementation of measures to enhance teachers' mental health, productivity (teaching) and quality of life.

Conflicts of Interest:
The authors declare no conflict of interest. The funder had no role in the design and conduct of the study; collection, management, analysis, the interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the results for publication.      Stress: school villages (personnel relation dimension) curriculum, facilities, student characteristics, administrative, and professional growth and self-satisfaction, subject taught, science budget.

Appendix A
Science teachers in the rural schools mean stress score of 47.25 (SD = 4.89), urban schools mean stress score of 51.29 (SD = 6.95).
Urban teachers were found to be more stressed than those in rural areas. Female science teachers were more stressed than their male counterparts. Stress: collective efficacy, student behavior, gender, workload, class size. 21.3% females rated the stress from workload "quite a bit" or "a great deal" of stress from workload factors. 13.4% of male teachers rated stress from workload at a mean of 7 or higher. More women (18.6%) than men (12.8%) reported feeling "quite a bit" or "a great deal" of stress from student behavior. Stress: marital status, teaching special needs, lack of pupils' progress in class work/academic achievement, societal attitudes/respect heavy workload and lack of help/assistance, degree and nature of disabilities of the special need children.
Anxiety: women only; psychosocial stress, sex differences, high correlations between psychosocial stress and anxiety, were found only for females.
Females reported more symptoms and had higher manifest anxiety than males.