The aim of this review was to systematically summarize the literature on the mental health of taxi drivers. The results of this systematic review indicate that taxi drivers carry a significant burden of mental health problems, including elevated levels of depression, anxiety, stress and psychological distress compared with the general population (World Health Organization 2022). It is crucial to identify and address associated risk factors, both occupational and personal, to enhance the mental health and well-being of taxi drivers. Anxiety, depression, and stress are closely intertwined and frequently co-occur within individuals (Lovibond 1995). Furthermore, chronic stress can precipitate symptoms of both anxiety and depression, establishing a cycle where each condition exacerbates the other (Hammen 2005).

The prevalence of depression among taxi drivers significantly exceeds that of the general population. For instance, in India, the prevalence of depression was 60.5% among taxi drivers (Rathi et al. 2019), compared to 4% in the general Indian population (Gururaj et al. 2016). In the United States, the rate of depression among taxi drivers was 38% (Burgel and Elshatarat 2019), contrasting with 8.1% in the adult population (Brody et al. 2018). Similarly, in Australia, 24.3% of taxi drivers experienced depression (Davidson et al. 2020), which is notably higher than the 4.9% observed in the general Australian population (Australian Bureau of Statistics, n.d.). Factors associated with depression include perceived mental strain (Burgel and Elshatarat 2019), lack of respect from dispatchers (Burgel and Elshatarat 2019), stressful personal life events (Burgel and Elshatarat 2019), sleep duration less than 8 h (Rathi et al. 2019), adverse working conditions and work-family conflict (Rathi et al. 2019). These factors can significantly impact the work engagement of taxi drivers (Shin and Jeong 2021). Although the instruments used are not diagnostic tools, their content allows meaningful connections to be made with the Diagnostic and Statistical Manual of Mental Disorders, Five Edition (DSM-5)(American Psychiatric Association 2013) criteria, the most recognised diagnostic standard for mental disorders. The DASS-D includes items that assess key aspects of major depressive disorder, such as depressed mood (‘I felt sad and depressed’) and loss of interest or pleasure in activities (‘I could not get excited about anything’). For its part, the CESD explicitly incorporates DSM-5 domains associated with major depression, such as recurrent thoughts of death or suicidal ideation (‘I wished I was dead’), difficulty concentrating (‘I couldn’t concentrate’) and loss of interest in usual activities (‘I lost interest in my activities’).

Alongside depression, anxiety is also a prevalent mental disorder among taxi drivers, with considerably higher rates than in the general population. In India, 47% of taxi drivers experienced some form of anxiety (Rathi et al. 2019), compared to 2.57% in the general Indian population (Manjunatha et al. 2022). In Australia, the prevalence of anxiety among taxi drivers was 24.1% (Davidson et al. 2020), exceeding 17.2% (Australian Bureau of Statistics, n.d.) in the general Australian population. Research indicates that sleep duration, particularly when less than 8 h (Rathi et al. 2019), is a significant factor contributing to anxiety levels among taxi drivers. As in the case of depression, the DASS-A and STAI instruments show a significant relationship with the DSM-5 (American Psychiatric Association 2013) diagnostic criteria for anxiety disorders. In the DASS-A, items such as ‘I felt I was on the verge of panic’, ‘It became difficult to breathe’ and ‘I felt my heart pounding even though I had not made any physical effort’ reflect symptoms of panic disorder. Other items such as ‘It was difficult to release tension’ and ‘I felt afraid for no reason’ reflect basic features of generalised anxiety disorder (GAD). On the other hand, STAI-S items such as ‘I feel scared for no apparent reason’, ‘I feel restless’ and ‘I feel tense or nervous’ match the intense emotional and physiological symptoms described for panic disorder and episodic anxiety. In the STAI-T, items such as ‘I am generally tense’, ‘I worry too much about unimportant things’ and ‘I often have disturbing thoughts’ reflect key aspects in the diagnosis of GAD.

The reviewed studies showed varying levels of stress among taxi drivers, mostly in the low to moderate range (Davidson et al. 2020; Djindjic et al. 2013; Jovanović et al. 2008a; Maguire et al. 2006; Mirpuri et al. 2020, 2021). Factors associated with stress include daily discrimination (Mirpuri et al. 2020), lack of English proficiency (Mirpuri et al. 2021), smoking (Mirpuri et al. 2021), sleep disturbance (Mirpuri et al. 2021), and insufficient sleep (Rathi et al. 2019). Additionally, stress levels appear to decrease with age, with older taxi drivers experiencing lower stress levels (Mirpuri et al. 2020). The DASS-S through items such as ‘I found it hard to relax’ reflect hyperarousal and chronic tension, symptoms aligned with DSM-5 (American Psychiatric Association 2013) stress-related disorders such as Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD). Similarly, items such as ‘I overreacted in certain situations’ highlight irritability and overreactivity, while ‘I did not tolerate anything that interfered with my tasks’ reflects difficulties in managing external demands, linked to Adjustment Disorders. The PSS-10 with items such as ‘How often have you felt that difficulties accumulated beyond your control?’ addresses a sense of loss of control and overwhelming stress, central to disorders such as ASD and Adjustment Disorder. Questions such as ‘How often have you felt angry because things were out of your control?’ assess emotional hyper-reactivity and persistent tension, common in stress-related disorders.

Contrary to the general results, in Serbia, studies on occupational stress among taxi drivers suggested that this population experiences overall low levels of stress. Compared to other drivers (Jovanović et al. 2008) and other professions (Aryal and D’mello 2020; Desouky and Allam 2017; Jovanović et al. 2021), taxi drivers in Serbia exhibited significantly lower stress scores. The stress levels reported in Serbian taxi drivers contrast not only with those in other regions, but also with those of other drivers and professionals within the same cultural context. The perception and reporting of stress may differ in Serbia due to cultural factors. For instance, strong community resilience and close social ties, particularly in rural areas, may play a protective role in mitigating the perception of work-related stress. Additionally, cultural values that emphasize emotional strength and stoicism may lead to an underestimation or underreporting of stress levels among Serbian taxi drivers. Even within the same cultural context, differences in reported stress levels between Serbian taxi drivers and other drivers or professionals could be attributed to variations in work demands. Factors such as workload intensity, scheduling flexibility, or exposure to occupational hazards may differ between professions, influencing stress levels. These regional and occupational variations highlight the need for future research to examine the interplay between cultural, policy, and job-specific factors in shaping the perception and reporting of stress. This would provide a more comprehensive understanding of the observed differences. To measure occupational stress, the Occupational Stress Index (OSI) was used. The OSI is based on an additive load model that assesses stress-related work factors, especially those with an impact on the cardiovascular system (Belkic et al. 2004) which is considered a specific feature of high-risk jobs. This index integrates elements of Karasek’s Job Strain Model (Karasek 1979), Occupational stress among taxi drivers can be effectively contextualized through the Job Demand-Control (JDC) Model (Bakker and Demerouti 2007) a widely recognized framework for understanding work-related stress. The JDC Model suggests that the interaction between high job demands (e.g., workload, time constraints, and emotional strain) and low job control (e.g., limited autonomy over work tasks and decision-making) significantly influences stress outcomes. Taxi drivers are typically exposed to a high-demand, low-control work environment, characterized by extended working hours, unpredictable schedules, and constrained decision-making power, all of which contribute to heightened stress and adverse mental health outcomes, including anxiety, depression, and sleep disturbances. In this regard, (Useche et al., 2018), found that on public transport drivers, high levels of job strain (characterized by high psychological demands and low decision latitude) were associated with increased traffic accidents and sanctions, highlighting the broader implications of stress on both well-being and performance.

Moreover, the data on psychological distress among taxi drivers is concerning. An Australian study found that 33% of taxi drivers exhibited high levels of psychological distress (Davidson et al. 2020) compared to 15% of the general Australian population as reported in the National Survey of Mental Health and Wellbeing 2021 (Australian Institute of Health and Welfare, n.d.). This high level of psychological distress underscores the urgent need for targeted interventions to address risk factors and enhance the mental health of taxi drivers.

As evidenced in the review, mental health problems among taxi drivers are significantly influenced by both occupational and personal factors. For instance, poor sleep quality and short sleep durations (≤ 7 h per night) (Mirpuri et al., 2021; Rathi et al. 2019), are identified as critical risk factors for depression, anxiety, and occupational stress. These issues not only impair cognitive functioning but also increase susceptibility to occupational hazards such as traffic accidents and reduced job performance(Elshatarat and Burgel 2023). Additionally, working conditions—particularly during night shifts—expose drivers to heightened risks, such as aggressive or intoxicated passengers and violence (e.g., robbery or physical assault), which exacerbate stress, anxiety, and psychological hyper-alertness, ultimately deteriorating their mental and physical well-being(Burgel et al. 2014).

Drivers face cumulative trauma from repeated exposure to distressing events, including witnessing accidents or experiencing discrimination. Immigrant taxi drivers, in particular, encounter compounded challenges due to cultural and social barriers, limited access to support networks, and systemic discrimination (Facey 2003). These factors contribute to higher levels of psychological distress, affecting their quality of life and work performance.

Regional policy environments and cultural attitudes significantly shape mental health outcomes. For example, countries with stricter labor protections and better access to mental health services report more favorable outcomes among drivers compared to regions with lax policies and limited resources (Burns 2015). Furthermore, cultural attitudes toward mental health and masculinity play an important role. In certain cultures, stigma associated with seeking help, coupled with societal expectations of men as stoic providers, hinders the recognition and treatment of mental health problems (Courtenay 2000; Leong and Kalibatseva 2011).

Mental health challenges among taxi drivers are closely intertwined with physical health risks, particularly cardiovascular diseases. Chronic stress, anxiety, and depression elevate the risk of hypertension, cardiac arrhythmias, and coronary heart disease, creating a vicious cycle in which deteriorating mental and physical health reinforce each other (Elshatarat & Burgel, 2016).

To the authors’ knowledge, this study is the first systematic review to examine the mental health of taxi drivers in detail, providing comprehensive coverage of the topic by analyzing studies from diverse geographies and socioeconomic contexts. The inclusion of studies from various countries (Australia, USA, India, United Kingdom, Serbia, and Korea) provides a global perspective on the mental health of taxi drivers, allowing international comparisons and understanding contextual differences. The review not only documents the prevalence of mental health problems among taxi drivers but also identifies associated risk factors and contextual variables, providing valuable information for future research and intervention policies.

Despite its comprehensive scope, this study has several limitations that must be acknowledged. A first limitation is the heterogeneity of the studies in terms of methodology, assessment instruments, and sample characteristics, which makes the comparison of results and generalization difficult. For example, the use of different assessment instruments may lead to discrepancies in the prevalence and severity of reported mental health problems. In this systematic review, the included articles do not provide specific subtypes or categories of disorders such as anxiety, depression and stress, as defined in the DSM-5, nor do they distinguish between conditions such as generalised anxiety disorder, panic disorder or major depressive disorder. Instead, the studies employ a variety of diagnostic tools, as discussed in the manuscript, rather than specialist diagnoses according to DSM-5 criteria. Also, variations in sample sizes and demographic compositions may introduce biases, such as over- or under-representation of certain subgroups. Second, another important source of heterogeneity is the variation in the theoretical frameworks employed by the studies The presence or absence of theoretical models in the reviewed studies has been examined to better contextualize the findings and to highlight the limitations when comparing or generalizing the results. Some studies employ well-established frameworks, such as the Occupational Stress Index (OSI), which is grounded in models like the Job Strain (Karasek 1979) and Effort-Reward Imbalance models (Siegrist et al. 1991), enabling the exploration of links between job stress and physiological outcomes (e.g., metabolic and cardiovascular disturbances). Other studies apply frameworks such as the Self-Medication Hypothesis (Bolton et al. 2006), which explains substance use as a coping mechanism for untreated emotional issues, or the ABC Theory of Emotions (Ellis 1963), which analyzes how individual beliefs influence maladaptive behaviors. However, a notable proportion of the reviewed articles do not adopt an explicit theoretical framework. This absence limits the interpretation of causal relationships and often results in studies with a predominantly descriptive focus. Also, differences in theoretical frameworks, measurement tools, sample sizes, and sample compositions introduce significant heterogeneity, complicating direct comparisons between studies. For instance, the use of varying diagnostic tools or survey instruments can yield inconsistent results, while differences in sample size and population demographics may skew prevalence rates or associations with mental health outcomes. These methodological and theoretical discrepancies underscore the need for caution when synthesizing findings and interpreting results across studies. Furthermore, they highlight the importance of standardizing research approaches in future studies to enhance comparability and generate more generalizable knowledge. Third, some research studies have found that taxi drivers’ mental health is not an independent variable and do not provide sufficient data on possible causes. Additionally, in many of the studied countries, most taxi drivers were migrants, so the results may be influenced by this condition. Factors such as country of origin, language proficiency, under- or over-qualification, lack of a socio-familial network, or racism come into play. A clear example is the research by Davidson et al., who found that the distribution of psychological distress scores among urban taxi drivers was comparable to the distribution reported in studies focusing on immigrant groups from high-conflict countries (Davidson et al. 2018). Finally, the review itself has focused on three specific mental health problems—depression, anxiety, and stress—whereas broader concepts of mental health are increasingly understood within a biopsychosocial framework, extending beyond purely diagnostic categories.

Moreover, in terms of methodological quality, there was considerable variability among the studies. Only one study (9.1%) satisfied more than 50% of the quality criteria, indicating that most of the included studies present significant methodological limitations. Key issues identified in the lower-quality studies included a lack of blinding of assessors, insufficient justification of sample sizes, failure to control for confounding variables, and inconsistencies in the application of inclusion and exclusion criteria. These methodological shortcomings may introduce biases and affect the validity of the results, emphasizing the importance of interpreting the findings with caution.

Future studies on this topic should address key methodological limitations identified in the reviewed studies. These include the lack of sample size calculations, the absence of clear and standardized inclusion and exclusion criteria, and insufficient control for confounding variables. For instance, variables such as age, working hours, years of employment, and experience with night shifts should be systematically recorded and adjusted for in analyses to minimize bias and enhance the reliability of findings. Incorporating these elements would improve study rigor and facilitate more robust comparisons across different contexts.

The analysis conducted in this study has identified a number of factors that influence the mental health of taxi drivers, revealing specific challenges and areas for improvement. These recommendations are derived directly from the findings and aim to bridge research and practice. On a scientific level, more research is needed to assess the health of taxi drivers in underrepresented regions and to expand the concept of mental health beyond depression, stress, and anxiety, providing a more comprehensive understanding of their health and associated factors. Longitudinal and prospective studies are necessary to confirm observed associations and establish causal relationships. At the policy level, addressing structural issues such as long working hours and poor working conditions is essential. This could include implementing regulations to limit working hours and promote safer working environments, as well as establishing regular medical check-up programs that include mental health assessments to enable early detection and intervention. At the individual level, our findings highlight the urgency of adopting measures to help taxi drivers manage stress and improve sleep habits. Examples include workshops on stress management, relaxation exercises, sleep hygiene education, and the creation of peer support networks, especially for immigrant drivers who often face additional cultural and social barriers. These proposals should be designed with the social, cultural, and economic realities of taxi drivers in mind, ensuring they are viable even in low-resource settings. Investing in the mental health of this occupational group represents a significant opportunity to reduce suffering, improve health outcomes, enhance quality of life, and positively impact road safety and overall community well-being (World Health Organization 2022a).