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This quantitative study examines how work stress and mental health symptoms predict self-efficacy and leave intentions among Texas public school principals. Guided by allostatic load theory, we used regression and PROCESS models to analyze mediation and moderation effects. Results show that higher stress and poorer mental health are associated with lower leadership self-efficacy—particularly in instructional and management domains—and greater intentions to leave. Leadership self-efficacy partially mediates these relationships, though it does not moderate them. Gender and alcohol use further impacts some effects. These findings highlight the burden of the principalship and the need to re-envision a future workplace environment that promotes principal well-being, strengthens leadership self-efficacy, and improves leadership sustainability.