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1. REVIEW
A Systematic Narrative Review on Stress-Management Interventions
for Medical Students
Chiara Buizza1
& Valentina Ciavarra1
& Alberto Ghilardi1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Objectives The objectives of this study are to identify all studies for stress-management carried out in medical students, in order
to analyze their impact on psychological distress and on academic performance, and to assess how these interventions are
incorporated into the medical education curriculum. For this purpose, a systematic narrative review was conducted according
to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
Methods A systematic search was performed in PubMed, Embase, and PsycInfo, using the following keywords: “stress” AND
(“intervention” OR “treatment”) AND (“college” OR “university”) AND “medical” AND “student.” The quality of study was
assessed using the Cochrane quality assessment tool and the Methodological Index for Nonrandomized Studies.
Results Seventeen studies were included in the review: 3 randomized controlled trials and 14 non-randomized. The results have
identified different stress-management interventions, mainly focused on mindfulness programs. Most studies were also carried
out on the pre-clinical students in the first 2 years. Results showed that students who attended stress-management interventions
had a decrease in their stress level; conversely, the data concerning the decrease in depression scores were contrasting.
Conclusions Findings suggest that stress-management programs may be helpful for medical students, but further studies are
needed to assess a broader range of outcomes, including the correlation of stress-reduction with academic and health conditions.
Trial Registration Prospective Registering of Systematic Reviews (PROSPERO). Identifier: CRD42019130789.
Keywords Stress-management . Interventions . Medical students . Well-being . Education
It is known that medical education is highly stressful and
challenging and that medical students have lower quality of
life compared with their peers (Henning et al. 2012; Rapaport
et al. 2005). Moreover, compared with other academic disci-
plines, medical students demonstrate more significant reduc-
tions in psychological well-being (Aktekin et al. 2001).
The medical education is considered particularly stressful
for several reasons: it is generally more intensive and longer to
complete than many other courses; students are in contact with
illness and suffering; they are aware that at the end of the
course of study they will be responsible for the health of other
people; there is a high competitiveness within the healthcare
environment, which leads students to always have to display
an excellent performance. For all these factors, many students
suffer from psychological distress, which may lead to academ-
ic failure and unhealthy behaviors. Some studies suggest that
substance use among medical students is ongoing and associ-
ated with consequences in various domains, such as interper-
sonal altercations, serious suicidal ideation, cognitive deficits,
compromised academic performance, and driving under the
influence of substances (Arora et al. 2016; Ayala et al. 2017).
A recent study shows that alcohol is the most common sub-
stance misused by the medical student followed by tobacco
and marijuana (Kushwaha et al. 2019). Other unhealthy be-
haviors concern the lack of physical activity (Blake et al.
2017) and mobile phone overuse that is associated with poor
sleep quality and unhealthy eating behaviors (Fang et al.
2019). Other researches also show that medical students suffer
from anxiety and depression (Brazeau et al. 2014; Dahlin et al.
2005; Drybye et al. 2006; Hope and Henderson 2014; Puthran
et al. 2016). A recent review and meta-analysis display that
medical students are at high risk for depression and suicidal
ideation, despite the prevalence estimates of these disorders
vary between studies. The prevalence of depression or
* Chiara Buizza
chiara.buizza@unibs.it
1
Department of Clinical and Experimental Sciences, University of
Brescia, V.le Europa 11, Cap, 25123 Brescia, Italy
Mindfulness
https://doi.org/10.1007/s12671-020-01399-2

2. depressive symptoms among medical students is 27.2% and
suicidal ideation is 11.1% (Rotenstein et al. 2016).
Several studies also indicate that there is a difference in the
level of perceived stress during the transition from pre-clinical
to clinical period, which usually occurs in the third year of
medical school (Dubè et al. 2015). This transition is a signif-
icant and unique phase in a medical student’s education in that
students are exposed to many stressful events and heavy
workload (Gaufberg et al. 2010; Haglund et al. 2009). With
“clinical period,” we refer to the phase in which the students
begin their clerkship within the hospital wards, in contact with
patients and also with doctors, nurses, and health staff. This
clinical period is characterized by specific challenges, both
because the amount of workload is very high and because
practical activities in hospitals, in contact with sick people
and with experienced doctors, can cause experiences of sad-
ness, discomfort, and feelings of inferiority, especially in the
most vulnerable students (Moss and McManus 1992; Prince
et al. 2005). The medical school is therefore stressful to man-
age for many students, not only for organizational or academic
reasons but also from a mental and emotional point of view.
For this reason, it would be important to offer to all medical
students stress-management interventions to limit distress and
to improve their well-being. Considering that distress has an
important impact on the physical and mental health and on the
lifestyle of medical students, it would be important to offer
programs aimed not only at reducing stress but also at increas-
ing healthy behaviors (e.g., physical activity, good sleep-wake
rhythm, healthy eating, study life balance).
Promoting these interventions in the medical student cur-
riculum would be useful, also given the difficulty that students
have in asking for help. Distressed students have to cope with
several self-limitations, the major one being the perceived
stigma associated with stress or mental illness; secondly, the
fear that they will be considered as weak by others; and final-
ly, students are also concerned that admitting to problems as
an undergraduate would affect their future career as a doctor
(Chew-Graham et al. 2003).
Although there is consensus that stress-reduction interven-
tions in medical students are necessary, little remains known
about which interventions are most effective and how to in-
corporate them into the medical education curriculum. Few
reviews have been carried out on this topic; furthermore, they
are not very updated or they include not only medical students
(Regehr et al. 2013; Shapiro et al. 2000; Shiralkar et al. 2013).
The main aim of this review is to identify all studies
for stress-management carried out in medical students, in
order to analyze their impact on psychological distress
and on academic performance. Secondary aims are to
assess how these interventions are incorporated into the
medical education curriculum, and if there are different
types of intervention between the pre-clinical and the
clinical period of study.
Methods
The systematic review was conducted according to the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement (Moher et al. 2009).
The study was registered with the Prospective Registering of
Systematic Reviews (PROSPERO) database. Registration
number is CRD42019130789. A systematic search was per-
formed in PubMed, Embase, and PsycInfo, using the follow-
ing keywords: “stress” AND (“intervention” OR “treatment”)
AND (“college” OR “university”) AND “medical” AND “stu-
dent.” Moreover, the reference lists of the systematic reviews
were screened to identify further relevant articles. The search
included all articles that were published until March 2019.
Inclusion Criteria
Two authors independently analyzed the records of the
searches. Studies were included if they satisfied the following
criteria: being in English language; having original data; fo-
cusing on interventions aimed to manage stress in medical
students; papers that reported tools and data on pre-post eval-
uations. Due to lack of funds, one article requiring payment
was excluded, as it was not included in the journals to which
our institution was a subscriber. As reported in Fig. 1, out of
the 221 articles generated by the preliminary search strategy,
189 were excluded by title and abstract as they were irrelevant
to the study criteria. After reading abstract or the full text, 15
more studies were excluded.
162 results from the search in Embase
27 results from the search in Pubmed
28 results from the search in PsycInfo
32 selected based on title
189 excluded based on title
17 included
Studies were excluded after reading
abstract and full text for the following
reasons:
8 concerned college students (not medical
students);
2 not based on stress-management
interventions;
4 conducted on medical students and other
students, but the results were not separate
for medical students;
1 did not report tools and data on pre-post
evaluations.
4 results from reference
lists of reviews
Fig. 1 Flow chart of the selection process
Mindfulness

3. Data Extraction
Data were collected in a standardized data extraction form,
reporting aim of the study, study design, participants, type of
stress-management intervention, outcome, and main study re-
sults. Data were independently abstracted by two authors, and
any discordance was revolved by consensus. Because the
studies were different in terms of design, setting, interven-
tions, and outcome measures, a narrative synthesis was
planned (Popay et al. 2006).
Methodological Quality Assessment
The quality of study was assessed by two authors using the
Cochrane quality assessment tool (Higgins et al. 2011) and the
Methodological Index for Nonrandomized Studies
(MINORS) (Slim et al. 2003). The Cochrane quality assess-
ment tool is developed to assess quality of randomized studies
regarding the following domains: selection bias, performance
bias, detection bias, attrition bias, reporting bias. Each domain
is rated as low risk, high risk, or unclear risk of bias. The
MINORS is developed to assess the quality of non-
randomized studies, both comparative and non-comparative.
It consists of 12 items concerning study design and method.
Each item is scored as 0 when the information is not reported,
1 when the information is reported but appears inadequate,
and 2 when the information is reported and appears adequate.
Items 1–8 refer to all non-randomized studies, while items 9–
12 only apply to comparative studies.
Results
Methodological Quality of the Included Studies
Among the studies included in the review, there were 3 ran-
domized controlled trials (Phang et al. 2015; Shapiro et al.
1998; Warnecke et al. 2011) and 14 non-randomized studies
(Bond et al. 2013; Brennan et al. 2016; Bughi et al. 2006;
Dayalan et al. 2010; Dhanvijay and Chandan 2018;
Finkelstein et al. 2007; Gruzelier et al. 2001; Hassed et al.
2009; Phang et al. 2016; Prasad et al. 2016; Rosenzweig
et al. 2003; Scholz et al. 2016; Simard and Henry 2009;
Whitehouse et al. 1996). Risk bias of randomized studies
based on the Cochrane quality assessment tool is reported in
Table 1. The risk was low on all domains for two studies
(Shapiro et al. 1998; Warnecke et al. 2011). Only one study
had two domains with a high risk (Phang et al. 2015). Quality
assessment of non-randomized studies based on the MINORS
tool is reported in Table 2. The quality of the studies was quite
low; often there was not enough information to evaluate the
items.
Characteristics of the Included Studies
Table 3 shows the characteristics of the included studies. Eight
studies were conducted in the USA (Bond et al. 2013;
Brennan et al. 2016; Bughi et al. 2006; Finkelstein et al.
2007; Prasad et al. 2016; Rosenzweig et al. 2003; Shapiro
et al. 1998; Whitehouse et al. 1996), two in India (Dayalan
et al. 2010; Dhanvijay and Chandan 2018), two in Malaysia
(Phang et al. 2015, 2016), two in Australia (Hassed et al.
2009; Warnecke et al. 2011), one in the UK (Gruzelier et al.
2001), one in Canada (Simard and Henry 2009), and one in
Germany (Scholz et al. 2016).
Most of the studies was aimed at the pre-clinical students in
the first 2 years. One study included pre-medical students
(Shapiro et al. 1998). Pre-medical is an educational track that
undergraduate students in the USA and Canada pursue prior to
becoming medical students. It involves activities that prepare
a student for medical school, such as pre-med coursework,
volunteer activities, clinical experience, research, and the ap-
plication process.
Two studies involved clinical third- and fourth-year stu-
dents: in one study, the students were doing a rotation in
diabetes/endocrine service (Bughi et al. 2006); in the other
study, the students were doing a psychiatric postings (Phang
et al. 2016). Only one study did not report the students’ course
year (Dayalan et al. 2010).
Description of the Stress-Management Interventions
Mindfulness-Based Interventions
Five studies reported mindfulness-based interventions (Phang
et al. 2015, 2016; Rosenzweig et al. 2003; Shapiro et al. 1998;
Warnecke et al. 2011), adapted from and based on the princi-
ples of the Kabat-Zinn program (Kabat-Zinn 1982). The core
of all these interventions was focused on training the students
in the mindfulness practice. A variety of mindfulness medita-
tion practices were taught, such as sitting meditation, body
scan, and Hatha yoga. The duration of these interventions
ranged from 4 to 8 weeks. Compared with the standard
MBSR, the training was often shorter in duration with more
emphasis on informal practice, including sessions on gratitude
and cultivation of loving-kindness, and contains instructions
tailored for medical students (Phang et al. 2015, 2016). In
another study, mindfulness was instead incorporated into a
larger program, named Health Enhancement Program, aimed
both at fostering behaviors, attitudes, skills, and knowledge
and at leading to learning personal self-care strategies. These
strategies are meant to allow the students to manage stress and
maintain a healthy lifestyle, by enhancing the students’ phys-
ical health, leading them to understand the mind-body rela-
tionship and developing a holistic approach to healthcare. A
supportive environment is developed, which will enhance
Mindfulness

4. students’ performance (Hassed et al. 2009). This program is
the only one that is part of the core curriculum, in contrast with
all the other studies, in which the stress-reduction intervention
was proposed to students as an elective extracurricular
activity.
Relaxation Techniques
Four studies were based on relaxation techniques and had a
duration that ranged from 6 to 16 weeks. The main techniques
used were Hatha yoga, consisting mainly of asanas (postures),
pranayama (breathing exercises), and meditation (Prasad
et al. 2016; Simard and Henry 2009); and Nadi Shuddhi
Pranayama, also called the “alternate nostril breathing”
(Dhanvijay and Chandan 2018). In one study, the autogenic
training and the progressive muscle relaxation were used; in
addition, the students were introduced to the basics of medical
hypnosis (Scholz et al. 2016).
Interventions Based on Broader Mind-Body Approaches
Four studies used wider mind-body techniques that ranged
from 8 to 10 sessions such as the following: a combination
of breathing, meditation, and Yoga, with an educational
component (Bond et al. 2013); psychoeducational lectures
on stress plus a brief behavioral intervention program in man-
aging stress, which included deep diaphragmatic breathing,
self-control relaxation, and walking meditation (Bughi et al.
2006); a stress-management/relaxation course, including
mindful breathing, slow-tense muscle relaxation, guided im-
agery, nutrition, coping skills, balancing life and school, pos-
itive psychology, and mindfulness meditation (Brennan et al.
2016); a mind-body skills course, including stress response,
meditation, imagery, nutrition, genograms, and spirituality
(Finkelstein et al. 2007).
Self-Hypnosis Training
Two studies reported self-hypnosis training: the first study
was a 19-week prospective conducted to determine the effec-
tiveness of a self-hypnosis intervention to relieve psycholog-
ical distress and moderate immune system reactivity to exam-
ination stress (Whitehouse et al. 1996); in the second study, 10
sessions of immune imagery and relaxation imagery were
compared in two groups (Gruzelier et al. 2001). Immune im-
agery was aimed at improving immune function and involved
envisaging increases in NK cells and lymphocytes and sur-
veillance by white blood cells in the form of sharks or
Table 2 MINORS tool
Study Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Total score
Bond et al. (2013) 2 0 2 2 0 0 0 0 - - - - 6
Brennan et al. (2016) 2 1 2 2 0 0 0 1 - - - - 8
Bughi et al. (2006) 2 1 2 1 0 0 0 1 - - - - 7
Dayalan et al. (2010) 2 0 2 2 0 1 0 1 1 2 2 1 14
Dhanvijay and Chandan (2018) 2 1 2 2 0 0 0 1 - - - - 8
Finkelstein et al. (2007) 2 1 2 2 0 1 1 1 1 2 1 1 15
Gruzelier et al. (2001) 2 0 2 1 0 0 0 1 1 2 2 1 12
Hassed et al. (2009) 2 2 2 2 0 1 1 1 - - - - 11
Phang et al. (2016) 2 1 2 2 0 0 0 1 - - - - 8
Prasad et al. (2016) 2 1 2 2 0 0 0 1 - - - - 8
Rosenzweig et al. (2003) 2 1 2 2 0 0 0 1 2 2 2 2 16
Scholz et al. (2016) 2 1 2 2 0 0 0 1 - - - - 8
Simard and Henry (2009) 2 1 2 1 0 0 0 1 - - - - 7
Whitehouse et al. (1996) 2 1 2 1 0 1 0 1 1 2 2 2 15
The MINORS includes 12 items: clearly stated aim (item 1); inclusion of consecutive patients (item 2); prospective collection data (item 3); endpoints
appropriate to the aim of the study (item 4); unbiased assessment of the study endpoint (item 5); follow-up period appropriate to the aim of the study (item
6); loss to follow-up less than 5% (item 7); prospective calculation of the study size (item 8); adequate control group (item 9); contemporary group (item
10); baseline equivalence of groups (item 11); adequate statistical analyses (item 12)
Table 1 Cochrane quality assessment tool
Study Selection bias Performance bias Detection bias Attrition bias Reporting bias Other bias
Phang et al. (2015) Low risk High risk High risk Low risk Low risk Low risk
Shapiro et al. (1998) Low risk Low risk Low risk Low risk Low risk Low risk
Warnecke et al. (2011) Low risk Low risk Low risk Low risk Low risk Low risk
Mindfulness

5. Table 3 Characteristics of the included studies
Authors Study type Subjects
experimental
group/control
group
Training level Assessment methods and
tools
Intervention Intervention duration and
frequency
Results
Bond et al. (2013) Non-randomized 27/0 First- and second-year
medical students.
Jefferson Scale of Physician
Empathy (JSPE);
Perceived Stress Scale
(PSS); Self-Regulation
Questionnaire (SRQ);
Self-Compassion Scale
(SCS).
Breathing, meditation and yoga
sessions.
Once weekly for 11 weeks.
Each class providing
30 min of lecture about the
neuroscience of yoga,
relaxation, and breathing
exercises.
Students reported an improvement
in self-regulation and in self--
compassion.
Brennan et al.
(2016)
Non-randomized 42/0 First-year medical
students.
Beck Depression Inventory
(BDI-II); Beck Anxiety
Inventory (BAI); Social
Readjustment Rating
Scale-Revised (SRRS-R);
Coping Self Efficacy
Scale (CSE).
Stress-management/relaxation
intervention.
8 sessions of
stress-management/-
relaxation from September
until May (4 per semester).
Students reported a decrease in
anxiety and an increase in total
self-efficacy coping and in two
of the self-efficacy subcate-
gories: stop unpleasant thoughts
and problem focus coping.
Bughi et al. (2006) Non-randomized 104/0 Third- and fourth-year
medical students.
General Well-Being Scale
(GWBS).
Brief behavioral intervention
program on stress
management.
NA Students reported stress and
anxiety level decreased, and
positive well-being improved.
Dayalan et al.
(2010)
Non-randomized 21/21 Not specified. Duke’s Health Profile
(DHP).
Mind Sound Technology
program versus control.
6 weeks. Experimental group, during exam,
reported an improvement in
general, social, and mental
health scores and in self-esteem;
and a decrement in perceived
health, anxiety, and depression
scores.
Dhanvijay and
Chandan (2018)
Non-randomized 60/0 First-year medical
students.
Perceived Stress Scale
(PSS); Heart Rate (HR);
Blood Pressure (BP);
Isometric Handgrip Test
(IHG).
Nadi Shuddhi Pranayama
(relaxation technique).
12 weeks. Students reported a decrease in
stress level, in heart rate, and in
systolic and diastolic BP.
Finkelstein et al.
(2007)
Non-randomized 30/46 Second-year medical
students.
SCL-90-R Anxiety
Subscale; Profile of Mood
States (POMS); 2-Item
Depression Index;
Perceived Stress of
Medical School (PSMS).
Mind-Body skills course versus
control.
10 weekly 2-h session. At baseline, the experimental
group had an initial score of
anxiety and perceived stress
higher than the control group.
At the end of the intervention, the
level of anxiety and stress in the
experimental group became
equal to the level of the control
group.
Three months after the end of the
intervention, the level of anxiety
decreased in the experimental
group.
Gruzelier et al.
(2001)
Non-randomized 11/11/9 (in
this study,
25 min per session for 6
weeks.
Students receiving immune-related
imagery reported an increase in
Mindfulness

6. Table 3 (continued)
Authors Study type Subjects
experimental
group/control
group
Training level Assessment methods and
tools
Intervention Intervention duration and
frequency
Results
there were
two control
groups)
First- and second-year
pre-clinical medical
students.
Scales of tension, calmness,
energy, and tiredness;
immune assays.
Immune imagery versus
relaxation imagery versus
control.
energy, and fewer viral illness
and buffering decline in total
lymphocytes and subsets during
the exam period.
Hassed et al.
(2009)
Non-randomized 148/0 First-year medical
students.
SCL-90-R Depression,
Anxiety and Hostility
Subscales, and GSI index;
World Health
Organization Quality of
Life (WHOQOL-BREF).
Health Enhancement Program,
including a
mindfulness-based stress--
management and cognitive
therapy program.
NA Students reported a decrease in
depression and hostility scores
and in overall psychological
distress, and an improvement on
the psychological domain of the
WHOQOL-BREF.
Phang et al. (2015) Randomized 37/38 Medical students in
year 1 to 3 of
studies.
Mindful Attention
Awareness Scale
(MAAS); Perceived
Stress Scale (PSS);
General Health
Questionnaire (GHQ-12);
General Self-Efficacy
(GSE).
Mindfulness-based
stress-management/Mindfuln-
ess Gym versus control.
2-h session for 4 consecutive
weeks.
One week after the end of the
intervention, the experimental
group reported improvements in
perceived stress, mental distress,
self-efficacy, and mindfulness.
Six months after the end of the
intervention, the experimental
group reported a higher
self-efficacy than the control
group.
Phang et al. (2016) Non-randomized 135/0 Four-year medical
students.
Perceived Stress Scale
(PSS); General Health
Questionnaire (GHQ-12);
Mindful Attention
Awareness Scale
(MAAS).
Brief Group Mindfulness-based
Cognitive Therapy for Stress
Reduction.
5 weeks.
Participants in each group met
their trainer weekly for 2-h
session.
Students reported a decrease in
perceived stress and in general
psychological distress, and an
increase in mindfulness.
Prasad et al. (2016) Non-randomized 34/0 First- through
third-year medical
students.
Physical Activity
Questionnaire (PAR-Q);
Perceived Stress Scale
(PSS); Self-Assessments
Survey (SAS).
Hatha yoga practice. 6 weeks. Students reported a reduction in
stress level, and improvements
in feelings of peace, focus,
endurance, happiness,
positivity, personal satisfaction,
self-confidence, patience, and
fatigue.
Rosenzweig et al.
(2003)
Non-randomized 140/162 Second-year medical
students.
Profile of Mood States
(POMS).
Mindfulness-Based Stress
Reduction program versus
control (students introduced to
mind-body techniques but not
formally trained in them).
10 weekly sessions, each
providing 90 min of
contact time plus 20 min of
formal meditation daily (6
days per week).
Experimental group reported
improvement in total mood
disturbance and in the following
subscales: tension-anxiety,
vigor-activity, fatigue-inertia,
confusion-bewilderment.
Scholz et al. (2016) Non-randomized 42/0 First-year medical
students.
Sense of Coherence Scale
(SOC-L9); Beck
Depression Inventory
(BDI-II).
Relaxation techniques. NA Students reported a decline in
depression and an improvement
of sense of coherence, but these
measurements did not reach
statistical significance.
Mindfulness

7. Table 3 (continued)
Authors Study type Subjects
experimental
group/control
group
Training level Assessment methods and
tools
Intervention Intervention duration and
frequency
Results
Shapiro et al.
(1998)
Randomized 37/41 Pre-medical students;
first- and
second-year medical
students.
Empathy Construct Rating
Scale (ECRS);
SCL-90-R; State Trait
Anxiety Inventory
(STAI-1); Index of Core
Spiritual Experiences
(INSPIRIT).
Stress Reduction and Relaxation
Program versus wait-list con-
trol.
7 weeks. Experimental group reported a
decrease of depressive and
anxious symptoms and an
increase in empathy and
spirituality.
Simard and Henry
(2009)
Non-randomized 16/0 First-year medical
students.
General Health
Questionnaire (GHQ-12);
Perceived Stress Scale
(PSS); Center for
Epidemiologic Studies
Depression Scale
(CES-D).
Short Yoga intervention. 18 sessions. Students reported an improvement
in the general health and a
reduction in the stress level.
Warnecke et al.
(2011)
Randomized 32/34 Final 2 years of study. Perceived Stress Scale
(PSS); Depression,
Anxiety and Stress Scales
(DASS).
Audio compact disc (CD) of
guided mindfulness practice
versus control.
8 weeks. At the end of the intervention, the
experimental group reported
reductions in scores on the
perceived stress and anxiety.
The effect was maintained at 8
weeks after the end of the
intervention.
Whitehouse et al.
(1996)
Non-randomized 21/14 First-year medical
students.
Profile of Mood States
(POMS); Brief Symptom
Inventory (BSI); UCLA
Loneliness Scale; immune
measures.
Self-hypnosis training versus
control.
19 weeks. Experimental group reduced levels
of anxiety throughout the
semester and assigned lower
stressfulness rating to the exam
period. No difference was found
with respect to immune
function.
NA Non-available
Mindfulness

8. dolphins devouring germ cells. In the relaxation imagery,
these dynamics were replaced by instructions of peace, hap-
piness, and tranquility.
Mind Sound Technology
One study described a 6-week Mind Sound Technology
(MST), an intelligence-enhancing program developed by
Mind Sound Institute, a Californian corporation (Dayalan
et al. 2010). In MST, the participants introduce sounds into
various parts of the body with their own voice and incorporate
brainwave entrainment tones, stimulating different regions of
the brain with the aim to reduce perceived stress and improve
well-being.
Assessment Measures
All studies evaluated changes after the stress-management in-
tervention. Some studies also evaluated the differences in the
stress level between the baseline and during the examination
period (Dayalan et al. 2010; Gruzelier et al. 2001; Shapiro
et al. 1998; Whitehouse et al. 1996). The outcome was always
measured using standardized self-report questionnaires, which
varied greatly among the studies. Although in all the studies
the authors spoke about “stress,” only 8 articles used a specific
scale to assess stress, such as the Perceived Stress Scale (PSS)
or the Perceived Stress of Medical School (PSMS). In all the
other articles, even when it was explicitly stated that the goal
of the study was to implement an intervention for stress-re-
duction, tools to evaluate anxiety, mood, or general well-being
were used. Few studies evaluated biological parameters, such
as the effect of the stress-management intervention on im-
mune measures (Gruzelier et al. 2001; Whitehouse et al.
1996) and on cardiovascular autonomic functions
(Dhanvijay and Chandan 2018).
Outcomes
Students who were involved in mindfulness-based programs
showed a decrease of perceived stress and in general of psy-
chological distress (Hassed et al. 2009; Phang et al. 2015,
2016; Warnecke et al. 2011), anxiety (Shapiro et al. 1998;
Warnecke et al. 2011), mood disturbances (Hassed et al.
2009; Rosenzweig et al. 2003; Shapiro et al. 1998), and hos-
tility (Hassed et al. 2009). Moreover, the practice of mindful-
ness led to an increase in mindfulness (Phang et al. 2015,
2016), self-efficacy (Phang et al. 2015), in empathy and spir-
ituality (Shapiro et al. 1998), and in the psychological domain
of the quality of life (Hassed et al. 2009).
The relaxation techniques led to an improvement in the
general health (Simard and Henry 2009) and a decrease in
stress level (Dhanvijay and Chandan 2018; Prasad et al.
2016; Simard and Henry 2009). Prasad et al. (2016) also
found improvements in feelings of peace, focus, endurance,
happiness, positivity, personal satisfaction, self-confidence,
patience, and fatigue. Moreover, a study that related relaxation
with cardiovascular autonomic functions showed a decrease in
heart rate, in systolic and diastolic BP (Dhanvijay and
Chandan 2018). Only one study that used relaxation tech-
niques found no statistically significant changes in the stress
level of the students participating in the stress-management
intervention (Scholz et al. 2016). The studies which used
mind-body techniques showed a decrease in stress and anxiety
(Brennan et al. 2016; Bughi et al. 2006; Finkelstein et al.
2007), and an improvement in well-being (Bughi et al.
2006), in self-regulation, in self-compassion (Bond et al.
2013), and in self-efficacy, but no significant decrease in de-
pression scores (Brennan et al. 2016).
The students who practiced the self-hypnosis showed an
increase in energy (Gruzelier et al. 2001) and a reduction of
levels of anxiety throughout the semester and assigned lower
stressfulness rating to the exam period (Whitehouse et al.
1996). As for the effects of hypnosis on the immune system,
the data were mixed: one study did not report an immune
decrease (Whitehouse et al. 1996); the other one showed few-
er viral illness and decline in total lymphocytes and subsets
during the exam period (Gruzelier et al. 2001). In particular,
the immune-related imagery was more successful than relax-
ation imagery. Finally, in the study based on the Mind Sound
Technology program, the students reported during the exam
period an increase in their mental health and self-esteem, and a
decrement in anxiety and depression (Dayalan et al. 2010). In
the studies that had a follow-up period, the results showed that
the students who had participated in the intervention main-
tained over time lower levels of perceived stress, anxiety,
and depression (Finkelstein et al. 2007; Warnecke et al.
2011) and a higher self-efficacy (Phang et al. 2015) compared
with students who did not participate in the stress-reduction
intervention.
Discussion
This review has identified different stress-management inter-
ventions, which took place in the form of practical training,
group lectures, reading, etc. Most studies are focused on
mindfulness program, an approach which refers to nonjudg-
mental awareness of moment-to-moment experience. This re-
view suggests that students who participated in mindfulness
programs reduced their psychological distress and improved
their well-being. This was detected both by the questionnaires
used to assess the efficacy of the mindfulness intervention,
and by what was reported by the students themselves. In fact,
they considered the mindfulness programs as very helpful;
they reported being more mindful in their day-to-day life
and estimated themselves as more effective in handling
Mindfulness

9. stressful situations as a result of the intervention (Rosenzweig
et al. 2003). For this reason, almost all students recommended
mindfulness to other medical students. Through the mindful-
ness practice, students cultivated the ability to pay attention to
whatever is occurring in the present moment without judging
it, and reported developing a higher concentration and insight
as well as a deeper physiologic relaxation. It is likely that the
mindfulness practice contributed to acquiring a greater ability
to appraise challenges in medical school with a positive atti-
tude. This is consistent with one of the proposed mechanisms
of action of the mindfulness practice for stress-reduction: it
has been found that mindfulness is a meta-cognitive form of
awareness; it involves the process of decentering, a shifting of
cognitive sets that enables alternative appraisals of life events,
and consequently more adaptive stress responses and coping
strategies (Garland et al. 2009). This may be what has also
contributed to an increase in student self-efficacy, as observed
in some studies (Phang et al. 2015).
Regarding the other stress-management interventions, the
relaxation techniques appear to provide conflicting data. In
one study, the relaxation has led to a decrease in the stress
level of medical students, with also a decrease in their heart
rate (Dhanvijay and Chandan 2018), but in another study, no
differences were found (Scholz et al. 2016). As regards self-
hypnosis, the immune-related imagery seems to be more ef-
fective than the relaxation imagery (Gruzelier et al. 2001), and
has shown a positive effect in terms of reduction of levels of
stress and anxiety in medical students (Whitehouse et al.
1996). As with relaxation techniques, the results of self-
hypnosis are conflicting, because it has not always shown a
positive effect on the immune system (Whitehouse et al.
1996). We must also mention that the studies that have used
self-hypnosis and relaxation techniques are the only ones in
which the effect of these interventions has been studied also in
terms of changes of the biological parameters (e.g., immune
function, heart rate, blood pressure).
It should also be emphasized that mindfulness makes a
person aware of his/her body and how it works. This could
explain the interest and effectiveness of this practice in a med-
ical population that will take care of patients’ bodies. The
differences in the results obtained in this review could suggest
that, if the anti-stress technique is too mental or psychological
(e.g., self-hypnosis), it works less than a physical relaxation
(e.g., mindfulness) in medical students. A body technique
could be more accepted by medical students, because it is
closer to their field of study (the patient’s body).
With regard to the other interventions based on more exten-
sive mind-body approach, which include psychoeducational
lectures on stress, breathing, meditation, imagery, relaxation,
nutrition, coping skills, positive psychology, and balancing life
and school, the results have shown a decrease in stress and
anxiety (Brennan et al. 2016; Bughi et al. 2006; Finkelstein
et al. 2007), and in general an improvement in well-being of
medical students (Bughi et al. 2006). These interventions were
aimed at increasing personal resources and at learning tech-
niques to cope more effectively with the stressors of medical
school.
All the interventions included in this review showed an
impact only on subjective appraisal of stress symptoms: stress
assessment was always carried out using self-administered
questionnaires. In fact, no data on biochemical parameters of
stress were collected (e.g., serum cortisol). No study also
assessed the effects of these interventions on academic perfor-
mance. Furthermore, stress has been evaluated with very dif-
ferent tools, such as tools to assess stress, mood, and anxiety.
This can lead to a divergence between the outcome declared
by the authors (to reduce stress) and the tools used to evaluate
it. With this regard, further research is needed which should
use more precise tools, in order to achieve a higher consisten-
cy with the declared research goals.
The results of this review seem to confirm the results found
by other reviews and meta-analysis, according to cognitive,
behavioral, and mindfulness-based approaches being effective
in reducing stress in medical students and more generally in
university students (Regehr et al. 2013; Shapiro et al. 2000;
Shiralkar et al. 2013). These approaches are certainly quite
simple to implement and offer the advantage that they train
the mind and create community in the competitive and stress-
ful environment of medical schools (Bond et al. 2013). In fact,
the study of medicine is extensive and time-consuming.
Moreover, medical students deal with patients during their
clinical period and this represents an additional stressor com-
pared with other undergraduates, which can negatively affect
their psychological and physical health, their interpersonal
relationships, and their medical training (Schwenk et al.
2010).
For this reason, medical schools are called upon to help
medical students to manage stress, especially since learning to
cope with stress early in the medical training will prepare them
to better deal with the high stress they will be exposed to in their
future medical practice. These stress-reduction interventions
could prepare future doctors to cope with the stressors related
to their medical practice, and thus, they offer an opportunity to
learn techniques that medical students can use later in order to
prevent burnout. In fact, there is emerging evidence that these
interventions may contribute to lower levels of burnout in phy-
sicians (Regehr et al. 2014). This can influence the quality of
the doctor-patient relationship, which in turn has an impact on
the general patient well-being, medical compliance, and recov-
ery from surgery. These interventions could therefore help to
avoid many consequences at professional level, reducing mis-
takes, preventing burn out, and improving the doctor-patient
relationship, but also at personal level, preventing unhealthy
behaviors, substance use, suicide risk, etc.
Furthermore, these stress-reduction interventions are all
based on an integrated mind-body vision, which favors the
Mindfulness

10. development of competency and interest in adopting mind-
body practices in medical students, and this could benefit pa-
tients. Besides, these interventions may help students to culti-
vate listening skills and developing new more compassionate
perspectives and paradigms to approach their own lives as
well as their future patients’ lives.
For all these reasons, it might be useful to integrate these
stress-management programs into the core curriculum of med-
ical school. In particular, specific and differentiated programs
for students of the non-clinical and clinical period could be
developed. For example, the programs aimed at the students
of the clinical period could be more focused on managing the
emotions deriving from the relationship with the patient and
the disease.
Academic pressures may create a barrier to students’ par-
ticipation in extracurricular stress-reduction programs. In or-
der to avoid the risk that the students may live these interven-
tions as something that takes them away from their study, it
could be useful to offer these programs within the required
curriculum structure, and therefore not require extra time com-
mitment. However, all stress-management interventions in-
cluded in this review are not integrated into the main curricu-
lum (with the exception of one). It is possible to hypothesize
that it is difficult to insert these interventions in the curriculum
of the medical schools, because this would require a cultural
change, which implies that the preparation for the physician’s
role should occur on many levels, including care of the per-
sonal well-being of students in training.
Moreover, despite the positive results in terms of stress and
anxiety reduction, these interventions have not always been
equally effective in reducing depression (Brennan et al. 2016).
It is important to underline that the Brennan et al. study had
higher than usual depression scores, and it could be that, since
this study was voluntary, some students, who were more de-
pressed, may have self-selected to try to obtain some help.
This may have been the reason for the difference in lowering
the depression scores in one study and not in another.
Depression can be a consequence of psychological dis-
tress and can impair cognitive performance with subse-
quent academic difficulties and further emotional suffer-
ing. Besides, poorly managed depression can lead to alco-
hol and other drug abuse. For this reason, it would be
important to create interventions that not only develop
skills to cope with stress but also include strategies to ef-
fectively manage mood deflections in medical students.
Stress-management skills probably are not enough to treat
medical students with clinical conditions, such as depres-
sive or anxiety disorders. For this reason, different types of
interventions are needed: primary prevention interventions
to be included in the medical education curriculum, and
secondary or tertiary prevention interventions should be
aimed at students at high risk of developing mental disor-
ders or at students who already have symptoms.
Finally, the studies included in this review did not consider
more strong outcomes, for example, if the students took more
exams or improved their grade point average. It would be
interesting to carry out further research to understand if these
stress-reduction interventions also produce changes in these
aspects.
Limitations
This review has several limitations. Out of 17 studies included
in this review, only 3 were randomized. In the non-
randomized studies, the control group was often missing.
When there was a control group, it received no intervention.
All studies were conducted on small samples size, which re-
duces the generalizability of the results. Moreover, it is diffi-
cult to generalize from a population of medical students who
voluntarily chose to enroll in this elective intervention.
Students taking the course could have traits and interests that
other students did not have and they may need a stress-
management intervention; this can lead to being more amena-
ble to change. Few studies had follow-up, and when it was
reported, it was short. For this reason, conclusion about the
long-term benefits of these interventions should be interpreted
with caution. Furthermore, often the instructor of the interven-
tion was one of the investigators of the study. This could have
resulted in expectation bias from all parts: instructor, investi-
gator, and students. Finally, no biochemical parameters of
stress (such as serum cortisol) were collected.
This review seems to suggest that stress-management pro-
grams may be helpful for medical students to improve knowl-
edge of stress and to increase their well-being. Nevertheless,
more research is needed to validate these findings: the number
of studies is small and most of them are non-randomized.
Moreover, further studies should assess a broader range of
outcomes, including the correlation between the stress-
reduction interventions and the academic performance (e.g.,
number of exams, exam grade) and the effects of these inter-
ventions on the doctor-patient relationship. Further studies
should also be carried out in the advanced professional field,
among specialist doctors, in order to assess the effects of these
stress-management interventions on the well-being of both
doctors and patients. Finally, research could further investi-
gate the influence of culture on the efficacy and acceptability
of particular interventions.
Author Contributions CB and AG had the idea for the article. CB and VC
performed the literature search and data analysis, and drafted the work.
AG drafted the work and critically revised it.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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