**Stress Management for Medical Students: A Systematic Review**

Muhamad Saiful Bahri Yusoff and Ab Rahman Esa

*Medical Education Department, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Public Health, Faculty of Medicine & Health Sciences, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia* 

#### **1. Introduction**

476 Social Sciences and Cultural Studies – Issues of Language, Public Opinion, Education and Welfare

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Tertiary education has always been regarded as highly stressful environment to students (Saipanish, 2003; Sherina et. al, 2003). Medical training further adds to the already stressful environment. Studies have revealed a high prevalence of psychological distress in medical students, ranging from 21.6% to 56% (Aktekin et al., 2001; Chandrasekhar et al., 2007; Dahlin et al., 2005; Firth, 1986; Guthrie et al., 1995; Miller & Surtees, 1991; Johari & Hashim, 2009; Saipanish, 2003; Sherina et al., 2003; Yusoff et al., 2011; Yusoff et al., 2010; Zaid et. al, 2007). Two studies in Malaysian government universities reported that 29.1 % to 41.9% of the medical students surveyed had psychological distress (Sherina et al., 2003; Yusoff et al., 2010) and another study in a Malaysian private medical school reported that 46.2% had psychological distress (Zaid et al, 2007). Apart from that, the stress level is higher in medical students compared to students in other courses. A study in Singapore reported that 57% of medical students had psychological distress compared to 47.3% of law students (Ko et al., 1999). Another study in Turkey reported that 47.9% of medical students had psychological distress compared to 29.2% of economic and physical education students as measured by GHQ (Aktekin et al., 2001). The alarming facts suggested that a sense of growing pressure on medical students.

The prevalence of psychological distress among year 1 medical students ranged from 17.6% to 50% (Aktekin et al., 2001; Guthrie et al., 1998; Sherina et al., 2003; Yusoff et al., 2011; Zaid et., 2007). The prevalence of psychological distress among year 2 medical students ranged from 36.5% to 47.9% (Aktekin et al., 2001; Sherina et al., 2003; Yusoff et al., 2010). The prevalence of psychological distress among year 3 medical students ranged from 29.8% to 40.5% (Sherina et al., 2003; Yusoff et al., 2010; Zaid et al., 2007). The prevalence of psychological distress among year 4 medical students ranged from 28.3% to 48.7% (Guthrie et al., 1998; Sherina et al., 2003; Yusoff et al., 2010; Zaid et al., 2007). The prevalence of stress among year 5 medical students ranged from 21.9% to 62.7% (Guthrie et al., 1998; Sherina et al., 2003; Yusoff et al., 2010; Zaid et al., 2007;). These facts showed that psychological distress were different depending on the stages of medical training (Yusoff et al., 2010).

Stress Management for Medical Students: A Systematic Review 479

The literature search was performed using the Google Scholar, PubMed database, EbscoHost databases, Cochrane Library database, Scopus database, and Science Direct database. Keywords used in searching include 'medical student', 'stress management', 'medical student wellbeing', and 'stress intervention'. No time limit was specified in searching. Abstracts of the searched articles were read through for relevance. Participants, sampling method, study design, intervention structure, content and technique, and outcomes were the key issues of inclusion criteria for in-depth study of the full articles. Articles must describe stress management specifically for medical students otherwise they were not included in this review. Some of the articles were searched from the reference lists

Based on the keywords stated in the method, our search found that Google scholar database yielded over 1000 articles, Pubmed database yielded 275 articles, Cochrane Library database yielded 99 articles, EBSCO host database yielded 408 articles, Scopus database yielded 324 articles and Science Direct yielded 14 articles. However, based on abstract reading we found 28 articles fulfilled our inclusion criteria and they were selected for in-depth review. After the in-depth review 22 articles were included for review, 6 articles were excluded due to irrelevant content for current review. A new article was found from the reference list of the primary search and it was included in this current review. Approximately 23 articles were appraised and the results were summarised in tables. The earliest study was found in 1978 and the latest study was found in 2011. The earliest study was reported in 1978 (Soskis, 1978) and the latest study was reported in 2011 (Yusoff, 2011). Results of this systematic review were tabulated based on the five areas which were 1) nature of participants, 2) research methods (table 1), 3) structure, facilitators and duration of intervention (table 2), 4) measure outcomes and instrumed used to measure them (table 3) and 5) outcomes of the

In general, participation of the interventions were categorized into random (i.e. selection of participants were made based on random sampling method) (Mitchell et al., 1983) and nonrandom (i.e. selection of participants were made based on non-random sampling method such as volunteer, convenient and purposive sampling method). Majority of the studies (i.e. 22 out of 23 studies) used non-random sampling method in selecting participants (Bughi et al., 2009; Finkelstein et al., 2007; Hassed et al., 2008; Hassed et al., 2009; Holtzworth-Munroe et al., 1985; Jain et al., 2007;Kelly et al., 1982; Kiecolt-Glaser et al., 1986; Klamen, 1997; Lee & Graham, 2001; MacLaughin et al., 2010; Michie & Sandhu, 1994; Nathan et al., 1987; Rosenzweig et al., 2003; Redwood & Polak, 2007; Simard & Henry, 2009; Shapiro et al., 1998; Soskis, 1978; Whitehouse et al., 1996; Yusoff & Rahim, 2010; Yusoff, 2011; Zeitlin et al., 2000). As shown in table 1, approximately 10 (43.48%) studies had no comparison groups (Bughi et al., 2009; Hassed et al., 2008; Hassed et al., 2009; Lee & Graham, 2001; Klamen, 1997; Redwood & Polak, 2007; Simard & Henry, 2009;; Soskis, 1978; Yusoff & Rahim, 2010; Zeitlin et al., 2000;) and 13 (56.52%) studies had comparison groups (Finkelstein et al., 2007; Holtzworth-Munroe et al., 1985; Jain et al., 2007; Kelly et al., 1982; Kiecolt-Glaser et al., 1986;

**2. Methodology** 

**3. Results** 

of the articles of primary search.

interventions (table 4-8).

Chronic exposure to stressful condition exerts negative effects on emotional, mental and physical well-being of the students. Numerous studies have revealed that persistence stressful condition associated with mental and physical health problems in medical students at various stages of their training (Aktekin et al., 2001; Firth, 1986; Guthrie et al., 1995; Miller and Surtees, 1991; Sherina et al., 2003; Zaid et. al, 2007). Studies reported an association of prolongeds psychological distress with lowered medical students' selfesteem (Silver & Glicken, 1990; Linn & Zeppa, 1984), anxiety and depression (Rosal et al., 1997; Shapiro et al., 2000), difficulties in solving interpersonal conflicts (Clark & Rieker, 1986), sleeping disorders (Niemi & Vainiomaki, 2006), increased alcohol and drug consumption (Flaherty & Richman, 1993; Newbury-Birch et al, 2000; Pickard et al., 2000), cynicism, decreased attention, reduced concentration and academic dishonesty (Liselotte et. al, 2005). It also associated with inhibition of students' academic achievement and personal growth development (Linn & Zeppa, 1984). Prolonged psychological distress was also linked with medical student suicide (Hays et al., 1996). As a result, medical students may feel inadequate and unsatisfied with their career as a medical practitioner in the future (Saipanish, 2003). It is noteworthy that many researchers stated the importance of early diagnosis as well as effective intervention programmes, that can prevent possible future mental illnesses among medical students (Aktekin et al., 2001; Firth, 1986; Sherina, 2003).

Studies revealed that the stressors affecting medical students' well being seems to be related to the medical training especially related to academic matters (Aktekin et al., 2001; Guthrie et al, 1995; Kaufman et al., 1996, 1998; Saipanish, 2003; Yusoff et al., 2011; Yusoff et al., 2010). They found that the top four stressors were tests and examinations, time pressure, too many content to be studied, and getting behind in work. Another three common stressors were conflicting demands, not getting work done within time planned and heavy workload. A small number of medical students suffer from personal problems, but the effect of this on medical students' psychological morbidity and academic success is unclear (Guthrie et al, 1995; Firth, 1986; Saipanish, 2003). Curriculum differences in medical schools may not necessarily cause differences in the overall pattern of stressors (i.e. most of the top stressors are related to academic matters), although frequency (rank) of some stressors may be significantly different (Kaufman et al., 1996, 1998).

It is worth to highlight that several medical education constituencies have emphasized the importance of teaching stress management and self-care skills to medical students (Steven et al., 2003; Susan et al., 2007). A recent literature review discovered that, although more than 600 articles addressed the importance of stress management programs in medical curricula, only 24 reported intervention programs with accompanying data; however none of the programmes provide convincing evidence of their effectiveness (Shapiro et al., 2000). Apart from that, their specific applications to medical education have been largely unexplored (Shapiro et al., 2000). Therefore a systematic review was done to evaluate the effectiveness of stress management specifically done on medical students with regard to five aspects which were 1) nature of participation, 2) research methods, 3) structure, facilitator and duration of intervention, 4) measured outcomes and instruments used to measure them and 5) outcomes of the intervention. On top of that we also categorized studies based on country.

#### **2. Methodology**

478 Social Sciences and Cultural Studies – Issues of Language, Public Opinion, Education and Welfare

Chronic exposure to stressful condition exerts negative effects on emotional, mental and physical well-being of the students. Numerous studies have revealed that persistence stressful condition associated with mental and physical health problems in medical students at various stages of their training (Aktekin et al., 2001; Firth, 1986; Guthrie et al., 1995; Miller and Surtees, 1991; Sherina et al., 2003; Zaid et. al, 2007). Studies reported an association of prolongeds psychological distress with lowered medical students' selfesteem (Silver & Glicken, 1990; Linn & Zeppa, 1984), anxiety and depression (Rosal et al., 1997; Shapiro et al., 2000), difficulties in solving interpersonal conflicts (Clark & Rieker, 1986), sleeping disorders (Niemi & Vainiomaki, 2006), increased alcohol and drug consumption (Flaherty & Richman, 1993; Newbury-Birch et al, 2000; Pickard et al., 2000), cynicism, decreased attention, reduced concentration and academic dishonesty (Liselotte et. al, 2005). It also associated with inhibition of students' academic achievement and personal growth development (Linn & Zeppa, 1984). Prolonged psychological distress was also linked with medical student suicide (Hays et al., 1996). As a result, medical students may feel inadequate and unsatisfied with their career as a medical practitioner in the future (Saipanish, 2003). It is noteworthy that many researchers stated the importance of early diagnosis as well as effective intervention programmes, that can prevent possible future mental illnesses among medical students (Aktekin et al., 2001; Firth, 1986; Sherina,

Studies revealed that the stressors affecting medical students' well being seems to be related to the medical training especially related to academic matters (Aktekin et al., 2001; Guthrie et al, 1995; Kaufman et al., 1996, 1998; Saipanish, 2003; Yusoff et al., 2011; Yusoff et al., 2010). They found that the top four stressors were tests and examinations, time pressure, too many content to be studied, and getting behind in work. Another three common stressors were conflicting demands, not getting work done within time planned and heavy workload. A small number of medical students suffer from personal problems, but the effect of this on medical students' psychological morbidity and academic success is unclear (Guthrie et al, 1995; Firth, 1986; Saipanish, 2003). Curriculum differences in medical schools may not necessarily cause differences in the overall pattern of stressors (i.e. most of the top stressors are related to academic matters), although frequency (rank) of some stressors may be

It is worth to highlight that several medical education constituencies have emphasized the importance of teaching stress management and self-care skills to medical students (Steven et al., 2003; Susan et al., 2007). A recent literature review discovered that, although more than 600 articles addressed the importance of stress management programs in medical curricula, only 24 reported intervention programs with accompanying data; however none of the programmes provide convincing evidence of their effectiveness (Shapiro et al., 2000). Apart from that, their specific applications to medical education have been largely unexplored (Shapiro et al., 2000). Therefore a systematic review was done to evaluate the effectiveness of stress management specifically done on medical students with regard to five aspects which were 1) nature of participation, 2) research methods, 3) structure, facilitator and duration of intervention, 4) measured outcomes and instruments used to measure them and 5) outcomes of the intervention. On top of that we also categorized

significantly different (Kaufman et al., 1996, 1998).

studies based on country.

2003).

The literature search was performed using the Google Scholar, PubMed database, EbscoHost databases, Cochrane Library database, Scopus database, and Science Direct database. Keywords used in searching include 'medical student', 'stress management', 'medical student wellbeing', and 'stress intervention'. No time limit was specified in searching. Abstracts of the searched articles were read through for relevance. Participants, sampling method, study design, intervention structure, content and technique, and outcomes were the key issues of inclusion criteria for in-depth study of the full articles. Articles must describe stress management specifically for medical students otherwise they were not included in this review. Some of the articles were searched from the reference lists of the articles of primary search.

#### **3. Results**

Based on the keywords stated in the method, our search found that Google scholar database yielded over 1000 articles, Pubmed database yielded 275 articles, Cochrane Library database yielded 99 articles, EBSCO host database yielded 408 articles, Scopus database yielded 324 articles and Science Direct yielded 14 articles. However, based on abstract reading we found 28 articles fulfilled our inclusion criteria and they were selected for in-depth review. After the in-depth review 22 articles were included for review, 6 articles were excluded due to irrelevant content for current review. A new article was found from the reference list of the primary search and it was included in this current review. Approximately 23 articles were appraised and the results were summarised in tables. The earliest study was found in 1978 and the latest study was found in 2011. The earliest study was reported in 1978 (Soskis, 1978) and the latest study was reported in 2011 (Yusoff, 2011). Results of this systematic review were tabulated based on the five areas which were 1) nature of participants, 2) research methods (table 1), 3) structure, facilitators and duration of intervention (table 2), 4) measure outcomes and instrumed used to measure them (table 3) and 5) outcomes of the interventions (table 4-8).

In general, participation of the interventions were categorized into random (i.e. selection of participants were made based on random sampling method) (Mitchell et al., 1983) and nonrandom (i.e. selection of participants were made based on non-random sampling method such as volunteer, convenient and purposive sampling method). Majority of the studies (i.e. 22 out of 23 studies) used non-random sampling method in selecting participants (Bughi et al., 2009; Finkelstein et al., 2007; Hassed et al., 2008; Hassed et al., 2009; Holtzworth-Munroe et al., 1985; Jain et al., 2007;Kelly et al., 1982; Kiecolt-Glaser et al., 1986; Klamen, 1997; Lee & Graham, 2001; MacLaughin et al., 2010; Michie & Sandhu, 1994; Nathan et al., 1987; Rosenzweig et al., 2003; Redwood & Polak, 2007; Simard & Henry, 2009; Shapiro et al., 1998; Soskis, 1978; Whitehouse et al., 1996; Yusoff & Rahim, 2010; Yusoff, 2011; Zeitlin et al., 2000).

As shown in table 1, approximately 10 (43.48%) studies had no comparison groups (Bughi et al., 2009; Hassed et al., 2008; Hassed et al., 2009; Lee & Graham, 2001; Klamen, 1997; Redwood & Polak, 2007; Simard & Henry, 2009;; Soskis, 1978; Yusoff & Rahim, 2010; Zeitlin et al., 2000;) and 13 (56.52%) studies had comparison groups (Finkelstein et al., 2007; Holtzworth-Munroe et al., 1985; Jain et al., 2007; Kelly et al., 1982; Kiecolt-Glaser et al., 1986;

Stress Management for Medical Students: A Systematic Review 481

A

**Participant Facilitator Total** 

Psychiatrist and Professional teachers.

Psychiatrists and Clinical Psychologist.

A Clinical Psychologist.

Clinical Psychologists

Not mentioned.

Not mentioned.

Faculty members.

2nd year medical students trained and guided by two

Psychologists.

Four Clinical Psychologists. **Duration** 

400 minutes over 8 weeks.

360 minutes over 3 weeks.

1050 minutes over 7 weeks.

over 6 weeks.

1200 minutes over 10 weeks.

Over one month duration.

1320 minutes over 11 weeks.

420 minutes over 7 weeks.

360 to 540 minutes over 3 weeks.

Physicians 360 minutes

Not mentioned. **Source and Country** 

Soskis (1978),

Nathan et al (1987), US.

Michie & Sandhu (1994),

Shapiro et al (1998), US.

Lee & Graham (2001), US.

Finkelstein et al (2007), US.

Bughi et al (2009), US.

MacLaughin et al (2010), US.

Redwood & Polak (2007),

Kelly et al (1992), US.

US.

UK.

US.

**Number of** 

42: 1st and 2nd year medical students.

96 to 103: 1st year medical students.

69: 1st clinical year (3rd year) medical students

38: 1st and 2nd year medical students. 35: premedical students

66: 1st and 2nd year medical students.

32: 2nd year medical students.

34: 3rd and 4th year medical students.

24: 1st year medical students.

1282 (over 16 years): 1st year medical students. Average participant in a year was 80.

Seminar 38: 1st, 2nd and

4th year medical students. 10: residents and nurses

**Structure (frequency)** 

**Elective course (8)** 

**Name of intervention** 

Meditation & Healing.

The stress management training course.

The stress management course.

The Mindfulness Based Stress Reduction.

The Help programme.

The Mind-Body Medicine: An Experiential Elective

The Brief Behavioural Intervention Program (BPIP)

The Mind Body Medicine

Student-led stress management program

Skills.

**Volunteer program (1)** 

**Seminar/ workshop (6)** 

The

MacLaughin et al., 2010; Michie & Sandhu, 1994; Mitchell et al., 1983; Nathan et al., 1987; Rosenzweig et al., 2003; Shapiro et al., 1998; Whitehouse et al., 1996; Yusoff, 2011). Out of 13, about seven studies randomly assigned participants to control and intervention groups (Holtzworth-Munroe et al., 1985; Jain et al., 2007; Kiecolt-Glaser et al., 1986; Mitchell et al., 1983; Nathan et al., 1987; Shapiro et al., 1998; Whitehouse et al., 1996). Out of the seven randomized control studies, only one study sampled their participants randomly (Mitchell et al., 1983). Even more only two studies (Jain et al., 2007; Yusoff, 2011) clearly mentioned about sample size calculation for the intervention and comparison groups while the rest of studies had not mentioned about it. The longest follow up duration for measurement of outcomes was 12 months (Nathan et al., 1987) and the shortest follow up duration for measurement of outcomes was immediately right after the intervention completed (Klamen, 1997; Redwood & Polak, 2007; Soskis, 1978; Zeitlin et al., 2000).


Table 1. Summary of research design, frequency measurement of outcomes and country of the 23 studies were conducted.

Approximately 34.8% (n=8) of interventions was offered as elective course, 26.1% (n=6) was offered as a seminar/workshop, 17.4% (n=4) was offered as a specific training/therapy, 8.7% (n=2) was offered as support group, 8.7% (n=2) was offered as a program built in the core curriculum and 4.3% (n=1) was offered as a volunteer program (table 2).

MacLaughin et al., 2010; Michie & Sandhu, 1994; Mitchell et al., 1983; Nathan et al., 1987; Rosenzweig et al., 2003; Shapiro et al., 1998; Whitehouse et al., 1996; Yusoff, 2011). Out of 13, about seven studies randomly assigned participants to control and intervention groups (Holtzworth-Munroe et al., 1985; Jain et al., 2007; Kiecolt-Glaser et al., 1986; Mitchell et al., 1983; Nathan et al., 1987; Shapiro et al., 1998; Whitehouse et al., 1996). Out of the seven randomized control studies, only one study sampled their participants randomly (Mitchell et al., 1983). Even more only two studies (Jain et al., 2007; Yusoff, 2011) clearly mentioned about sample size calculation for the intervention and comparison groups while the rest of studies had not mentioned about it. The longest follow up duration for measurement of outcomes was 12 months (Nathan et al., 1987) and the shortest follow up duration for measurement of outcomes was immediately right after the intervention completed (Klamen,

> **Source (arranged based on year of study)**

Holtzworth-Munroe et al (1985), Shapiro et al (1998), Jain et al (2007)., and Mitchell et al (1983).

Nathan et al (1987) and Whitehouse et al (1996).

Kiecolt-Glaser et al (1986).

Michie & Sandhu (1994) and Finkelstein et al (2007).

(2010).

(2000).

(2010). Once: post-intervention Soskis (1978) and Redwood &

Table 1. Summary of research design, frequency measurement of outcomes and country of

Approximately 34.8% (n=8) of interventions was offered as elective course, 26.1% (n=6) was offered as a seminar/workshop, 17.4% (n=4) was offered as a specific training/therapy, 8.7% (n=2) was offered as support group, 8.7% (n=2) was offered as a program built in the

core curriculum and 4.3% (n=1) was offered as a volunteer program (table 2).

Polak (2007).

Yusoff (2011).

Simard & Henry (2009).

Klamen (1997) and Zeitlin et al

Lee & Graham (2001), Hassed et al (2008), Hassed et al (2009), Bughi et al (2009) and Yusoff & Rahim

Kelly et al (1982), Rosenzweig et al (2003) and MacLaughin et al

**Country (frequency)** 

US (7)

US (4) UK (1) Malaysia (1)

US (6) Australia (2) Canada (1) Malaysia (1)

1997; Redwood & Polak, 2007; Soskis, 1978; Zeitlin et al., 2000).

**Measurement of outcomes (frequency)** 

Four times: pre (1x) and post (3x) intervention

Three times: pre (1x) and post (2x) intervention

Two times: pre and post

Three times: pre (1x) and post (2x) intervention

Two times: pre and post

Three times: pre (1x) and post (2x) intervention

Two times: pre and post

Two times: post (2x) intervention

Two times: post (2x) intervention

intervention

intervention

intervention

the 23 studies were conducted.

**Study design (frequency)** 

**Randomized controlled trial (7)** 

**Quasiexperimental: nonequivalent comparison group (6)** 

**Quasiexperimental: time series without comparison group (10)** 



Stress Management for Medical Students: A Systematic Review 483

**Participant Facilitator Total** 

A certified yoga teacher.

Table 2. Summary of structure, participants, facilitator and total duration of interventions of

Approximately 43.5% (n=10) of interventions was conducted by Psychologist/Psychiatrist, 13% (n=3) by trained instructor, 13% (n=3) by faculty member, 4.3% (n=1) by medical

The shortest duration of intervention was 60 minutes as massage therapy over an afternoon (Zeitlin et al., 2000) and the longest duration of intervention was 1920 minutes (32 hours) over a 16-week yoga exercise (Simard & Henry, 2009). However majority of intervention

The smallest and biggest number of participants involved in an intervention were 9 (Zeitlin et al., 2000) and 315 (Hassed et al., 2008) respectively. However, majority of those studies

Most of studies (n=11) measured participants' perception on acceptability and feasibility of stress management interventions using evaluation questionnaire at the end of the interventions (table 3). Items of the evaluation questionnaires used were different between studies depending on objectives of the interventions. Despite of the differences, this fact clearly suggested that perception of participants towards feasibility and acceptability of stress management interventions were considered as one of important outcomes of the interventions. Apart from participants' feedback on acceptability and feasibility of the interventions, there were three other most common measured outcomes that were considered as major indicators of effectiveness of stress management interventions regardless of its types which were anxiety (n=14), depression (n=13) and psychological distress (n=10) as shown in table 3. Majority of studies (n=7) measured anxiety level among participants using the State-Trait Anxiety Inventory (STAI) followed by the Brief Symptom Inventory (BSI) (n=3), the Anxiety Subscale of Symptom Checklist Revised (n=2), The Depression Anxiety Stress Scale (n=1) and other inventories (table 3). Depressive symptoms were mostly measured by the Brief Symptom Inventory (BSI) (n=3) and the Depression Subscale of Symptom Checklist Revised (n=3) followed by the Beck Depression Inventory (n=1), the Depression Anxiety Stress Scale (n=1) and others inventories (table 3).

Two mindfulness instructors and two relaxation instructors

**Duration** 

360 minutes over 4 weeks.

1920 minutes over 16 weeks. **Source and Country** 

Jain et al (2007), US.

Simard & Henry (2009), Canada.

**Number of** 

81 (divided into 3 groups which were Mindfulness, Somatic & Control): mixture of medical and allied health students.

medical students.

student, 4.3% (n=1) by physician and 21.7% (n=5) was not reported (table 2).

**Structure (frequency)** 

**Name of intervention** 

Yoga exercise 16: 1st year

(n=9) utilised 360 to 540 minutes over 3 to 8 weeks (table 2).

(n=12) had involved 30 to 50 participants in an intervention (table 2).

Mindfulness Meditation-Somatic Relaxation

the 23 studies were conducted.

**Participant Facilitator Total** 

A Clinical Psychologist.

Psychiatrist.

A

Not mentioned.

Faculty members.

Faculty members.

Not mentioned

12 trained tutors.

Two Clinical Psychologists.

A Clinical Psychologist.

Two Psychiatrists

Not mentioned **Duration** 

360 minutes over 6 weeks.

360 minutes over 3 weeks.

900 minutes over 10 weeks.

240 minutes over a halfday.

240 minutes over a halfday.

1260 minutes over half of a semester.

1260 minutes over half of a semester.

400 minutes over 8 weeks.

1260 minutes over 14 sessions throughout one semester.

60 minutes one day before examination.

Not mentioned. **Source and Country** 

Holtzworth-Munroe et al (1985), US.

Klamen (1997), US.

Yusoff & Rahim (2010), Malaysia.

Yusoff (2011), Malaysia.

Hassed et al (2008), Australia.

Hassed et al (2009), Australia.

Mitchell et al (1983), US.

Kiecolt-Glaser et al (1986), US.

Whitehouse et al (1996), US.

Zeitlin et al (2000), US.

Rosenzweig et al (2003), US.

**Number of** 

year medical students.

30: 1st year medical students.

302 (1996- 2000): 2nd year medical students. Average participant in a year was 60.

34: 2nd, 3rd, 4th and 5th year medical students.

48: 1st year medical students.

315: 1st year medical students.

148: 1st year medical students.

medical students.

medical students

35: 1st year medical students

9: 1st and 2nd year medical students

**Structure (frequency)** 

**Built in core curriculum (2)** 

**Support group (2)** 

**Specific training/ therapy (4)** 

**Name of intervention** 

The stress management workshop

The Medical Student Wellbeing Workshop.

The Medical Student Wellbeing Workshop.

The Health Enhancement Programme (HEP)

The Health Enhancement Programme (HEP)

Self-hypnosis training

Massage therapy

Support group 38: 1st year

Support group 34: 1st year

The Mindfulness Based Stress Reduction seminar

Workshop 40: 1st and 2nd


Table 2. Summary of structure, participants, facilitator and total duration of interventions of the 23 studies were conducted.

Approximately 43.5% (n=10) of interventions was conducted by Psychologist/Psychiatrist, 13% (n=3) by trained instructor, 13% (n=3) by faculty member, 4.3% (n=1) by medical student, 4.3% (n=1) by physician and 21.7% (n=5) was not reported (table 2).

The shortest duration of intervention was 60 minutes as massage therapy over an afternoon (Zeitlin et al., 2000) and the longest duration of intervention was 1920 minutes (32 hours) over a 16-week yoga exercise (Simard & Henry, 2009). However majority of intervention (n=9) utilised 360 to 540 minutes over 3 to 8 weeks (table 2).

The smallest and biggest number of participants involved in an intervention were 9 (Zeitlin et al., 2000) and 315 (Hassed et al., 2008) respectively. However, majority of those studies (n=12) had involved 30 to 50 participants in an intervention (table 2).

Most of studies (n=11) measured participants' perception on acceptability and feasibility of stress management interventions using evaluation questionnaire at the end of the interventions (table 3). Items of the evaluation questionnaires used were different between studies depending on objectives of the interventions. Despite of the differences, this fact clearly suggested that perception of participants towards feasibility and acceptability of stress management interventions were considered as one of important outcomes of the interventions. Apart from participants' feedback on acceptability and feasibility of the interventions, there were three other most common measured outcomes that were considered as major indicators of effectiveness of stress management interventions regardless of its types which were anxiety (n=14), depression (n=13) and psychological distress (n=10) as shown in table 3. Majority of studies (n=7) measured anxiety level among participants using the State-Trait Anxiety Inventory (STAI) followed by the Brief Symptom Inventory (BSI) (n=3), the Anxiety Subscale of Symptom Checklist Revised (n=2), The Depression Anxiety Stress Scale (n=1) and other inventories (table 3). Depressive symptoms were mostly measured by the Brief Symptom Inventory (BSI) (n=3) and the Depression Subscale of Symptom Checklist Revised (n=3) followed by the Beck Depression Inventory (n=1), the Depression Anxiety Stress Scale (n=1) and others inventories (table 3).


Stress Management for Medical Students: A Systematic Review 485

Brief Symptom Inventory (3) Kiecolt-Glaser et al (1986),

Depression Adjective Checklist (1) Nathan et al (1987).

2-item Depression Index (1) Finkelstein et al (2007).

Jenkins Activity Schedule (2) Kelly et al (1982), Nathan et

Helper/Inducer T Lymphocytes (2) Kiecolt-Glaser et al (1986),

Suppressor/Cytotoxic T Lymphocytes (2) Kiecolt-Glaser et al (1986),

Total Iron-Binding Protein (TIBC) (1) Kiecolt-Glaser et al (1986), Transferrin (1) Kiecolt-Glaser et al (1986), Albumin (1) Kiecolt-Glaser et al (1986), Natural Killer Cell (NK-cell) (3) Kiecolt-Glaser et al (1986),

B Lymphocytes (1) Whitehouse et al (1996) Monocytes (1) Whitehouse et al (1996) Granulocytes Whitehouse et al (1996) Total White Blood Count (1) Zeitlin et al (2000), Mitogen-Induced Lymphocyte Stimulation (1) Zeitlin et al (2000)

Depression Anxiety Stress Scale 21-item (1) Yusoff (2011).

Holtzworth-Munroe et al

Whitehouse et al (1996), Jain

Michie & Sandu (1994).

Simard & Henry (2009).

Bughi et al (2009).

Nathan et al (1987), Whitehouse et al (1996).

Nathan et al (1987)

Whitehouse et al (1996)

Whitehouse et al (1996)

Whitehouse et al (1996), Zeitlin et al (2000)

et al (2009)

al (1987)

Rosenzweig et al (2003), Finkelstein et al (2007).

Shapiro et al (1998), Hassed et al (2008), Hassed et al

(1985).

(2009).

et al (2007).

**(frequency) Instrument (frequency) Source Depression (13)** Beck's Depression Inventory (1) Mitchell et al (1983). Rating scales of the frequency and intensity of

7 Questions covered on anxiety, depression and

Depression subscale of General Well Being Scale

**Loneliness (3)** UCLA Loneliness scale (3) Kiecolt-Glaser et al (1986),

**Mood state (3)** Profile of Mood States (POMS) (3) Whitehouse et al (1996),

**Quality of life (2)** WHOQOL (2) Hassed et al (2008), Hassed

Bortner's short rating scale of Type A behaviour

Depression subscale of Symptom Checklist

The Center of Epidemiologic Studies Depression (CES-D) scale (1)

weekly tension and depression (1)

satisfaction (1)

(1)

(1)

Revised (SCL-90R) (3)

**Outcomes Measured** 

**Type A behaviour** 

**Physiologic & Immunologic Health marker (3)** 

**(2)** 


Interview (1) Soskis (1978).

Essay (1) Lee & Graham (2001).

Social Readjustment Rating Scale (1) Nathan et al (1987),

Visual Analogue Perceived Stress (1) Zeitlin et al (2000), Perceived Stress of Medical School (1) Finkelstein et al (2007), General Health Questionnaire 12 item (2) Simard & Henry (2009),

Perceived Stress Scale (1) Simard & Henry (2009), Saliva Cortisol Level (1) MacLaughin et al (2010)

Saliva Testosterone level (1) MacLaughin et al (2010)

Brief Symptom Inventory (3) Kiecolt-Glaser et al (1986),

Anxiety subscale of General Well Being Scale (1) Bughi et al (2009). Depression Anxiety Stress Scale 21-item (1) Yusoff (2011).

Depression Anxiety Stress Scale 21-item (1) Yusoff (2011) **Anxiety (14)** State-Trait Anxiety Inventory (7) Kelly et al (1982), Mitchell et

Evaluation Questionnaire (11) Soskis (1978), Nathan et al

(1987), Michie & Sandu (1994), Klamen (1997), Shapiro et al (1998), Lee & Graham (2001), Rosenzweig et al (2003), Redwood & Polak (2007), Hassed et al (2008), Simard & Henry (2009), Yusoff & Rahim

Holtzworth-Munroe et al

Shapiro et al (1998), Hassed

Yusoff & Rahim (2010)

MacLaughin et al (2010)

MacLaughin et al (2010)

al (1983), Holtzworth-Munroe et al (1985), Nathan et al (1987), Michie & Sandu (1994), Shapiro et al (1998), Zeitlin et al (2000),

Holtzworth-Munroe et al

Whitehouse et al (1996), Jain

Michie & Sandu (1994).

Finkelstein et al (2007), Hassed et al (2009).

(1985),

et al (2007).

(2010).

(1985),

et al (2008),

**(frequency) Instrument (frequency) Source** 

Rating scales of the frequency and intensity of

Distress subscale of Symptom Checklist Revised

Saliva Dehydroepiandrosterone-sulfate (DHEA-

Saliva Secretory Immunoglobulin A (sIgA) level

Rating Scales of Anxiety and Intensity in Test

7 Questions covered on anxiety, depression and

Anxiety subscale of Symptom Checklist Revised

and Social Situation (1)

satisfaction (1)

(SCL-90R) (2)

weekly tension and depression (1)

(SCL-90R) (2)

S) level (1)

(1)

**Outcomes Measured** 

**Students' perception on feasibility and acceptability of intervention (11)** 

**Psychological Distress (10)** 




Stress Management for Medical Students: A Systematic Review 487

Despite of the four most common measured outcomes (i.e. students' perception, anxiety, depression and psychological distress), they were other important outcomes to be considered in future research such as loneliness (n=3), mood states (n=3), academic performance (n=3), health biomarkers (n=3), quality of life (n=2) and general wellbeing

Outcomes of interventions were summarized based on five categories which were brief intervention (less than 2 days), short-duration intervention (2 days to 4 weeks), mediumduration intervention (more than 4 weeks and up to 8 weeks), long-duration intervention

There were three brief interventions reported by previous studies (table 4) and all of them had significant positive impacts on psychological health of medical students (table 4). The massage therapy improved immunologic and physiologic health marker (Zeitlin et al., 2000). While the Medical Student Wellbeing Workshop improved awareness of participants about stress, its effect and management as well as a well-accepted intervention by

> - Reduced respiratory rate - Decreased anxiety state. - Decreased perceived stress - Decreased percentage of T Lymphocyte cells post intervention - Increased natural killer cell activity


effect and management.





Five short-duration interventions were reported by previous studies (table 5). About three interventions were reported to have significant positive impacts on psychological health of medical students (Bughi et al., 2009; Jain et al., 2007; Michie & Sandhu, 1994) whereas other outcomes were different from each intervention (table 5). Nevertheless, these facts had provided evidence of positive impacts of short-duration intervention on medical students'

There were six medium-duration interventions reported and most of them were well accepted by medical students as well as increased awareness of the students about handling

post intervention.

intervention.

**intervention Outcome Summary of outcome** 

**(n)** 


psychological health


marker (1)

(3) - Improved immunologic health

(more than 8 weeks) and other (duration was not mentioned in the articles).

(n=1) (table 3).

**Source and Country** 

**Zeitlin et al (2000), US.** 

**Yusoff & Rahim (2010), Malaysia.** 

**Yusoff (2011), Malaysia.** 

days)

participants (Yusoff & Rahim, 2010).

**Name of** 

Massage therapy

The Medical Student Wellbeing Workshop

The Medical Student Wellbeing Workshop

psychological health, awareness and general wellbeing.

Table 3. Summary of measured outcomes and instruments used to measure them.

Psychological distress level was measured by mostly by General Health Questionnaire 12 item (n=2) and the Distress Subscale of Symptom Checklist Revised (n=2) followed by the Depression Anxiety Stress Scale (n=1) and other inventories (table 3).

Respiratory Rate (1) Zeitlin et al (2000) Blood Pressure (1) Zeitlin et al (2000) Body Temperature (1) Zeitlin et al (2000) Pulse Rate (1) Zeitlin et al (2000)

General Well Being Scale (1) Bughi et al (2009)

Positive States of Mind Scales (1) Jain et al (2007)

Daily Emotion Report (1) Jain et al (2007)

Stress Knowledge Inventory (1) Kelly et al (1982)

Stressful Situations Rating (1) Kelly et al (1982) Hassles Scale (1) Nathan et al (1987)

The Inventory of Self-Hyonosis (1) Whitehouse et al (1996)

Self-Reporting questionnaire (1) Kiecolt-Glaser et al (1986), Health Chart (1) Nathan et al (1987) Duke-UNC Health Profile (1) Nathan et al (1987)

7 Questions covered on anxiety, depression and

**Quality of sleep (1)** Daily Dairies (1) Whitehouse et al (1996)

Questionnaire on procedural and non-

Table 3. Summary of measured outcomes and instruments used to measure them.

Psychological distress level was measured by mostly by General Health Questionnaire 12 item (n=2) and the Distress Subscale of Symptom Checklist Revised (n=2) followed by the

**Self-esteem (1)** A Self-Esteem Measure (1) Holtzworth-Munroe et al

**Personality (3)** Minnesota Multiphasic Personality Inventory

satisfaction (1)

**Hypnotic ability (1)** The Harvard Group Scale of Hypnotic Susceptibility (1)

procedural specialty (1)

Depression Anxiety Stress Scale (n=1) and other inventories (table 3).

(2)

INSPIRIT (2) Shapiro et al (1998), Jain et

Grade Point Average (3) Mitchell et al (1983), Kiecolt-

16 Personality Factor Test (1) Kiecolt-Glaser et al (1986)

al (2007)

al (1987).

(1985)

et al (1987),

Glaser et al (1986), Nathan et

Mitchell et al (1983), Nathan

Mitchie & Sandu (1994)

Whitehouse et al (1996)

Klamen (1997)

**(frequency) Instrument (frequency) Source** 

**Empathy (1)** Empathy Construct Rating Scale (1) Shapiro et al (1998)

**Outcomes Measured** 

**Spiritual Experience** 

**General Wellbeing** 

**Psychological State** 

**Distractive & Ruminative thought** 

**Knowledge of stress & its management** 

**Perceived stressors** 

**Intrinsic & Extrinsic Satisfaction (1)** 

**Preferred specialty** 

**General Health Status (2)** 

**choice (1)** 

**(2)** 

**(1)** 

**(1)** 

**(1)** 

**(1)** 

**(2)** 

**Academic performance (3)** 

**Positive** 

Despite of the four most common measured outcomes (i.e. students' perception, anxiety, depression and psychological distress), they were other important outcomes to be considered in future research such as loneliness (n=3), mood states (n=3), academic performance (n=3), health biomarkers (n=3), quality of life (n=2) and general wellbeing (n=1) (table 3).

Outcomes of interventions were summarized based on five categories which were brief intervention (less than 2 days), short-duration intervention (2 days to 4 weeks), mediumduration intervention (more than 4 weeks and up to 8 weeks), long-duration intervention (more than 8 weeks) and other (duration was not mentioned in the articles).

There were three brief interventions reported by previous studies (table 4) and all of them had significant positive impacts on psychological health of medical students (table 4). The massage therapy improved immunologic and physiologic health marker (Zeitlin et al., 2000). While the Medical Student Wellbeing Workshop improved awareness of participants about stress, its effect and management as well as a well-accepted intervention by participants (Yusoff & Rahim, 2010).


Table 4. Outcomes of brief stress management intervention (required duration of less than 2 days)

Five short-duration interventions were reported by previous studies (table 5). About three interventions were reported to have significant positive impacts on psychological health of medical students (Bughi et al., 2009; Jain et al., 2007; Michie & Sandhu, 1994) whereas other outcomes were different from each intervention (table 5). Nevertheless, these facts had provided evidence of positive impacts of short-duration intervention on medical students' psychological health, awareness and general wellbeing.

There were six medium-duration interventions reported and most of them were well accepted by medical students as well as increased awareness of the students about handling


Stress Management for Medical Students: A Systematic Review 489















There were seven long-duration interventions reported and most of them had significant positive effects on psychological health of medical students as well as they were well accepted by the students (table 7) while other outcomes were varied from each intervention ranging from increased awareness about stress management and it's important to improved immunologic health markers. Among these interventions, the Mind Body Medicine Skills

by high rate completion.


effect and management.



performance.

depression level.

symptomatology.

Workshop - Increased awareness about stress, its effect and management - Positive perception toward the

personality.

intervention.

intervention.

symptoms.

intervention.

more than 85%.

self-care.

type A behaviour.

**intervention Outcome Summary of outcome (n)** 


health (1).

feeling (1)




**Source and Country** 

Mitchell et al (1983), US.

Holtzworth-Munroe et al (1985), US.

Nathan et al (1987), US.

Shapiro et al (1998), US.

Lee & Graham (2001), US.

Redwood & Polak (2007), US.

**Name of** 

Support group

The stress management training course

The Mindfulness Based Stress Reduction

The Help programme

Student-led stress management program

of more than 4 weeks and up to 8 weeks).


Table 5. Outcomes of short-duration stress management intervention (required duration of 2 days to 4 weeks)

stress (table 6). However other outcomes were different from each intervention. Among the interventions, the Mindfulness Based Stress Reduction demonstrated very positive impacts on medical students' psychological health, empathy and spirituality (Shapiro et al., 1998). Nonetheless, these facts had provided evidence of positive impacts of the medium-duration intervention on medical students' psychological health, empathy, spirituality, awareness related to handling stress as well as general wellbeing (table 6).















Table 5. Outcomes of short-duration stress management intervention (required duration of 2

stress (table 6). However other outcomes were different from each intervention. Among the interventions, the Mindfulness Based Stress Reduction demonstrated very positive impacts on medical students' psychological health, empathy and spirituality (Shapiro et al., 1998). Nonetheless, these facts had provided evidence of positive impacts of the medium-duration intervention on medical students' psychological health, empathy, spirituality, awareness


post intervention.

related to handling stress as well as general wellbeing (table 6).

Seminar - Reduction of type A behaviour pre and post intervention.

effect and management.

of stressful events.

satisfaction.

intervention.

psychiatry.

behaviour.

behaviour.

symptoms.

and management.


**intervention Outcome Summary of** 

**outcome (n)** 

psychological health



choice (1)

(1)

(1)




(3)

**Source and Country** 

**Kelly et al (1982), US.** 

**Michie & Sandhu (1994), UK.** 

**Klamen (1997), US.** 

**Jain et al (2007), US.** 

**Bughi et al (2009), US.** 

days to 4 weeks)

**Name of** 

The stress management course

The stress management workshop

Mindfulness Meditation-Somatic Relaxation

The Brief Behavioural Intervention Program (BPIP)


Table 6. Outcomes of medium-duration stress management intervention (required duration of more than 4 weeks and up to 8 weeks).

There were seven long-duration interventions reported and most of them had significant positive effects on psychological health of medical students as well as they were well accepted by the students (table 7) while other outcomes were varied from each intervention ranging from increased awareness about stress management and it's important to improved immunologic health markers. Among these interventions, the Mind Body Medicine Skills

Stress Management for Medical Students: A Systematic Review 491

symptoms

anxiety

life.

symptoms.

depression.

level

levels

sIgA level.

Table 7. Outcomes of long-duration stress management intervention (required duration of

There were two interventions reported under other category. In general the outcomes of these interventions were related to improvement of psychological health, general wellbeing


Yoga exercise - Reduced distress

**intervention Outcome Summary of** 










**outcome (n)** 

**Source and Country** 

**Hassed et al (2009), Australia.** 

**Simard & Henry (2009), Canada.** 

**MacLaughin et al (2010),** 

more than 8 weeks).

and awareness about coping strategies (table 8).

**US.** 

**Name of** 

The Health Enhancement Programme (HEP)

The Mind Body Medicine Skills.

showed very good impacts on medical students' stress biomarkers such as Cortisol, DHEA-S and testosterone (MacLaughin et al., 2010). In general, the outcomes of these interventions were related to improvement of psychological health, stress biomarkers, immunologic health marker, awareness about stress and its management, and general wellbeing (table 7).


showed very good impacts on medical students' stress biomarkers such as Cortisol, DHEA-S and testosterone (MacLaughin et al., 2010). In general, the outcomes of these interventions were related to improvement of psychological health, stress biomarkers, immunologic health marker, awareness about stress and its management, and general wellbeing (table 7).

**intervention Outcome Summary of** 













stressful period.



loneliness state. - Lowered number of T Lymphocyte at the late

semester.

events.

scores.

scores.

health.

stress

intervention.

their stresses.

**outcome (n)** 


perception toward

stressor (1) - Improved quality of life (1) - Reduced hostility (1) - Improved stress biomarkers (1) - Improved mood disturbances (1)


(2).

**Source and Country** 

**Whitehouse et al (1996), US.** 

**Rosenzweig et al (2003), US.** 

**Finkelstein et al (2007), US.** 

**Hassed et al (2008), Australia.** 

**Name of** 

The Mindfulness Based Stress Reduction seminar

The Mind-Body Medicine: An Experiential Elective

The Health Enhancement Programme (HEP)

Self-hypnosis training


Table 7. Outcomes of long-duration stress management intervention (required duration of more than 8 weeks).

There were two interventions reported under other category. In general the outcomes of these interventions were related to improvement of psychological health, general wellbeing and awareness about coping strategies (table 8).

Stress Management for Medical Students: A Systematic Review 493

**Total participant [n1 + n2]/ total sample size [N]**

> 1st study 96/100

2nd s tudy 103/103

**Response** 

1st study 96%

2nd study 100%

35/35 100% Whitehouse

73/78 93.58% Shapiro et al

81/104 77.88% 1Jain et al

**rate Source** 

Nathan et al (1987)\*\*

et al (1996)\*\*

(1998)\*\*

(2007)\*\*

**Control Group size [n2]** 

1st study (year 1 medical students 1983) No Rx group = 46

2nd study (year 1 medical students 1984) No Rx group = 54

Waiting list control group = 14 year 1 medical students

Waiting list control group = 37 (mixed of premedical, year 1 and 2 medical students)

Waiting list control group = 30 (mixed of medical and allied health students)

\* Random sampling method \*\* Non-random sampling method 1Sample size was calculated Table 9. Summary of sample size of intervention and control groups for the randomized

For randomized control trial (RCT) studies (table 9), the smallest and biggest number of participants in an intervention were 4 and 50 respectively. The smallest and biggest number of participants in a control group were 4 and 54 respectively. Majority (n=6) of the RCT studies involved year 1 medical students as study subjects. The response rate for nonrandom sampling RCT studies (n=6) ranged from 72.5% to 100%. While the response rate for random sampling RCT study (n=1) ranged from 29.29% to 38.38%. It seems that response rate for random sampling RCT study substantially poorer than non-random sampling RCT

**Study design (frequency)** 

**Intervention Group size [n1]** 

1st study (year 1 medical students 1983) Intervention group = 50

2nd study (year 1 medical students 1984) Intervention group = 49

Intervention group = 21 year 1 medical students

Intervention group = 36 (mixed of premedical, year 1 and 2 medical students)

Medidation group = 27 (mixed of medical and allied health students) Relaxation group = 24 (mixed of medical and allied health students)

studies. On top of that, only one RCT calculated sample size.

control trial studies.


Table 8. Outcomes of other stress management intervention (duration was not mentioned in the articles).


**Country Name of intervention Outcome Summary of outcome** 

method.

patients.

between groups.

personality score.

martkers.

Table 8. Outcomes of other stress management intervention (duration was not mentioned in

**Control Group size [n2]** 

1st study (year 1 medical students 1979/1980) Lecture group = 13 No Rx group = 13

2nd study (year 1 medical students 1980/1981) Lecture group = 8 No Rx group = 8

No Rx group = 9 year 1 medical students

Waiting list control group = 17 year 1 medical students

**Kiecolt-Glaser** state (1)






> **Total participant [n1 + n2]/ total sample size [N]**

> > 1st study 38/99

2nd study 29/99

**(n)** 


psychological health


about coping strategies (1) - Improved

(1)

**Response** 

1st study 38.38%

2nd study 29.29%

24/40 72.5% Holtzworth-

34/34 100% Kiecolt-

**rate Source** 

Mitchell et al (1983)\*

Munroe et al (1985)\*\*

Glaser et al (1986)\*\*

**Source and** 

**Soskis (1978),** 

**et al (1986), US.** 

the articles).

**Study design (frequency)** 

Randomized controlled trial (7)

The Meditation &

Support group (hypnotic/ relaxation

exercise)

**Intervention Group size [n1]** 

1st study (year 1 medical students 1979/1980) 1st group = 12 2ns group = 7

2nd study (year 1 medical students 1980/1981) 1st group = 4 2nd group = 4

Intervention group = 15 year 1 medical students

Hypnotic/relaxation group = 17 year 1 medical students

Healing

**US.** 


\* Random sampling method \*\* Non-random sampling method 1Sample size was calculated

Table 9. Summary of sample size of intervention and control groups for the randomized control trial studies.

For randomized control trial (RCT) studies (table 9), the smallest and biggest number of participants in an intervention were 4 and 50 respectively. The smallest and biggest number of participants in a control group were 4 and 54 respectively. Majority (n=6) of the RCT studies involved year 1 medical students as study subjects. The response rate for nonrandom sampling RCT studies (n=6) ranged from 72.5% to 100%. While the response rate for random sampling RCT study (n=1) ranged from 29.29% to 38.38%. It seems that response rate for random sampling RCT study substantially poorer than non-random sampling RCT studies. On top of that, only one RCT calculated sample size.

Stress Management for Medical Students: A Systematic Review 495

related ethical, feasibility and practicality of randomizing participants into intervention and

This systematic review demonstrated that majority of interventions was conducted by psychologist/psychiatrist, offered as an elective course as well as seminar or workshop, consumed a duration of 360 to 540 minutes over 3 to 8 weeks and involved 30 to 50 participants. For RCT studies, majority involved year 1 medical students as study subjects, sample size for intervention groups ranged from 4 to 50 participants and relatively RCT used random sampling method had poorer response rate compared to non-random sampling (table 9). Perhaps stress management interventions should be conducted by general faculty members of medical schools instead of few experts so that the interventions can be implemented effectively to medical students. On top of that, most of the studies had not explained theoretical basis of the intervention was designed. Perhaps, future studies should describe the theoretical basis of stress management intervention was designed so that researchers could compare and come out with more effective intervention based on more robust theory of stress management intervention for medical students. It is worth highlighted that generally the interventions were categorised into brief, short-duration,

This review revealed that various aspects of health outcomes were measured ranging from students' perception up to health biomarkers. Despite the variability of measured outcomes, there were three main outcomes related to psychological health as measured by most of the studies which were anxiety, depressive and psychological distress symptoms. These outcomes were mainly measured by established psychological health measurements such as the State-Trait Anxiety Inventory, Brief symptoms Inventory, Symptoms Checklist Revised, Depression Anxiety Stress Scale and Beck Depression Inventory. Other important outcomes that should be considered in future researches such as academic performance, patient-doctor relationship, loneliness state, health biomarkers,

For the past 24 years, regardless of the duration of stress management interventions, this literature review revealed the interventions done on medical students had important positive outcomes on several areas related to health. The outcomes ranged from positive students feedback up to improvement of health biomarkers. The reported positive outcomes were related to 1) positive student feedbacks, 2) improved psychological health, 3) improved loneliness and mood disturbances, 4) improved physiologic and immunologic health markers, 5) improved quality of life, spirituality, and empathy, 6) improved psychological states of mind, 7) increased awareness about stress, its effects and management, and 8) improved perceived ability to cope effectively and positively. Despite of these positive outcomes, none of studies demonstrated effectiveness of the interventions

control groups (Finkelstein et al., 2007; Piaw, 2009; Katz, 2010).

medium-duration and long-duration stress management internvetions.

**4.4 Measured outcomes and instruments used to measure them** 

quality of life, and suicidal thoughts.

**4.5 Outcomes of the interventions** 

**4.3 Structure, facilitators and duration of intervention** 
