Well-Being of Students
Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and Canadian Medical Students
Dyrbye, Liselotte N. MD; Thomas, Matthew R. MD; Shanafelt, Tait D. MD
Dr. Dyrbye is assistant professor of medicine, Mayo Clinic, Rochester, Minnesota.
Dr. Thomas is assistant professor of medicine, Mayo Clinic, Rochester, Minnesota.
Dr. Shanafelt is assistant professor of medicine, Mayo Clinic, Rochester, Minnesota.
Correspondence should be addressed to Dr. Dyrbye, 200 First Street SW, Rochester, MN 55906; telephone: (507) 284-2511; fax: (507) 266-2297; e-mail: 〈firstname.lastname@example.org〉.
Purpose: To systematically review articles reporting on depression, anxiety, and burnout among U.S. and Canadian medical students.
Method: Medline and PubMed were searched to identify peer-reviewed English-language studies published between January 1980 and May 2005 reporting on depression, anxiety, and burnout among U.S. and Canadian medical students. Searches used combinations of the Medical Subject Heading terms medical student and depression, depressive disorder major, depressive disorder, professional burnout, mental health, depersonalization, distress, anxiety, or emotional exhaustion. Reference lists of retrieved articles were inspected to identify relevant additional articles. Demographic information, instruments used, prevalence data on student distress, and statistically significant associations were abstracted.
Results: The search identified 40 articles on medical student psychological distress (i.e., depression, anxiety, burnout, and related mental health problems) that met the authors' criteria. No studies of burnout among medical students were identified. The studies suggest a high prevalence of depression and anxiety among medical students, with levels of overall psychological distress consistently higher than in the general population and age-matched peers by the later years of training. Overall, the studies suggest psychological distress may be higher among female students. Limited data were available regarding the causes of student distress and its impact on academic performance, dropout rates, and professional development.
Conclusions: Medical school is a time of significant psychological distress for physicians-in-training. Currently available information is insufficient to draw firm conclusions on the causes and consequences of student distress. Large, prospective, multicenter studies are needed to identify personal and training-related features that influence depression, anxiety, and burnout among students and explore relationships between distress and competency.
The goal of medical education is to train knowledgeable, competent, and professional physicians equipped to care for the nation's sick, advance the science of medicine, and promote public health. Medical schools undertake an extensive selection process to identify intelligent and altruistic individuals with a strong commitment to these goals and then spend four years trying to prepare those individuals to achieve them. The U.S. and Canadian systems of medical education typically begin after candidates have achieved a bachelor's degree that includes at least basic training in biology, chemistry, and physics, as well as training in the humanities. Applicants typically have some experience caring for patients through employment or volunteer work prior to applying to medical school and must undergo standardized examinations and a rigorous application and interview process.
In addition to identifying individuals with the necessary aptitude and commitment to pursue a career in medicine, this process is intended to identify individuals who choose to pursue a career in medicine based on significant insight into the demands, challenges, and rewards of the profession. Once enrolled, students and schools make a mutual commitment intended to prepare students for a socially useful and personally fulfilling career.1
Based on these characteristics, one may anticipate medical school would be a time of personal growth, fulfillment, and well-being despite its challenges. Unfortunately, studies suggest the current educational process may have an inadvertent negative effect on students' mental health, with a high frequency of depression, anxiety, and stress among medical students.2–16 It has also been postulated that burnout, a measure of distress common among residents and physicians in practice,17–19 has its origin in medical school.20,21 A number of factors—including academic pressure,22 workload,2,23 financial concerns,23 sleep deprivation,23 exposure to patients' suffering and deaths,24,25 student abuse,26–30 and a “hidden curriculum” of cynicism31–38—have been hypothesized to contribute to this decline in students' mental health. Some have suggested that psychological distress among students may adversely influence their academic performance,22,39–41 contribute to academic dishonesty,42–45 and play a role in alcohol and substance abuse.13,29,46–49 Student distress has also been reported to be associated with cynicism,50–52 an unwillingness to care for the chronically ill,53,54 and decreased empathy.50,52,55 In recognition of the importance of these issues, the Association of American Medical Colleges (AAMC) report from the Ad Hoc Committee of Deans calls for the medical education system to take into account “the health and well-being of the learners” as part of the vision for improving medical education in the United States.56
In the present report, we describe our systematic review and evaluation of studies of personal and professional distress among U.S. and Canadian medical students, which we carried out in 2005 to address the following questions:
1. What is the prevalence of medical student distress? (We use the term distress here to cover depression, anxiety, burnout, and related mental health problems.)
2. How does the prevalence of distress in medical students in these countries compare to that among an age-matched population and other graduate students?
3. What personal and curricular factors are associated with student distress?
4. What are the causes of medical student distress?
5. What are the consequences of distress among medical students?
We have attempted to synthesize the findings of a large number of studies in as focused and concise a manuscript as possible. The manuscript discusses the significance of these findings, limitations of the current research, and specific areas where future research is needed in the discussion section of the manuscript. Due to the dissimilarities between the studies, use of different instruments to measure student distress, and other methodological limitations, it was not possible to pool the available studies for a meta-analysis. As such, the results are reported qualitatively with appropriate critical review.
We searched Medline and PubMed databases for peer-reviewed articles reporting primary data on medical student distress. Medical subject heading terms used were combinations of medical student and depression, depressive disorder—major, depressive disorder, professional burnout, mental health, depersonalization, distress, anxiety, or emotional exhaustion. The search was limited to articles published in English within the last 25 years (January 1980 to May 2005) and yielded a total of 248 citations. After reviewing the titles and online abstracts, articles were retrieved for full examination if inclusion in our study was likely or could not be determined. Reference lists of these articles were inspected to identify relevant additional articles. Studies conducted outside the United States and Canada were excluded due to significant differences between (1) the U.S. and Canadian student demographics (i.e., age at matriculation and prior schooling) and (2) the curricula of the U.S. and Canadian systems of medical training and these two factors in other systems around the world. Only studies that presented original, primary data on medical students separate from other learners, and that used standardized tools to assess anxiety, depression, burnout, or global mental health were included. Studies that assessed student reaction to a specific recent event (such as suicide of a colleague) or evaluated test anxiety were also excluded.
Forty studies met the eligibility criteria. Thirteen studies evaluated medical student depression, one anxiety, eight general mood disorder, and ten a combination of these variables. No studies of burnout among medical students were identified. The majority of studies on anxiety and depression were small, cross-sectional surveys intended to document prevalence and associations between depression/anxiety and students' demographic characteristics, personality attributes, academic performance, and stress. Although the studies were conducted in a variety of geographic settings, only three included students from more than one school. Sixteen longitudinal studies explored how student distress changes through the course of schooling or evaluated the effects of an intervention. Table 1 lists the studies, sample sizes, student populations, instruments used, and covariates measured in the studies we reviewed. Table 2 summarizes response rates, prevalence of distress, and other statistically significant findings. (Both tables are in the Appendix.)
A variety of tools to assess depression, anxiety, and overall mental health were used in the included articles. We describe these tools in detail below, both to help readers interpret our findings and also to assist other medical educators who are interested in selecting tools for their own research on student stress and related topics.
The most commonly employed tools to evaluate depression were the Beck Depression Inventory (BDI)57–59 and the Center for Epidemiological Studies Depression Scale (CES-D),60–62 followed by the depression subscale of the Hopkins Symptom Checklist (HSCL),63 the depression subscale of the SCL-90,64 and the Zung Self-Rating Depression Scale (SDS).65 The most commonly used tools to evaluate anxiety were the anxiety subscale of the SCL-90,64,66 the Symptom Checklist Anxiety Scale,66 the State-Trait Anxiety Inventory (STAI),67 the anxiety subscale of the HSCL and the tension-anxiety subscale of Profile of Mood States (POMS).68 Composite scores for the Brief Symptom Inventory (BSI),69 HSCL, SCL-90, and POMS were also used as measures of overall level of psychological distress in several studies. All of these instruments are considered standard tools that have been used in a wide variety of settings to assess mood disorders.57–82 The psychometric properties of these instruments have been described in detail elsewhere.57–82
The BDI is a well-established questionnaire used to screen for depression,57,58 which has been validated for use in nonpsychiatric patients57,70 including college students71,72 and medical students.73,74 It correlates well with a diagnosis of clinical depression in nonpsychiatric patients (mean correlation coefficient 0.60) as well as do other tools used to measure depression such as the SDS57 and the depression-dejection subscale of the POMS75 (mean correlation coefficient 0.71, 0.60, and 0.75, respectively). Zoccolillo and colleagues74 demonstrated concurrent validity between BDI scores and diagnosis of depression using DSM-III diagnostic criteria among medical students. While various ranges of scores have been advocated as suggesting a diagnosis of clinical depression (rather than simply “depressive symptoms”), a score of 10–18 is generally considered an indicator of mild to moderate depression, 19–29 indicates moderate to severe depression, and 30–63 indicates severe depression.57 The shorter 13-item BDI used in some studies of medical students correlates exceptionally well (r = 0.96) with the original 21-item BDI and has a similar correlation with a diagnosis of depression (r = 0.61). On the 13-item BDI, scores of 5–7, 8–15, and ≥ 16 suggest mild, moderate, and severe depression, respectively.59
The CES-D is a 20-item self-reported rating scale designed by the National Institute of Mental Health to measure depressive symptoms in the general population. This instrument has high internal consistency (0.85), adequate test-retest repeatability, and substantial concurrent and construct validity in the general population.60,61 A score of ≥ 16 is considered indicative of depression,60,61 although a score of ≥ 27 improves its specificity.62,76
The HSCL is a 58-item tool that scores symptoms in five dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, and anxiety. Each dimension is scored individually but also pooled to generate a “total symptom score.” The HSCL has primarily been used in psychiatric outpatients,63 where the internal consistency and test-retest reliability have been 0.86 and 0.81 for the depression subscale and 0.84 and 0.75 for the anxiety subscale. The SCL-90, SCL-90-R, Symptom Checklist Anxiety Scale, and BSI are related instruments that are sequential derivations of the original HSCL tool. The SCL-90 added hostility, phobic anxiety, paranoid ideation, and psychoticism.64 The SCL-90-R comes with an interpretive report that is based on age-appropriate nonpatient normative groups and provides an overview of a study subject's symptoms and their intensity. The BSI is an abbreviated version of the SCL-90-R that evaluates 9 symptom dimensions; and is typically scored by the composite General Severity Index (GSI), a global index of distress,69 where a score of more than 63 indicates clinically relevant psychological distress.83 The internal consistency of the BSI ranges from 0.71 to 0.83, with a test-retest correlation of 0.9 for GSI scores among psychiatric outpatients.69
The POMS measures six mood/affective states: tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment. Both individual subscale scores and a total mood disturbance score (considered a global measure of affective state) are calculated. The instrument has been validated in numerous study populations68,79 and has good internal consistency and test-retest reliability.68 The POMS depression-dejection subscale correlates well with the BDI (r = 0.69) and the POMS tension-anxiety subscale correlates with the STAI trait (r = 0.7) and state (r = 0.72) score.79
The SDS is a 20-item questionnaire evaluating symptoms of depression including questions regarding mood, somatic, and psychological disturbances.65 The SDS is considered a good discriminator between depressed and nondepressed individuals.81 A score of less than 50 is normal, 50–59 suggests mild depression not typically requiring medical treatment, 60–69 indicates moderate depression typical of patients receiving outpatient treatment for depression, and 70–100 indicates severe depression characteristic of patients hospitalized for treatment of depression.80 The reliability coefficients of the SDS is r = 0.88–0.9367,81 and the instrument correlates with the Minnesota Multiphasic Personality Inventory (MMPI) (r = 0.55–0.70) and the Beck Depression Inventory (r = 0.52–0.8).82
The STAI is a derivation of the MMPI widely used to measure anxiety. The STAI has two subscales: the A-State scale, which indicates current level of anxiousness, and the A-Trait scale, which indicates how the respondent generally feels. The internal consistency alpha coefficients are high for both subscales at 0.93 for A-State and 0.87 for A-Trait in the general population.67
Prevalence of medical student depression
Sixteen cross-sectional studies meeting the inclusion criteria evaluated student mood/depression. Six studies evaluated medical student depression; one dealt with general mood disorder and nine dealt with a combination of these two variables. Most studies surveyed either a limited student group (e.g., first-year students) or a limited subset of students (e.g., women).
Whether or not medical students begin their training with a greater predisposition to depression than is the case for comparable nonstudent populations is unclear. Two studies suggest medical students have more symptoms of depression than the general population and age-matched peers at the time of matriculation. In a study published in 1988, Sherry et al.84 measured using SDS) the prevalence of depressed mood among 95 first-year female medical students matriculating at two Northeastern medical schools. Mean scores were below the cutoff for depression,80 but were higher than age- and gender-matched population norms (mean = 40.1 ± 8.5 for medical students84 and mean = 34.4 ± 6.8 for 20–29-year-old women67). Buchman et al.85 reported similar findings in a 1986–87 survey of 243 students at the University of California, San Diego, School of Medicine who completed the CES-D at the time of orientation.61,85
Such findings, however, are not uniform. Lloyd et al.86 reported that at the time of orientation, fewer first-year students (n = 199) at the University of Texas Medical School at Houston had CES-D scores ≥ 16 than did normative samples (n = 16, 13%) among medical students versus 15–19% in the general population).60 Hendryx et al.87 reported similar findings in a questionnaire administered at the end of the first year at a private medical school in Southern California (n = 175; 75% response rate). Although 21 students (19%) had mild depression (BDI > 9), the mean 21-item BDI scores among medical students were lower than is true for both the general population and college student norms (mean 5.9 ± 5.8 for medical students,87 mean 6.8 ± 5.5 for general population,79 and mean 7.7 ± 5.1 for college students88). Likewise, Givens et al.6 found 46 (24%) first- and second-year students, who completed the 13-item BDI in the spring of 1994 at the University of California, San Francisco School of Medicine, were depressed (score ≥ 8).
Three cross-sectional studies surveyed medical students in all 4 years of training.89–91 While it is unclear whether or not at the start of medical school the percentage of depressed students is higher than the percentage of depressed individuals in comparable nonstudent population, studies of students in the later years of training consistently suggest a greater degree of depression among medical students. Lloyd et al.90 surveyed 745 students (response rate 39%) at the University of Texas Medical School at Houston near the end of the 1981–82 academic year using the HSCL and found depression subscale scores were higher than is the case in population norms (mean 1.61 ± 0.54 for medical students versus mean 1.14 ± 0.28 for the general population). A study of students at the University of Calgary Faculty of Medicine had similar findings.91 In 2001–02, Tjia et al.89 surveyed students in years one through four at a private medical school (n = 564; response rate 57%) and found moderate (13-item BDI ≥ 8) and severe depression (13-item BDI scores ≥ 16) in 49 (15%) and 7 (2%) students, respectively.
Longitudinal studies assessing medical student depression have focused primarily on changes occurring during the first year of schooling11,13,92–96 with one study following some students into the second year74 and two spanning all four years.7,8 Both Vitaliano et al.92 and Richman et al.93 reported that more students were depressed at the end of their first year than at their orientation. Ball et al.13 reported an increase in BDI scores during the first semester of training but noted scores peaked midsemester and returned to baseline by the end of the semester.
In contrast to these results, two other longitudinal studies94,96 found depressive symptoms were similar at the beginning and end of the first year. In 1978, Lloyd and Gartrell96 surveyed 159 first-year students at the University of Texas Medical School at Houston at orientation, 4 months later, and at the end of the academic year. Mean HSCL Depression subscale scores were similar initially and at the end of the year although women had a greater increase in depressive symptoms midyear (p < .01). Pyskoty et al.94 also reported that there was no change in depression scores in first-year students at one school during the 1987–88 academic year.
One prospective study followed students through the first two years of training. In 1982–83, Zoccolillo et al.74 invited all first- and second-year students at the Washington University School of Medicine to be prospectively monitored for depression by monthly completion of the BDI. Three hundred and four students agreed to participate (79% of eligible students) with some students followed up for one year and others followed up for two years. At each time point, students who scored above 9 on the BDI were interviewed using the Diagnostic Interview Schedule (DIS) to formally diagnose depression. After completion of the study, a sample of students who had not scored above 9 at any time point were randomly selected to be interviewed to determine if the written questionnaire tool had missed cases. Sixty-eight students (22%) scored above 9 at some time point during the study, of whom 93% were interviewed. Twenty-three (37%) of these students were diagnosed as having major depression after completing the DIS. The mean BDI score of these 23 students was 13.8 ± 6. None of the randomly selected “control” sample reported having depressive symptoms during the study period. After one year 8 of 124 (6%) first-year students and 7 of 87 (8%) second-year students were depressed. By two years 11 of 91 (12%) students were depressed. The estimated lifetime prevalence of major depression among these students was at least three times higher than the lifetime prevalence among the 18–24-year-old cohort in the Epidemiologic Catchment Area study.74
Two prospective studies followed medical students through all four years of medical school.7,8 Clark et al.7 surveyed 116 students at six time points during the four years of training (overall participation rate 96%; response rate range for individual questionnaires (70–88%), and reported 12% (number of students varied) students experienced mild to moderate depression (21-item BDI > 14) at some time point during medical school. Mean BDI scores peaked at the end of the second year but remained higher than baseline scores throughout the duration of the study. At peak, 24 of 96 (25%) students experienced mild to moderate depression (21-item BDI scores ≥ 14). In the fall of 1987, Rosal et al.8 surveyed 300 students prior to matriculation and again during the middle of the second and fourth years. Only 99 students completed all three surveys due to a steadily decline in response rate (88%, 65%, 48%). Similar to the findings of Clark et al.7 CES-D scores peaked during the second year but remained higher than baseline among fourth-year students. Forty-eight (18%) at baseline, 67 (39%) by the middle of the second year, and 39 (31%) by the middle of the fourth year had CES-D scores ≥ 80th percentile of population norms.8
Prevalence of medical student anxiety
Only three cross-sectional studies have explored medical student anxiety.90,97,98 In 1978, Vontver et al.97 administered the STAI to 349 second-year students (response rate 93%) and found mean trait anxiety scores were substantially higher than the mean score among 20–29-year-olds in the general population (mean 43 ± 3.8 for medical students versus mean 32.7 ± 7.37 for men and mean 36.85 ± 8.41 for women in the general population).67 Similarly, in the report by Lloyd et al.90 medical students in all four years had mean HSCL anxiety subscale scores more than a standard deviation higher than the norms for the general population. Hojat et al.98 used an abbreviated version of the Taylor Manifest Anxiety Scale and evaluated differences by gender, which are discussed below.
Four longitudinal studies92–94,96 reported on changes in anxiety through the course of schooling. Vitaliano et al.92 noted mean baseline anxiety scores (Symptom Checklist Anxiety Scale) among male medical students were one standard deviation higher than general population norms but did not change appreciably over the course of the first year. In contrast, mean anxiety scores among female medical students were similar to mean anxiety population norms at baseline but were one standard deviation higher than mean anxiety population norms by the end of the first year of training. Pyskoty et al.94 reported no change in anxiety between the fall of the first and second years. The other 2 longitudinal studies focused on evaluating differences by gender and are discussed below.93,96
Global mental health of medical students
In the studies that investigated mental health in a more global fashion, medical students also tended to have greater overall psychological distress than is found in the general population.83,90,91,99,100 In two separate studies at the University of Calgary Faculty of Medicine, Toews et al. reported total GSI scores on the SCL-90-R91 and SCL-9099 among first- to fourth-year medical students that were higher than those for population norms.101 In a survey of 703 first- and second-year students at the University of Washington School of Medicine conducted in the spring annually between 1980 and 1983 (response rate 86%),100 151 (25%) students had SCL-90 scores above the 98th percentile of nonpatient norms. Lloyd et al.90 and Henning et al.83 reported similar findings.
Minimal longitudinal information is available on global mental health among medical students and have primarily focused on gender or analysis by intervention (please see below).95,96,102
Distress among medical and nonmedical students
Four studies meeting the inclusion criteria investigated whether increased distress is unique to physician training or is a characteristic of professional/graduate school training in general. In the spring of 1996, Henning et al.83 surveyed 988 medical (n = 221), dental (n = 102), pharmacy (n = 72), and nursing (n = 82) students at the Medical University of South Carolina College of Medicine using the BSI (overall response rate 48%). The mean gender-normed GSI scores were 54.7 ± 10.2 for medical students, 56.9 ± 10.2 for dental students, and 62.3 ± 8.8 for pharmacy students, with pharmacy students being more distressed than medical and dental students, whose levels of distress were the same (p < .05). Thirty-six (50%) pharmacy students had clinical psychological distress (GSI T-score ≥ 63) in comparison to 46 (21%) medical students and 30 (29.7%) dental students (p < .001). While these students were similar in age, pharmacy students were dramatically more likely to be women (56 pharmacy students [78%], 103 medical students [47%], 28 dental students [27%]) and to have had prior treatment for mental health problems (16 pharmacy students [22%]. 26 medical students [12%], 8 dental students [8%]). No effort was made to control for these variables, confounding interpretation of the results.
In the two studies of students at the University of Calgary,91,99 Toews et al. compared SCL-90 and SCL-90-R scores of medical students, residents, and graduate science students. In the 1991–92 study,91 graduate students had the highest scores on all the SCL-90-R indices, with the composite scores (GSI) being statistically different between graduate students and residents (p < .05). Medical students scored lower than graduate students but higher than residents on the depression and anxiety subscales and had a higher composite score. In the 1994–95 study,99 scores on the depression and anxiety subscales and composite score differed between graduate students, residents, and medical students (p < .001). Graduate students had the highest depression and anxiety subscale scores as well as the highest composite score, and medical students had greater anxiety subscores than did residents. Male medical students had higher depression and composite scores than did male residents, but female residents had higher depression and composite scores than did female medical students. Kellner at al.103 surveyed 60 first- and third-year medical students and 60 first- and third-year law students at the University of New Mexico during the second semester using the HSCL. Although they reported medical students had lower depression subscales scores than did law students,103 methodological issues (including sample size, methods of student recruitment, and response rate) limit interpretation and generalizability of the results.
Distress and demographic variables
Women in the general population have a higher lifetime risk of depression104–106 and anxiety106,107 than men do. Comparisons of depressive symptoms by gender among medical students have yield mixed findings, with 4 of 5 cross-sectional studies85,86,89,98 and 3 of 7 longitudinal studies7,92,93 reporting no difference in depression scores by gender. Lloyd et al.90 reported that female first- to fourth-year students at the University of Texas Medical School at Houston scored higher on the HSCL depression subscale than did male students (p < .01; response rate 39%). Camp et al.108 found that despite similar SDS scores at baseline among 275 first-year medical students at Bowman Gray School of Medicine (now Wake Forest University School of Medicine), female medical students were 2.68 times more likely than males to have an increased SDS scores by November of the first year. Similarly, Zoccolillo et al.74 also reported more female than male medical students (10 of 64 female students [16%] versus 16 of 240 male students [7%]; p < .05) became depressed during the first 2 years of schooling. Although variation in response rate (range 60% to 93%) somewhat confounds results, Lloyd et al.96 reported a greater increase in depressive symptoms midyear among female than among male medical students (p < .01) that persisted only at a trend level (p < .06) by the end of the first year. The two four-year longitudinal studies exploring the effect of gender came to different conclusions, with no difference in the likelihood of becoming depressed based on gender in the study by Clark et al.7 and female students having higher mean depression scores (CES-D) at the end of both the second and fourth years in the study by Rosal et al.8
Five studies reported on differences in anxiety by gender.90,92,93,96,98 In the previously mentioned cross-sectional study by Lloyd et al.90 female medical students reported higher anxiety than their male colleagues did (p < .05). In 1999, Hojat et al.98 reported similar findings. In the three longitudinal studies, baseline anxiety scores were similar among men and women; however, women developed higher anxiety levels through the course of the first year than their male counterparts did. This increase demonstrated a trend toward significance in the first study (p < .10),93 was significant in the second study (p = .001),92 and was present only midyear in the third study (p < .01) with no differences by gender at the end of the year.96
Four of the ten studies assessing students' global psychological state reported results by gender, with all studies demonstrating higher psychological distress among female medical students.90,96,99,100 In the cross-sectional survey of 745 first- to fourth-year students at the University of Texas Medical School at Houston, mean total HSCL scores were 87.2 for male students and 98.2 for female students (p < .01).90 Similarly, both Vitaliano et al.100 and Toews et al.99 noted higher SCL-90 scores among female students. Only one longitudinal study reported global mental health by gender.96 Lloyd et al.96 found HSCL scores were generally stable for men over the course of the first year (84.2, 85.5, and 85.4) but increase for women (85.4, 92.9, and 93.9). The midyear increase in total symptom score for female medical students was statistically significant (p < .05).
Marriage and children.
In 1996, approximately 4,272 (32.4%) of medical students were married and another 1,525 (11.6%) were engaged or partnered by the time of graduation.109 Lower stress has been found among married students relative to their single counterparts. A longitudinal study of 61 medical students110 attending a private East Coast medical school measured stress by attrition rates, a nonvalidated Likert scale, and interviews (participation rate not reported). Six of 7 students who withdrew were married and 17 (33%) married students, in comparison to 44 (43%) unmarried students, had considered withdrawing from medical school. At the conclusion of the first, second, and third years, mean stress scores were higher among unmarried students (p < .05). When students married, they reported a decrease in stress over the subsequent year (p < .05). Interview sessions supported the hypothesis that marital partners provide emotional support to their spouses. Katz et al.111 recruited married medical students and their spouses from a large Southeastern medical school to explore effects of stress on marital satisfaction and depressive symptoms. Fifty of these married students were screened and asked to invite their spouses to participate. Out of 100 possible individuals, 71 completed the questionnaires (41 medical students and 30 spouses). Both stress and marital support correlated with depression (p < .001), with predicted values for depression (BDI score) differing as a linear function of perceived support among high-stress medical students. Among married students with high stress scores on the Perceived Stress Scale,112 those who reported high marital support had lower BDI scores than did those who reported low marital support. Perceived marital support also inversely correlated with medical students' BDI scores (r = –0.47, p < .01).111 Despite methodological limitations, both these studies suggest that the supportive quality of the marriage relationship rather than marriage itself may modulate the experience of stress.110,111 Henning et al.83 also noted less psychological distress (BSI) among married students (r = –0.15, p < .05); however the correlation coefficient was small, calling into question the importance of this finding.
Not all researchers have found that marriage is associated with reduced distress. In a longitudinal study by Rosal et al.,8 married students had higher depression scores (CES-D scores) at the start of medical school (p = .04), and marital status did not predict second-year CES-D scores or the magnitude of the change in CES-D scores between the first and second years.
Although marriage is relatively common among medical students, according to the AAMC's Graduation Questionnaire, in 1995, 1,678 (13%) students had children by the time of graduation.113 (1995 was the last year this question was administered.) While childbirth and childrearing are typically considered positive life events, children add a level of complexity to students' lives,114,115 and little is known about the mental health consequences of pregnancy or childrearing during medical school. Only one study examined the mental health impact of childrearing among medical students. Rosal et al.8 found that depression scores (CES-D) scores at the start of medical school were higher among students of both sexes who had children (p = .06). In the bivariate analysis, having a child was also associated with higher second-year CES-D scores among women (p = .008) but not men. Similarly, women with children had a greater increase in their CES-D scores between the first and second years of medical school than did women without children (p = .001), while a difference was not found between men with or without children. Although this study suggests that the mental health impact of having a child during medical school may be gender-specific,8 further studies are needed.
Stressful personal life events.
Besides the rigors of training, medical students face major personal life events (illnesses, deaths of family members, marriages, births of children, etc.) common to individuals their age. Such personal life events are known to contribute to depression, anxiety, and substance use in the general population.116–121 Among first- and second-year students at the Jefferson Medical College of Thomas Jefferson University, 175 (15%) had experienced the death of a family member, 297 (25%) had experienced a personal illness or injury, 420 (36%) had experienced a change of health in a relative, and 491 (42%) had experienced financial problems in the last 12 months.98 Despite the frequency of these events, Vitaliano et al.92 found no correlation between the experience of a stressful life event (engagement/marriage, pregnancy/birth, death of family member or friend, physical illness/injury, or serious illness in family member) and student distress.
The education of a diverse group of learners is a stated priority of the AAMC.56 Despite significant efforts to increase minority representation in the physician workforce by accepting and training minority medical students, increased rates of attrition (e.g., dismissal or withdrawal) among minority stu-dents limit the effectiveness of such efforts.122–129 Little is known about how the mental health of minority students relates to their higher rate of attrition.130 In a one-year longitudinal study of 184 first-year medical students at a state medical college in 1987 (response rate 86%: 90 whites, 19 blacks, and 17 Hispanics), no differences in mental health were observed by race or ethnicity.94 All the underrepresented minority students in this study attended a prematriculation program for minority students, making the generalizability of the results to other medical schools nearly two decades later uncertain. Camp et al.108 found no association between depression and race among 238 white and 39 nonwhite students, while Henning et al.83 reported slightly lower distress among minority students (r = −0.14, p < .05). In Tjia et al.'s89 cross-sectional study of first- through fourth-year students (208 whites, 62 Asians, 29 Hispanics, 17 blacks, and six other), Hispanic students were 3.4 times more likely to be depressed (BDI ≥ 8) than were non-Hispanic students.
Distress and other variables
Based on research suggesting that personality traits influence an individual's perception of stress,131,132 achievement in medical school,133–136 and transition from suicidal ideation to suicide planning,137 a number of investigators have studied the relationship between medical student distress and personality.7–9,11,83,85,86,92,93,108,135,138–141 These studies suggest the traits of self-actualization, self-awareness, and sense of fulfillment may lower the risk of depression,108 while maladaptive perfectionism,135 socially prescribed perfectionism (perception that others expect a great deal of you),83 Type A personality,85,92 and anger suppression8,85,92 may increase the risk of depression.
Some degree of stress is typically considered a normal and unavoidable aspect of both medical training and the practice of medicine. While measuring stress was not the focus of any of the studies identified, several studies suggest stress varies over time8,92 and peaks in the second year of medical school.8 Toews,99 Vitaliano,100 and Notman et al.142 identified the volume of information to learn, time constraints, examinations (and other forms of evaluation), competition, intimate relationships, money, family concerns, and feelings of self-doubt as self-reported stressors for medical students. Others have suggested an unstructured learning environment, long on-duty assignments, abuse, ethical challenges, and exposure to human suffering as additional sources of distress. 23,25,26,32–35,37,131,143–146
Stress may motivate some but not all students.131 Several studies explored the relationship between level of perceived stress and student depression/anxiety. Perceptions of stress were found to correlate with depression (p < .001),9,85,111,142,147 anxiety,142,147 somatic symptoms (p < .001),9 and health problems,99,142 and to predict future risk of depression (p < .001).8 The lack of a validated instrument to assess stress in the vast majority of these studies is a major limiting factor.
How students cope with stress may influence their adjustment to medical school and whether or not stress detrimentally affects their quality of life. Limited evidence suggest coping strategies, such as cognitive restructuring and problem solving, may protect against symptoms of depression, while disengagement strategies, such as problem avoidance and social withdrawal, appear to increase the risk of depression.9,11 Vitaliano et al.11 found that first-year students decrease their reliance on engagement coping strategies and use more disengagement coping strategies as the first year progresses,92 which temporally coincides with an increase in depression during the first year.92,93
While calls for curricular changes to address sources of distress attributable to the training experience have been made,7,33,35,148–151 little is known about how the curriculum contributes to distress, how it should be changed, and what effects could be expected. Only three of the identified studies investigated the relationship between the curriculum or training process and psychological well-being. Vontver et al.97 randomized 40 volunteers from the second-year class of 349 students to pelvic exam instruction from a professional patient or control group and found no difference in the pre- or postintervention STAI scores between groups. Camp et al.108 evaluated first-year medical students assigned either to a problem-based learning (PBL) curriculum or to a traditional lecture-based curriculum (LBL). There were no differences in SDS scores at baseline, and the weak relationship between curriculum type and follow-up SDS scores (p = .074) disappeared after adjusting for other variables. Not surprisingly, Ball et al.13 found a moderate association between first-year students' midterm satisfaction with their education (reported on a seven-point Likert scale) and their depression severity (r = –0.47, p < .001). However, issues with cause-effect cloud interpretation. Further studies are necessary to detect what curricular factors play a role in student distress.
Consequences of student distress
Despite the prevalence of student distress detailed above, little research has been done on the consequences of depression and anxiety among medical students. Although both Givens et al.6 and Tjia et al.89 documented that few students (22% to 27%) with mental health problems access counseling services,6,89 only Clark et al.7 investigated the relationship between mood and academic performance. In their four-year longitudinal study first- and second-year grade point averages did not correlate with BDI scores, although students with severe dysphoria (BDI scores ≥ 21) at any time point during medical school had lower first-year grades. BDI scores in April of both the first and second years inversely correlated with the National Board of Medical Examiners Part I exam scores (r = –0.21 and –0.22, p = .04 and 0.03, respectively),7 although the students with the lowest BDI scores also had the highest undergraduate grade point average, making the basis of this association uncertain.152 Students with severe dysphoria were more likely to quit medical school despite being in good academic standing at the time of departure. Although the reasons for attrition from medical school have not been well documented,153–155 medical schools report that poor academic standing is the culprit less than half of the time.153,156,157 In one study, Fogleman et al.155 found that psychological morbidity was second to academic performance as the reason for temporary or permanent withdrawals among 818 students attending the University of Tennessee Health Science Center College of Medicine between 1974 and 1977.
Anxiety, stress, and tension are also cited as common reasons for alcohol consumption among medical students.46,49,158 Although problematic alcohol consumption is common in both age-related peers159,160 and among medical students13,46–48,161,162 up to 20% of first-year medical students have admitted to excessive alcohol intake.13,47,161 Persistent high alcohol use throughout training parallels student distress.13,47,162 Only Clark et al.7 have explored the relationship between alcohol consumption and mood. In their longitudinal study, severe dysphoria (BDI scores ≥ 21) at any time point during medical school was not associated with abuse of alcohol or other drugs during medical school, but did correlate with drinking less alcohol in the second and third years of school (p = .009 and p = .04).
Interventions to prevent distress
Three studies explored the outcome of an intervention on depression,13 anxiety,163 and overall mental health.102 Among approximately one-third of the first-year students at the Indiana University School of Medicine,13 neither receiving written feedback on depressive symptoms and alcohol usage (n = 29) nor attending a one and a half hour lecture and discussion group on self-care (n = 23) affected future depression scores or alcohol use. In 1980, Mitchell et al.163 randomized 99 first-year students (participation rate 29%) at Creighton University School of Medicine to support groups, a lecture on stress management, or no intervention. No differences in STAI or BDI scores were found among the groups; however, the small sample size and major problems with methodological design and response rate (only 24 participants' information included in analysis) confound interpretation.
Rosenzweig et al.102 evaluated the effect of an elective seminar on mindful-based stress-reduction (MBSR) techniques intended to foster concentration, insight, and relaxation through nonjudgmental awareness of current events on student mood disorder using the POMS. All second-year students at the Jefferson Medical College of Thomas Jefferson University were offered a participation in this seminar from 1996–2000 with approximately 40 students (18%) from each class participating. Among the 302 students who completed the questionnaire, 140 had participated in the MBSR seminars (response rate among participants 87.5%), and 162 had not participated (response rate among nonparticipants 22%). Instruction in stress reduction appeared to reduce the adverse impact of stress on mental health; however, selection bias and response bias were major confounders.
As stated earlier, medical school training is intended to prepare graduates for a personally rewarding and socially meaningful career promoting health and caring for the sick. Unfortunately, as the reports we have described show, this is a time of great personal distress for physicians-in-training. Despite the fact that most studies to date have been single-center, cross-sectional studies, the existing literature consistently demonstrates higher overall psychological distress among U.S. and Canadian medical students relative to both the general population and age-matched peers. Whether or not distress among medical students is comparable, higher, or worse than distress among other professional students cannot be conclusively ascertained from the available studies. Regardless, the importance of such comparisons is debatable, since distress among any of the groups should not be disregarded, no matter how the groups' distress levels compare.
Studies of medical students in other parts of the world under a wide range of systems of medical training have also identified a high frequency of distress.2–5, 14, 164–171 In a longitudinal study from the United Kingdom, 63 (37%) of students had poor mental health (GHQ-12 score greater than 3) by the middle of the first year, and 48 (31%) and 34 (22%) had poor mental health in the fourth year and fifth year, respectively.2,5 Another U.K. study of first-year students found the incidence of poor mental health doubled over the course of the first year, increasing from 48 (25%) to 108 (52%).3 In 2001, Aktekin et al.4 reported a similar worsening in global mental health, depression, and anxiety between the first-year orientation and the beginning of the second year among Turkish medical students. Dahlin et al.171 recently reported 40 (13%) Swedish medical students were depressed in comparison to 48 persons (7.8%) in an age- and gender-matched population sample (p < .05), with approximately one third of the students reporting thoughts of suicide during the course of training. Tyssen et al.14 also reported a high prevalence of suicidal thoughts among senior Norwegian medical students, with 33 (6%) having made a plan to commit suicide during medical school.
Despite the strikingly high prevalence of distress, little is known about how demographic variables, personality characteristics, and stressful life events relate to student distress. Overall, the studies suggest that psychological distress may be higher among female students than their male colleagues. Although some may attribute this difference to similar trends in the general population, a number of studies found no difference in anxiety and depression among male and female medical students at the start of medical school but greater increases in distress among female students through the course of training.92,93,96,108 This finding suggests that the differences observed by gender in several studies may have other origins and warrant further investigation. Minimal information is available regarding unique challenges faced by other student populations such as minority students and students with children, and additional research in this area would also be useful.
No studies on burnout among U.S. or Canadian medical students were identified in our systematic review, despite speculation that residents' burnout has its origin in medical school.20,21 Studies of recent medical school graduates suggest burnout may adversely impact professionalism17,18,172and patient care17,18; exploration of burnout among medical students would lead to useful insights into this problem.
Student distress may influence professional development8,22,23,54,173–177 and appears to adversely impact academic performance,7,22,39–41,178–180 contribute to academic dishonesty42–45 and substance abuse,13,29,46–49 and play a role in attrition from medical school.7,155 The increase in cynicism,50–52 decay in humanitarian attitudes,53,54 and decline in empathy50,52,55 documented during the four years of medical school parallel the incidence of student distress, suggesting a possible relationship between these variables. Studies of recent medical school graduates also suggest that distress may negatively affect quality of patient care,17 patient safety,17 and professionalism.181 On a personal level, distress can be devastating to the individual student by contributing to substance abuse,46,49,158 broken relationships,143 decline in physical health, poor self-care (e.g., lack of exercise, poor diet),13,161 and even suicide.137
Widespread distress among medical students has now been recognized for several decades. Future studies are needed to explore causes, consequences, and solutions for this problem rather than simply chronicling the problem. A great deal of research and work is still needed to determine how academic training programs can structure their curricula, systems of evaluation, and support systems to reduce student distress and identify and support struggling students. Whether opportunities for shared reflection,182,183 training in stress management,184–188 or promotion of self-care/coping strategies3,9,150,164 can reduce student distress is not established and is worthy of investigation. The potential for enhanced well-being to enhance student and physician professionalism is largely unexplored.
Hypothesis-driven, prospective, multicenter studies are desperately needed to provide valid, generalizable information on this issue. Historically, institutional support and funding for such studies have been limited,189 and this problem must be remedied. Additional research to improve our understanding of the causes and consequences of medical student distress, and to investigate potential solutions, is likely to benefit not only the affected individuals, but also the patients for whom they provide care.
1Liaison Committee on Medical Education. Functions and structure of a medical school. Standards for accreditation of medical education programs leading to the MD degree 〈http://www.lcme.org/pubs.htm#fands
〉. Accessed 29 December 2005. Washington, DC, AAMC, October 2004 edition with updates as of October 2005.
2Guthrie EA, Black D, Shaw CM, Hamilton J, Creed FH, Tomenson B. Embarking upon a medical career: psychological morbidity in first year medical students. Med Educ. 1995;29:337–41.
3Moffat KJ, McConnachie A, Ross S, Morrison JM. First-year medical student stress and coping in a problem-based learning medical curriculum. Med Educ. 2004;38:482–91.
4Aktekin M, Karaman T, Senol YY, Erdem S, Erengin H, Akaydin M. Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey. Med Educ. 2001;35:12–17.
5Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: a five-year prospective longitudinal study. J R Soc Med. 1998;91:237–43.
6Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002;77:918–21.
7Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. JAMA. 1988;260:2521–28.
8Rosal MC, Ockene IS, Ockene JK, Barrett SV, Ma Y, Hebert JR. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72:542–46.
9Mosley TH Jr, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping, and well-being among third-year medical students. Acad Med. 1994;69:765–67.
10Roberts LW, Warner TD, Lyketsos C, Frank E, Ganzini L, Carter D. Perceptions of academic vulnerability associated with personal illness: a study of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Health. Compr Psychiatry. 2001;42:1–15.
11Vitaliano PP, Maiuro RD, Russo J, Mitchell ES, Carr JE, Van Citters RL. A biopsychosocial model of medical student distress. J Behav Med. 1988;11:311–31.
12Raj SR, Simpson CS, Hopman WM, Singer MA. Health-related quality of life among final-year medical students. CMA J. 2000;162:509–10.
13Ball S, Bax A. Self-care in medical education: effectiveness of health-habits interventions for first-year medical students. Acad Med. 2002;77:911–917.
14Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. J Affect Disord. 2001;64:69–79.
15Parkerson GR Broadhead WE, Tse CK. The health status and life satisfaction of first-year medical students. Acad Med. 1990;65:586–88.
16Carson AJ, Dias S, Johnston A, et al. Mental health in medical students: a case control study using the 60 item General Health Questionnaire. Scott Med J. 2000;45:115–16.
17Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. March 5.2002;136:358–67.
18Thomas N. Resident burnout. JAMA. 2004;292:2880–89.
19Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA.. Effect of the 80-hour workweek on resident burnout. Arch Surg. 2004;139:933–38; discussion 938–40.
20Wolf TM, Balson PM, Faucett JM, Randall HM. A retrospective study of attitude change during medical education. Med Educ. 1989;23:19–23.
21Krakowski A. Stress and the practice of medicine: the myth and the reality. J Psychosom Res. 1982;26:91–98.
22Stewart SM, Lam TH, Betson CL, Wong CM, Wong AM. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 1999;33:243–50.
23Wolf TM, Faucett JM, Randall HM, Balson PM. Graduating medical students' ratings of stresses, pleasures, and coping strategies. J Med Educ. 1988;63:636–42.
24MacLeod R, Parkin C, Pullon S, Robertson G. Early clinical exposure to people who are dying: learning to care at the end of life. Med Educ. 2003;37:51–58.
25Wear DP. “Face-to-face with It”: medical students' narratives about their end-of-life education. Acad Med. 2002;77:271–77.
26Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA. 1990;263:527–32.
27Elnicki DM, Linger B, Asch E, et al. Patterns of medical student abuse during the internal medicine clerkship: perspectives of students at 11 medical schools. Acad Med. 1999;74(10 suppl):S99–S101.
28Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and correlates of reported medical student abuse. JAMA. 1992;267:692–94.
29Sheehan H, Sheehan D, White K, Leibowitz A, Baldwin DC Jr,. A pilot study of medical student ‘abuse': student perceptions of mistreatment and misconduct in medical school. JAMA. 1990;263:533–37.
31Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73:403–7.
32Stern DT. In search of the informal curriculum: when and where professional values are taught. Acad Med. 1998;73(10 suppl):S28–S30.
33Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.
34Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med. 1994;69:670–79.
35Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med. 1993;68:249–54.
36Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med. 1998;129:734–37.
37Hundert EM, Hafferty F, Christakis D. Characteristics of the informal curriculum and trainees' ethical choices. Acad Med. 1996;71:624–42.
38Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med. 1998;73:1149–58.
39Spiegel DA, Smolen RC, Hopfensperger KA. Medical student stress and clerkship performance. J Med Educ. 1986;61:929–31.
40Spiegel DA, Smolen RC, Jonas CK. An examination of the relationships among interpersonal stress, morale and academic performance in male and female medical students. Soc Sci Med. 1986;23:1157–61.
41Hojat M, Robeson M, Damjanov I, Veloski JJ, Glaser K, Gonnella JS. Students' psychosocial characteristics as predictors of academic performance in medical school. Acad Med. 1993;68:635–37.
42Dans PE. Self-reported cheating by students at one medical school. Acad Med. 1996;71(1 suppl):S70–S72.
43DeWitt C, Baldwin DC Daugherty SR, Beverley D, Rowley BD, Schwarz M. Cheating in Medical School: a survey of second year students at 31 schools. Acad Med. 1996;71:267–73.
44Rennie S, Rudland J. Differences in medical students' attitudes to academic misconduct and reported behavior across the years-a questionnaire study. J Med Ethics. 2003;29:97–102.
45Anderson RE, Obenshain SS. Cheating by students: findings, reflections, and remedies. Acad Med. 1994;69:323–32.
46Newbury-Birch D, Walshaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug Alcohol Depend. 2001;64:265–70.
47Clark D, Eckenfels EJ, Daugherty SR, Fawcett J. Alcohol-use patterns through medical school. A longitudinal study of one class. JAMA. 1987;257:2921–26.
48Croen LG, Woesner M, Herman M, Reichgott M. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997;72:376–81.
49Baldwin DC Hughes PH, Conard SE, Storr CL, Sheehan DV. Substance use among senior medical students. A survey of 23 medical schools. JAMA. 1991;265:2074–78.
50Crandall SJ, Volk RJ, Loemker V. Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians? JAMA. 1993;269:2519–23.
51Eron L. Effect of medical education on medical students' attitudes. J Med Educ. 1955;30:559–66.
52Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38:522–34.
53Griffith CH, Wilson JF. The loss of idealism throughout internship. Eval Health Prof. 2003;26:415–26.
54Davis BE, Nelson DB, Sahler OJ, McCurdy FA, Goldberg R, Greenberg LW. Do clerkship experiences affect medical students' attitudes toward chronically ill patients? Acad Med. 2001;76:815–20.
55Hojat M, Mangione S, Nasca T, et al. An empirical study of decline in empathy in medical school. Med Educ. 2004;38:934–41.
56Association of American Medical Colleges. Educating Doctors to Provide High Quality Medical Care. A Vision for Medical Education in the United States. Report of the Ad Hoc Committee of Deans. Washington, DC: AAMC, 2004.
57Beck A, Steer R, Garbin M. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988;8:77–100.
58Beck AT, Ward CH, Mendelson M et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.
59Beck AT, Beck RW. Screening depressed patients in family practice: a rapid technic. Postgrad Med. 1972;52:81–85.
60Radloff LS. The CES-D Scale: a self report depressive scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.
61Weissman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke BZ. Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol. 1977;106:203–14.
62Schulberg HC, Saul M, McClelland M, Ganguli M, Christy W, Frank R. Assessing depression in primary medical and psychiatric practices. Arch Gen Psychiatry. 1985;42:1164–70.
63Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19:1–15.
64Derogatis LR, Rickels K, Rock AF. The SCL-90 and the MMPI: a step in the validation of a new self-report scale. Br J Psychiatry. 1976;128:280–89.
65Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic: further validation of the SDS. Arch Gen Psychiatry. 1965;13:508–15.
66Derogatis LR.. SCL-90: Administration, Scoring, and Procedures Manual-I for the Revised Version
. Baltimore, MD: The Johns Hopkins Hospital, 1977.
67Knight RG, Waal-Manning HJ, Spears GF. Some norms and reliability data for the State–Trait Anxiety Inventory and the Zung Self-Rating Depression scale. Br J Clin Psychology. 1983;22 (Pt 4):245–49.
68McNair DM, Lorr M, Droppleman L.. Manual for the Profile of Mood States
. San Diego, CA: EdITS/Educational and Industrial Testing Service, 1992.
69Derogatis LR, Melisaratos N. The Brief symptom Inventory: an introductory report. Psychol Med. 1983;13:596–605.
70Nielsen AC, Williams TA. Depression in ambulatory medical patients. Arch Gen Psychiatry. 1980;37:999–1004.
71Storch EA, Roberti JW, Roth DA, et al. Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory—Second Edition in a sample of college students. Depress Anxiety. 2004;19:187–89.
72Hojat M, Shapurian R, Mehryar AH. Dimensionality of the short form of the Beck Depression Inventory: a study with Iranian college students. Psychol Rep. 1986;59:1069–70.
73Hojat M, Erdmann JB, Robeson M, Damjanov I, Glaser K. A study of psychometric characteristics of abridged versions of selected psychological measures given medical students for the purpose of predicting clinical competence. Interdisciplinaria. 1994;11:129–48.
74Zoccolillo M, Murphy GE, Wetzel RD. Depression among medical students. J Affect Disord. 1986;11:91–96.
75Jacobs KW, Boze MM. Correlations among scales of the Beck Depression Inventory and the profile of mood states. Psychol Rep. 1993;73:431–34.
76Coulehan JL, Schulberg HC, Block MR, Janosky JE, Arena VC. Medical comorbidity of major depressive disorder in a primary medical practice. Arch Intern Med. 1990;150:2363–67.
77Zich JM, Attkisson CC, Greenfield TK. Screening for depression in primary care clinics: the CES-D and the BDI. Int J Psychiatry Med. 1990;20:259–77.
78Hunter EE, Penick EC, Powell BJ, Othmer E, Nickel E, Desouza C.. Development of scales to screen for eight common psychiatric disorders. J Nerv Ment Dis. 2005;193:131–35.
79Nyenhuis DL, Yamamoto C, Luchetta T, Terrien A, Parmentier A. Adult and geriatric normative data and validation of the profile of mood states. J Clin Psychology. 1999;55:79–86.
80Barrett J, Hurst MW, DiScala C, Rose RM. Prevalence of depression over a 12-month period in a nonpatient population. Arch Gen Psychiatry. 1978;35:741–44.
81Gabrys JB, Peters K. Reliability, discriminant and predictive validity of the Zung Self-rating Depression Scale. Psychol Rep. 1985;57 (3 Pt 2):1091–96.
82Hedlund JL. The Zung Self-Rating Depression Scale: a comprehensive review. J Oper Pscyhiatr. 1979;10:51–64.
83Henning K, Ey S, Shaw D. Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ. 1998;32:456–64.
84Sherry S, Notman MT, Nadelson CC, Kanter F, Salt P. Anxiety, depression, and menstrual symptoms among freshman medical students. J Clin Psychiatry. 1988;49:490–93.
85Buchman BP, Sallis JF, Criqui MH, Dimsdale JE, Kaplan RM. Physical activity, physical fitness, and psychological characteristics of medical students. J Psychosom Res. 1991;35 (2-3):197–208.
86Lloyd C, Miller PM. The relationship of parental style to depression and self-esteem in adulthood. J Nerv Ment Dis. 1997;185:655–63.
87Hendryx MS, Haviland MG, Shaw DG. Dimensions of alexithymia and their relationships to anxiety and depression. J Pers Assess. 1991;56:227–37.
88Kerner SA, Jacobs KW. Correlation between scores on the Beck Depression Inventory and the Zung Self-rating Depression Scale. Psychol Rep. 1983;53 (3 Pt 1):969–70.
89Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005;53:219–24.
90Lloyd C, Gartrell NK. Psychiatric symptoms in medical students. Compr Psychiatry. 1984;25:552–65.
91Toews JA, Lockyer JM, Dobson DJ, Brownell AK. Stress among residents, medical students, and graduate science (MSc/PhD) students. Acad Med. 1993;68(10 suppl):S46–S48.
92Vitaliano PP, Maiuro RD, Russo J, Mitchell ES. Medical student distress: a longitudinal study. J Nerv Ment Dis. 1989;177:70–76.
93Richman JA, Flaherty JA. Gender differences in medical student distress: contributions of prior socialization and current role-related stress. Soc Sci Med. 1990;30:777–87.
94Pyskoty CE, Richman JA, Flaherty JA. Psychosocial assets and mental health of minority medical students. Acad Med. 1990;65:581–85.
95Whitehouse WG, Dinges DF, Orne EC, et al. Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school. Psychosom Med. 1996;58:249–63.
96Lloyd C, Gartrell NK. Sex differences in medical student mental health. Am J Psychiatry. 1981;138:1346–51.
97Vontver L, Irby D, Rakestraw P, Haddock M, Prince E, Stenchever M. The effects of two methods of pelvic examination instruction on student performance and anxiety. J Med Educ. 1980;55:778–85.
98Hojat M, Glaser K, Xu G, Veloski JJ, Christian EB. Gender comparisons of medical students' psychosocial profiles. Med Educ. 1999;33:342–49.
99Toews JA, Lockyer JM, Dobson DJ, et al. Analysis of stress levels among medical students, residents, and graduate students at four Canadian schools of medicine. Acad Med. 1997;72:997–1002.
100Vitaliano PP, Russo J, Carr JE, Heerwagen JH. Medical school pressures and their relationship to anxiety. J Nerv Ment Dis. 1984;172:730–36.
101Psujek JK, Martz DM, Curtin L, Michael KD, Aeschleman SR. Gender differences in the association among nicotine dependence, body image, depression, and anxiety within a college population. Addict Behav. 2004;29:375–80.
102Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15:88–92.
103Kellner R, Wiggins RJ, Pathak D. Distress in medical and law students. Compr Psychiatry. 1986;27:220–23.
104Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry. 1994;151:979–86.
105Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–105.
106Regier DA, Farmer MD, Rae DS, et al. One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study. Acta Psychiatr Scand. 1993;88:35–47.
107Regier DA, Boyd JH, Burke JD. et al. One-month prevalence of mental disorders in the United States. Based on five Epidemiologic Catchment Area sites. Arch Gen Psychiatry. 1988;45:977–86.
108Camp DL, Hollingsworth MA, Zaccaro DJ, Cariaga-Lo LD, Richards BF. Does a problem-based learning curriculum affect depression in medical students? Acad Med. 1994;69(10 suppl):S25–S27.
110Coombs RH. The effect of marital status on stress in medical school. Am J Psychiatry. 1982;139:1490–93.
111Katz J, Monnier J, Libet J, Shaw D, Beach S. Individual and crossover effect of stress on adjustment in medical student marriages. J Marital Fam Ther. 2000;26:341–351.
112Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–96.
114Lazo R. Family Matters. JAMA. 1991;265:119.
115Law J. Starting a Family in Medical School. JAMA. 1997;227:767.
116Paykel ES. The evolution of life events research in psychiatry. J Affect Disord. 2001;62:141–49.
117Paykel ES. The Interview for Recent Life Events. Psychol Med. 1997;27:301–10.
118Frank E, Tu XM, Anderson B, et al. Effects of positive and negative life events on time to depression onset: an analysis of additivity and timing. Psychol Med. 1996;26:613–24.
119Moerk KC, Klein DN. The development of major depressive episodes during the course of dysthymic and episodic major depressive disorders: a retrospective examination of life events. J Affect Disord. 2000;58:117–23.
120Honkalampi K, Koivumaa-Honkanen H, Hintikka J, et al. Do stressful life-events or sociodemographic variables associate with depression and alexithymia among a general population? A 3-year follow-up study. Compr Psychiatry. 2004;45:254–60.
121Frank E, Anderson B, Reynolds CF 3rd, Ritenour A, Kupfer DJ. Life events and the research diagnostic criteria endogenous subtype: a confirmation of the distinction using the Bedford College methods. Arch Gen Psychiatry. 1994;51:519–24.
122Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000. Racial and ethnic diversity in U.S. medical schools. N Engl J Med. 1994;331:472–76.
123Ready T. Project 3000 by 2000: toward a unified solution to the problem of minority underrepresentation in the health professions. J Dent Educ. 1995;59:649–54.
124Crump R, Byrne M, Joshua M.. The University of Louisville Medical School's comprehensive programs to increase its percentage of underrepresented-minority students. Acad Med. 1999;74:315–17.
125Tekian A. A thematic review of the literature of underrepresented minorities and medical training, 1981-1995: securing the foundations of the bridge to diversity. Acad Med. 1997;72(10 suppl 1):S140–S146.
126Hardy VD. Premedical enrichment program at East Carolina University School of Medicine. Acad Med. 1999;74:373–75.
127Payne JL, Nowacki CM, Girotti JA, Townsel J, Plagge JC, Beckham TW. Increasing the graduation rates of minority medical students. J Med Educ. 1986;61:353–58.
128Girotti JA.. The Urban Health Program to encourage minority enrollment at the University of Illinois at Chicago College of Medicine. Acad Med. 1999;74:370–72.
129Giordani B, Edwards AS, Segal SS, Gillum LH, Lindsay A, Johnson N. Effectiveness of a formal post-baccalaureate pre-medicine program for underrepresented minority students. Acad Med. 2001;76:844–48.
130Tekian A. Cognitive factors, attrition rates, and underrepresented minority students: the problem of predicting future performance. Acad Med. 1998;73(10 suppl):S38–S40.
131Linn BS, Zeppa R. Stress in junior medical students: relationship to personality and performance. J Med Educ. 1984;59:7–12.
132McManus IC, Keeling A, Paice E. Stress, burnout and doctors' attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med. 2004;2:29.
133Lipton A, Huxham GJ, Hamilton D. Influence of personality on achievement of medical students. Br J Med Educ. 1975;9:215–22.
134Hobfoll SE, Anson O, Antonovsky A. Personality factors as predictors of medical students performance. Med Educ. 1982;16:251–58.
135Enns MW, Cox BJ, Sareen J, Freeman P. Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation. Med Educ. 2001;35:1034–42.
136Lievens F, Coetsier P, De Fruyt F, De Maeseneer J. Medical students' personality characteristics and academic performance: a five-factor model perspective. Med Educ. 2002;36:1050–56.
137Tyssen R, Hem E, Vaglum P, Gronvold NT, Ekeberg O. The process of suicidal planning among medical doctors: predictors in a longitudinal Norwegian sample. J Affect Disord. 2004;80 (2-3):191–98.
138Zeldow PB, Daugherty SR, Clark DC. Masculinity, femininity, and psychosocial adjustment in medical students: a 2-year follow-up. J Pers Assess. 1987;51:3–14.
139Zeldow PB, Daugherty SR, McAdams DP. Intimacy, power, and psychological well-being in medical students. J Nerv Ment Dis. 1988;176:182–87.
140Richman JA, Flaherty JA. Adult psychosocial assets and depressive mood over time. Effects of internalized childhood attachments. J Nerv Ment Dis. 1987;175:703–12.
141Richman J, Flaherty J. Coping and depression. The relative contribution of internal and external resources during a life cycle transition. J Nerv Ment Dis. 1985;173:590–95.
142Notman MT, Salt P, Nadelson CC. Stress and adaptation in medical students: who is most vulnerable? Compr Psychiatry. 1984;25:355–66.
143Colford JM Jr, McPhee SJ. The ravelled sleeve of care. Managing the stresses of residency training. JAMA. 1989;261:889–93.
144Rappaport, Witzke D. Education about death and dying during clinical years of medical school. Surgery. 1993;113:163–65.
145Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med. 1994;120:609–14.
146Rezler AG. Attitude changes during medical school: a review of the literature. J Med Educ. 1974;49:1023–30.
147Vitaliano PP, Maiuro RD, Mitchell E, Russo J. Perceived stress in medical school: resistors, persistors, adaptors and maladaptors. Soc Sci Med. 1989;28:1321–29.
148Strayhorn G. Effect of a major curriculum revision on students' perceptions of well-being. Acad Med. 1989;64:25–29.
149Wolf TM, von Almen TK, Faucett JM, Randall HM, Franklin FA. Psychosocial changes during the first year of medical school. Med Educ. 1991;25:174–81.
150Wolf TM. Stress, coping and health: enhancing well-being during medical school. Med Educ. 1994;28:8–17.
151Novack DH, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being. Acad Med. 1999;74:516–20.
152Clark DC, Daugherty SR, Zeldow PB, Gotterer GS, Hedeker D. The relationship between academic performance and severity of depressed mood during medical school. Compr Psychiatry. 1988;29:409–20.
153Stetto JE, Gackstetter GD, Cruess DF, Hooper TI.. Variables associated with attrition from Uniformed Services University of the Health Sciences Medical School. Mil Med. 2004;169:102–7.
154Rainey M. How do we retain minority health profession student? In: Smedley B, Stith, A, Colburn I, et al. (eds). The Right Thing to Do, the Smart Thing to Do: Enhancing Diversity in the Health Professions
. Washington, DC: National Academy Press, 2001:328–59.
155Fogleman BY, Vander Zwagg R. Demographic, situational, and scholastic factors in medical school attrition. South Med J. 1981;74:602–6.
156Crowley AE, Etzel SI, Petersen ES. Undergraduate medical education. JAMA. 1987;258 (8):1013–20.
157Jonas HS, Etzel SI. Undergraduate medical education [published erratum appears in JAMA. 1988;260:3008]. JAMA. 1988;260:1063–71.
158Tyssen R, Vaglum P, Aasland OG, Gronvold NT, Ekeberg O. Use of alcohol to cope with tension, and its relation to gender, years in medical school and hazardous drinking: a study of two nation-wide Norwegian samples of medical students. Addiction. 1998;93:1341–49.
159Wechsler H, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H. Changes in binge drinking and related problems among American college students between 1993 and 1997: results of the Harvard School of Public Health College Alcohol Study. J Am Coll Health. 1998;47:57–68.
160National Institute on Alcohol Abuse and Alcoholism Databases. Quick Facts 〈http://www.niaaa.nih.gov/
〉. Accessed 29 December 2005. NIAAA, 2004.
161Gutgesell M, Reeve R, Parsons B, Morse R. Exercise and alcohol consumption among medical students. Acad Med. 1999;74:750–51.
162Mangus R, Hawkins C, Miller M. Tobacco and Alcohol Use Among 1996 Medical School Graduates. JAMA. 1998;280:1192–93.
163Mitchell RE, Matthews JR, Grandy TG, Lupo JV. The question of stress among first-year medical students. J Med Educ. 1983;58:367–72.
164Stewart SM, Betson C, Lam TH, Marshall IB, Lee PW, Wong CM. Predicting stress in first year medical students: a longitudinal study. Med Educ. 1997;31:163–68.
165Bramness JG, Fixdal TC, Vaglum P. Effect of medical school stress on the mental health of medical students in early and late clinical curriculum. Acta Psychiatr Scand. 1991;84:340–45.
166Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Factors in medical school that predict postgraduate mental health problems in need of treatment: a nationwide and longitudinal study. Med Educ. 2001;35:110–20.
167Chan DW. Depressive symptoms and depressed mood among Chinese medical students in Hong Kong. Compr Psychiatry. 1991;32:170–80.
168Omokhodion FO, Gureje O. Psychosocial problems of clinical students in the University of Ibadan Medical School. Afr J Med Sci. 2003;32:55–58.
169Sherina MS, Rampal L, Kaneson N. Psychological stress among undergraduate medical students. Med J Malaysia. 2004;59:207–11.
170Okasha A, Lotaif F, Sadek A. Prevalence of suicidal feelings in a sample of non-consulting medical students. Acta Psychiatr Scand. 1981;63:409–15.
171Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: a cross-sectional study. Med Educ. 2005;39:594–604.
172Bellini LM, Baime M, Shea JA. Variation of mood and empathy during internship. JAMA. 2002;287:3143–46.
173Gill D, Palmer C, Mulder R, Wilkinson T. Medical student career intentions at the Christchurch School of Medicine. The New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE) survey of medical students pilot study. Results part II. N Z Med J. 2001;114:465–67.
174Newton BW, Savidge MA, Barber L, et al. Differences in medical students' empathy. Acad Med. 2000;75:1215.
175Merrill J, Lorimor R, Thornby J, Woods A. Caring for terminally ill persons: comparative analysis of attitudes (thanatophobia) of practicing physicians, student nurses, and medical students. Psychol Rep. 1998;83:123–28.
176Stecker T. Well-being in an academic environment. Med Educ. 2004;38:465–78.
178Van Der Ploeg H. Relationship of state-trait anxiety to academic performance in Dutch medical students. Psychol Rep. 1979;45:223–27.
179Tooth D, Tonge K, McManus IC. Anxiety and study methods in preclinical students: causal relation to examination performance. Med Educ. 1989;23:416–21.
180Grover PL, Smith DU. Academic anxiety, locus of control, and achievement in medical school. J Med Educ. 1981;56 (9 Pt 1):727–36.
181Mareiniss DP. Decreasing GME training stress to foster residents' professionalism. Acad Med. Sep. 2004;79:825–31.
182Branch W, Pels RJ, Lawrence RS, R. A.. Becoming a doctor: critical-incident reports from third-year medical students. N Engl J Med. 1993;329:1130–32.
183Pololi L, Frankel RM. Small-group teaching emphasizing reflection can positively influence medical students' values. Acad Med. 2001;76:1172–73.
184Kelly JA, Bradlyn AS, Dubbert PM, St Lawrence JS. Stress management training in medical school. J Med Educ. 1982;57:91–99.
185Rathbun J. Helping medical students develop lifelong strategies to cope with stress. Acad Med. 1995;70:955–56.
186Lee J, Graham AV. Students' perception of medical school stress and their evaluation of a wellness elective. Med Educ. 2001;35:652–59.
187Holtzworth-Munroe A, Munroe MS, Smith RE. Effects of a stress-management training program on first- and second-year medical students. J Med Educ. 1985;60:417–19.
188McCue JD, Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med. 1991;151:2273–77.
189Lim JK, Golub RM. Graduate medical education research in the 21st century and JAMA on call. JAMA. 2004;292:2913–15.
References that are in Table 1 only
190Vitaliano PP, Maiuro RD, Russo J, Becker J. Raw versus relative scores in the assessment of coping strategies. J Behav Med. 1987;10:1–18.
191Fenderson BA, Hojat M, Damjanov I, Rubin E. Characteristics of medical students completing an honors program in pathology. Hum Pathol. 1999;30:1296–301.
This article has been cited 92 time(s).
Bmc Medical EducationMindfulness training for stress management: a randomised controlled study of medical and psychology studentsBmc Medical Education
Journal of American College HealthAn Evaluative Review of Outcome Research on Universal Mental Health Promotion and Prevention Programs for Higher Education StudentsJournal of American College Health
General Hospital PsychiatryDetails on suicide among US physicians: data from the National Violent Death Reporting SystemGeneral Hospital Psychiatry
Psychiatrische PraxisScreening of Emotional and Somatic Complaints in Undergraduate Medical Students A Longitudinal StudyPsychiatrische Praxis
Hong Kong Medical Journal
Attitudes towards suicide following an undergraduate suicide prevention module: experience of medical students in Hong Kong
Hong Kong Medical Journal, 19(5):
European Journal of Dental EducationPerceived sources of stress amongst Chilean and Argentinean dental studentsEuropean Journal of Dental Education
European Journal of Dental EducationEffective and ineffective supervision in postgraduate dental education: a qualitative studyEuropean Journal of Dental Education
Journal of Psychiatric ResearchA systematic review of studies of depression prevalence in university studentsJournal of Psychiatric Research
Journal of General Internal MedicineCognitive Enhancement Drug Use Among Future Physicians: Findings from a Multi-Institutional Census of Medical StudentsJournal of General Internal Medicine
Psychological Distress of First Year Medical Students Who Underwent Two Different Admission Processes During a Stressful Period
Sains Malaysiana, 42(3):
Medical TeacherBurnout and career choice motivation in medical studentsMedical Teacher
Medical TeacherRelationship between academic performance and affective changes during the first year at medical schoolMedical Teacher
Iranian Journal of Public Health
Prevalence and Predictors of Anxiety and Depression among Female Medical Students in King Abdulaziz University, Jeddah, Saudi Arabia
Iranian Journal of Public Health, 42(7):
Journal of Affective DisordersRisk factors at medical school for later severe depression: A 15-year longitudinal, nationwide study (NORDOC)Journal of Affective Disorders
Medical EducationMedical students' health-related quality of life: roles of social and behavioural factorsMedical Education
Bmc Public HealthA home-visiting intervention targeting determinants of infant mental health: the study protocol for the CAPEDP randomized controlled trial in FranceBmc Public Health
Medical TeacherDeclining health anxiety throughout medical studies: It is mainly about a more relaxed perception of the health-related concernsMedical Teacher
A Systematic Review of Stress-Management Programs for Medical Students
Academic Psychiatry, 37(3):
Bmj OpenPrevalence and persistence of depression among undergraduate medical students: a longitudinal study at one UK medical schoolBmj Open
Psychology Health & MedicineThe impact of medical education on psychological health of students: A cohort studyPsychology Health & Medicine
Bmj-British Medical JournalProtecting students and promoting resilienceBmj-British Medical Journal
Journal of Research in Medical Sciences
Prevalence and clinical characteristics of headache among medical students, Isfahan, Iran
Journal of Research in Medical Sciences, 18():
Bmc Medical EducationTeaching strategies for coping with stress - the perceptions of medical studentsBmc Medical Education
Bmc Medical EducationA practical approach to mentoring students with repeated performance deficienciesBmc Medical Education
International Journal of Psychiatry in MedicineCreating A Culture of Wellness: Conversations, Curriculum, Concrete Resources, and ControlInternational Journal of Psychiatry in Medicine
Bmc Medical EducationPsychological distress and its correlates among dental students: a survey of 17 Colombian dental schoolsBmc Medical Education
Medical EducationGender differences in worry during medical schoolMedical Education
Medical Student Healthcare Barriers and Solutions: Perspectives of Students
Academic Psychiatry, 37(4):
Nurse Education TodayMental health behaviours among undergraduate nursing students: Issues for considerationNurse Education Today
Acta Clinica Croatica
A Ten-Year Study of Depressive Symptoms in Serbian Medical Students
Acta Clinica Croatica, 52(2):
Frontiers in Human NeuroscienceWalking a fine line: is it possible to remain an empathic physician and have a hardened heart?Frontiers in Human Neuroscience
Psychological BulletinCultural Meaning of Perceived Control: A Meta-Analysis of Locus of Control and Psychological Symptoms Across 18 Cultural RegionsPsychological Bulletin
Medical EducationPersonality traits and types predict medical school stress: a six-year longitudinal and nationwide studyMedical Education
Medical EducationThe learning environment and medical student burnout: a multicentre studyMedical Education
Personal health care of residents: Preferences for care outside of the training institution
Academic Psychiatry, 32(1):
Kaohsiung Journal of Medical Sciences
Performance anxiety at English PBL groups among Taiwanese medical students: A preliminary study
Kaohsiung Journal of Medical Sciences, 23(3):
International Journal of Social PsychiatrySymptoms of Anxiety and Depression in Medical Students and in Humanities Students: Relationship With Big-Five Personality Dimensions and Vulnerability to StressInternational Journal of Social Psychiatry
Archives of Internal Medicine
Race, ethnicity, and medical student well-being in the United States
Archives of Internal Medicine, 167():
Medical student health promotion: The increasing role of medical schools
Academic Psychiatry, 32(1):
Medical EducationHealth-related quality of life of medical studentsMedical Education
Advances in Health Sciences EducationEnhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle programAdvances in Health Sciences Education
British Journal of Guidance & CounsellingES[S]PRIT - an Internet-based programme for the prevention and early intervention of eating disorders in college studentsBritish Journal of Guidance & Counselling
Journal of Dental Education
Emotional intelligence and perceived stress in dental undergraduates: A multinational survey
Journal of Dental Education, 71(2):
Medical EducationFactors influencing treatment for depression among medical students: a nationwide sample in South KoreaMedical Education
Advances on Medical Sciences
A Comparative Cross-Sectional Study: "Is the Medical Degree Course Bad for Your Health?"
Advances on Medical Sciences, ():
Social Psychiatry and Psychiatric EpidemiologyPsychological distress in first year university students: socioeconomic and academic stressors, mastery and social support in young men and womenSocial Psychiatry and Psychiatric Epidemiology
Bmc PsychiatryEgo defense mechanisms in Pakistani medical students: a cross sectional analysisBmc Psychiatry
Journal of Affective DisordersEarly trauma and lifetime suicidal behavior in a nationwide sample of Korean medical studentsJournal of Affective Disorders
The role of academic psychiatry faculty in the treatment and subsequent evaluation and promotion of medical students: An ethical conundrum
Academic Psychiatry, 32(1):
Annals of Internal Medicine
Burnout and suicidal ideation among US medical students
Annals of Internal Medicine, 149(5):
Social Psychiatry and Psychiatric EpidemiologyThe prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university studentsSocial Psychiatry and Psychiatric Epidemiology
Health and Quality of Life OutcomesHow do medical students value health on the EQ-5D? Evaluation of hypothetical health states compared to the general populationHealth and Quality of Life Outcomes
Bratislava Medical Journal-Bratislavske Lekarske Listy
Depression, anxiety and substance use in medical students in the Republic of Macedonia
Bratislava Medical Journal-Bratislavske Lekarske Listy, 109():
Annals of Saudi Medicine
Perceived stress among male medical students in Egypt and Saudi Arabia: effect of sociodemographic factors
Annals of Saudi Medicine, 28(6):
Bmc Public HealthFactors associated with self-rated health status in university students: a cross-sectional study in three European countriesBmc Public Health
Medical Journal of Australia
Painting the picture: Australasian medical student views on wellbeing teaching and support services
Medical Journal of Australia, 192(4):
Annals of Surgical OncologyA career in surgical oncology: Finding meaning, balance, and personal satisfactionAnnals of Surgical Oncology
Journal of American College Health
Depressive Symptoms, Stress, and Social Support Among Dental Students at a Historically Black College and University
Journal of American College Health, 58(1):
A conceptual model of medical student well-being: Promoting resilience and preventing burnout
Academic Psychiatry, 32(1):
Journal of Clinical Psychiatry
A survey on the impact of being depressed on the professional status and mental health care of physicians
Journal of Clinical Psychiatry, 69(4):
European PsychiatryMental health treatment needs for medical students: a national longitudinal studyEuropean Psychiatry
Teaching and Learning in MedicineDeveloping an Online Prematriculation Orientation Program and Its Relation to Student Performance in the First Class Taken in Medical SchoolTeaching and Learning in Medicine
Health PsychologyA Real-Time Assessment of Work Stress in Physicians and NursesHealth Psychology
Revista Brasileira De Psiquiatria
Suicidal ideation among students enrolled in healthcare training programs: a cross-sectional study
Revista Brasileira De Psiquiatria, 31(4):
Teaching and Learning in MedicineCrying: Experiences and Attitudes of Third-Year Medical Students and InternsTeaching and Learning in Medicine
Arts in PsychotherapyVisual journaling: An intervention to influence stress, anxiety and affect levels in medical studentsArts in Psychotherapy
Early clinical experiences from students' perspectives: A qualitative study of narratives
Academic Medicine, 82():
Self-rated health among physicians
Journal of Affective DisordersMale depression in females?Journal of Affective Disorders
Revista Medica De Chile
Depression in medical students: A bibliometric approach
Revista Medica De Chile, 138(3):
Medical EducationThreat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitationsMedical Education
Annals Academy of Medicine Singapore
The association between parental socioeconomic status (SES) and medical students' personal and professional development
Annals Academy of Medicine Singapore, 36(9):
PsychotherapeutPsychological complaints and mental disorders of studentsPsychotherapeut
Physician wellness: a missing quality indicator
Jcpsp-Journal of the College of Physicians and Surgeons Pakistan
Depression, Anxiety and Their Associated Factors Among Medical Students
Jcpsp-Journal of the College of Physicians and Surgeons Pakistan, 20(2):
PsychotherapeutMental health of students of medicine. An empirical studyPsychotherapeut
Explore-the Journal of Science and Healing
The Health Enhancement Program At Monash University Medical School
Explore-the Journal of Science and Healing, 4(6):
Medical EducationPrimary prevention for future doctors: promoting well-being in traineesMedical Education
Deutsche Medizinische WochenschriftWorking conditions and depression in physiciansDeutsche Medizinische Wochenschrift
When Residents Need Health Care: Stigma of the Patient Role
Academic Psychiatry, 33(6):
Bmc Public HealthPhysical and mental health perspectives of first year undergraduate rural university studentsBmc Public Health
3Rd International Conference of Education, Research and Innovation (Iceri2010)
Emotional Intelligence, Academic Self-Efficacy, Academic Stress As Predictors of Potential for Academic Cheating Among Some Nigerian University Students
3Rd International Conference of Education, Research and Innovation (Iceri2010), ():
Medical Journal of AustraliaOnly the best: medical student selection in AustraliaMedical Journal of Australia
Teaching and Learning in MedicineExploring the Benefits of an Optional Theatre Module on Medical Student Well-BeingTeaching and Learning in Medicine
Orvosi HetilapSomatic and mental morbidity of young female physicians Does emotional exhaustion constitute the missing link?Orvosi Hetilap
Anaesthesia and Intensive Care
Mental health and welfare in Australian anaesthetists
Anaesthesia and Intensive Care, 41(5):
© 2006 Association of American Medical Colleges
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read