The feeling of stress is decisively dependent on how one assesses their own coping competences. If there is a lack of adequate stress management, chronic stress leads to a physical, cognitive and emotional state of fatigue, depression and psychosomatic reactions. However, users may print, download, or email articles for individual use. This abstract may be abridged.
No warranty is given about the accuracy of the copy. Forthcoming research should include the use of control groups, random allocation and long-term follow-up assessments. Furthermore, it should be considered to use a random sample of subjects instead of recruiting volunteers in order to minimize motivational effects [ 15 ].
As nothing is known at which stage of study a prevention training achieves the best health promoting effects, impacts of intervention on different stages of medical training should be compared [ 15 ]. Considering the fact that randomized controlled trials meet the requirements of a high scientific standard, the necessity of using a rigorous scientific method is called for. Although programs are used to promote health in medical schools at several universities in Germany [ 24 ], to the best of our knowledge no randomized controlled trial of a prevention program for German medical schools has yet been published.
In order to face the psychological health of medical students, our study aimed at evaluating the effect of a specifically developed mindfulness-based stress prevention training for medical students MediMind; MM on measures of distress, coping and psychological morbidity.
To overcome some of the methodological limitations, we carried out a comparison with a well evaluated relaxation technique as a standard treatment of stress reduction Autogenic Training; AT and a control group CG in a three armed randomized controlled trial. This would enable us to compare the efficacy of two different kinds of intervention. Furthermore, we realized a follow-up assessment in all three study groups to measure long-term effects of stress prevention.
Addressing potential discrepancies, we included students of different study sections. MediMind has a special focus on the challenges and issues of medical training and provides concrete coping strategies. Therefore, we expected MediMind to have a more beneficial effect on the experience of stress, the use of functional coping strategies and psychological morbidity than the standard treatment and the control group.
This was a prospective, three arm experimental treatment, standard treatment and a control group without treatment , randomized, controlled trial with three assessment time points baseline, post-intervention and follow-up one year post-intervention. This design was created in order to analyze both short term and long term effects while examining potential effects of the training in comparison to the waitlist control group and standard treatment with Autogenic Training.
According to the description in the study protocol [ 25 ], a sample size of participants at the 5-year follow-up was calculated leading to an initial sample size of participants. Related publications [ 20 , 23 , 26 ] used different designs and statistical approaches, with non-randomization or experimental vs. All participants provided written informed consent according to the Helsinki declaration and its later amendments. The study was offered to medical students in the second and eighth semester of the Johannes Gutenberg University in Mainz Germany. Because the curriculum and learning environment of dental students in the preclinical semesters is nearly analogous to that of medical students, dental students in their second semester were also included.
The trainings MediMind and Autogenic Training were provided as a voluntary extra-curricular activity and students were introduced to the study design and the opportunity of participation at lectures and by written information. In order to secure privacy, students were informed that all health data was strictly secured and held separately from their medical faculty.
The signed informed consent was a requirement to take part in the baseline assessment. At the post-intervention assessment time point, As a motivating incentive the participants of the control group received a Because of the low response rate, everyone who participated in the follow-up assessment received a The recruitment started in November Unfortunately, due to study limitations, the recruitment had to be terminated before full sampling had been completed.
This also included the provision of an accompanying booklet or handout to the participants containing the contents of each training session and the instructions for practice assignments. The treatment groups were led by a total of four trainers clinical psychologists, licensed in psychotherapy with relevant experience in mindfulness interventions, and one physical education instructor certified as a trainer of Autogenic Training.
Two of the trainers led MediMind and the other two trainers the Autogenic Training. There was no change between the trainers. The staff was instructed in the intervention trainings and followed a comprehensive operation manual. Participants of the control group remained without treatment but participated in the assessment time points. MediMind will be offered to them when the five-year follow-up assessment is completed.
In order to develop an intervention program tailored to the needs of students in medical education, interviews with the target group were conducted beforehand. Students often mentioned the need to acquire specific action-oriented strategies to help them face stressful situations, such as examinations or high workload. This was taken into consideration when developing MediMind and combining mindfulness aspects with approaches from cognitive behavioral therapies. Therefore, mindfulness meditation was practiced in each training session and CDs were provided for home practice.
In exercises, they became familiar with the presence-of-mind attitude in order to realize and target stress constructively. In this context, participants learned to address intrusive and distracting thoughts and feelings in an accepting attitude in order to feel less involved and to reduce their stressful impact. Another concept known to be effective in preventing stress is represented by the approaches of cognitive behavioral therapy [ 30 ].
This focuses on the stress heightening influence of dysfunctional cognitive judgment mechanisms and follows the approach of change and action-oriented strategies that do not require long-term training and work as skills in dealing with stressful situations. This was taken into account by additionally implementing stress-management techniques of the cognitive behavioral therapies to our training. The participants learned how to detect dysfunctional cognitive judgment mechanisms errors in reasoning and practice the use of functional reevaluation.
Additionally, the stress heightening influence of personal standards and assumptions were discussed. The students were introduced to various experiments in order to find a health-promoting way of dealing with these personal standards and assumptions. To cope with tense situations, the use of stress-tolerance skills and the concept of radical acceptance was imparted [ 31 ]. The combination of acceptance strategies concept of mindfulness with change strategies contents of cognitive behavioral therapies enabled the participants to be less reactive when experiencing stress and to decide more deliberately whether change is possible.
This offered the possibility to either modify the situation, adapt their judgment mechanisms, or to otherwise meet these conditions with acceptance. This combination follows the concept of dialectical behavior therapy developed by Linehan [ 31 ]. Practice assignments helped to generalize the effects of the training and to apply the techniques in everyday situations. The basic skills of Autogenic Training according to the Schulz method [ 34 ] were practiced in this intervention group.
As it is an auto-suggestive relaxation technique, the participants learned how to instruct themselves to suggest specific autonomic sensations such as muscular relaxation, vascular dilatation, stabilization of heart function or regulation of breathing [ 35 ]. These instructions consist of six exercises with corresponding formulas that are subvocally repeated e. Additionally, the training is extended by exercises including progressive muscle relaxation, breathing relaxation, exercises for body awareness, imaginary journeys and qigong movements.
Individual practice outside the training was supported by informational material. In the present study, we report the results of three assessment time points: 1 baseline, after receiving signed informed consent and before random assignment to the study groups; 2 post intervention, three weeks after the last training session; 3 follow-up, one year post trial. At each assessment time point, data of the primary, co-primary and secondary outcome measures were collected. Standard demographic measures were assessed at baseline.
"stress management" in German
Additionally, at post intervention and follow-up assessment participants were asked to assess how often per week they used the strategies that were taught in the trainings. Validity was confirmed by a principal component analysis resulting in a nine-factor solution and plausible correlations between the TICS and other stress questionnaires [ 36 ]. Brief COPE [ 37 ]. Construct validity could be confirmed by a nine-factor solution similar to the full inventory [ 37 ]. Convergent and discriminant validity is confirmed by plausible correlations between coping strategies and personality qualities [ 38 ].
A global measure of overall psychological distress is provided as an average response on each item Global Severity Index; GSI.
Validity is proven by plausible correlations between the BSI and other instruments [ 41 ]. After signing informed consent and baseline evaluation, participants were randomized to one of the three study groups MediMind, Autogenic Training or control group [ 25 ]. In order to control for potential confounding effects, students were stratified randomized by course of study medical versus dental , semester 2nd or 8th and sex. Regarding maximum power for analysis between experimental versus standard treatment, an allocation ratio with 2 MediMind : 2 Autogenic Training : 1 control group was realized.
Randomization was operationalized via drawing lots by an independent member of the institute not involved in the project. Differential analysis with t -tests of missing data, response, drop-out rates and time of post-data collection were used to access potentially confounding effects. All metric variables were tested for normality via Kolmogorov-Smirnoff-Tests [ 44 ] resulting in non-normality in the secondary outcome and normalization via logarithmic transformation of the data [ 45 ]. Compared to a reference sample of the general population, which is provided by the authors of the TICS [ 36 ], A student sample as reference was not available.
With regard to psychological morbidity, medical students of our study showed higher psychological morbidity at baseline than a student population given as a reference sample by the authors of the BSI [ 41 ]. Of the students, With regard to the T-distribution, it exceeded the expected percentage of 9.
To explore differences within the medical training, we compared the preclinical and clinical cohort of our sample. No differences could be found for the amount of perceived stress SSCS. An analysis was conducted to determine if there was a systematic dropout effect. Those participants who completed every assessment per-protocol participants were compared to those who dropped out after the baseline assessment non-starters. The dropout rates of the preclinical and clinical semester did not differ. Aside from the missing assessments, the participation rate in the trainings was higher. The evaluation of data therefore, does not include every student who attended the training.
A repeated measures multivariate analysis of covariance MANCOVA was run for the primary outcome in order to compare the experimental treatment MediMind , standard treatment Autogenic Training and control group. The scores of the three assessment time points were entered as dependent variables and the group status as the independent variable. Sex and time of post-data collection were entered as covariates in order to take the significant group differences into account.
To examine differences in co-primary outcome, a repeated measures MANCOVA was run with sex and time of post-data collection as covariates. In terms of the primary and co-primary outcome, our study revealed no significant interaction effect. Therefore, a positive effect of the interventions on the experience of stress or the use of functional coping strategies could not be proved. As previously assumed, an effect on psychological morbidity could be noticed one year post trial. Statistical analysis revealed a significant change on the subscales of the BSI between MediMind and the control group, but post hoc tests prevent any further interpretation of results.
Considering the means of the Global Severity Index GSI , students who participated in MediMind suffered less from psychological symptoms one year after the training compared to participants of the Autogenic Training and the control group. Due to the lack of significant post hoc tests, this observation does not statistically confirm a preventive efficacy of MediMind.
The increase of distress in the other study groups Autogenic Training and control group could be due to the imminence of the preliminary exams in medical education and the final exams in medical education after one year.
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Nevertheless, it can be noticed that even one year later, participants still used the strategies they had learned in the trainings. The frequency of using the skills that were taught in MediMind did not decrease as much as it did in the Autogenic Training. This result may indicate that the skills of MediMind are more practical and compatible with the daily realities of medical students and that they require less effort in practicing.
Our study did not succeed in confirming the promising results of the three-armed randomized controlled trial conducted by Jain [ 23 ]. They provided evidence for health promoting effects of stress prevention trainings in medical schools and revealed mindfulness meditation to be unique in reducing ruminative and distractive thoughts compared to a relaxation training.
It might be suggested that mindfulness meditation may provide a unique mechanism in reducing mental distress.
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In view of our results, differential effects of the concept of mindfulness and somatic relaxation were not apparent, as there were no significant differences in the use of coping strategies. Since no further study exists that compares different approaches, no conclusion can yet be drawn about their relative efficacy and which type of training works best for whom. To assess the efficacy of mindfulness, studies of different standards are available.
With reference to results of two-armed randomized controlled trials, mindfulness meditation shows good effects in reducing distress or enhancing mental health of medical students [ 18 , 19 , 20 , 22 ], whereas one study investigating mindfulness meditation could not confirm these effects [ 49 ]. In comparison, MediMind is unique in its combination of mindfulness meditation and teaching skills that enable the student to reduce a stressful experience when change is possible. This should have the advantage to provide the participants with specific strategies that can be used directly without the necessity of long-term practice.
A loss of motivation as a probable long-term effect could thereby be reduced. In order to optimize control of possible confounding factors we conducted a randomized controlled trial with a comparison of three study groups that made it possible to examine two different types of interventions and to realize a follow-up assessment.
In contrast to other studies [ 20 , 23 , 50 , 51 ], we decided on a conservative approach by conducting a per-protocol analysis, correcting for multiple testing and interpreting the interaction effect of the repeated measures MANCOVA as an evidence of the effectiveness of the trainings.
Since stress prevention programs seem to affect the experience of distress and mental health of medical students in other countries positively, the question is how the results of our study can be explained. In this context the limiting effect of the high dropout rate has to be discussed, but the response rate and the participation rate should be treated separately. As it can be seen in Fig. For MediMind and Autogenic Training, the participation was nearly twice as high as data was available. This shows a high motivation for attending the trainings, but not for filling in the questionnaires.
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Since post assessment time points overlap with the exam period, this may explain the high dropout rate. Furthermore, regarding the control group, the offer of a participation in the trainings five years after the start of our study might have caused in a decrease of motivation.
This may explain that the highest dropout rate in our study was found for the control group. It has to be questioned if the control group represents the natural progress of data and is therefore suitable as a control condition. A comparable dropout rate is also reported by McGrady et al. Statistical analysis at baseline revealed that students who dropped out of our study were of significantly poorer mental health compared to the students who formed our evaluation sample, and it can be assumed that this had an impact on our results.
It is well known that approaches in primary prevention of mental disorders face small effects, thus a reduction in sample size might impede results in a way that small effects cannot be detected [ 52 , 53 ]. Furthermore, it is recognized that the highest effect of an intervention arises in participants who are initially heavily burdened [ 54 ]. Therefore, students who would possibly have improved the most by the trainings are not included in our evaluation.
This assumption is supported by McGrady et al. Therefore, our data do not provide a reliable statement on every participant and do not allow drawing conclusions on the effectiveness of stress prevention trainings in German medical schools. Another limitation was the small sample size that involved a certain risk of not having enough power to detect potential effects. Due to study limitations, the recruitment had to be terminated before the required sample size had been reached.
As we used an ambitious study design with three study groups, an inclusion of more participants than in other randomized controlled trials was required. To our knowledge, only Jain et al. In contrast to a control group, Jain et al. Furthermore, they detected differences between the two interventions concerning their mechanisms of action. Therefore, it can be assumed that this pre-selection may have had an impact on the results since the participants were of poorer mental health at baseline.
With respect to our study design, it has to be mentioned that our data included students of preclinical and clinical semesters. Since these two cohorts differed significantly at baseline in terms of their overall psychological distress, this might moderate the overall effect of our study. Former studies on stress prevention trainings in medical school primarily included students in their first or second year of study [ 15 ], and therefore, these differences were of no consequence.
It is still unclear if the positive results of previous approaches can be transferred to students at a stage of advanced studies. Our aim of comparing the effectiveness of stress prevention at different stages of studies could not be achieved because of the insufficient sample size. Furthermore, our sample has no equal distribution of sex which may lead to distortions and effect the generalizability.
This limitation is in line with other studies [ 18 , 23 ] that included predominantly female participants. With respect to the gender ratio in German medical schools, it should be stated that there is no equal distribution in sex and that female students predominate [ 55 ].
Future research on stress prevention in German medical schools should focus on how to improve the response rate. A successful approach seems to be offering a training as an elective course [ 20 ] or as a curricular tool [ 22 ] to minimize motivational effects. Since this was not possible for the realization of our trainings, we had to provide the training sessions as an extracurricular activity.
In order to increase the response rate of the follow-up assessment, every participant who returned the questionnaire was rewarded by a voucher.
- The Life of a Master in the West, Omraam Mikhaël Aïvanhov.
- Through Grannys Garden Gate?
- Stress, Mobbing und Burn-out am Arbeitsplatz (German Edition).
- Four Dragons Daughters (Daisy Dunbar, Dragons Daughter Book 1)?
- Life is Good, Just Spit the Pit.
- Gemeinsame Agrarpolitik der EU (GAP) (German Edition);
This showed good effects and highlights the need of an external motivation in this field of research. It needs to be emphasized that this reward only had an effect on the response rate, but that no reward was necessary to increase the participation in the trainings, since the participation rate of the trainings was higher than the return rate of post-measurements.
In conclusion, the present study provides important suggestions for future research. It will be necessary to improve the outcome of a randomized controlled trial by offering an appropriate and sensible implementation of a training in the curriculum. Time of post-measurements should be reconsidered to reduce the drop-out rate during exam periods.
Moreover, incentives should be provided in order to increase the response rate, and finally, a waitlist control condition should be chosen. In accordance with former studies [ 2 , 3 , 7 ], our data confirm the high experience of stress and the vulnerability for psychological disorders in students of German medical schools.
Since this is still evident in later professional life [ 5 , 56 ], appropriate preventive interventions should already be provided during the time of studies to decrease the risk of suffering from mental disorders and to guarantee a stable performance of future doctors in patient care.
Currently, no data are available on the effectiveness of stress prevention programs for students in German medical schools. Therefore, nothing is yet known about how an offer of a preventive training would be accepted by the students and how it could be successfully implemented in their curriculum.
Our data demonstrate that the stress prevention training was well accepted by the participants and provided skills that were still used one year later. Due to the small sample size, the before mentioned objectives could not be answered conclusively. Although means of the Global Severity Index BSI indicate that MediMind may contribute to decreased psychological morbidity of the participants, a significant preventive effect cannot be proved. Due to the high dropout rate and the small sample size, the results cannot be generalized and can, therefore, not be regarded as conclusive.
Future research is necessary to evaluate preventive programs in German medical schools and to determine how they can be implemented within the heavy course load in order to reach those students who are severely burdened. Moreover, the evaluation of a larger sample size is necessary to represent the gender ratio in German medical schools for differential analysis. In conclusion, future research seems to be promising as the stress prevention trainings in our study were highly accepted, and with respect to preventing psychological disorders in future doctors, there is a need for action.
To prevent a high dropout rate and to generate a sufficiently large sample, the design to assess post-intervention and follow-up data has to be optimized. The authors would like to thank Prof. Hanna Christiansen for helpful comments on this article. We would also like to acknowledge the proof reading provided by Patricia Meinhardt. The dataset is set up in German language and therefore not suitable for an international use. Interested researchers are encouraged to contact the authors for a provision of data. SMK and AB developed the intervention program. SMK and FH elaborated the study protocol and gained ethical approval.
SMK wrote the manuscript and FH complemented the description of the design, randomization and the statistical analysis.
MH and AB participated in a critical review of the manuscript. All authors have contributed to the revision of the initial manuscript and have read and approved of the final version of the article submitted. All participants provided written informed consent and gave their consent to an anonymous publication of data.
Skip to main content Skip to sections. Advertisement Hide. Download PDF. Coping with stress in medical students: results of a randomized controlled trial using a mindfulness-based stress prevention training MediMind in Germany. Authors Authors and affiliations S. Kuhlmann M. Huss A.