Effects of meditation on Medical students health: a literature rapid reviewABSTRACT
Introduction: Increasing research suggests that medical students are at high risk of experiencing numerous psychological disorders. This population shows higher rates of stress, depression, mental distress, burnout, and lower levels of life satisfaction compared to students from other disciplines and the general population. Consequently, there is a clear need to seek effective strategies that promote emotional regulation and self-care among medical students.
Objective: Review and summarize existing evidence in the literature on the impact of meditation practice on the health of medical students, thereby encouraging its individual use or as part of programs implemented by medical schools.
Method: This is a Literature Rapid Review conducted following the recommendations of the PRISMA protocol. The search used Health Sciences Descriptors (DeCS/MeSH) based on the research guiding question, including only Randomized Controlled Trials published in the last 10 years.
Result: Six documents were included in this research. The findings show that meditation was effective in reducing perceived stress, psychological distress, and vulnerability to the development of psychopathologies, as well as in promoting well-being, life satisfaction, mindfulness, perceived self-efficacy, self-compassion, and altruism. In addition, long-term positive effects were also identified, especially in increasing well-being, self-compassion, self-efficacy, life satisfaction, and decreasing vulnerability to the development of psychopathologies.
Conclusion: The results found reveal that meditation presents benefits in various aspects of the health of medical students. Although further studies are needed for confirmation, these findings suggests that the practice can be a promising tool in reducing stress and, consequently, suicide rates, as well as potentially boosting academic performance and patient care.
Keywords:
Meditation; Mindfulness; Students, Medical
RESUMO
Introdução: Pesquisas crescentes sugerem que os estudantes de Medicina estão em alto risco de experimentar inúmeras doenças psicológicas. Nessa população, são maiores os índices de estresse, depressão, sofrimento mental, burnout, e menores os índices de satisfação com a vida quando comparados com estudantes de outros cursos e com a população em geral. Nesse contexto, é evidente a necessidade de buscar estratégias eficazes que ajudem a regulação emocional e o autocuidado dos estudantes de Medicina.
Objetivo: Este estudo teve como objetivos examinar e resumir as evidências existentes na literatura sobre o impacto da prática meditativa na saúde dos estudantes de Medicina e, assim, estimular sua utilização de forma individual ou como parte de programas implementados pelas escolas médicas.
Método: Trata-se de uma revisão rápida de literatura, realizada de acordo com as recomendações do protocolo PRISMA. A busca utilizou os Descritores em Ciências da Saúde (DeCS/MeSH) com base na pergunta norteadora da pesquisa, incluindo apenas ensaios controlados randomizados publicados no período de 2013 a 2023.
Resultado: Foram incluídos nesta pesquisa seis documentos. Os achados evidenciam que a prática de meditação mostrou-se eficaz na redução do estresse percebido, do sofrimento psicológico e da vulnerabilidade ao desenvolvimento de psicopatologias, bem como na promoção do bem-estar, da satisfação com a vida, da atenção plena, da autoeficácia percebida, da autocompaixão e do altruísmo. Ademais, efeitos positivos em longo prazo também foram identificados, especialmente no incremento do bem-estar, da autocompaixão, da autoeficácia, da satisfação com a vida e na diminuição da vulnerabilidade ao desenvolvimento de psicopatologias.
Conclusão: Os resultados encontrados revelam que a meditação apresenta benefícios em vários aspectos da saúde dos estudantes de Medicina. Embora novos estudos sejam necessários para comprovação, esses achados sugerem que a prática pode ser uma ferramenta promissora na redução do estresse e, por consequência, dos índices de suicídio, além de poder impulsionar o desempenho acadêmico e o cuidado destinado ao paciente.
Palavras-chave:
Meditação; Atenção Plena; Estudantes de Medicina
INTRODUCTION
A growing body of research suggests that medical students are at high risk of experiencing numerous psychological illnesses1. In this population, the rates of stress, depression, mental distress, and burnout are higher, and rates of life satisfaction are lower when compared to students in other courses and the general population2. The prevalence of depression in the general population ranges from 7.2% to 9.3%, while for medical students it is estimated at 27.2%1. A review of 32 meta-analyses found a prevalence of 32.5% of depressive or anxious symptoms, 41.7% of perceived stress, 42% of sleep disorders, and 8.9% of suicidal ideation in this population3. In agreement, North American studies indicate a prevalence of 47% of burnout and 49% of depressive symptoms, while Australian studies demonstrated a prevalence of 48% of psychological distress4. In Brazil, the prevalence of psychological conditions among medical students is expressively high. According to a systematic review and meta-analysis, approximately 49.9% of students experience high stress, 51.5% have poor sleep quality, 32.9% have symptoms of anxiety, and 30.6% have depressive symptoms5.
In this sense, the literature shows that the factors most related to the genesis of this suffering are high study load, high competitiveness among colleagues, sleep deprivation, irregular eating, abuse of power by teachers, high levels of demand, social isolation, lack of leisure time6, frequent exams, family problems, extracurricular activities4, financial worries, exposure to ethical dilemmas, and death7. The combination of academic stressors can lead to poor mental health and dissatisfaction with life1, in addition to negatively impacting professional development and academic performance8. Such situations can impair the ability to connect with the patient, provide empathetic care1, and take correct medical actions2. Long-term consequences can involve providing unequal or lower-quality care to patients, as well as increased absenteeism, presenteeism, and low workforce retention, observed when doctors temporarily or permanently leave the profession9. It then becomes evident that there is a need for strategies that help with emotional regulation and self-care among medical students, especially in the academic environment.
Present in various religious and philosophical traditions, meditation is a very ancient practice and encompasses several activities that seek relaxation by focusing on certain objectives10. In general, the different types of meditation are classified into two groups: concentration techniques, which use focusing on an object, music, or sensation (e.g., Transcendental Meditation), and Mindfulness, which seeks complete attention in the present moment, without judging one’s emotions or experiences11.
Some systematic reviews have shown that meditation programs and mindfulness-based interventions have led to improvements in resilience to stress, anxiety, depression1, psychological distress, attention deficit, self-compassion, self-awareness, empathy, affection, and knowledge retention among university students and other populations2. The observed effects may be related to decreased activity of the sympathetic nervous system, resulting in consistent reductions in cortisol, heart rate, systolic blood pressure, and inflammatory markers such as C-reactive protein and TNF-α12. On the other hand, the effects on medical students remain uncertain, as studies targeting this population are still scarce.
In this sense, the aim of this article is to systematically gather all the information in the literature that indicates the impact of meditation practice on medical students’ health and, thus, encourage its use individually or as part of programs implemented by medical schools. It is expected that mindfulness and other meditation methods will have positive effects on medical students’ health, not only related to stress, anxiety, depression and quality of life, but also on empathy, attention, memory and self-awareness.
METHODS
This study is a Rapid Literature Review, carried out in accordance with the recommendations of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)13, to investigate the effects of meditation on medical students. The PICO strategy (P - population; I - intervention; C - comparison; O - outcomes)14 guided the creation of the guiding question: “What are the health effects of meditation on medical students?”.
The data search took place in May 2023 and the following electronic databases were used: Scientific Electronic Library Online (SciELO) and the indexed databases of the Virtual Health Library (VHL) and the National Library of Medicine (NLM) from the PubMed platform, including the Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS), Models of Health and Traditional, Complementary and Integrative Medicines in the Americas (MOSAICO) and the Spanish Bibliographic Index in Health Sciences (IBECS).
The following Health Sciences Descriptors (DeCS/MeSH) in English and their translations were used: “Meditation”, “Mindfulness” and “Students, Medical”. The terms were combined using the Boolean operators “AND” and “OR”. Advanced research was conducted as follows on each search platform: VHL: (mh:(Meditação OR Meditation OR Meditación OR “Atenção Plena” OR “Mindfulness” OR “Atención Plena”)) AND (mh:(“Estudantes de Medicina” OR “Students, Medical” OR “Estudiantes de Medicina”)); SciELO: ((*”meditação” OR “atenção plena”) AND (“estudantes de medicina”)); PubMed: Meditation [Mesh] OR Mindfulness [Mesh] AND Students, Medical [Mesh].
According to the guiding question of the review, the inclusion criteria were: 1) articles published with full text available in the databases; 2) articles published in the last 10 years (2013 to 2023); 3) articles published in Portuguese, English and Spanish; 4) articles with a Randomized Controlled Trial design; 5) articles that addressed the topic of the effects of meditation on medical students; 6) articles in which the intervention is applied for at least 4 weeks and 7) articles with primary or secondary health outcomes.
The exclusion criteria were: 1) articles with populations that were not solely medical students; 2) articles that addressed meditation associated with another intervention method; 3) articles in which the control group received some type of intervention; and 4) literature review articles, observational and cross-sectional studies.
After identifying the results from the search terms used, the following search filters were applied: 1) publication date, in SciELO and PubMed, and 2) Randomized Controlled Trial, in PubMed. No filters were applied to the VHL platform. Using the web automation tool “Rayyan: systematic review” (https://www.rayyan.ai), duplicate articles and those with inadequate methodology were excluded, and subsequently, the remaining articles were evaluated by the main author according to the title and abstract, followed by full reading and final inclusion based on the pre-established eligibility criteria. Articles excluded by the automation tool due to inadequate methodology were reviewed according to title and abstract to avoid exclusion errors. The references cited in the studies included in this review, as well as those from similar systematic reviews, were examined in an attempt to broaden the inclusion.
The following information was collected from the included articles: 1) first author’s name; 2) study design; 3) population; 4) number of participants; 5) type and duration of the intervention; 6) measurement tools; and 7) outcomes and p-value. Due to heterogeneity regarding the type of intervention, outcome measures, and reporting method, the results were synthesized in a narrative manner and presented both in text and in tables. The quality of the included studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP) (https://www.ephpp.ca), which considers the method of participant selection, study design, confounding factors, blinding method, data collection method, and follow-up.
RESULTS
Initially, 931 documents were screened, of which 5 were found in the VHL database, 102 in PubMed, and 824 in SciELO. Then, after applying filters and using the automation tool, duplicate articles, those published more than 10 years ago, and those with inadequate methodological design were excluded, leaving 38 articles for subsequent analysis. After reading the title and abstract, 31 articles were eliminated because it was not possible to identify a relationship with the topic or they did not answer the study question. Of the 7 articles analyzed by full reading, 2 were excluded for not answering the guiding question. From the search in other sources, 1 article met the eligibility criteria and was included in the review. In summary, 6 documents were included in this research7),(15)-(19. The flowchart of the identification, screening, and inclusion methods is shown in Figure 1.
Flowchart of the methods for identifying, screening, and including articles in the review, adapted according to the PRISMA Flow Diagram.
During the analysis, 5 articles met the inclusion criteria, but were excluded due to association with other intervention methods20),(21, short intervention time22 and sample contamination with another population23)-(28. Finally, the included studies were all Randomized Clinical Trials, encompassing 560 medical students from the 1st to the 4th year, 279 (49.9%) in the intervention group and 281 (50.1%) in the control group. Other characteristics of the included articles are shown in Table 1. Secondary information regarding sociodemographic aspects was not considered noteworthy.
All included documents used similar interventions, adapted from Mindfulness-Based Stress Reduction (MBSR). The original training is a structured 8-week program, which includes weekly theoretical-practical meetings lasting approximately 2.5 hours, using approaches such as body scan, seated meditation focusing on breath, sounds, thoughts, and emotions. In addition, participants must dedicate approximately 45 minutes daily to practice, using guided recordings29. In general, the interventions in the analyzed studies included weekly meetings consisting of theoretical-practical classes, where the basic precepts and evidence of Mindfulness, its techniques, and how to incorporate them into daily practice were addressed. The adaptations differ from the original training in the duration of the daily individual training, varying from 3 to 20 minutes per day, as well as in the duration and content of the weekly meetings, but always maintaining the essence of the original training, which is to cultivate awareness in the present moment. Two studies adapted the program content to incorporate central issues faced by medical students during the meetings18),(19. One study used a digital tool based on Mindfulness as an intervention7, without using practical/theoretical sessions. Specific information on the duration of the meetings and the complete training for each intervention can be found in Table 2.
The measurement instruments used were validated and proved to be reliable, such as the Depression Anxiety Stress Scale (DASS), Perceived Stress Scale (PSS), Five Facet Mindfulness Questionnaire (FFMQ), among others. The use of these scales aimed to analyze mindfulness, stress, depression and anxiety, self-compassion, empathy, quality of life, well-being, psychological suffering, mental health, life satisfaction, vulnerability to developing psychopathies, resilience, perceived self-efficacy and altruism.
The questionnaires were administered before and immediately after the end of the intervention, and some studies also administered them after a follow-up period of 60 days7, 6 months17),(18 and 20 months16. A summary of the interventions and measurement tools are shown in Table 2.
According to the results found, MBSR and its adaptations, in the short term, were effective in reducing perceived stress7),(17),(18),(19, psychological distress16),(18, vulnerability to developing psychopathy16, as well as increasing well-being7, life satisfaction16, mindfulness level7),(15),(16),(18),(19, perceived self-efficacy18, self-compassion17),(19 and altruism19. These results corroborate the positive evidence found for the technique in other populations1),(2),(18),(30),(31, as well as the effectiveness of reduced MBSR adaptations15. On the other hand, in the short and long term, no effects were found on empathy16),(19 and measured resilience17.
Regarding the analysis of the quality of the studies by the EPHPP, no article was classified as strong. All showed limitations, such as selection bias due to self-selection of participants7),(16),(18),(19, lack of blinding of evaluators or participants15),(17 and insufficient control of confounders19. In general, the studies were classified as having a moderate level of quality, with the exception of one study, which was assessed as weak19.
Table 3 shows the relationship between the outcomes found and the methodological quality of the articles.
DISCUSSION
Of the analyzed outcomes, the reduction in perceived stress and the increase in mindfulness levels were the most prevalent ones. The quantification of the mindfulness level is significantly related to the meditation experience and has a negative relationship with psychological symptoms related to depression, anxiety, anhedonia, and insomnia7.
Similarly, chronic stress can result in burnout, a syndrome characterized by the triad of emotional exhaustion, negativism towards work, and decline in professional efficacy, associated with psychiatric disorders and suicidal ideation8. Thus, tools that can help reduce stress and, consequently, prevent burnout, may play a role in suicide prevention.
Furthermore, it is possible to state that there are contradictory results regarding the long-term effects of meditation. Positive results were observed in well-being7, self-compassion17, self-efficacy18, mental health, life satisfaction, and vulnerability to developing psychopathy16. Although a reduction in perceived stress levels was also observed after 60 days7, this effect disappears when analyzed after 6 months17),(18. Thus, future research is needed to investigate the long-term implications of meditation on medical students’ health.
Similarly, positive results were observed in psychological distress and mindfulness after 20 months16, but not at 6 months18. These conflicting results may be explained by the commitment to the practice being less than that expected by the authors.
According to Phang et al.18, after 6 months, the average number of days of practiced meditation dropped significantly when compared to the average during the intervention. Similarly, Erogul et al.17 comment that the average number of minutes meditated per week was 40.7, below the established target of 140.
In contrast, Dijk et al.16 comment that, at the end of the study, of the 67 participants who remained, 33 stated that they continued with regular home practices, maintaining the same average number of minutes meditated. In this trial, the practical/theoretical sessions took place during curricular activity hours, which, according to the author, encouraged satisfactory participant retention. These facts may explain the better results of this study compared to that of Phang et al.18.
Neto et al.15 was the only study that found no differences in any of the analyzed outcomes. However, in this study, the practical/theoretical sessions were given within the mandatory curriculum and to a large group, which is why the author correlates the unsatisfactory commitment. Although they found positive outcomes, Yang et al.7 and Danilewitz et al.19 state that only 60% of the participants used the app at least once during the 30 days of the study and only 26% of the participants reported regular meditation practice. Thus, it is clear that there is a difficulty in keeping students motivated with meditation practice.
Furthermore, the quality of the articles assessed by the EPHPP was, in general, moderate. It is possible to observe some methodological limitations, such as the most used way of selecting participants, from self-selected groups7),(16),(18),(19, that is, it included volunteers more likely to be experiencing high levels of stress and, consequently, more susceptible to biased results. Another limitation of the studies was the lack of commentary regarding7),(16),(18),(19 or the lack of blinding15),(17 of the interveners and participants, associating the variable of suggestion and expectation. This assessment reinforces the need for cautious interpretations of the results and highlights the urgency of new studies with more robust methodologies.
To overcome these limitations, future studies should adopt more rigorous methodological designs, with larger and random samples, adequate blinding, training and supervision of instructors, in addition to implementing strategies that strengthen participant adherence. The use of standardized protocols would also contribute to comparability between studies, strengthening the scientific evidence on the effects of meditation on medical students’ health.
Only six articles were included in the review. This demonstrates the current scarcity of trials related to medical students. In addition, the use of other meditation methods with this population, such as Transcendental Meditation, still lacks evidence, as only adaptations of MBSR were found.
The various positive results found regarding meditation on medical students’ health, although still modest, seem promising. Therefore, new studies are needed, with better methodological quality and participant commitment, to increase the robustness of the outcomes presented here, and consequently, to better understand the long-term effects of meditation and its possible role in suicide prevention. Other similar systematic reviews have sought to understand the effects of Mindfulness meditation on stress and burnout8, psychological distress1, well-being4, and depression32. However, the present study stands out insofar as it delivers a new research protocol and expands the intervention method and the outcomes sought.
It is hoped that the results of this research will contribute to reflection on the impact that meditation techniques can have on future medical professionals. It is of utmost importance that the subject be discussed and its use considered, both individually by the individuals themselves who study how to alleviate the suffering of others, and also by medical schools, which are often directly responsible for the genesis of psychological suffering.
CONCLUSION
In summary, this review suggests that meditation practices, particularly those adapted from MBSR, can have beneficial effects on various aspects of medical students’ health. In this population, meditation has shown to be capable, primarily, of increasing levels of mindfulness, reducing perceived stress and vulnerability to developing psychopathy, as well as promoting improvements in well-being and life satisfaction. These effects may have indirect implications for academic performance, patient care, and the reduction of suicide among medical students.
This study is unprecedented in its targeted synthesis of evidence on the effects of meditation on medical students’ health, a population highly vulnerable to stress, anxiety, and burnout. Its relevance lies in highlighting meditation as a low-cost, accessible tool with virtually no side effects, capable of promoting well-being, emotional self-regulation, and life satisfaction. Furthermore, the findings of this review provide support for medical schools to consider implementing structured meditation programs, integrated into the curriculum or as extracurricular activities, aiming not only to improve student quality of life, but also potentially to enhance academic performance and the training of more balanced professionals better prepared to handle the demands of medical practice. Given the limited number of studies and methodological variations, further research is needed to confirm these findings and deepen the understanding of the role of meditation as a support tool in medical education.
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Research data are available in the body of the document.
Source: The author, 2023.