Examining stress: an investigation of stress, mood and exercise in medical students

Associations of coping and health-related behaviors with medical students' well-being and performance during objective structured clinical examination

Objective structured clinical examination (OSCE) is a valid method to evaluate medical students' competencies. The present cross-sectional study aimed at determining how students' coping and health-related behaviors are associated with their psychological well-being and performance on the day of the OSCE. Fourth-year medical students answered a set of standardized questionnaires assessing their coping (BCI) and health-related behaviors before the examination (sleep PSQI, physical activity GPAQ). Immediately before the OSCE, they reported their level of instant psychological well-being on multi-dimensional visual analogue scales. OSCE performance was assessed by examiners blinded to the study. Associations were explored using multivariable linear regression models. A total of 482 students were included. Instant psychological well-being was positively associated with the level of positive thinking and of physical activity. It was negatively associated with the level of avoidance and of sleep disturbance. Furthermore, performance was negatively associated with the level of avoidance. Positive thinking, good sleep quality, and higher level of physical activity were all associated with improved well-being before the OSCE. Conversely, avoidance coping behaviors seem to be detrimental to both well-being and OSCE performance. The recommendation is to pay special attention to students who engage in avoidance and to consider implementing stress management programs.Clinical trial: The study protocol was registered on clinicaltrial.gov NCT05393206, date of registration: 11 June 2022.

Association of polygenic scores for depression and neuroticism with perceived stress in daily life during a long-lasting stress period

Genetic factors contribute significantly to interindividual differences in the susceptibility to stress-related disorders. As stress can also be conceptualized as environmental exposure, controlled gene-environment interaction (GxE) studies with an in-depth phenotyping may help to unravel mechanisms underlying the interplay between genetic factors and stress. In a prospective-longitudinal quasi-experimental study, we investigated whether polygenic scores (PGS) for depression (DEP-PGS) and neuroticism (NEU-PGS), respectively, were associated with responses to chronic stress in daily life. We examined law students (n = 432) over 13 months. Participants in the stress group experienced a long-lasting stress phase, namely the preparation for the first state examination for law students. The control group consisted of law students without particular stress exposure. In the present manuscript, we analyzed perceived stress levels assessed at high frequency and in an ecologically valid manner by ambulatory assessments as well as depression symptoms and two parameters of the cortisol awakening response. The latter was only assessed in a subsample (n = 196). No associations between the DEP-PGS and stress-related variables were found. However, for the NEU-PGS we found a significant GxE effect. Only in individuals experiencing academic stress a higher PGS for neuroticism predicted stronger increases of perceived stress levels until the exam. At baseline, a higher NEU-PGS was associated with higher perceived stress levels in both groups. Despite the small sample size, we provide preliminary evidence that the genetic disposition for neuroticism is associated with stress level increases in daily life during a long-lasting stress period.

Psychobiotic Lactobacillus plantarum JYLP-326 relieves anxiety, depression, and insomnia symptoms in test anxious college via modulating the gut microbiota and its metabolism

Introduction

Test anxiety is a common issue among college students, which can affect their physical and psychological health. However, effective interventions or therapeutic strategies are still lacking. This study aims to evaluate the potential effects of Lactobacillus plantarum JYLP-326 on test anxious college students.

Methods

Sixty anxious students were enrolled and randomly allocated to the placebo group and the probiotic group. Both groups were instructed to take placebo and JYLP-326 products twice per day for three weeks, respectively. Thirty unanxious students with no treatments were assigned to a regular control group. The anxiety, depression, and insomnia questionnaires were used to measure students' mental states at the baseline and the end of this study. 16S rRNA sequencing and untargeted metabolomics were performed to analyze the changes in the gut microbiota and fecal metabolism.

Results

The questionnaire results suggested that JYLP-326 administration could relieve the symptoms of anxiety, depression, and insomnia in test anxious students. The gut microbiomes of the placebo group showed a significantly greater diversity index than the control group (p < 0.05). An increased abundance of Bacteroides and Roseburia at the genus level was observed in the placebo group, and the relative abundance of Prevotella and Bifidobacterium decreased. Whereas, JYLP-326 administration could partly restore the disturbed gut microbiota. Additionally, test anxiety was correlated with disordered fecal metabolomics such as a higher Ethyl sulfate and a lower Cyclohexylamine, which could be reversed after taking JYLP-326. Furthermore, the changed microbiota and fecal metabolites were significantly associated with anxiety-related symptoms.

Conclusion

The results indicate that the intervention of L. plantarum JYLP-326 could be an effective strategy to alleviate anxiety, depression, and insomnia in test anxious college students. The potential mechanism underlying this effect could be related to the regulation of gut microbiota and fecal metabolites.

Daily life stress and the cortisol awakening response over a 13-months stress period - Findings from the LawSTRESS project

The LawSTRESS project is a controlled prospective-longitudinal study on psychological, endocrine, central nervous and genetic predictors of responses to long-lasting academic stress in a homogenous cohort. In this first project report, we focused on the association between daily life stress and the cortisol awakening response (CAR). The CAR, a distinct cortisol rise in the first 30-45 min after morning awakening, is a well-established marker of cortisol regulation in psychoneuroendocrinology. Law students from Bavarian universities (total n = 452) have been studied over a 13-months period at six sampling points starting 12 months prior exam. The stress group (SG) consisted of students experiencing a long-lasting and significant stress period, namely the preparation for the first state examination for law students. Law students assigned to the control group (CG) were studied over an equally long period without particular and sustained stress exposure. To investigate stress related alterations in the CAR, we examined a subsample of the LawSTRESS project consisting of 204 students with 97 participants from the SG (69.1% female, mean age = 22.84 ± 1.82) and 107 from the CG (78.5% female, mean age = 20.95 ± 1.93). At each sampling point, saliva samples for cortisol assessment were collected immediately upon awakening and 30 as well as 45 min later. Perceived stress in daily life was measured by repeated ambulatory assessments (about 100 queries over six sampling points). The time course of perceived stress levels in the two groups differed significantly, with the SG showing an increase in perceived stress until the exam and a decrease thereafter. Stress levels in the CG were relatively stable. The CAR was not significantly different between groups at baseline. However, a blunted CAR in the SG compared to the baseline measure and to the CG developed over the measurement timepoints and reached significance during the exam. Remarkably, this effect was neither associated with the increase in perceived stress nor with anxiety and depression symptoms, test anxiety and chronic stress at baseline. The present study successfully assessed multidimensional stress trajectories over 13 months and it documented the significant burden, law students preparing for the first state examination are exposed to. This period was related to a blunted CAR with presumed physiological consequences (e.g., on energy metabolism and immune function). Mean psychological stress levels as well as the CAR returned to baseline levels after the exam, suggesting a fast recovery in the majority of the participants.

The relationship between acute stress and neurophysiological and behavioral measures of food-related inhibitory control: An event-related potential (ERP) study

Stress influences many health-related behaviors including diet and nutrition intake, often resulting in increased calorie intake, fewer healthy eating behaviors, and poorer nutrition. Food intake is modulated by inhibitory control and has important implications for our physical, mental, and emotional health. Yet, little is known about the relationship between stress and food-related inhibitory control. We tested the influence of a short-term experimental stressor on behavioral and event-related potential (ERP; N2 and P3 components) measures of food-related inhibitory control. Ninety-seven healthy participants were randomly assigned to complete the Trier Social Stress Test (TSST) (n = 48, 27 females [52.9%]) or a neutral control condition (n = 49, 35 females [70%]) immediately followed by food-specific go/no-go and neutral go/no-go tasks while electroencephalogram (EEG) data were recorded. Stress levels were successfully manipulated, with heightened self-report and physiological measures (heart rate and systolic blood pressure) of the stress response in individuals who completed the TSST compared to control. As expected, the high calorie food-specific go/no-go task elicited larger N2 amplitude than the neutral task. N2 component amplitude was also significantly larger following the TSST relative to the control task. There were no significant between-group or task differences for P3 amplitude or behavioral measures. Findings suggest heightened N2 amplitude following psychological stress that is not specific to food or inhibition processes and may reflect heightened arousal following stress. Future research in individuals with overweight/obesity or experiencing chronic stress will further clarify the role of stress in food-related inhibitory control.

Effects of open-label placebos on test performance and psychological well-being in healthy medical students: a randomized controlled trial

Psychological distress is prevalent in students and can predispose to psychiatric disorders. Recent findings indicate that distress might be linked to impaired cognitive performance in students. Experimental findings in healthy participants suggest that placebo interventions can improve cognition. However, whether non-deceptive (i.e., open-label, OLP) placebos can enhance cognitive function and emotional well-being is unclear. Using a randomized-controlled design we demonstrate a positive impact of OLP on subjective well-being (i.e., stress, fatigue, and confusion) after a 21-day OLP application in healthy students during midterm exams. OLP did not improve test performance, but, within the OLP group, test performance was positively correlated with measures of general belief in the benefit of medication. These results show that OLP can counteract negative effects of acute stress on psychological well-being and might improve cognitive performance if supported by positive treatment expectations. Additionally, our findings in healthy volunteers warrant further investigation in exploring the potential of OLP in reducing stress-related psychological effects in patients. The trial was preregistered at the German Clinical Trials Register on December 20, 2017 (DRKS00013557).

A feasibility study of an exercise intervention to educate and promote health and well-being among medical students: the 'MED-WELL' programme

BACKGROUND

Medical School programme workloads challenge the physical and mental health of students particularly in compressed graduate entry programmes. There is evidence that physical activity (PA) can improve holistic care and help maintain wellness among medical students. We tested the feasibility of introducing an exercise programme to the medical school curriculum which would educate and promote health and well-being among its students.

METHODS

This study was conducted in a single graduate entry medical school at the University of Limerick (UL). The 'MED-WELL' programme was a six-week programme of 1 hour-long weekly sessions, each involving a different type of PA (45 min). These sessions were prefaced by an interactive lecture about how to incorporate exercise theory into daily medical practice (15 min). The study was conducted in a single graduate entry medical school at UL and involved year one and year two graduate entry medical students. Three parameters were used to test feasibility: 1. Recruitment and retention of participants, 2. Acceptability of the programme and 3. Efficacy in terms of health and well-being. The latter was assessed by administering questionnaires pre and post the intervention. The questionnaires used the following validated measurement scales: EQ-VAS; WHO-5 Well-Being Index; 3-item Loneliness Scale; Social Support Measure 3-item scale. Free text boxes also encouraged participants to discuss the merits of the programme.

RESULTS

In total, 26% (74/286 students) participated in the programme. Of those who participated, 69 students (93%) attended one or more sessions of the programme and completed questionnaires at baseline and at follow-up. Significant improvements were seen in scores after the programme in the WHO-5 Well-Being Index which increased from 63.2 (95%CI: 48-78.4) to 67.5 (95%CI: 55.1-79.9); (P < 0.01), the sleep scale which increased from 3.1 (95%CI: 2.2-4.0) to 3.5 (95%CI: 2.5-4.5); (P < 0.001), and the loneliness scale which decreased from 4.1 (95%CI: 2.7-5.5) to 3.5 (95%CI: 2.5-4.5); (P < 0.005). Students level of PA during a typical week also increased from 3.7 (95%CI: 2.1-5.4) to 4.0 (95%CI, 3.5-4.5); (P < 0.05).

CONCLUSION

This study has shown it is feasible to deliver this programme in a medical school's curriculum. The programme seems to be of benefit and is acceptable to students. Well-designed randomised controlled trials are needed to measure outcomes, durability of effect, and cost effectiveness.

Predicting future performance in medical students. A longitudinal study examining the effects of resilience on low and higher performing students

Introduction: Medical students have high rates of distress and burnout, exacerbated by a high academic workload. Resilience is stated to mitigate such stress, and even allow positive adaptations in the face of such challenges. Despite this, no research has examined the relationship of resilience on the academic performance of medical students. Methods: The goal of our study was to investigate the association between resilience on academic performance. We surveyed all year 2, 3, and 4 medical students (n = 160), and combined this with data on past and future course performance. We conducted an analysis of the internal consistency and validity of the RS-14, suggesting two factors: which we represent as self-assuredness and drive. We then analyzed future course performance using multiple regression. Results: Models utilizing the combined RS-14 score suggested past-performance as the only significant predictor of future course performance. Considering self-assuredness and drive as separate predictors demonstrated self-assuredness to be a predictor of improved performance in lower-than-average students, whilst drive was a predictor of improvement in higher-than-average students. Conclusions: We suggest that the conceptualization of resilience needs greater nuance, and consideration in tandem with broader psychosocial concepts, as it may exert different effects for different students.

The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis

Anxiety, although as common and arguably as debilitating as depression, has garnered less attention, and is often undetected and undertreated in the general population. Similarly, anxiety among medical students warrants greater attention due to its significant implications. We aimed to study the global prevalence of anxiety among medical students and the associated factors predisposing medical students to anxiety. In February 2019, we carried out a systematic search for cross-sectional studies that examined the prevalence of anxiety among medical students. We computed the aggregate prevalence and pooled odds ratio (OR) using the random-effects model and used meta-regression analyses to explore the sources of heterogeneity. We pooled and analyzed data from sixty-nine studies comprising 40,348 medical students. The global prevalence rate of anxiety among medical students was 33.8% (95% Confidence Interval: 29.2–38.7%). Anxiety was most prevalent among medical students from the Middle East and Asia. Subgroup analyses by gender and year of study found no statistically significant differences in the prevalence of anxiety. About one in three medical students globally have anxiety—a prevalence rate which is substantially higher than the general population. Administrators and leaders of medical schools should take the lead in destigmatizing mental illnesses and promoting help-seeking behaviors when students are stressed and anxious. Further research is needed to identify risk factors of anxiety unique to medical students.

"N-of-1"-Study: A concept of acute and chronic stress research using the example of ballroom dancing

Athletes often report on heightened stress, higher disease susceptibility, and a deterioration in mood and performance throughout periods of high training load and competitions. This paper presents a single-case study combining different research approaches to monitor the dynamic, idiosyncratic responses to competitive stress in elite sports using the example of professional ballroom dancing. Throughout an 8-month period (313 data points), one international-level female dancer provided data on mood, stress, and fatigue. In parallel, she collected saliva samples for the assessment of cortisol (sCort) and alpha-amylase (sAA). A hair strand was collected every 3 months to examine cumulative cortisol secretion. As expected, perceived stress was related to a reduction in well-being. On a daily basis, sCort predicted lower fatigue. In addition, tournaments resulted in a 3-fold and a 2-fold increase in sCort and sAA, respectively, and there was a pronounced drop in hair cortisol in the aftermath of a surgery-related break from dancing. We confirm competitive ballroom dancing to constitute a major stressor with immediate and prolonged consequences for self-reported well-being and biological stress markers. Single-case studies offer much potential for the observation of complex dynamic associations. In a next step, this approach will also become relevant when evaluating the efficacy of preventive and therapeutic interventions on an individual level.

Medical student psychological distress and academic performance

INTRODUCTION

The impact of medical student psychological distress on academic performance has not been systematically examined. This study provided an opportunity to closely examine the potential impacts of workplace and study related stress factors on student's psychological distress and their academic performance during their first clinical year.

METHODS

This one-year prospective cohort study was performed at a tertiary hospital based medical school in Melbourne, Australia. Students completed a questionnaire at three time points during the year. The questionnaire included the validated Kessler psychological distress scale (K10) and the General Health Questionnaire-28 (GHQ-28), as well as items about sources of workplace stress. Academic outcome scores were aggregated and correlated with questionnaire results.

RESULTS

One hundred and twenty six students participated; 126 (94.7%), 102 (76.7%), and 99 (74.4%) at time points one, two, and three, respectively. 33.1% reported psychological distress at time point one, increasing to 47.4% at time point three. There was no correlation between the K10 scores and academic performance. There was weak negative correlation between the GHQ-28 at time point three and academic performance. Keeping up to date with knowledge, need to do well and fear of negative feedback were the most common workplace stress factors.

CONCLUSIONS

Poor correlation was noted between psychological distress and academic performance.