Well-Being of Students
Systematic Review of Depression, Anxiety,
and Other Indicators of Psychological Distress
Among U.S. and Canadian Medical Students
Liselotte N. Dyrbye, MD, Matthew R. Thomas, MD, and Tait D. Shanafelt, MD
Abstract
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Purpose
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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
T he 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
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: 具dyrbye.liselotte@mayo.edu典.
354
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
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
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.
Acad Med. 2006; 81:354–373.
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
Academic Medicine, Vol. 81, No. 4 / April 2006

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
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2005 to address the following questions:
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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.
Method
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
Academic Medicine, Vol. 81, No. 4 / April 2006
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.
Results
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.)
Instruments used
A variety of tools to assess depression,
anxiety, and overall mental health were
used in the included articles. We describe
Well-Being of Students
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
355
 Well-Being of Students
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 ⱖ 16 suggest mild,
moderate, and severe depression,
respectively.59
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The CES-D is a 20-item self-reported
rating scale designed by the National
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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 ⱖ 16 is
considered indicative of depression,60,61
although a score of ⱖ 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
356
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
Cross-sectional studies. 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 ⱖ 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 ⱖ 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
Academic Medicine, Vol. 81, No. 4 / April 2006

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
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population). A study of students at the
University of Calgary Faculty of Medicine
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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 ⱖ 8) and severe
depression (13-item BDI scores ⱖ 16) in
49 (15%) and 7 (2%) students,
respectively.
Longitudinal studies. 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
Academic Medicine, Vol. 81, No. 4 / April 2006
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 ⱖ 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
Well-Being of Students
second year, and 39 (31%) by the middle
of the fourth year had CES-D scores
ⱖ 80th percentile of population norms.8
Prevalence of medical student anxiety
Cross-sectional studies. 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.
Longitudinal studies. 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
357
 Well-Being of Students
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
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reported similar findings.
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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 ⱖ 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
358
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
Gender. 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).
Academic Medicine, Vol. 81, No. 4 / April 2006

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
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medical school measured stress by
attrition rates, a nonvalidated Likert
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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.
Academic Medicine, Vol. 81, No. 4 / April 2006
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
Well-Being of Students
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.
Ethnicity. 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 ⱖ 8) than
were non-Hispanic students.
Distress and other variables
Personality. 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
359
 Well-Being of Students
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.
Stress. Some degree of stress is typically
considered a normal and unavoidable
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aspect of both medical training and the
practice of medicine. While measuring
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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
360
Curricular factors. 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 ⱖ 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 ⱖ 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
Academic Medicine, Vol. 81, No. 4 / April 2006

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
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stress-reduction (MBSR) techniques
intended to foster concentration, insight,
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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.
Discussion
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
Academic Medicine, Vol. 81, No. 4 / April 2006
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
Well-Being of Students
burnout may adversely impact
professionalism17,18,172 and 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.
361
 Well-Being of Students
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.
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173 Gill D, Palmer C, Mulder R, Wilkinson T.
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174 Newton BW, Savidge MA, Barber L, et al.
Differences in medical students’ empathy.
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175 Merrill J, Lorimor R, Thornby J, Woods A.
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176 Stecker T. Well-being in an academic
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177 American Board of Internal Medicine. Project
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178 Van Der Ploeg H. Relationship of state-trait
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179 Tooth D, Tonge K, McManus IC. Anxiety
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180 Grover PL, Smith DU. Academic anxiety,
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181 Mareiniss DP. Decreasing GME training
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182 Branch W, Pels RJ, Lawrence RS, R. A..
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183 Pololi L, Frankel RM. Small-group teaching
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184 Kelly JA, Bradlyn AS, Dubbert PM, St
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185 Rathbun J. Helping medical students
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186 Lee J, Graham AV. Students’ perception of
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187 Holtzworth-Munroe A, Munroe MS, Smith
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188 McCue JD, Sachs CL. A stress management
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189 Lim JK, Golub RM. Graduate medical
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References that are in Table 1 only
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191 Fenderson BA, Hojat M, Damjanov I, Rubin
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365
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366
Appendix
Table 1
Demographic and Methodologies Employed in 40 Studies Examining Medical
Student Depression and Anxiety*
Period of Medical student
Well-Being of Students

Source Sample size study† population Study design Tool† Covariates measured†
Depression
......................................................................................................................................................................................................................................................................................................................................................................................................................
Zoccolillo et 304 1982-83, 1st- and 2nd-year students, Longitudinal survey, beginning of BD FH of psychiatric illness; PMH of
al.,74 1986 1983-84 Washington University School of academic year with monthly surveys IDIS psychiatric treatment
Medicine up to 2 years
......................................................................................................................................................................................................................................................................................................................................................................................................................
Clark et al.,7 121 NR Midwestern Medical College Longitudinal survey, September and 21-item Rosenberg Self-Esteem Scale,
1988; see also April of 1st year, November and BDI Pleasure Capacity Scale, Self
Zeldow et April of 2nd year, and December of Confidence Scale, Social Network
al.,138 1987; 3rd and 4th year Inventory, Humanistic Scale,
Zeldow et Neuroticism Scale, Perceived Stress
al.,139 1988; Scale, Locus of Control, Personal
Clark et al.,152 Attributes Questionnaire, FH of
1988 Major Depression, alcohol and drug
use
......................................................................................................................................................................................................................................................................................................................................................................................................................
Katz et al.,111 100 NR Married medical students , a Cross-sectional survey 21-item Dynamic Adjustment Scale,
2000 Southeastern medical university, BDI Perceived Stress Scale, spousal
and their spouses support
......................................................................................................................................................................................................................................................................................................................................................................................................................
Enns et al.,135 96 NR 1st-, 2nd-, and 3rd-year students Longitudinal survey, baseline and 6 13-item Multidimensional Perfectionism
2001 (published months BDI Scale, Neuroticism and
2001) Conscientiousness scales from the
NEO Five-Factor Inventory, Beck
Hopelessness Scale, Suicidal Ideation
Questionnaire, self-report of
academic measures
......................................................................................................................................................................................................................................................................................................................................................................................................................
Ball et al.,13 64 NR Convenience sample of 1st-year Interventional study, 29 students in 21-item AUDIT, Epworth Sleepiness Scale,
2002 (published students, Indiana University feedback group, 23 in lecture BDI health habits, satisfaction with
2002) School of Medicine group, and 19 controls various aspects of life within and
outside of medical school
......................................................................................................................................................................................................................................................................................................................................................................................................................
Givens et al.,6 194 1994 1st- and 2nd-year students, Cross-sectional survey, spring 13-item Self-reported use of counseling
2002 University of California, San BDI services, barriers to use, suicidal
Francisco, School of Medicine ideation
......................................................................................................................................................................................................................................................................................................................................................................................................................
Tjia et al.,89 564 2001-02 1st- through 4th-year students , Cross-sectional survey 13-item Self-reported use of counseling
2005 private U.S. medical school BDI services, barriers to use, use of
antidepressants, suicidal ideation,
PMH or FH of depression
......................................................................................................................................................................................................................................................................................................................................................................................................................
Richman et 211 1984 1st-year students, University of Longitudinal survey, fall and 7 CES-D Demographics, Social Support
al.,140 1987; Illinois College of Medicine months later Network Inventory, Parental
see also Bonding Instrument, locus of
Richman et control, interpersonal dependency,
al.,141 1985 flexibility, self-esteem
......................................................................................................................................................................................................................................................................................................................................................................................................................
Buchman et 243 1986-87 1st-year students, University of Cross-sectional survey, orientation CES-D Bortner Short Rating Scale, State-
al.,85 1991 California, San Diego, School of Trait Anger Scale, Anger Expression
Medicine Self-Analysis Questionnaire
(Table continues)

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Table 1
(Continued)

Period of Medical student

Source Sample size study† population Study design Tool† Covariates measured†
9 rd
Mosley et al., 69 1992-93 3 -year students, University of Cross-sectional survey, completion CES-D Medical Education Hassles Scale-R,
1994 Mississippi School of Medicine of a psychiatry rotation Coping Strategies Inventory, Wahler
Physical Symptoms Inventory
......................................................................................................................................................................................................................................................................................................................................................................................................................
Lloyd et al.,86 199 NR 1st-year students, University of Cross-sectional survey, orientation CES-D Parental Bonding Instrument,
1997 Texas Medical School at Houston Rosenberg Self-Esteem Scale, visual
analog rating of Miller and Ingham
for depression
......................................................................................................................................................................................................................................................................................................................................................................................................................
Rosal et al.,8 300 1987-89 University of Massachusetts Longitudinal survey, 4 weeks prior CES-D Bortner Type A Behavior Scale,
1997 Medical School to start of medical school and Spielberger Trait Anger Scale,

Academic Medicine, Vol. 81, No. 4 / April 2006

middle of the 2nd and 4th year Spielberger Anger Expression Scale,
stress, demographics, social-life
......................................................................................................................................................................................................................................................................................................................................................................................................................
Camp et 324 1991-1993 Convenience sample, 1st-year Interventional study. 60 students in SDS Self-actualization scale of the
al.,108 1994 students, Bowman Gray School problem-based learning curriculum California Psychological Inventory
of Medicine (now Wake Forest and 264 in lecture-based
University School of Medicine) curriculum. Longitudinal survey,
August and November
Anxiety
......................................................................................................................................................................................................................................................................................................................................................................................................................
Vontver et 349 1978-79 2nd-year students, University of Cross-sectional survey, winter, 22 STAI Impact of 2 pelvic examination
al.,97 1980 Washington School of Medicine students randomly assigned to instructional methods on heart rate
standardized patient instruction and and anxiety
18 in control group
Global
mental
health
......................................................................................................................................................................................................................................................................................................................................................................................................................
Whitehouse et 110 (35 in intervention NR Convenience sample of 1st-year Interventional study but results POMS Fourteen 90-minute sessions of self-
al.,95 1996 group) (published students collapsed for reporting. hypnosis training throughout the 1st
1996) Longitudinal survey, orientation, 13 semester. Brief Symptom Inventory,
weeks, prior to final exam, and at UCLA Loneliness Scale, blood
the end of midyear break. samples for immune measures,
Harvard Group Scale of Hypnotic
Susceptibility, daily diaries on sleep,
mood, medications, and problems
experienced
......................................................................................................................................................................................................................................................................................................................................................................................................................
Rosenzweig et 302 (140 in intervention 1996-2000 2nd-year students, Jefferson Interventional study, experimental POMS 90-minute Mindfulness-based Stress
al.,102 2003 group) Medical College of Thomas convenience sample Reduction Seminar (MBSR) once per
Jefferson University week for 10 weeks
......................................................................................................................................................................................................................................................................................................................................................................................................................
Henning et 988 Sample included 1996 221 medical students, Medical Cross-sectional survey, spring BSI Multidimensional Perfectionism
al.,83 1998 medical, dental, University of South Carolina semester Scale, Clance’s Imposter
pharmacy and nursing College of Medicine Phenomenon Scale
students
......................................................................................................................................................................................................................................................................................................................................................................................................................
Lloyd et al.,96 159 1978-79 1st-year students, University of Longitudinal survey, orientation in HSCL Ego-Resiliency-Subtle Scale;
1981 Texas Medical School at Houston September, January, and end of the questions on positive psychological
academic year status, role conflict, role support,
demographics

367
Well-Being of Students

(Table continues)
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368
Table 1
(Continued)

Period of Medical student

Well-Being of Students

Source Sample size study† population Study design Tool† Covariates measured†
90 st th
Lloyd et al., 745 1982 1 - through 4 -year students, Cross-sectional survey, near HSCL Stress, social support, support
1984 University of Texas Medical the end of the academic year services
School, Houston
......................................................................................................................................................................................................................................................................................................................................................................................................................
Kellner et 120 NR 60 1st- and 3rd-year medical Cross-sectional survey, 2nd HSCL Symptom Questionnaire, Illness
al.,103 1986 (published students and 60 1st- and 3rd- semester Behavior Questionnaire, Illness
1986) year law students, University of Attitude Scales
New Mexico Albuquerque
......................................................................................................................................................................................................................................................................................................................................................................................................................
Toews et al.,91 216 1991-92 1st- through 4th-year students, Cross-sectional survey SCL-90-R Social Readjustment Rating Scale
1993 University of Calgary Faculty of
Medicine
......................................................................................................................................................................................................................................................................................................................................................................................................................
Toews et al.,99 3628 Sample 1994-95 1st- through 4th-year students, 4 Cross-sectional survey SCL-90 Stress, Social Readjustment Rating
1997 included medical medical schools in Canada Scale
students,
residents, and
graduate science
students
Combination
......................................................................................................................................................................................................................................................................................................................................................................................................................
Mitchell et 99 1980-81 1st-year students, Creighton Interventional study. 29 BDI MMPI
al.,163 1983 University School of Medicine students randomly selected to STAI
support group and/or lecture
on stress management or
control
......................................................................................................................................................................................................................................................................................................................................................................................................................
Notman et NR 1984 2 samples of entering students Cross-sectional survey, SDS Demographics, stressful life events,
al.,142 1984 at Harvard and Tufts medical orientation SAS stress, Cornell Medical Index
schools
......................................................................................................................................................................................................................................................................................................................................................................................................................
Vitaliano et 703 1980-83 1st- and 2nd-year students, Cross-sectional survey, 1 week SCL- School pressures, Ways of Coping
al.,100 1984; University of Washington School before spring exams 9013- Checklist
see also of Medicine item BDI
Vitaliano et
al.,190 1987
......................................................................................................................................................................................................................................................................................................................................................................................................................
Sherry et al.,84 95 NR Female 1st-year students, 2 Cross-sectional survey, SDS Self-reported measures of physical
1988 (published urban Northeastern medical orientation SAS health, menstrual symptoms
1988) schools
......................................................................................................................................................................................................................................................................................................................................................................................................................
Vitaliano et 350 1984-85; 1st-year students, University of Longitudinal survey, September 13-item Life Experiences Survey,
al.,92 1989; 1985-86 Washington School of Medicine and May BDI Framingham Type A Behavior
see also Symptom Pattern Scale and Anger Expression
Vitaliano et Checklist Scale, Social Network List, Ways of
al.,11 1988, Anxiety Coping Checklist, Stress
Vitaliano et Scale
al.,147 1989
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Table 1
(Continued)

Period of Medical student

Source Sample size study† population Study design Tool† Covariates measured†
Richman et 210 1985 1st-year students, a state college Longitudinal survey, start of CES-D Parental Bonding Instrument, Locus
al.,93 1990 of medicine medical school and 7 months ta-POMS of Control, and items from the
later Aggressiveness Scale of the Million
Clinical Multiaxial Inventory,
Emotional Reliance on Another

Academic Medicine, Vol. 81, No. 4 / April 2006

Person, Rosenberg Self-Esteem
Scale, Wheaton’s Flexibility Scale,
Social Support Network Inventory,
alcohol use
......................................................................................................................................................................................................................................................................................................................................................................................................................
Pyskoty et 184 1987 1st-year students, a state medical Longitudinal survey, start of CES-D Social Support Network Inventory,
al.,94 1990 college medical school and fall of 2nd ta-POMS Rosenberg Self-Esteem Scale, Locus
year of Control using items from the
Rotter Internal-External Scale,
hostility dimension of SCL-90-R,
school stressors
......................................................................................................................................................................................................................................................................................................................................................................................................................
Hendryx et 147 NR(published 1st-year students, private medical Cross-sectional survey, last 21-item Toronto Alexithymia Scale
al.,87 1991 1991) school in Southern California week of 1st year BDISTAI
......................................................................................................................................................................................................................................................................................................................................................................................................................
Richman et 184 1987 1st-year students, a state college Longitudinal survey, start of CES-D Hostility subscale of SCL-90-R,
al.,28 1992 of medicine medical school and during the ta-POMS Michigan Alcoholism Screening
winters of the 2nd, 3rd, and 4th Test, motives for drinking,
years masculinity and femininity subscales
of Personal Attributes
Questionnaire, experience of abuse
......................................................................................................................................................................................................................................................................................................................................................................................................................
Hojat et al.,98 1361 1988, 1st- and 2nd-year students, Cross-sectional survey, 13-item Components of scales assessing
1999 1992-96 Jefferson Medical College of orientation for 1st-year BDI loneliness, test anxiety, neuroticism,
See also Thomas Jefferson University students (1992-96) and during Elements extraversion, self-esteem, locus of
Fenderson et class for 2nd-year students of TMAS control; perception of general
al.,191 1999 (1988) health, stressful life events, and
relationship with mother looking for
gender differences
* The authors searched the literature for peer-reviewed English-language studies published between January 1980
and May 2005. They found 40 studies on medical student depression and anxiety that met their selection criteria
(see the text for details).
†
Abbreviations: BDI ⫽ Beck Depression Inventory; DIS, NIMH Diagnostic Interview Schedule; FH ⫽ Family History;
PMH ⫽ Past Medical History; NR ⫽Not Reported; STAI⫽ State-Trait Anxiety Inventory; TMAS ⫽ Taylor Manifest
Anxiety Scale; AUDIT ⫽ Alcohol Use Disorders Identification Test; CES-D, Center for Epidemiological Studies
Depression Scale; ta-POMS, tension-anxiety factor of POMS; POMS, Profile of Mood States; SDS Zung Self-
Rating Depression Scale; SAS, Zung Self-Rating Anxiety Scale; BSI, Brief Symptom Inventory; HSCL, 58-item
Hopkins Symptoms Checklist.

369
Well-Being of Students
 Well-Being of Students

Table 2
Findings from 40 Studies Examining Medical Student Depression and Anxiety*
Response Prevalence of mood Statistically significant
Source rate (%) disorder† findings (p < .05)†
Depression
...................................................................................................................................................................................................................................................................................................................
Zoccolillo et al.,74 64–79% BDI: 68 (22%) had depression More women than men were depressed.
1986 (BDI ⬎ 9) during the study. DIS: The PMH or FH of depression was more common
2-year prevalence of depression was among depressed students.
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12% with the 1-year prevalence of

depression 6% and 8% for the 1st-
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and 2nd-year classes, respectively.

Estimated lifetime prevalence of
depression was 15%.
...................................................................................................................................................................................................................................................................................................................
Clark et al.,7 1988; see 70–96% 4% of students had mild to BDI scores increased after start of MS and
also Zeldow et al.,138 moderate depression at orientation did not return to baseline by completion of
1987; Zeldow et (BDI ⬎ 14) with ⬎12% of students medical school. No gender difference in BDI
al.,139 1988; Clark et having depression on subsequent scores.BDI scores ⬎ 21 was associated with
al.,152 1988 assessments. The prevalence of quitting medical school and having lower
depression peaked at 25%. 1st-year grades but had no association with
Moderate to severe depression (BDI alcohol or drug abuse, FH of depression, or
⬎ 21) was present in 1% of students lower NBME Part 1 scores. Lower BDI scores
at orientation and ranged from 2- were associated with higher NBME Part 1
8% on subsequent assessments. scores.BDI scores correlated with
masculinity-femininity,7,138 intimacy and
power.139
...................................................................................................................................................................................................................................................................................................................
Katz et al.,111 2000 NR 71% of those NR Spousal BDI score (r ⫽ 0.67), stress
recruited (r ⫽ 0.54), and marital support (r ⫽ ⫺0.37)
participated. predicted medical student BDI score.
...................................................................................................................................................................................................................................................................................................................
Enns et al.,135 2001 46–60% Mean BDI score was 3.04. Time 2 Maladaptive perfectionism was correlated
BDI scores not reported. with depression at baseline and predicted
time-2 BDI scores.
...................................................................................................................................................................................................................................................................................................................
Ball et al.,13 2002 Participation rate Mean BDI scores increased from Interventions did not influence future
approximately baseline (6.19 ⫾ 6.32) to midterm depressive symptoms or alcohol use. Mean
33%, response rate (8.02 ⫾ 6.53) but return to baseline AUDIT scores doubled over the first semester
74–84% among at the end of the 1st semester. 3.8%, with 20% of students at risk for problematic
participants. 7.4%, 7.4%, and 0% of students alcohol use. Higher alcohol consumption
had moderate to severe depression was sustained over the 1st year.
(BDI ⬎ 20) at start of medical school,
midterm, end of 1st semester, and
end of 2nd semester.
...................................................................................................................................................................................................................................................................................................................
Givens et al.,6 2002 93% 46 (24%) of students had depression 10 (22%) of students with depression (BDI
(BDI ⬎ 8). scores⬎8) used mental health services.
...................................................................................................................................................................................................................................................................................................................
Tjia et al.,89 2005 57.1% 49 (15%) students were depressed No difference in depression by gender, age,
(BDI ⬎ 8). Of the students with year in school, or FH of depression. Students
depression, 10 (20%) reported with depression (BDI ⬎ 8) were more likely
suicidal ideation during medical to have a personal history of depression or
school and 13 (26%) reported be Hispanic.
getting psychological treatment.
...................................................................................................................................................................................................................................................................................................................
Richman et al.,140 65–73% NR Correlations: Time 1 CES-D score and
1987; see also external locus of control (r ⫽ 0.2); Time 2
Richman et al.,141 CES-D scores and maternal overprotection
1985 (r ⫽ 0.31) and paternal overprotection
(r ⫽ 0.21).
...................................................................................................................................................................................................................................................................................................................
Buchman et al.,85 85% Mean CES-D scores 10.5 in women No gender difference in CES-D scores.
1991 and 10.3 in men.
...................................................................................................................................................................................................................................................................................................................
Mosley et al.,9 1994 NR Mean CES-D score 11.48 While both coping strategies and frequency
of stressors correlated with CES-D scores,
coping strategies had the greatest
contribution to variance in CES-D scores.
Engagement coping strategies negatively
correlated with symptoms of depression,
while disengagement strategies were
positively associated.
...................................................................................................................................................................................................................................................................................................................
Lloyd et al.,86 1997 62% Mean CES-D scores 8.3 among all No differences in CES-D scores by gender.
students; 13% of students had Maternal care and overprotection correlated
depression (CES-D ⬎ 16). with CES-D scores among male medical
students.
(Table continues)

370 Academic Medicine, Vol. 81, No. 4 / April 2006

 Well-Being of Students

Table 2
(Continued)
Response Prevalence of mood Statistically significant
Source rate (%) disorder† findings (p < .05)†
Rosal et al.,8 1997 48–88% Mean CES-D score was 10.4 at No difference in CES-D scores by gender at
baseline, 14.5 in the 2nd year, and baseline, but women had higher scores
12.5 in the 4th year. during both the 2nd and 4th years. Married
medical students and medical students with
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children had higher CES-D scores.

...................................................................................................................................................................................................................................................................................................................
Camp et al.,108 1994 85%–91% From start of 1st year to November of No statistically significant relationship
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1st year the prevalence of mild between SDS score and type of curriculum
depression (SDS 50-59) increased (problem-based learning vs. lecture-based
from 10 (4.3%) to 26 (11.2%), and learning). Female medical students reported
moderate depression (SDS ⬎ 60) more depressive symptoms. No relationship
increased from 4 (1.7%) to 16 between SDS scores and race (Caucasian
(6.9)%. versus non-Caucasian). Strong relationship
between SDS scores and self-actualization
score.
Anxiety
...................................................................................................................................................................................................................................................................................................................
Vontver et al.,97 1980 92.8% (Intervention Mean STAI score 43.03. No difference in STAI score between groups
participation rate before or after the intervention.
11.5%)
Global mental
health
...................................................................................................................................................................................................................................................................................................................
Whitehouse et al.,95 NR GSI Mean 55.43 at orientation. Depression and anxiety subscales (BSI) and
1996 Results collapsed across treatment total mood disturbance (POMS) were highest
conditions immediately prior to test taking.
...................................................................................................................................................................................................................................................................................................................
Rosenzweig et al.,102 NR Mean total mood disturbance Overall psychological distress decreased
2003 increased from 28 to 38.6 in control 18% in the intervention group and
group. Mean total mood disturbance increased 38% in the control group.
decreased from 38.7 to 31.8 in the
intervention group.
...................................................................................................................................................................................................................................................................................................................
Henning et al.,83 1998 48% overall Mean gender normed GSI T- scores GSI T-scores decreased by academic year
54.7 for medical students. 21.1% of (r ⫽ ⫺0.18). Non-Caucasian medical
medical students had clinically students had lower GSI T-scores than
relevant levels of psychological Caucasian medical students did. Married
distress (GSI T-scores ⬎ 63). medical students reported lower GSI T-
scores than unmarried students did.
Strongest predictors of medical student GSI-
T scores were perfectionism (r ⫽ 0.38) and
imposter scale (r ⫽ 0.55). Pharmacy students
had the highest GSI-T scores.
...................................................................................................................................................................................................................................................................................................................
Lloyd et al.,96 1981 60–93% HSCL mean total score at 3 time- There were no differences in HSCL scores by
points during 1st year were 84.25, gender at baseline. HSCL total symptom
85.49, and 85.38 for men and score, depression subscale score, and anxiety
85.41, 92.89, and 93.87 for women. sub-scale score increased more for women
The mean HSCL Depression subscale than men by mid-year; however, this gender
scores were 15.77, 14.74, and 14.79 difference became non-statistically
for men and 16.4, 17.86, and 17.13 significant by the end of the 1st year.
for women. The mean HSCL Anxiety
subscale scores were 9.09, 10.02,
10.47 for men and 10.19, 11.04,
11.43 for women.
...................................................................................................................................................................................................................................................................................................................
Lloyd et al.,90 1984 39% Mean HSCL total score 87.2 for men Women had higher total HSCL scores and
and 98.2 for women Depression and Anxiety subscale scores.
HSCL scores were lowest among 4th- year
students, and highest in the 2nd-year
students, but differences by year were not
statistically significant. HSCL scores
correlated positively with perceived stress.
Mean scores compared between general
population, medical patients, and psychiatric
patients.
...................................................................................................................................................................................................................................................................................................................
Kellner et al.,103 1986 80% Depression and anxiety subscales HSCL Depression subscale score higher
higher in 3rd-year students than 1st- among law students than medical students.
year students and were also higher in
women.
(Table continues)

Academic Medicine, Vol. 81, No. 4 / April 2006 371

 Well-Being of Students

Table 2
(Continued)
Response Prevalence of mood Statistically significant
Source rate (%) disorder† findings (p < .05)†
Toews et al.,91 1993 69% SCL-90-R Depression and Anxiety Graduate students had highest depression
subscale scores higher among and anxiety subscale scores and overall
medical students than norms. Total psychological distress. Medical students had
scores higher among students than higher depression and anxiety subscale
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norms. scores and more overall psychological

distress (GSI) than residents did. Greatest
Mi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/18/2023

reported stressors included examination/

evaluation, volume of work, time pressures,
and self-expectation
...................................................................................................................................................................................................................................................................................................................
Toews et al.,99 1997 46% overall, 48% SCL-90 mean raw scores for Women had higher depression and anxiety
among medical Depression and Anxiety subscales subscale scores than men did. Graduate
students. 0.801 and 0.481 respectively for students had highest depression and anxiety
women and 0.754 and 0.442, subscale scores and composite score (GSI).
respectively, for men. GSI score for Medical students had greater anxiety sub-
women 0.485; men 0.490. scores than residents did. Male medical
students had higher depression and
composite scores than did male residents.
Female residents had higher depression and
composite scores than did female students.
Combination
...................................................................................................................................................................................................................................................................................................................
Mitchell et al.,163 Participation rate NR None
1983 29%. Note: results
from 5 students
were randomly
deleted.
...................................................................................................................................................................................................................................................................................................................
Notman et al.,142 69.5% at Harvard NR Total number of reported stressors
1984 and 94.5% at Tufts correlated with SDS score (r ⫽ 0.28), SAS
score (r ⫽ 0.31), and reported health
problems (r ⫽ 0.37). Total perceived stress
correlated with SDS score (r ⫽ 0.40), SAS
(r ⫽ 0 .37), and reported health problems
(r ⫽ 0.43).
...................................................................................................................................................................................................................................................................................................................
Vitaliano et al.,100 86% 25% of students had SCL-90 scores Female medical students had higher SCL-90
1984; see also above the 99th percentile of non- scores. Threat, mastering knowledge, and
Vitaliano et al.,190 patient norms, and 34% of students control of one’s life contributed to a
1987 had anxiety scores greater than the prediction model of anxiety and depression.
median for outpatient psychiatric BDI scores inversely correlated with problem
patients. In a subgroup of 185 1st- focused coping (r ⫽ ⫺0.21) and positively
and 2nd-year students, 35% had correlated with wishful thinking (r ⫽ 0.38),
no depression (BDI 0-4), 21% had avoidance (r ⫽ 0.34), and self-blame (r ⫽
mild depression (BDI 5-7), 14% 0.34).190
moderate depression (BDI 8-15),
and 1% had severe depression
(BDI ⬎ 16) Mean BDI was 3.7.190
...................................................................................................................................................................................................................................................................................................................
Sherry et al.,84 1988 86% Mean SDS was 40.1 among Mean SDS and SAS scores were higher than
matriculating female medical age matched norms
students.
...................................................................................................................................................................................................................................................................................................................
Vitaliano et al.,92 89% During 1st year, prevalence of BDI scores and stress increased significantly
1989; see also depression (BDI ⬎ 8) increased from over the course of the 1st year for both men
Vitaliano et al.,147 3.6% to 6.6% among men and and women, while anxiety scores increased
1989 6.4% to 11.9% among women. only for women. High stress level in May
Anxiety was 1 standard deviation was associated with greater depression and
worse than population norms by end anxiety.147 Students whose stress scores
of the year. increased or remained high had higher
depression and anxiety scores than did
students who had a persistently low level of
stress or whose stress declined.147
(Table continues)

372 Academic Medicine, Vol. 81, No. 4 / April 2006

 Well-Being of Students

Table 2
(Continued)
Response Prevalence of mood Statistically significant
Source rate (%) disorder† findings (p < .05)†
Richman et al.,93 1990 93% Over 7-month interval mean CES-D No differences in CES-D by gender at either
scores increased from 9.98 to 13.84 time point. No gender differences in POMS
for women and 10.72 to 12.51 for score at baseline, but women had greater
men. anxiety than men at follow-up. Paternal
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overprotection and perceived medical school

stress contributed to time 2 depression
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among men and women. Maternal

overprotection also contributed to time 2
depression in men, while paternal affectivity
contributed to time 2 anxiety among
women.
...................................................................................................................................................................................................................................................................................................................
Pyskoty et al.,94 1990 86–91% Mean CES-D score 13.1 to 14.78 for No statistically significant differences in CES-
whites, 10.36 to 13.9 for blacks, and D, tension-anxiety, or hostility scores
10.11 to 13.65 for Hispanics at times between ethnic groups at baseline or during
1 and 2. follow-up. No significant change in CES-D,
tension-anxiety, or hostility scores within
ethnic groups over time.
...................................................................................................................................................................................................................................................................................................................
Hendryx et al.,87 1991 74.8% 21 (19%) of students were Depression was associated with difficulty
depressed (BDI ⬎ 9). identifying and describing feelings, one
domain of alexithymia.
...................................................................................................................................................................................................................................................................................................................
Richman et al.,28 1992 75–91% NR Reporting one or more episodes of abuse
during medical school was associated with
increased risk of depressive symptoms and
report of drinking alcohol to “escape.”
Personality traits correlated with reporting
episodes of abuse on the survey.
...................................................................................................................................................................................................................................................................................................................
Hojat et al.,98 1999 85% Mean BDI 1.7 for men and 1.8 for No gender difference in BDI scores. Women
women. had higher anxiety.
* The authors searched the literature for peer-reviewed English-language studies published between January 1980
and May 2005. They found 40 studies on medical student depression and anxiety that met their selection criteria
(see the text and Figure 1 for details). The table’s data 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.
†
Abbreviations: BDI ⫽ Beck Depression Inventory; PMH ⫽ Past Medical History; FH ⫽ Family History; DIS, NIMH
Diagnostic Interview Schedule; NBME, National Board of Medical Examiners; NR, Not reported; AUDIT ⫽ Alcohol
Use Disorders Identification Test; CES-D, Center for Epidemiological Studies Depression Scale; POMS, Profile of
Mood States; SDS, Zung Self-Rating Depression Scale; SAS, Zung Self-Rating Anxiety Scale; STAI⫽ State-Trait
Anxiety Inventory; GSI, Global Severity Index from Brief Symptom Inventory; HSCL, 58-item Hopkins Symptoms
Checklist; STAI, State-Trait Anxiety Inventory.

Academic Medicine, Vol. 81, No. 4 / April 2006 373