Why is this review important?
The medical profession is recognised for its challenging and demanding nature. Medical students and junior doctors have been identified as having increased personal and professional stressors during their years of training. As a result, they face increased strain on their mental well-being. It is important that this group is supported in their mental well-being to ensure an overall balance in health, as well as to aid their responsibilities of patient care and patient safety. Furthermore, medical students and junior doctors are often time-poor. Therefore, it is important to establish whether mindfulness is an effective intervention which justifies its time commitment. There are no previous Cochrane Reviews examining mindfulness in our target population.
Who will be interested in this review?
Medical students and junior doctors; other medical professionals at different levels of training and expertise; and institutions such as universities and hospitals involved in the education and training of medical students.
What question does this review aim to answer?
What effects do mindfulness-based psychological interventions have on the mental well-being of medical students and junior doctors?
Which studies were included in this review?
We searched databases to find all studies of mindfulness in medical students and junior doctors published up to October 2021. In order to be included in this review, studies had to be randomised controlled trials (a type of study in which participants are assigned to groups using a random method). Studies needed to include medical students from any year level or junior doctors in postgraduate years one, two or three. We did not exclude any studies based on participants' age, nationality or pre-existing health conditions. We included 10 studies with a total of 731 participants in the analysis.
What does the evidence from the review tell us?
Overall, we did not identify any evidence of an effect of mindfulness-based interventions on anxiety or depression symptoms. However, mindfulness-based interventions appeared to have a small positive effect on stress and a borderline positive effect on burnout. We were unable to report if mindfulness-based interventions had any effect on deliberate self-harm, suicidal ideation or suicidal behaviour as no studies examined these outcomes. Lastly, as many studies lacked longer-term follow-up of participants, it is not possible to comment on the long-term effects of mindfulness in medical students and junior doctors.
We rated the overall certainty of evidence as 'low' or 'very low'.
What should happen next?
While there were no strong positive findings from the review, some results regarding mindfulness and stress outcomes suggest that there needs to be further research into mindfulness. Any future research should be rigorously designed, and ideally, include assessments of the longer-term impact of mindfulness.
The effectiveness of mindfulness in our target population remains unconfirmed. There have been relatively few studies of mindfulness interventions for junior doctors and medical students. The available studies are small, and we have some concerns about their risk of bias. Thus, there is not much evidence on which to draw conclusions on effects of mindfulness interventions in this population. There was no evidence to determine the effects of mindfulness in the long term.
Mindfulness interventions are increasingly popular as an approach to improve mental well-being. To date, no Cochrane Review examines the effectiveness of mindfulness in medical students and junior doctors. Thus, questions remain regarding the efficacy of mindfulness interventions as a preventative mechanism in this population, which is at high risk for poor mental health.
To assess the effects of psychological interventions with a primary focus on mindfulness on the mental well-being and academic performance of medical students and junior doctors.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and five other databases (to October 2021) and conducted grey literature searches.
We included randomised controlled trials of mindfulness that involved medical students of any year level and junior doctors in postgraduate years one, two or three. We included any psychological intervention with a primary focus on teaching the fundamentals of mindfulness as a preventative intervention. Our primary outcomes were anxiety and depression, and our secondary outcomes included stress, burnout, academic performance, suicidal ideation and quality of life.
We used standard methods as recommended by Cochrane, including Cochrane's risk of bias 2 tool (RoB2).
We included 10 studies involving 731 participants in quantitative analysis.
Compared with waiting-list control or no intervention, mindfulness interventions did not result in a substantial difference immediately post-intervention for anxiety (standardised mean difference (SMD) 0.09, 95% CI -0.33 to 0.52; P = 0.67, I2 = 57%; 4 studies, 255 participants; very low-certainty evidence). Converting the SMD back to the Depression, Anxiety and Stress Scale 21-item self-report questionnaire (DASS-21) showed an estimated effect size which is unlikely to be clinically important. Similarly, there was no substantial difference immediately post-intervention for depression (SMD 0.06, 95% CI -0.19 to 0.31; P = 0.62, I2 = 0%; 4 studies, 250 participants; low-certainty evidence). Converting the SMD back to DASS-21 showed an estimated effect size which is unlikely to be clinically important. No studies reported longer-term assessment of the impact of mindfulness interventions on these outcomes.
For the secondary outcomes, the meta-analysis showed a small, substantial difference immediately post-intervention for stress, favouring the mindfulness intervention (SMD -0.36, 95% CI -0.60 to -0.13; P < 0.05, I2 = 33%; 8 studies, 474 participants; low-certainty evidence); however, this difference is unlikely to be clinically important. The meta-analysis found no substantial difference immediately post-intervention for burnout (SMD -0.42, 95% CI -0.84 to 0.00; P = 0.05, I² = 0%; 3 studies, 91 participants; very low-certainty evidence). The meta-analysis found a small, substantial difference immediately post-intervention for academic performance (SMD -0.60, 95% CI -1.05 to -0.14; P < 0.05, I² = 0%; 2 studies, 79 participants; very low-certainty evidence); however, this difference is unlikely to be clinically important. Lastly, there was no substantial difference immediately post-intervention for quality of life (mean difference (MD) 0.02, 95% CI -0.28 to 0.32; 1 study, 167 participants; low-certainty evidence). There were no data available for three pre-specified outcomes of this review: deliberate self-harm, suicidal ideation and suicidal behaviour.
We assessed the certainty of evidence to range from low to very low across all outcomes. Across most outcomes, we most frequently judged the risk of bias as having 'some concerns'. There were no studies with a low risk of bias across all domains.