Online programs to strengthen the mental health of medical students: A systematic review of the literature

Figures & data

Figure 1. Flowchart for selecting the search results.

Table 1. Details of the studies included in the review

Approach	Authors, year, country	Objectives	Content of the intervention	Didactic format	Provided evidence	Participants	Key instruments/measurements	Key results
Mental health literacy (MHL)	Kurki et al (2021), Finland [60]	Assessment of a MHL program that covered blended life skills and mindfulness activities	Intervention comprised the following 3 themes: 1) Skills for independent life, study skills, relationships; 2) Stress management and mental health sustaining strategies; 3) Information about mental disorders, treatment, and help seeking Additional mindfulness component: theory of mindfulness and exercises based on mindfulness-based stress reduction	Two 60-minute lectures, four weeks apart, and online self-learning material in between; links to information sources and videos; mindfulness component was provided with a series of audio tapes	One group, quasi-experimental pretest-posttest design, 2-month follow-up evaluation	N = 374 first-year medical students, of which 158 completed all stages	Mental Health Knowledge questionnaire, Stigma questionnaire, The Help-seeking questionnaire, The General Health Questionnaire, PSS, Client Satisfaction Questionnaire (CSQ-1)	Scores for mental health knowledge improved and emotional symptoms were alleviated at posttest and 2-month follow-up; stress levels reduced and attitudes towards help-seeking improved after the program, but these changes were not maintained at 2-month follow-up
Mindfulness/meditation	Villalon Lopez (2021), Chile [62]	Assessment of the effectiveness of a brief online mindfulness, compassion and intercare based intervention (MIIM)	Mindfulness-based interventions such as mindfulness based cognitive training, self-compassion and cognitive based compassion training; modules consisting in meditation practices, inquiry and self or group reflections on topics such as mindfulness, automatic pilot, mind wandering, acceptance, gratitude and compassion, care resources and intercare	1 hour per week for 4 weeks, 4 synchronic ZOOM group sessions and home practice	Registered RCT; measurements at the beginning, 1-month and 3-month follow-up	Current enrollment: N = 360 medical students	PHQ9, GAD-7, Mental Health Continuum Scale – Short Form (MHC-14), FFMQ-SF	No results reported yet
	Rojas (2020), Spain [63]	Evaluation of the efficacy and mechanisms of change of Compassion Cultivation Training (CTT)	Online version of the CCT: behavioral meditation program designed at Stanford University comprising six sequential steps: 1) Settling the mind; 2) Loving-kindness and compassion for a loved one; 3) Self-directed loving-kindness and compassion; 4) Common humanity; 5) Cultivating compassion for others; 6) Active compassion	8-week program; weekly 2-hour online sessions, daily 20–30-minute online meditation and compassion instructions, guided by a certified instructor from the Compassion Institute	Registered RCT; 2 groups: intervention condition and waitlist control condition; measurements at pre-, inter-, and post-intervention, as well as 2-month and 6-month follow-up; program adherence and fidelity will be monitored through revisions of the recorded sessions	Actual enrollment: N = 40 medical students	Primary Outcome Measures: Compassion Scale Pommier (CSP), Self-Compassion Scale (SCS-SF), Interpersonal Reactivity Index (IRI) for empathy, 21-item Depression Anxiety Stress Scale (DASS-21), Pemperton Happiness Index (PHI) Secondary Outcome Measures: FFMQ, MBI, BRS, Difficulties in Emotion Regulations Scale (DERS), single-item to measure daily formal meditation practices and informal compassion practices, single-item to measure state changes in compassion, mindfulness, psychological distress, well-being, and cognitive-emotional regulation processes	No results reported yet
	Kemper & Khirallah (2015), USA [64]	Measurement of acute effects of online mind-body skills training (MBS) on stress, resilience, mindfulness, and empathy	Topics of meditation: focused attention meditation (relaxation response), mindfulness meditation, positive affect meditation, guided imagery/hypnosis; at least one module had to be completed which participants could choose freely	12 modules, divided into 4 general topics;1-hour modules with online lessons for meditation practices	Prospective cohort study, measurements pre- and immediately post-training; no control group; here, acute effects were measured as a part of a larger evaluation (mentioned below)	N = 513 enrollees including dietitians, nurses, physicians, social workers, clinical trainees, and health researchers; about 1/4 were clinical trainees	Data from the 5 modules that had at least 100 enrollees within the study period were analyzed; Visual analog scale (VAS) for stress, relaxation and resilience; 10-item Perceived Stress Scale (PSS), 10-item Cognitive and Affective Mindfulness Scale – Revised (CAMS-R), Mindful Attention Awareness Scale (MAAS), Brief Resilience Scale (BRS), IRI (Empathic Concern (EC) and Perspective Taking (PT) subscales), open-ended questions	Significant improvements in stress, mindfulness, empathy and resilience
	Kemper et al (2015), USA [65]	Investigation of the longer-term impact of online mind-body skills training on stress, mindfulness, resilience, empathy, self-compassion	MBS as mentioned above; this time, participants had to have finished the whole intervention	1-hour modules with online lessons for meditation practices	Cohort trial, pre- and post-training survey after 12 weeks, no control group	N = 103 participants who had finished the whole intervention	10-item CAMS-R, SCS-SF, 10-item Calm, Compassionate Care Scale (CCCS), 6-item BRS, 7-item Empathic Concern Scale (ECS) (IRI subscale), 7-item PT scale (IRI subscale), 5-item Santa Clara Brief Compassion Scale (SCBCS), module engagement	Significant improvements over 12 weeks in stress, mindfulness, self-compassion, and confidence in providing calm, compassionate care; no significant improvements in empathy and resilience
	Moore et al (2020), Australia [66]	Investigation of the effectiveness of an online mindfulness training for self-compassion, compassion levels, and stress	Mindfulness training providing information about mindfulness, regular mindfulness and meditation techniques and short sessions for motivation and to answer questions	8-week training; 10-minute weekly mini-lectures, 5-minute daily guided mindfulness meditation sessions, online video conference sessions	Prospective mixed method cohort study, no control group	N = 47 medical students	PSS, SCS, Compassion Scale (CS)	Statistically significant reduction in participants’ perceived stress levels and a significant increase in self-compassion at 4-month follow-up
	Danilewitz et al (2018), Canada [67]	To investigate the efficacy and feasibility of an online mindfulness-based program on burnout, empathy, mindfulness, self-compassion	MIND-MED: online mindfulness intervention; techniques like body scan, meditations, mindfulness eating, mindfulness yoga, mindfulness in daily activities	7 modules, 25–35 minutes each; audio files, video instructions, text and reading material, links to relevant other websites; weekly reminder E-mails	Prospective pilot cohort study, pre- and post-assessments, no control group	N = 52 medical students (convenience sample), of which 45 finished at least one module	Maslach Burnout Inventory (MBI), Jefferson Scale of Empathy – medical student version (JSE-M), Five Face of Mindfulness Questionnaire – short form (FFMQ-SF), Self-Compassion Scale – short form (SCS-SF), Interpersonal Reactivity Index (IRI) for empathy	No changes in burnout and empathy, high acceptance
Based on internet-based Cognitive Behavioral Therapy (iCBT)	Lattie et al (2017), USA [68]	To assess acceptability and usability of an iCBT program, and to examine the impact of the program on perceived stress, feelings of burnout, quality of life, and the development of cognitive and behavioral coping strategies	Program called ThinkFeelDo; topics such as behavioral activation, cognitive restructuring, and managing anxiety	6-week program; mobile accessible web program, 14 10-minute online lessons with text and video and 5 interactive tools including activity monitoring, cognitive restructuring, goal setting, relaxation, and mood tracking	Pre- and postintervention assessments, no control group	N = 14 medical students	Frequency and duration of site use, usability and user feedback with the Usefulness, Satisfaction, and Ease of use (USE) questionnaire; 9-item semi-structured interview via telephone; PSS, Medical Student Well-Being Index (MSWBI), Cognitive and Behavioral Response to Stress Scale (CB-RSS) to measure frequency and usefulness of cognitive and behavioral coping skills	High acceptability and usability; at the end of the program, fewer participants reported feeling burned out from medical school compared to baseline
	Lattie et al (2019), USA [69]	Primary aims: to examine program usage and the demographics of students who used the program. Secondary aims: to examine the impact of the program on perceived stress, quality of life, and the development of cognitive and behavioral coping skills	Slightly modified version of the ThinkFeelDo-program above	16-week program with 16 10-minute online lessons and again 5 interactive tools; content was the same as mentioned above	Pre- and postintervention assessments, no control group	N = 53 first year medical students	Frequency and duration of site use; MSWBI, CB-RSS, Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder Scale-7 (GAD-7)	No significant changes in PHQ-8, GAD-7 or PSS; slight increase in the frequency of cognitive coping strategy use; interest in this online program was high, actual program usage was low
Peer support	George et al (2013), USA [70]	To investigate the effect of peer-support via Facebook-based stress management group for first-year medical students	Stress management during the first eleven weeks of medical school; peer-support and assistance for building coping strategies	Facebook group, daily posts with videos or text, online peer-to-peer communication	Qualitative analysis of open questions (post-treatment), no control group	N = 95 first year medical students	Open questions, qualitative measurements	High engagement, better stress management and coping strategies afterwards
	Kazerooni et al (2020), Iran [72]	Investigation of the effectiveness of a Social-Media-platform for support of junior medical students during Covid-19 pandemic	Peer-support to maintain online social contacts and to offer mutual assistance	Social-Media-platform, online peer-to-peer communication	Post-intervention questionnaire measures, no control group	N = 371 junior medical students, 10 senior medical students	Valid and reliable questionnaire was used to measure the effect of this activity; not further specified	71% of junior medical students believed the platform had a significant impact on helping them adjust faster to these emergency conditions, students generally reported that they had benefited from the intervention

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