Easing the Burden: A Pilot Study on the Impact of Mindfulness on the Mental Health of Brazilian Medical Students

Easing the Burden: A Pilot Study on the Impact of Mindfulness on the Mental Health of Brazilian Medical Students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Easing the Burden: A Pilot Study on the Impact of Mindfulness on the Mental Health of Brazilian Medical Students Vinicius Vieira Neves, Daniel Teixeira dos Santos, Marcelo Demarzo, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6255794/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Aug, 2025 Read the published version in BMC Medical Education → Version 1 posted 11 You are reading this latest preprint version Abstract BACKGROUND Mental health disorders, such as anxiety and depression, are more prevalent in medical students than in the general population. Mindfulness-based interventions (MBIs) have shown evidence of effectiveness in treating these conditions. However, findings among medical students are mixed, particularly in Brazilian samples. This study aims to evaluate the feasibility and preliminary effects of the Mindfulness-Based Health Promotion (MBHP) program on perceived stress, mindfulness, and symptoms of anxiety and depression in Brazilian medical students. METHODS This single-arm pilot clinical trial involved medical students participating in the MBHP program for 2.5 hours per week over eight weeks. Outcomes were assessed at baseline and post-intervention. Feasibility was evaluated based on recruitment and retention rates. Depressive and anxiety symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7), respectively, while perceived stress and mindfulness were assessed using the Perceived Stress Scale-10 (PSS-10) and the Five Facet Mindfulness Questionnaire (FFMQ). Data were analyzed using descriptive statistics and the Wilcoxon Signed-Rank test. RESULTS Feasibility findings indicated that all 13 eligible participants enrolled and attended at least 50% of the program’s sessions, resulting in recruitment and retention rates of 100%. Participants (76.9% female, 92.3% Caucasian, mean age = 23.6 years) showed significant reductions in depressive ( p = .001; r = .62) and anxiety ( p = .014; r = .41) symptoms post-intervention. Additionally, overall mindfulness increased significantly ( p = .001; r = .62) along with four out of its five facets: observe ( p = .012; r = .49), act with awareness ( p = .009; r = .51), non-judgement ( p = .046; r = .39) and non-reaction (p = .007; r = .52). Perceived stress was not significantly reduced ( p = .059; r = .37). CONCLUSION Our results suggest that the MBHP program is feasible and may be effective in reducing anxiety and depression while enhancing mindfulness in Brazilian medical students. Higher-quality randomized trials with a larger sample size and longer follow-up are needed to confirm these preliminary findings. REGISTRATION: The trial was retrospectively registered with the Registro Brasileiro de Ensaios Clínicos (ReBEC) on February 26, 2025, under registration number RBR-44cvfnq. Mindfulness Students Medical Depression Anxiety Perceived Stress Mental Health Pilot Projects Intervention Studies Mindfulness-Based Interventions Education Medical Background Due to the inherent demands of healthcare training, medical school presents a particularly challenging environment, predisposing students to mental health issues. For instance, a meta-analysis of 167 cross-sectional (n = 116,628) and 16 longitudinal (n = 5,728) studies from 43 countries found a 27.2% prevalence of depressive symptoms and an 11.1% prevalence of suicidal ideation among medical students ( 1 ). Anxiety appears to be even more prevalent, as evidenced by a meta-analysis of 69 cross-sectional studies including 40,348 medical students, which reported a global anxiety prevalence of 33.8% ( 2 ). Comparatively, medical students generally exhibit higher levels of depression and anxiety, as well as poorer overall mental health, than age-matched nonmedical students ( 3 – 5 ). Data on Brazilian medical students is relatively scarce; however, existing studies indicate a similar trend ( 6 – 8 ). A 2017 meta-analysis of 57 cross-sectional studies (n = 18,015) reported prevalence rates of depression, anxiety, and stress at 30.6%, 32.9%, and 49.9%, respectively ( 7 ). Additionally, a study conducted at the same university as the present study found an association between depressive symptoms and alcohol dependence ( 9 ). In line with this, a recent cross-sectional study reported that 36.48% of students had used the school’s mental health services, and 85.13% sought emotional support from the institution and friends ( 8 ). A qualitative analysis of their findings revealed that anxiety, depression, and stress were among the primary reasons for seeking the school’s mental health services. Some authors suggest that cultural factors, such as the belief that medical schools must be demanding to push students perceived as ‘weak’ to drop out, may contribute to this issue ( 10 , 11 ). Other proposed factors include the competitiveness of medical education, perfectionism, the increasing volume of learning materials, and exposure to severely ill and dying patients ( 11 , 12 ). The feelings of inadequacy that arise in this high-pressure environment, where mistakes can have serious consequences, often lead to heightened self-criticism, which may culminate in depressive and anxiety symptoms or even suicidal ideation ( 13 ). Additionally, mental health issues during medical school can have long-term consequences that extend beyond the individual and the period in which they arise. For instance, perceived stress in medical school has been identified as an independent predictor of post-graduation mental health issues requiring treatment ( 14 ). One such issue is physician burnout, which the World Health Organization (WHO) defines as “a syndrome resulting from chronic workplace stress that has not been managed successfully” ( 15 ). Burnout is significantly associated with poorer patient care, increased medical errors ( 16 ), reduced patient safety, and a higher risk of malpractice claims ( 17 , 18 ). It also contributes to reduced clinical hours, high physician turnover, and is estimated to cost the United States $ 4.6 billion annually ( 19 ). Although these concerns date back to 1936 ( 20 ), advances in treatment interventions have only emerged more recently ( 11 , 21 ). To avoid placing the burden solely on one aspect of the issue, these interventions target two main areas: the individual and the educational environment, both of which have shown promising results ( 21 – 23 ). Interventions focusing on the educational environment primarily involve changes to the medical school curriculum structure (21), while those targeting the individual level aim to enhance medical students’ coping skills ( 24 ). Examples include relaxation training, Mindfulness-Based Stress Reduction (MBSR), self-hypnosis, discussion and educational groups on self-care, and support groups ( 22 , 23 , 25 – 28 ). Among these approaches, mindfulness-based interventions (MBIs) show the greatest promise in both mental health and medical education ( 29 – 32 ). Mindfulness is often defined as the awareness that arises from intentionally and nonjudgmentally paying attention to present-moment experience ( 33 ). To standardize training for cultivating this awareness, Jon Kabat-Zinn developed Mindfulness-Based Stress Reduction (MBSR) in 1979. MBSR is an eight-week, group-based intervention led by certified instructors trained in mindfulness-based skills ( 33 ). Since then, several adaptations of MBSR have been developed for different populations and settings, including Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Eating Awareness Training (MB-EAT), Mindfulness-Based Relapse Prevention (MBRP), Mindfulness-Based Blood Pressure Reduction (MB-BP), and Mindfulness-Based Health Promotion (MBHP), the latter of which was employed in the present study ( 34 – 40 ). These programs have demonstrated improved outcomes in clinical research. An individual patient data meta-analysis of nine randomized controlled trials (RCTs) (n = 1,258) found that the MBCT program was noninferior to pharmacologic treatment in preventing depression relapse ( 41 ). This study influenced the National Institute for Health and Care Excellence (NICE) guidelines for adult depression management in the United Kingdom, leading to a formal recommendation of MBCT for individuals with three or more previous depressive episodes ( 42 ). Regarding anxiety disorders, a recent RCT (n = 276) comparing MBSR with escitalopram, a first-line pharmacologic treatment, found MBSR to be noninferior to the medication ( 43 ). Earlier reviews support these findings for both anxiety and depression ( 44 , 45 ). Specifically among medical students, although data remains somewhat limited, findings follow a similar trend. A few reviews and meta-analyses have reported reductions in depression, anxiety, and stress, along with increases in mindfulness ( 29 – 31 ). However, significant heterogeneity exists between studies, the risk of bias—particularly selection bias—is high, the quality of evidence is low to moderate, and most studies have been conducted in the United States (US) ( 29 – 31 ). As of 2014, mindfulness programs were offered in approximately two-thirds of US medical schools ( 32 ). A few studies have examined MBIs in Brazilian medical students, with some showing no effects on mental health outcomes, while others have demonstrated promising results ( 46 – 48 ). Additionally, the MBHP program, which focuses specifically on health promotion and quality of life, has only been tested in healthcare workers in Colombia ( 49 , 50 ). Therefore, this study aims to contribute to the literature of MBIs among Brazilian medical students by assessing the feasibility and preliminary effects of the MBHP program on their mental health, particularly in relation to depressive symptoms, anxiety symptoms, perceived stress, and mindfulness. Methods Study Design and Sample This was a non-controlled, single-arm pilot clinical trial assessing mental health variables before and after the MBHP program in Brazilian medical students. The trial was retrospectively registered with the Registro Brasileiro de Ensaios Clínicos (ReBEC) (approved on February 26, 2025) under registration number RBR-44cvfnq. Primary outcomes included feasibility, depressive symptoms, anxiety symptoms, perceived stress, and mindfulness. Secondary outcomes consisted of five mindfulness subdimensions, described in detail below (see: Description of measures ). Participants were recruited in August 2018 through referrals from the university’s Integrative Medicine and Spirituality Interest Group. Assessments and the intervention took place in September and October 2018. Inclusion criteria were: ( 1 ) enrollment as a medical student at Universidade do Grande Rio Professor José de Souza Herdy (UNIGRANRIO); ( 2 ) ownership of a smartphone with WhatsApp® and internet access; ( 3 ) age 18 years or older; and ( 4 ) provision of written informed consent. Exclusion criteria were: ( 1 ) attending less than 50% of the program’s sessions and ( 2 ) worsening of a pre-existing psychiatric condition. The exclusion of participants with less than 50% attendance was based on a per-protocol analysis, which, in mindfulness intervention studies, considers attendance at four or more sessions as the criterion for completers ( 51 ). The study protocol was approved by the institutional review board at UNIGRANRIO under Certificado de Apresentação para Apreciação Ética (CAAE) number 86916318.5.0000.5283, on June 28, 2018. Intervention Descriptions Inspired by the MBSR, MBCT, and MBRP programs, the Mente Aberta Center at the Universidade Federal do Estado de São Paulo (UNIFESP), in partnership with Zaragoza University, developed the MBHP program. This eight-week program included weekly two-hour sessions conducted on the UNIGRANRIO campus. The program was led by two instructors certified by the Mente Aberta Center. Designed for the Hispanic/Latin American context, MBHP emphasizes meditative practices such as breathing exercises, walking meditation, body scanning, mindful movement, self-compassion, and loving-kindness ( 52 ). These practices were guided in class by the instructors, and recorded audio versions (15–20 minutes in length) were provided to participants for home practice, with recommendations to practice approximately once daily for six days a week. Weekly session topics included: ( 1 ) What is Mindfulness? Escaping autopilot; ( 2 ) Awareness of the breath; ( 3 ) Mindfulness in daily life; ( 4 ) Mindfulness for difficult situations; ( 5 ) Mindfulness of the mind and thoughts; ( 6 ) Silence; ( 7 ) Mindfulness and compassion; and ( 8 ) Mindfulness for life. Additional teaching strategies included videos, metaphors, group activities, mindful eating, breathing exercises, guided reflections, and journaling. Description of measures Data were collected in person one hour before the first MBHP session (baseline) and one hour before the final MBHP session (two-month follow-up) using printed questionnaires. Demographic variables included age, employment status, living arrangement, marital status, gender, medical school year, ethnicity, and physical activity. Feasibility of the intervention was assessed through the percentage of eligible participants who enrolled (recruitment rate) and the percentage of participants who completed the program (retention rate). Depressive symptoms were assessed using the Portuguese version of the Patient Health Questionnaire-9 (PHQ-9). This self-report instrument evaluates the presence of depressive symptoms over the past two weeks through nine Likert-scale items based on the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria. The PHQ-9 has demonstrated good internal consistency ( 53 ) and was validated in Brazil in 2008 ( 54 ). Evidence suggests that scores ≥ 10 have high accuracy for diagnosing major depressive disorder ( 53 , 55 ). Anxiety symptoms were assessed using the Portuguese version of the Generalized Anxiety Disorder-7 (GAD-7) self-report questionnaire. Based on DSM-IV criteria, it evaluates the presence of generalized anxiety disorder symptoms over the past two weeks through seven Likert-scale items. The GAD-7 has demonstrated excellent internal consistency and high accuracy for diagnosing the disorder when scores are ≥ 10 ( 56 ). The Portuguese version has also demonstrated excellent internal consistency ( 57 ). Perceived stress was assessed using the Portuguese version of the Perceived Stress Scale-10 (PSS-10), a self-report questionnaire consisting of 10 Likert-scale items that measure the extent to which certain situations are perceived as stressful in one’s life ( 58 ). The instrument was validated in a Brazilian sample and demonstrated good internal consistency ( 59 ). Mindfulness was assessed using the Portuguese version of the Five Facet Mindfulness Questionnaire (FFMQ), a self-report instrument that evaluates five dimensions: Observing, Acting with Awareness, Nonjudging, Describing, and Nonreacting. The first four dimensions contain eight Likert-scale items each, while the fifth consists of seven. Higher scores indicate greater levels of mindfulness ( 60 ). Each dimension can also be assessed individually, with scores calculated for each subscale. The Portuguese version was validated in Brazil in 2014, demonstrating good internal consistency and high test-retest reliability ( 61 ). Statistical analysis Statistical analyses were conducted using IBM Statistical Package for the Social Sciences (SPSS)® version 23 for macOS. A per-protocol analysis was followed, considering only participants who completed at least 50% of the program’s sessions. In addition to sociodemographic variables, descriptive statistics included the prevalence of depressive and anxiety disorders, calculated as the percentage of participants with scores ≥ 10, based on the clinical cutoffs for the PHQ-9 and GAD-7 (see Description of measures ). Due to the small sample size and nonnormal distribution of continuous outcome variables, a nonparametric test was chosen. Consequently, paired Wilcoxon signed-rank tests were performed to compare median outcome differences pre- and post-intervention. The test statistic ( Z ) and its p -value were reported alongside the effect size ( r ), calculated using the formula Z / √N. Calculating effect sizes is recommended for nonparametric analyses ( 62 ) and was interpreted according to Cohen’s criteria: r values between .1 and .3 indicate a small effect, between .3 and .5 a medium effect, and ≥ .5 a large effect ( 63 ). Since SPSS provides Z as a standardized statistic, it was reported as positive regardless of the direction of change, which was determined by observing median differences and explicitly described in the results. A p -value < .05 was considered statistically significant. All participants completed the questionnaires in full, resulting in no missing data, and analyses were conducted as complete cases. Results A total of 13 participants were assessed for eligibility, and none were excluded for not meeting the inclusion criteria. Feasibility findings showed that all 13 eligible participants enrolled in the MBHP program and attended at least 50% of its sessions, resulting in recruitment and retention rates of 100%. Baseline sociodemographic data are presented in Table 1 . Participants were mostly female (76.9%) and Caucasian (92.3%), with a mean age of 23.6 years (standard deviation [SD] = 5.23). The majority were in the first two years of medical school, were single, and did not live alone. Based on cutoff scores, the prevalence of major depressive disorder in the sample was 69.2%, while generalized anxiety disorder was 84.6%. Table 1 Baseline sociodemographic characteristics (N = 13). Mean Age (SD) 23.6 (5.23) Gender Female 10 (76.9) Male 3 (23.1) Living arrangement Alone 4 (30.8) With others 9 (69.2) Marital Status Single 13 (100) Ethnicity Caucasian 12 (92.3) Mixed race 1 (7.7) Medical school year 1st e 2nd 8 (61.5) 3rd e 4th 1 (7.7) 5th e 6th 4 (30.8) Physical Activity Do not practice 8 (61.5) Practice 1 to 2h per week 1 (7.7) Practice 3 to 6h per week 4 (30.8) Employment No 10 (76.9) Yes 3(23.1) Prevalence of Mental Health Disorders Major Depression 9 (69.2) Generalized Anxiety 11 (84.6) Data is presented as n (%) unless specified otherwise. SD = Standard Deviation The effects of the MBHP program on primary outcomes are presented in Table 2 . Median depression scores decreased by 69%, from 13 at baseline to 4 post-intervention ( Z = 3.18, p = .001, r = .62). Similarly, anxiety symptoms showed significant reductions, with median scores decreasing by 62.5%, from 16 at baseline to 6 at the eighth week ( Z = 2.45, p = .014, r = .41). Perceived stress decreased by 20.5%, from a median score of 39 at baseline to 31 post-intervention, though this reduction was not statistically significant ( Z = 1.89, p = .059, r = .37). Finally, mindfulness levels showed a significant 35.8% increase, from a median score of 95 at baseline to 129 at the eighth week ( Z = 3.18, p = .001, r = .62). Table 2 Within-group changes in median primary outcome scores from baseline to post-intervention (N = 13). Outcome Baseline Median Post-Intervention Median Z -value p -value Effect Size ( r ) Depression (PHQ-9) 13 4 3.18 .001 .62 Anxiety (GAD-7) 16 6 2.45 .014 .41 Perceived Stress (PSS-10) 39 31 1.89 .059 .37 Mindfulness (FFMQ) 95 129 3.18 .001 .62 PHQ-9, Patient Health Questionnaire-9. GAD-7, Generalized Anxiety Disorder-7. PSS-10, Perceived Stress Scale-10. FFMQ, Five Facet Mindfulness Questionnaire. *Boldface indicates p < .05 Table 3 summarizes the effects of the MBHP program on secondary outcomes, which consist of the five mindfulness dimensions assessed individually. Observing median scores significantly increased by 31.8%, from 22 at baseline to 29 at the eighth week ( Z = 2.51, p = .012, r = .49). Acting with awareness median scores increased significantly by 62.5%, from 16 at baseline to 26 post-intervention ( Z = 2.62, p = .009, r = .51). Nonjudging median scores demonstrated a significant 35% increase, from 20 at baseline to 27 at the eighth week ( Z = 1.99, p = .046, r = .39). Finally, nonreacting mean scores showed a significant 35.7% increase, from 14 at baseline to 19 at the eighth week ( Z = 2.70, p = .007, r = .52). In contrast, describing median scores did not differ significantly, changing from 21 at baseline to 24 post-intervention ( Z = 1.19, p = .233, r = .23). Table 3 Within-group changes in median secondary outcome scores from baseline to post-intervention (N = 13). Mindfulness Dimension Baseline Median Post-Intervention Median Z -value p -value Effect Size ( r ) Observing 22 29 2.51 .012 .49 Acting with Awareness 16 26 2.62 .009 .51 Nonjudging 20 27 1.99 .046 .39 Describing 21 24 1.19 .233 .23 Nonreacting 14 19 2.70 .007 .52 *Boldface indicates p < .05 Discussion Main Findings The findings of this study suggest that the MBHP program is feasible and may help mitigate mental health disorders in medical students. Preliminary results include a significant reduction in depressive symptoms with a large effect size, a significant reduction in anxiety symptoms with a medium effect size, and a significant increase in mindfulness with a large effect size. However, the effect on perceived stress did not reach statistical significance. Additionally, an exploratory analysis of mindfulness dimensions revealed significant increases in observing, nonjudging, acting with awareness, and nonreacting, with the first two demonstrating moderate effect sizes and the latter two showing large effect sizes. The describing dimension did not change significantly. Reductions in Depressive Symptoms Depressive symptoms in this study decreased by 69% from pre- to post-intervention, aligning with prior research indicating that MBIs reduce depressive symptoms in medical students ( 29 – 31 ). Although the systematic review by Daya et al. reports mixed evidence for this outcome, the majority of included trials (67%) that assessed depression showed significant reductions ( 30 ). A recent systematic review and meta-analysis, which included only RCTs, also reported significant reductions in depression immediately following the MBI in three out of four studies (n = 307) ( 29 ). However, due to insufficient data, a meta-analysis could not be conducted for this specific outcome. Nonetheless, both reviews highlight important limitations, including the low quality of evidence in the included studies (measured using validated quality assessments), heterogeneity in intervention protocols and outcome measures, short-term follow-up, and the predominance of small studies with mostly female samples ( 29 , 30 ). The need for higher-quality trials in this field remains evident. Brazilian studies on this topic have been limited ( 46 , 48 ), with only one assessing depression as an outcome. This study, an RCT with a sample of 141 first-year medical students, did not find a reduction in depression ( 47 ). To our knowledge, the present study is the first to demonstrate a decrease in depressive symptoms following an MBI in Brazilian medical students. The authors of the RCT primarily attributed these negative results to the course being a required component of this medical school’s curriculum, unlike most other studies where participation was elective ( 29 – 31 ). Similarly, previous trials involving mandatory MBIs for medical students have also reported negative outcomes ( 64 – 66 ). Since MBIs are not passive, motivation to engage in class and home practice is essential. However, the authors noted that some students engaged minimally with the program components, and only a few reported adhering to home practice ( 47 ). Another possible explanation for these negative results is the larger group size in this RCT (45 students per group) compared to smaller groups in other trials (typically around 10 to 20 students) ( 25 , 67 , 68 ), including the present study. Additionally, the timing of the intervention, which began as early as the second week of medical school, may have been suboptimal, as this period is not typically associated with high stress levels. Although research on mindfulness and depression in medical students remains limited, findings from other depressive populations are fairly robust. An individual patient data meta-analysis of over 1,200 patients demonstrated the noninferiority of the MBCT program compared to first-line pharmacologic treatment in preventing depression relapse ( 41 ). The high prevalence of depression in both national (30%) and international (28%) samples of medical students ( 1 , 7 ) underscores the significance of the present study, as MBIs may help mitigate the long-term health and financial consequences for both individual students and the healthcare system ( 14 – 19 ). Additionally, since higher levels of depression are associated with poor academic performance, increased medical errors, cynicism, and reduced empathy ( 3 ), MBIs could potentially enhance medical students’ training. Future studies should assess these outcomes directly. Reductions in Anxiety Symptoms With respect to anxiety, we observed that the MBHP program reduced symptoms by 62.5% immediately post-intervention. Data on this outcome is somewhat more limited than on depression, with two non-RCTs ( 69 , 70 ), and one systematic review including four RCTs directly assessing it ( 29 ). Nevertheless, consistent with our findings, the systematic review and meta-analysis by da Silva et al. reported significant reductions in anxiety in three out of four studies involving 307 participants ( 29 ). Similar to depression, the limited data made it unfeasible to conduct a meta-analysis for this outcome. Findings from the non-RCTs have been mixed: one study reported significant reductions in anxiety in the MBSR group compared to the control group ( 69 ), while another, which tested an MBI tailored for medical students developed by Epstein and colleagues ( 71 ), found no significant effect ( 70 ). The same limitations discussed previously apply here, particularly the low quality and high risk of bias in trials assessing anxiety ( 29 ). Thus, it is prudent to refrain from drawing definitive conclusions until higher-quality trials are conducted. The landscape of mindfulness research on anxiety in Brazilian medical students reflects similar challenges. Only the RCT by Damião Neto et al. has assessed this outcome in Brazilian samples, and it did not find significant results, primarily due to the intervention’s compulsory nature ( 47 ). Thus, to our knowledge, this is the first study to demonstrate significant reductions in anxiety among medical students immediately following an MBI. Despite the mixed evidence in this specific population, the substantial body of research supporting the efficacy of MBIs for anxiety disorders—including a recent RCT of 276 individuals demonstrating the noninferiority of MBSR to first-line pharmacologic treatment ( 43 )—suggests that further trials assessing anxiety in medical students should be encouraged. Findings on Perceived Stress Regarding perceived stress, our study did not find statistically significant reductions. Previous international and Brazilian research evaluating the effects of MBIs on perceived stress in medical students—as well as related concepts such as psychological distress and overall stress—has also yielded conflicting results ( 29 – 31 , 46 – 48 ). Although the meta-analysis by da Silva et al. reported significantly lower stress levels post-intervention and up to a one-year follow-up, the authors rated the risk of bias as moderate, and the effect sizes were small, likely due to substantial heterogeneity among studies ( 29 ). Additionally, a prior review found that only 57% of studies assessing stress reported significant reductions, with one study even documenting an increase in stress ( 30 ). A few factors may explain these discrepant findings. First, interventions that focus solely on the individual aspect of stress may be insufficient, as effective stress reduction may also require institutional-level changes, such as curricular restructuring and pass/fail grading systems ( 21 , 23 ). Second, the heterogeneity of stress assessment tools is noteworthy, as different instruments may reflect varying definitions of the construct, assess distinct dimensions of stress, and apply different scoring criteria or cut-off points ( 30 ). Future studies should prioritize interventions that integrate both individual and institutional components and employ more reliable stress assessment tools, potentially including physiological measures such as salivary cortisol. Increases in Mindfulness and its Dimensions Lastly, the present study found that overall mindfulness increased by 35.8%, with four out of five facets — observing, nonjudging, nonreacting, and acting with awareness — also showing significant increases, ranging from 32–62%. These findings align with both international and Brazilian literature ( 29 , 47 , 48 ). Meta-analytic data on 462 medical students suggest that mean mindfulness scores in MBI groups were significantly higher than those in control groups at the end of the intervention. The evidence was rated as high quality, although effect sizes were small ( 29 ). However, Brazilian studies contradict these findings. Both a large RCT and a small single-arm study using the FFMQ reported no significant differences in overall mindfulness scores or any of its five dimensions ( 47 , 48 ). To the best of our knowledge, this is the first study to demonstrate significant increases in mindfulness following an MBI in a sample of Brazilian medical students. Limitations A strength of this study is the per-protocol analysis, which supports the intervention’s efficacy. However, several limitations must be acknowledged. First, the small sample size, with a predominantly Caucasian (92%) and female (77%) participant pool, reduced the statistical power and generalizability of our findings. This type of gender selection bias is common in mindfulness research, with one review reporting that at least 73% of participants were female ( 30 ). Although future studies should strive for a more balanced gender distribution, it is important to note that depression and anxiety are more prevalent in women than in men ( 72 ). Second, since participation was voluntary, another form of selection bias may have increased the likelihood of enrolling more motivated participants or those predisposed to respond to MBIs due to personality traits ( 31 ). Conversely, individuals with poorer mental health may have viewed the program as an opportunity to alleviate their distress, which could explain the higher baseline prevalence of generalized anxiety (84.6%) and depression (69.2%) in our sample compared to national averages ( 3 – 5 ). Similarly, other MBI studies on medical students have reported higher baseline levels of mental health distress compared to age-matched samples ( 73 , 74 ), making this a common occurrence in this field of research. Although this limits the generalizability of our findings, previous studies on compulsory MBI participation among medical students have largely been unsuccessful ( 47 , 64 – 66 ), likely because active engagement in program practices is essential for its efficacy. Notably, students reported significantly higher satisfaction with elective MBSR participation compared to mandatory participation ( 65 ). Hence, despite these limitations, we believe that future studies should continue offering these programs on an optional basis while acknowledging that only a specific subset of medical students may benefit from them. Third, the single-arm design, lack of a control group, and short-term follow-up limited the ability to draw causal inferences, rule out placebo effects, and assess whether the effects are long-lasting. Fourth, this study was retrospectively registered in a clinical trials registry rather than before participant enrollment. Although this does not affect the validity of the findings, prospective registration is recommended to enhance transparency and reduce the risk of selective reporting. Finally, the impact of the MBI was assessed exclusively through self-report tools, which are inherently prone to response and recall biases. Future studies are encouraged to use an RCT design with longer follow-ups and incorporate physiological markers of stress alongside psychological measures. Conclusions To the best of our knowledge, despite its limitations, this study is the first to demonstrate significant reductions in depressive and anxiety symptoms, as well as increases in mindfulness, following an MBI—specifically the MBHP program—in a sample of Brazilian medical students. Additionally, the program exhibited high feasibility. However, definitive conclusions cannot be drawn until larger RCTs offering elective MBIs to Brazilian medical students are conducted. Pilot trials like this one provide preliminary insights into potential mechanisms and offer effect size estimations to guide future larger trials. Abbreviations MBHP Mindfulness–Based Health Promotion MBI Mindfulness–Based Intervention PHQ 9–Patient Health Questionnaire–9 GAD 7–Generalized Anxiety Disorder–7 PSS 10–Perceived Stress Scale–10 FFMQ Five Facet Mindfulness Questionnaire WHO World Health Organization MBSR Mindfulness–Based Stress Reduction MBCT Mindfulness–Based Cognitive Therapy MB EAT–Mindfulness–Based Eating Awareness Training MBRP Mindfulness–Based Relapse Prevention MB BP–Mindfulness–Based Blood Pressure Reduction RCT Randomized–Controlled Trial US United States ReBEC Registro Brasileiro de Ensaios Clínicos UNIGRANRIO Universidade do Grande Rio Professor José de Souza Herdy CAAE Certificado de Apresentação para Apreciação Ética UNIFESP Universidade Federal do Estado de São Paulo DSM IV–Diagnostic and Statistical Manual of Mental Disorders IV SPSS Statistical Package for the Social Sciences SD Standard Deviation Declarations Ethics approval and consent to participate The study protocol was approved by the institutional review board at Universidade do Grande Rio Professor José de Souza Herdy (UNIGRANRIO) under Certificado de Apresentação para Apreciação Ética (CAAE) number 86916318.5.0000.5283, on June 28, 2018. All participants provided written informed consent. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not Applicable. Authors' contributions VVN, DTS, CABM, and ARAB conceptualized the study and contributed to the study design and methodology. VVN conducted participant recruitment, data collection, analysis, and interpretation and drafted the original manuscript. DTS, MD, LA, CABM, and ARAB provided critical revisions and contributed to reviewing and editing the final manuscript. CABM and ARAB supervised the study. All authors read and approved the final version of the manuscript. Acknowledgements We would like to thank Dr. Mário Henrique Elesbão de Borba and Dr. Renato Fernandes de Paulo for their valuable guidance and advice during the initial stages of study design and ethical review application. We would like to thank the meditation instructors, Danilo Correa and Fernanda Terra, for their dedication and essential contribution in delivering the sessions of the Mindfulness-Based Health Promotion (MBHP) program. References Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316(21):2214–36. Tian-Ci Quek T, Wai-San Tam W, Tran X, Zhang B, Zhang M, Su-Hui Ho Z. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int J Environ Res Public Health. 2019;16(15):2735. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81(4):354–73. Suarez DE, Cardozo AC, Ellmer D, Trujillo EM. cross sectional comparison of anxiety and depression symptoms in medical students and the general population in Colombia. Psychol Health Med. 2021;26(3):375–80. Voltmer E, Kötter T, Spahn C. Perceived medical school stress and the development of behavior and experience patterns in German medical students. Med Teach. 2012;34(10):840–7. de Oliva Costa EF, Santana YS, de Abreu Santos ATR, Martins LAN, de Melo EV, de Andrade TM. Depressive symptoms among medical intern students in a Brazilian public university. Revista da Associação Médica Brasileira (English Edition). 2012;58(1):53–9. Pacheco JP, Giacomin HT, Tam WW, Ribeiro TB, Arab C, Bezerra IM, et al. Mental health problems among medical students in Brazil: a systematic review and meta-analysis. Brazilian J Psychiatry. 2017;39:369–78. SILVA-MENDONçA SILVAV. V. Symptoms of anxiety and depression and reasons for seeking mental health services among medical students from São Paulo, Brazil;[Síntomas de ansiedad y depresión y razones para buscar servicios en salud mental en estudiantes de medicina de São Paulo, Brasil]. 2024. dos Santos DT, Nazário FP, Freitas RA, Henriques VM, de Paiva IS. Alcohol abuse and dependence among Brazilian medical students: Association to sociodemographic variables, anxiety and depression. J Subst Use. 2019;24(3):285–92. Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403–7. Slavin SJ. Medical Student Mental Health: Culture, Environment, and the Need for Change. JAMA. 2016;316(21):2195–6. MacLean L, Booza J, Balon R. The impact of medical school on student mental health. Acad Psychiatry. 2016;40:89–91. Eley DS, Bansal V, Leung J. Perfectionism as a mediator of psychological distress: Implications for addressing underlying vulnerabilities to the mental health of medical students. Med Teach. 2020;42(11):1301–7. Tyssen R, Vaglum P, Grønvold NT, Ekeberg Ø. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Educ. 2001;35(2):110–20. Organization WH. Burn-out an occupational phenomenon: International classification of diseases. 2019 [Available from: https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995–1000. Al-Ghunaim TA, Johnson J, Biyani CS, Alshahrani KM, Dunning A, O'Connor DB. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. 2022;224(1):228–38. Panagioti M, Geraghty K, Johnson J, Zhou A, Panagopoulou E, Chew-Graham C, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(10):1317–31. Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784–90. Strecker EA, Appel KE, Palmer HD, Braceland FJ. Psychiatric studies in medical education: II. Neurotic trends in senior medical students. Am J Psychiatry. 1937;93(5):1197–229. Wasson LT, Cusmano A, Meli L, Louh I, Falzon L, Hampsey M, et al. Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review. JAMA. 2016;316(21):2237–52. Ungar P, Schindler A-K, Polujanski S, Rotthoff T. Online programs to strengthen the mental health of medical students: A systematic review of the literature. Med Educ Online. 2022;27(1):2082909. Yusoff MSB. Interventions on medical students’ psychological health: a meta-analysis. J Taibah Univ Med Sci. 2014;9(1):1–13. Shapiro SL, Shapiro DE, Schwartz GE. Stress Management in Medical EducationTable 1. A Review of the Literature on Stress Management in Medical Education, 1969 to 1998Table 1. Continued. Table 1. Continued. Table 1. Continued. Table 1. Continued. Table 1. Continued.: A Review of the Literature. Acad Med. 2000;75(7):748–59. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581–99. Whitehouse WG, Dinges DF, Orne EC, Keller SE, Bates BL, Bauer NK, et al. Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school. Psychosom Med. 1996;58(3):249–63. Jain S, Shapiro SL, Swanick S, Roesch SC, Mills PJ, Bell I, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33:11–21. Shiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Acad Psychiatry. 2013;37:158–64. da Silva CCG, Bolognani CV, Amorim FF, Imoto AM. Effectiveness of training programs based on mindfulness in reducing psychological distress and promoting well-being in medical students: a systematic review and meta-analysis. Syst Reviews. 2023;12(1):79. Daya Z, Hearn JH. Mindfulness interventions in medical education: A systematic review of their impact on medical student stress, depression, fatigue and burnout. Med Teach. 2018;40(2):146–53. Polle E, Gair J. Mindfulness-based stress reduction for medical students: a narrative review. Can Med Educ J. 2021;12(2):e74–80. Barnes N, Hattan P, Black DS, Schuman-Olivier Z. An Examination of Mindfulness-Based Programs in US Medical Schools. Mindfulness. 2017;8(2):489–94. Kabat-Zinn J, Clinic UMMCWSR. Full catastrophe living: Using the wisdom of your body and mind to face stress. pain, and illness: Delta; 1990. Sipe WE, Eisendrath SJ. Mindfulness-based cognitive therapy: theory and practice. Can J Psychiatry. 2012;57(2):63–9. Lattimore P. Mindfulness-based emotional eating awareness training: taking the emotional out of eating. Eating and Weight Disorders-Studies on Anorexia. Bulimia Obes. 2020;25(3):649–57. Grant S, Colaiaco B, Motala A, Shanman R, Booth M, Sorbero M, et al. Mindfulness-based relapse prevention for substance use disorders: A systematic review and meta-analysis. J Addict Med. 2017;11(5):386–96. Lima LC, Mendes LC. Mindfulness and psychological well-being: effects of a mindfulness-based health promotion program on healthy adults. Trends Psychol. 2020;28(2):213–29. Loucks EB, Neves VV, Cafferky V, Scarpaci MM, Kronish IM. Sustainability of Blood Pressure Reduction Through Adapted Mindfulness Training: The MB-BP Study. Am J Cardiol. 2024;217:31–4. Loucks EB, Nardi WR, Gutman R, Kronish IM, Saadeh FB, Li Y, et al. Mindfulness-based blood pressure reduction (MB-BP): Stage 1 single-arm clinical trial. PLoS ONE. 2019;14(11):e0223095. Loucks EB, Schuman-Olivier Z, Saadeh FB, Scarpaci MM, Nardi WR, Proulx JA, et al. Effect of Adapted Mindfulness Training in Participants With Elevated Office Blood Pressure: The MB‐BP Study: A Randomized Clinical Trial. J Am Heart Association. 2023;12(11):e028712. Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA psychiatry. 2016;73(6):565–74. National Institute for Health and Care Excellence. Guidelines. Depression in adults: recognition and management. London: National Institute for Health and Care Excellence (NICE) Copyright © NICE 2019.; 2018. Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. 2023;80(1):13–21. Vøllestad J, Nielsen MB, Nielsen GH. Mindfulness-and acceptance‐based interventions for anxiety disorders: A systematic review and meta‐analysis. Br J Clin Psychol. 2012;51(3):239–60. Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169. Araujo ACd S, CLAd, Kozasa EH, Lacerda SS, Tanaka LH. Effects of a mindfulness meditation course on healthcare students in Brazil. Acta Paulista de Enfermagem. 2020;33:eAPE20190170. Damião Neto A, Lucchetti ALG, da Silva Ezequiel O, Lucchetti G. Effects of a required large-group mindfulness meditation course on first-year medical students’ mental health and quality of life: a randomized controlled trial. J Gen Intern Med. 2020;35:672–8. Carvalho Filho CV, Matos MTL, de Andrade MM, de Souza NCVF, Valadão AF, Cunha ÂGJ, et al. Série de casos: avaliação de uma intervenção baseada em Mindfulness no estresse percebido e qualidade de vida de estudantes de medicina: Case series: evaluation of a Mindfulness-based intervention in perceived stress and quality of life of medical students. Brazilian J Health Rev. 2022;5(5):20155–73. Quiroz-González E, Lupano Perugini ML, Delgado-Abella LE, Arenas-Granada J, Demarzo M. Effects of a mindfulness-based health promotion program on mindfulness, psychological capital, compassion fatigue, and affect in healthcare workers. Front Psychol. 2024;15:1470695. Demarzo MMP, Andreoni S, Sanches N, Perez S, Fortes S, Garcia-Campayo J. Mindfulness-based stress reduction (MBSR) in perceived stress and quality of life: an open, uncontrolled study in a Brazilian healthy sample. Explore: J Sci healing. 2014;10(2):118–20. Demarzo M, Montero-Marin J, Puebla-Guedea M, Navarro-Gil M, Herrera-Mercadal P, Moreno-González S et al. Efficacy of 8- and 4-Session Mindfulness-Based Interventions in a Non-clinical Population: A Controlled Study. Front Psychol. 2017;8. Demarzo M. Mindfulness y Promoción de la Salud. 2020. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. de Lima Osório F, Vilela Mendes A, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ‐2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care. 2009;45(3):216–27. Yoon S, Lee Y, Han C, Pae C-U, Yoon H-K, Patkar AA, et al. Usefulness of the Patient Health Questionnaire-9 for Korean medical students. Acad Psychiatry. 2014;38:661–7. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7. Moreno AL, DeSousa DA, Souza AMFLPd, Manfro GG, Salum GA, Koller SH, et al. Estructura factorial, confiabilidad, y ítems parámetros de la versión de portugués brasileño del cuestionario GAD-7. Temas em Psicologia. 2016;24(1):367–76. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983:385–96. Siqueira Reis R, Ferreira Hino AA. Romélio Rodriguez Añez C. Perceived stress scale: Reliability and validity study in Brazil. J Health Psychol. 2010;15(1):107–14. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27–45. Barros VVd, Kozasa EH, Souza ICWd, Ronzani TM. Validity evidence of the Brazilian version of the Five Facet Mindfulness Questionnaire (FFMQ). Psicologia: Teoria e Pesquisa. 2014;30:317 – 27. Pallant J. SPSS survival manual: A step by step guide to data analysis using. IBM SPSS: Taylor & Francis; 2020. Cohen J. Statistical power analysis for the behavioral sciences. routledge; 2013. Dyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D, Wolanskyj AP. The impact of a required longitudinal stress management and resilience training course for first-year medical students. J Gen Intern Med. 2017;32:1309–14. Aherne D, Farrant K, Hickey L, Hickey E, McGrath L, McGrath D. Mindfulness based stress reduction for medical students: optimising student satisfaction and engagement. BMC Med Educ. 2016;16:1–11. Hassed C, De Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ. 2009;14:387–98. Phang CK, Mukhtar F, Ibrahim N, Keng S-L, Mohd. Sidik S. Effects of a brief mindfulness-based intervention program for stress management among medical students: the Mindful-Gym randomized controlled study. Adv Health Sci Educ. 2015;20:1115–34. Greeson JM, Toohey MJ, Pearce MJ. An adapted, four-week mind–body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care. Explore. 2015;11(3):186–92. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88–92. Danilewitz M, Bradwejn J, Koszycki D. A pilot feasibility study of a peer-led mindfulness program for medical students. Can Med Educ J. 2016;7(1):e31. Epstein RM, Mindful Practice. JAMA. 1999;282(9):833–9. Albert PR. Why is depression more prevalent in women? J Psychiatry Neurosci; 2015. pp. 219–21. van Dijk I, Lucassen PLBJ, Speckens AEM. Mindfulness training for medical students in their clinical clerkships: two cross-sectional studies exploring interest and participation. BMC Med Educ. 2015;15(1):24. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45(4):381–8. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6255794","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446902713,"identity":"988d5928-c674-4ec3-8b8c-0b4da53f3a64","order_by":0,"name":"Vinicius Vieira Neves","email":"data:image/png;base64,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","orcid":"","institution":"Universidade Unigranrio","correspondingAuthor":true,"prefix":"","firstName":"Vinicius","middleName":"Vieira","lastName":"Neves","suffix":""},{"id":446902714,"identity":"f9c323a1-5ace-4700-a669-9ba942508e53","order_by":1,"name":"Daniel Teixeira dos Santos","email":"","orcid":"","institution":"Hospital de Clínicas de Porto Alegre","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Teixeira dos","lastName":"Santos","suffix":""},{"id":446902715,"identity":"ce192027-318f-4346-9fd7-e6ffb2c3c5a0","order_by":2,"name":"Marcelo Demarzo","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Marcelo","middleName":"","lastName":"Demarzo","suffix":""},{"id":446902716,"identity":"50047671-1d97-42f0-8330-7979af7afd4c","order_by":3,"name":"Lia Antico","email":"","orcid":"","institution":"Brown University","correspondingAuthor":false,"prefix":"","firstName":"Lia","middleName":"","lastName":"Antico","suffix":""},{"id":446902717,"identity":"35928a04-4089-477a-8da5-46ebcd82b762","order_by":4,"name":"Cynthia de Almeida Brandão Meirelles","email":"","orcid":"","institution":"Universidade Unigranrio","correspondingAuthor":false,"prefix":"","firstName":"Cynthia","middleName":"de Almeida Brandão","lastName":"Meirelles","suffix":""},{"id":446902718,"identity":"6b469e43-aff0-4f98-819b-cb7cbd43f8dc","order_by":5,"name":"Ana Rosa Airão Barboza","email":"","orcid":"","institution":"Federal University of the State of Rio de Janeiro","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Rosa Airão","lastName":"Barboza","suffix":""}],"badges":[],"createdAt":"2025-03-18 19:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6255794/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6255794/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07726-2","type":"published","date":"2025-08-01T16:13:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88268235,"identity":"8b0878bf-dddf-4b7e-a612-9a46bb2c1760","added_by":"auto","created_at":"2025-08-04 16:50:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":822053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6255794/v1/2b695c02-79af-470a-bcda-db0f4f545b33.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Easing the Burden: A Pilot Study on the Impact of Mindfulness on the Mental Health of Brazilian Medical Students","fulltext":[{"header":"Background","content":"\u003cp\u003eDue to the inherent demands of healthcare training, medical school presents a particularly challenging environment, predisposing students to mental health issues. For instance, a meta-analysis of 167 cross-sectional (n\u0026thinsp;=\u0026thinsp;116,628) and 16 longitudinal (n\u0026thinsp;=\u0026thinsp;5,728) studies from 43 countries found a 27.2% prevalence of depressive symptoms and an 11.1% prevalence of suicidal ideation among medical students (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Anxiety appears to be even more prevalent, as evidenced by a meta-analysis of 69 cross-sectional studies including 40,348 medical students, which reported a global anxiety prevalence of 33.8% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Comparatively, medical students generally exhibit higher levels of depression and anxiety, as well as poorer overall mental health, than age-matched nonmedical students (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eData on Brazilian medical students is relatively scarce; however, existing studies indicate a similar trend (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A 2017 meta-analysis of 57 cross-sectional studies (n\u0026thinsp;=\u0026thinsp;18,015) reported prevalence rates of depression, anxiety, and stress at 30.6%, 32.9%, and 49.9%, respectively (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, a study conducted at the same university as the present study found an association between depressive symptoms and alcohol dependence (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In line with this, a recent cross-sectional study reported that 36.48% of students had used the school\u0026rsquo;s mental health services, and 85.13% sought emotional support from the institution and friends (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). A qualitative analysis of their findings revealed that anxiety, depression, and stress were among the primary reasons for seeking the school\u0026rsquo;s mental health services.\u003c/p\u003e \u003cp\u003eSome authors suggest that cultural factors, such as the belief that medical schools must be demanding to push students perceived as \u0026lsquo;weak\u0026rsquo; to drop out, may contribute to this issue (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Other proposed factors include the competitiveness of medical education, perfectionism, the increasing volume of learning materials, and exposure to severely ill and dying patients (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The feelings of inadequacy that arise in this high-pressure environment, where mistakes can have serious consequences, often lead to heightened self-criticism, which may culminate in depressive and anxiety symptoms or even suicidal ideation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, mental health issues during medical school can have long-term consequences that extend beyond the individual and the period in which they arise. For instance, perceived stress in medical school has been identified as an independent predictor of post-graduation mental health issues requiring treatment (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). One such issue is physician burnout, which the World Health Organization (WHO) defines as \u0026ldquo;a syndrome resulting from chronic workplace stress that has not been managed successfully\u0026rdquo; (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Burnout is significantly associated with poorer patient care, increased medical errors (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), reduced patient safety, and a higher risk of malpractice claims (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). It also contributes to reduced clinical hours, high physician turnover, and is estimated to cost the United States \u003cspan\u003e$\u003c/span\u003e4.6\u0026nbsp;billion annually (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough these concerns date back to 1936 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), advances in treatment interventions have only emerged more recently (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). To avoid placing the burden solely on one aspect of the issue, these interventions target two main areas: the individual and the educational environment, both of which have shown promising results (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Interventions focusing on the educational environment primarily involve changes to the medical school curriculum structure (21), while those targeting the individual level aim to enhance medical students\u0026rsquo; coping skills (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Examples include relaxation training, Mindfulness-Based Stress Reduction (MBSR), self-hypnosis, discussion and educational groups on self-care, and support groups (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Among these approaches, mindfulness-based interventions (MBIs) show the greatest promise in both mental health and medical education (\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMindfulness is often defined as the awareness that arises from intentionally and nonjudgmentally paying attention to present-moment experience (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). To standardize training for cultivating this awareness, Jon Kabat-Zinn developed Mindfulness-Based Stress Reduction (MBSR) in 1979. MBSR is an eight-week, group-based intervention led by certified instructors trained in mindfulness-based skills (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Since then, several adaptations of MBSR have been developed for different populations and settings, including Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Eating Awareness Training (MB-EAT), Mindfulness-Based Relapse Prevention (MBRP), Mindfulness-Based Blood Pressure Reduction (MB-BP), and Mindfulness-Based Health Promotion (MBHP), the latter of which was employed in the present study (\u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38 CR39\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese programs have demonstrated improved outcomes in clinical research. An individual patient data meta-analysis of nine randomized controlled trials (RCTs) (n\u0026thinsp;=\u0026thinsp;1,258) found that the MBCT program was noninferior to pharmacologic treatment in preventing depression relapse (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This study influenced the National Institute for Health and Care Excellence (NICE) guidelines for adult depression management in the United Kingdom, leading to a formal recommendation of MBCT for individuals with three or more previous depressive episodes (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Regarding anxiety disorders, a recent RCT (n\u0026thinsp;=\u0026thinsp;276) comparing MBSR with escitalopram, a first-line pharmacologic treatment, found MBSR to be noninferior to the medication (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Earlier reviews support these findings for both anxiety and depression (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSpecifically among medical students, although data remains somewhat limited, findings follow a similar trend. A few reviews and meta-analyses have reported reductions in depression, anxiety, and stress, along with increases in mindfulness (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, significant heterogeneity exists between studies, the risk of bias\u0026mdash;particularly selection bias\u0026mdash;is high, the quality of evidence is low to moderate, and most studies have been conducted in the United States (US) (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). As of 2014, mindfulness programs were offered in approximately two-thirds of US medical schools (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA few studies have examined MBIs in Brazilian medical students, with some showing no effects on mental health outcomes, while others have demonstrated promising results (\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Additionally, the MBHP program, which focuses specifically on health promotion and quality of life, has only been tested in healthcare workers in Colombia (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Therefore, this study aims to contribute to the literature of MBIs among Brazilian medical students by assessing the feasibility and preliminary effects of the MBHP program on their mental health, particularly in relation to depressive symptoms, anxiety symptoms, perceived stress, and mindfulness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Sample\u003c/h2\u003e \u003cp\u003eThis was a non-controlled, single-arm pilot clinical trial assessing mental health variables before and after the MBHP program in Brazilian medical students. The trial was retrospectively registered with the \u003cem\u003eRegistro Brasileiro de Ensaios Cl\u0026iacute;nicos\u003c/em\u003e (ReBEC) (approved on February 26, 2025) under registration number RBR-44cvfnq. Primary outcomes included feasibility, depressive symptoms, anxiety symptoms, perceived stress, and mindfulness. Secondary outcomes consisted of five mindfulness subdimensions, described in detail below (see: \u003cem\u003eDescription of measures\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eParticipants were recruited in August 2018 through referrals from the university\u0026rsquo;s Integrative Medicine and Spirituality Interest Group. Assessments and the intervention took place in September and October 2018.\u003c/p\u003e \u003cp\u003eInclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) enrollment as a medical student at \u003cem\u003eUniversidade do Grande Rio Professor Jos\u0026eacute; de Souza Herdy\u003c/em\u003e (UNIGRANRIO); (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) ownership of a smartphone with WhatsApp\u0026reg; and internet access; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) age 18 years or older; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) provision of written informed consent.\u003c/p\u003e \u003cp\u003eExclusion criteria were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) attending less than 50% of the program\u0026rsquo;s sessions and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) worsening of a pre-existing psychiatric condition. The exclusion of participants with less than 50% attendance was based on a per-protocol analysis, which, in mindfulness intervention studies, considers attendance at four or more sessions as the criterion for completers (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study protocol was approved by the institutional review board at UNIGRANRIO under \u003cem\u003eCertificado de Apresenta\u0026ccedil;\u0026atilde;o para Aprecia\u0026ccedil;\u0026atilde;o \u0026Eacute;tica\u003c/em\u003e (CAAE) number 86916318.5.0000.5283, on June 28, 2018.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntervention Descriptions\u003c/h3\u003e\n\u003cp\u003eInspired by the MBSR, MBCT, and MBRP programs, the \u003cem\u003eMente Aberta\u003c/em\u003e Center at the \u003cem\u003eUniversidade Federal do Estado de S\u0026atilde;o Paulo\u003c/em\u003e (UNIFESP), in partnership with Zaragoza University, developed the MBHP program. This eight-week program included weekly two-hour sessions conducted on the UNIGRANRIO campus. The program was led by two instructors certified by the \u003cem\u003eMente Aberta\u003c/em\u003e Center.\u003c/p\u003e \u003cp\u003eDesigned for the Hispanic/Latin American context, MBHP emphasizes meditative practices such as breathing exercises, walking meditation, body scanning, mindful movement, self-compassion, and loving-kindness (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). These practices were guided in class by the instructors, and recorded audio versions (15\u0026ndash;20 minutes in length) were provided to participants for home practice, with recommendations to practice approximately once daily for six days a week.\u003c/p\u003e \u003cp\u003eWeekly session topics included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) What is Mindfulness? Escaping autopilot; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Awareness of the breath; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Mindfulness in daily life; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Mindfulness for difficult situations; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Mindfulness of the mind and thoughts; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Silence; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Mindfulness and compassion; and (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Mindfulness for life. Additional teaching strategies included videos, metaphors, group activities, mindful eating, breathing exercises, guided reflections, and journaling.\u003c/p\u003e\n\u003ch3\u003eDescription of measures\u003c/h3\u003e\n\u003cp\u003eData were collected in person one hour before the first MBHP session (baseline) and one hour before the final MBHP session (two-month follow-up) using printed questionnaires. Demographic variables included age, employment status, living arrangement, marital status, gender, medical school year, ethnicity, and physical activity.\u003c/p\u003e \u003cp\u003eFeasibility of the intervention was assessed through the percentage of eligible participants who enrolled (recruitment rate) and the percentage of participants who completed the program (retention rate).\u003c/p\u003e \u003cp\u003eDepressive symptoms were assessed using the Portuguese version of the Patient Health Questionnaire-9 (PHQ-9). This self-report instrument evaluates the presence of depressive symptoms over the past two weeks through nine Likert-scale items based on the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria. The PHQ-9 has demonstrated good internal consistency (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) and was validated in Brazil in 2008 (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Evidence suggests that scores\u0026thinsp;\u0026ge;\u0026thinsp;10 have high accuracy for diagnosing major depressive disorder (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnxiety symptoms were assessed using the Portuguese version of the Generalized Anxiety Disorder-7 (GAD-7) self-report questionnaire. Based on DSM-IV criteria, it evaluates the presence of generalized anxiety disorder symptoms over the past two weeks through seven Likert-scale items. The GAD-7 has demonstrated excellent internal consistency and high accuracy for diagnosing the disorder when scores are \u0026ge;\u0026thinsp;10 (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). The Portuguese version has also demonstrated excellent internal consistency (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerceived stress was assessed using the Portuguese version of the Perceived Stress Scale-10 (PSS-10), a self-report questionnaire consisting of 10 Likert-scale items that measure the extent to which certain situations are perceived as stressful in one\u0026rsquo;s life (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). The instrument was validated in a Brazilian sample and demonstrated good internal consistency (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMindfulness was assessed using the Portuguese version of the Five Facet Mindfulness Questionnaire (FFMQ), a self-report instrument that evaluates five dimensions: Observing, Acting with Awareness, Nonjudging, Describing, and Nonreacting. The first four dimensions contain eight Likert-scale items each, while the fifth consists of seven. Higher scores indicate greater levels of mindfulness (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Each dimension can also be assessed individually, with scores calculated for each subscale. The Portuguese version was validated in Brazil in 2014, demonstrating good internal consistency and high test-retest reliability (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were conducted using IBM Statistical Package for the Social Sciences (SPSS)\u0026reg; version 23 for macOS. A per-protocol analysis was followed, considering only participants who completed at least 50% of the program\u0026rsquo;s sessions.\u003c/p\u003e \u003cp\u003eIn addition to sociodemographic variables, descriptive statistics included the prevalence of depressive and anxiety disorders, calculated as the percentage of participants with scores\u0026thinsp;\u0026ge;\u0026thinsp;10, based on the clinical cutoffs for the PHQ-9 and GAD-7 (see \u003cem\u003eDescription of measures\u003c/em\u003e). Due to the small sample size and nonnormal distribution of continuous outcome variables, a nonparametric test was chosen. Consequently, paired Wilcoxon signed-rank tests were performed to compare median outcome differences pre- and post-intervention.\u003c/p\u003e \u003cp\u003eThe test statistic (\u003cem\u003eZ\u003c/em\u003e) and its \u003cem\u003ep\u003c/em\u003e-value were reported alongside the effect size (\u003cem\u003er\u003c/em\u003e), calculated using the formula \u003cem\u003eZ\u003c/em\u003e / \u0026radic;N. Calculating effect sizes is recommended for nonparametric analyses (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) and was interpreted according to Cohen\u0026rsquo;s criteria: \u003cem\u003er\u003c/em\u003e values between .1 and .3 indicate a small effect, between .3 and .5 a medium effect, and \u0026ge;\u0026thinsp;.5 a large effect (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Since SPSS provides \u003cem\u003eZ\u003c/em\u003e as a standardized statistic, it was reported as positive regardless of the direction of change, which was determined by observing median differences and explicitly described in the results.\u003c/p\u003e \u003cp\u003eA \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;.05 was considered statistically significant. All participants completed the questionnaires in full, resulting in no missing data, and analyses were conducted as complete cases.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 13 participants were assessed for eligibility, and none were excluded for not meeting the inclusion criteria. Feasibility findings showed that all 13 eligible participants enrolled in the MBHP program and attended at least 50% of its sessions, resulting in recruitment and retention rates of 100%.\u003c/p\u003e \u003cp\u003eBaseline sociodemographic data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Participants were mostly female (76.9%) and Caucasian (92.3%), with a mean age of 23.6 years (standard deviation [SD]\u0026thinsp;=\u0026thinsp;5.23). The majority were in the first two years of medical school, were single, and did not live alone. Based on cutoff scores, the prevalence of major depressive disorder in the sample was 69.2%, while generalized anxiety disorder was 84.6%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline sociodemographic characteristics (N\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Age (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.6 (5.23)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving arrangement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (69.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (92.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed race\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical school year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st e 2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (61.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd e 4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5th e 6th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (61.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice 1 to 2h per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice 3 to 6h per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevalence of Mental Health Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (69.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (84.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData is presented as n (%) unless specified otherwise. SD\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026lt; Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u0026gt;\u003c/p\u003e \u003cp\u003eThe effects of the MBHP program on primary outcomes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Median depression scores decreased by 69%, from 13 at baseline to 4 post-intervention (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.62). Similarly, anxiety symptoms showed significant reductions, with median scores decreasing by 62.5%, from 16 at baseline to 6 at the eighth week (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.014, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.41). Perceived stress decreased by 20.5%, from a median score of 39 at baseline to 31 post-intervention, though this reduction was not statistically significant (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.89, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.059, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.37). Finally, mindfulness levels showed a significant 35.8% increase, from a median score of 95 at baseline to 129 at the eighth week (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.62).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWithin-group changes in median primary outcome scores from baseline to post-intervention (N\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEffect Size (\u003cem\u003er\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDepression (PHQ-9)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAnxiety (GAD-7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePerceived Stress (PSS-10)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMindfulness (FFMQ)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003ePHQ-9, Patient Health Questionnaire-9. GAD-7, Generalized Anxiety Disorder-7. PSS-10, Perceived Stress Scale-10. FFMQ, Five Facet Mindfulness Questionnaire.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Boldface indicates \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026lt; Insert Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026gt;\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the effects of the MBHP program on secondary outcomes, which consist of the five mindfulness dimensions assessed individually. Observing median scores significantly increased by 31.8%, from 22 at baseline to 29 at the eighth week (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.012, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.49). Acting with awareness median scores increased significantly by 62.5%, from 16 at baseline to 26 post-intervention (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.62, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.009, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.51). Nonjudging median scores demonstrated a significant 35% increase, from 20 at baseline to 27 at the eighth week (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.046, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.39). Finally, nonreacting mean scores showed a significant 35.7% increase, from 14 at baseline to 19 at the eighth week (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.70, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.52).\u003c/p\u003e \u003cp\u003eIn contrast, describing median scores did not differ significantly, changing from 21 at baseline to 24 post-intervention (\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.233, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.23).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWithin-group changes in median secondary outcome scores from baseline to post-intervention (N\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMindfulness Dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-Intervention Median\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEffect Size (\u003cem\u003er\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eObserving\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.51\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eActing with Awareness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.62\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNonjudging\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.99\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDescribing\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNonreacting\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e2.70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Boldface indicates \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026lt; Insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026gt;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMain Findings\u003c/h2\u003e \u003cp\u003eThe findings of this study suggest that the MBHP program is feasible and may help mitigate mental health disorders in medical students. Preliminary results include a significant reduction in depressive symptoms with a large effect size, a significant reduction in anxiety symptoms with a medium effect size, and a significant increase in mindfulness with a large effect size. However, the effect on perceived stress did not reach statistical significance.\u003c/p\u003e \u003cp\u003eAdditionally, an exploratory analysis of mindfulness dimensions revealed significant increases in observing, nonjudging, acting with awareness, and nonreacting, with the first two demonstrating moderate effect sizes and the latter two showing large effect sizes. The describing dimension did not change significantly.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReductions in Depressive Symptoms\u003c/h3\u003e\n\u003cp\u003eDepressive symptoms in this study decreased by 69% from pre- to post-intervention, aligning with prior research indicating that MBIs reduce depressive symptoms in medical students (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Although the systematic review by Daya et al. reports mixed evidence for this outcome, the majority of included trials (67%) that assessed depression showed significant reductions (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A recent systematic review and meta-analysis, which included only RCTs, also reported significant reductions in depression immediately following the MBI in three out of four studies (n\u0026thinsp;=\u0026thinsp;307) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). However, due to insufficient data, a meta-analysis could not be conducted for this specific outcome.\u003c/p\u003e \u003cp\u003eNonetheless, both reviews highlight important limitations, including the low quality of evidence in the included studies (measured using validated quality assessments), heterogeneity in intervention protocols and outcome measures, short-term follow-up, and the predominance of small studies with mostly female samples (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The need for higher-quality trials in this field remains evident.\u003c/p\u003e \u003cp\u003eBrazilian studies on this topic have been limited (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), with only one assessing depression as an outcome. This study, an RCT with a sample of 141 first-year medical students, did not find a reduction in depression (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). To our knowledge, the present study is the first to demonstrate a decrease in depressive symptoms following an MBI in Brazilian medical students.\u003c/p\u003e \u003cp\u003eThe authors of the RCT primarily attributed these negative results to the course being a required component of this medical school\u0026rsquo;s curriculum, unlike most other studies where participation was elective (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Similarly, previous trials involving mandatory MBIs for medical students have also reported negative outcomes (\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince MBIs are not passive, motivation to engage in class and home practice is essential. However, the authors noted that some students engaged minimally with the program components, and only a few reported adhering to home practice (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Another possible explanation for these negative results is the larger group size in this RCT (45 students per group) compared to smaller groups in other trials (typically around 10 to 20 students) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e), including the present study. Additionally, the timing of the intervention, which began as early as the second week of medical school, may have been suboptimal, as this period is not typically associated with high stress levels.\u003c/p\u003e \u003cp\u003eAlthough research on mindfulness and depression in medical students remains limited, findings from other depressive populations are fairly robust. An individual patient data meta-analysis of over 1,200 patients demonstrated the noninferiority of the MBCT program compared to first-line pharmacologic treatment in preventing depression relapse (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe high prevalence of depression in both national (30%) and international (28%) samples of medical students (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) underscores the significance of the present study, as MBIs may help mitigate the long-term health and financial consequences for both individual students and the healthcare system (\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Additionally, since higher levels of depression are associated with poor academic performance, increased medical errors, cynicism, and reduced empathy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), MBIs could potentially enhance medical students\u0026rsquo; training. Future studies should assess these outcomes directly.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReductions in Anxiety Symptoms\u003c/h2\u003e \u003cp\u003eWith respect to anxiety, we observed that the MBHP program reduced symptoms by 62.5% immediately post-intervention. Data on this outcome is somewhat more limited than on depression, with two non-RCTs (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e), and one systematic review including four RCTs directly assessing it (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Nevertheless, consistent with our findings, the systematic review and meta-analysis by da Silva et al. reported significant reductions in anxiety in three out of four studies involving 307 participants (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Similar to depression, the limited data made it unfeasible to conduct a meta-analysis for this outcome.\u003c/p\u003e \u003cp\u003eFindings from the non-RCTs have been mixed: one study reported significant reductions in anxiety in the MBSR group compared to the control group (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e), while another, which tested an MBI tailored for medical students developed by Epstein and colleagues (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e), found no significant effect (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). The same limitations discussed previously apply here, particularly the low quality and high risk of bias in trials assessing anxiety (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Thus, it is prudent to refrain from drawing definitive conclusions until higher-quality trials are conducted.\u003c/p\u003e \u003cp\u003eThe landscape of mindfulness research on anxiety in Brazilian medical students reflects similar challenges. Only the RCT by Dami\u0026atilde;o Neto et al. has assessed this outcome in Brazilian samples, and it did not find significant results, primarily due to the intervention\u0026rsquo;s compulsory nature (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Thus, to our knowledge, this is the first study to demonstrate significant reductions in anxiety among medical students immediately following an MBI.\u003c/p\u003e \u003cp\u003eDespite the mixed evidence in this specific population, the substantial body of research supporting the efficacy of MBIs for anxiety disorders\u0026mdash;including a recent RCT of 276 individuals demonstrating the noninferiority of MBSR to first-line pharmacologic treatment (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u0026mdash;suggests that further trials assessing anxiety in medical students should be encouraged.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFindings on Perceived Stress\u003c/h2\u003e \u003cp\u003eRegarding perceived stress, our study did not find statistically significant reductions. Previous international and Brazilian research evaluating the effects of MBIs on perceived stress in medical students\u0026mdash;as well as related concepts such as psychological distress and overall stress\u0026mdash;has also yielded conflicting results (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Although the meta-analysis by da Silva et al. reported significantly lower stress levels post-intervention and up to a one-year follow-up, the authors rated the risk of bias as moderate, and the effect sizes were small, likely due to substantial heterogeneity among studies (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Additionally, a prior review found that only 57% of studies assessing stress reported significant reductions, with one study even documenting an increase in stress (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA few factors may explain these discrepant findings. First, interventions that focus solely on the individual aspect of stress may be insufficient, as effective stress reduction may also require institutional-level changes, such as curricular restructuring and pass/fail grading systems (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Second, the heterogeneity of stress assessment tools is noteworthy, as different instruments may reflect varying definitions of the construct, assess distinct dimensions of stress, and apply different scoring criteria or cut-off points (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Future studies should prioritize interventions that integrate both individual and institutional components and employ more reliable stress assessment tools, potentially including physiological measures such as salivary cortisol.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIncreases in Mindfulness and its Dimensions\u003c/h2\u003e \u003cp\u003eLastly, the present study found that overall mindfulness increased by 35.8%, with four out of five facets \u0026mdash; observing, nonjudging, nonreacting, and acting with awareness \u0026mdash; also showing significant increases, ranging from 32\u0026ndash;62%. These findings align with both international and Brazilian literature (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Meta-analytic data on 462 medical students suggest that mean mindfulness scores in MBI groups were significantly higher than those in control groups at the end of the intervention. The evidence was rated as high quality, although effect sizes were small (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, Brazilian studies contradict these findings. Both a large RCT and a small single-arm study using the FFMQ reported no significant differences in overall mindfulness scores or any of its five dimensions (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). To the best of our knowledge, this is the first study to demonstrate significant increases in mindfulness following an MBI in a sample of Brazilian medical students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA strength of this study is the per-protocol analysis, which supports the intervention\u0026rsquo;s efficacy. However, several limitations must be acknowledged.\u003c/p\u003e \u003cp\u003e First, the small sample size, with a predominantly Caucasian (92%) and female (77%) participant pool, reduced the statistical power and generalizability of our findings. This type of gender selection bias is common in mindfulness research, with one review reporting that at least 73% of participants were female (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Although future studies should strive for a more balanced gender distribution, it is important to note that depression and anxiety are more prevalent in women than in men (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSecond, since participation was voluntary, another form of selection bias may have increased the likelihood of enrolling more motivated participants or those predisposed to respond to MBIs due to personality traits (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Conversely, individuals with poorer mental health may have viewed the program as an opportunity to alleviate their distress, which could explain the higher baseline prevalence of generalized anxiety (84.6%) and depression (69.2%) in our sample compared to national averages (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, other MBI studies on medical students have reported higher baseline levels of mental health distress compared to age-matched samples (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e), making this a common occurrence in this field of research.\u003c/p\u003e \u003cp\u003eAlthough this limits the generalizability of our findings, previous studies on compulsory MBI participation among medical students have largely been unsuccessful (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), likely because active engagement in program practices is essential for its efficacy. Notably, students reported significantly higher satisfaction with elective MBSR participation compared to mandatory participation (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Hence, despite these limitations, we believe that future studies should continue offering these programs on an optional basis while acknowledging that only a specific subset of medical students may benefit from them.\u003c/p\u003e \u003cp\u003eThird, the single-arm design, lack of a control group, and short-term follow-up limited the ability to draw causal inferences, rule out placebo effects, and assess whether the effects are long-lasting.\u003c/p\u003e \u003cp\u003eFourth, this study was retrospectively registered in a clinical trials registry rather than before participant enrollment. Although this does not affect the validity of the findings, prospective registration is recommended to enhance transparency and reduce the risk of selective reporting.\u003c/p\u003e \u003cp\u003eFinally, the impact of the MBI was assessed exclusively through self-report tools, which are inherently prone to response and recall biases. Future studies are encouraged to use an RCT design with longer follow-ups and incorporate physiological markers of stress alongside psychological measures.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo the best of our knowledge, despite its limitations, this study is the first to demonstrate significant reductions in depressive and anxiety symptoms, as well as increases in mindfulness, following an MBI\u0026mdash;specifically the MBHP program\u0026mdash;in a sample of Brazilian medical students. Additionally, the program exhibited high feasibility. However, definitive conclusions cannot be drawn until larger RCTs offering elective MBIs to Brazilian medical students are conducted. Pilot trials like this one provide preliminary insights into potential mechanisms and offer effect size estimations to guide future larger trials.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBHP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness\u0026ndash;Based Health Promotion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness\u0026ndash;Based Intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e9\u0026ndash;Patient Health Questionnaire\u0026ndash;9\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e7\u0026ndash;Generalized Anxiety Disorder\u0026ndash;7\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e10\u0026ndash;Perceived Stress Scale\u0026ndash;10\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFFMQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFive Facet Mindfulness Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBSR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness\u0026ndash;Based Stress Reduction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness\u0026ndash;Based Cognitive Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEAT\u0026ndash;Mindfulness\u0026ndash;Based Eating Awareness Training\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMindfulness\u0026ndash;Based Relapse Prevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBP\u0026ndash;Mindfulness\u0026ndash;Based Blood Pressure Reduction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized\u0026ndash;Controlled Trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eReBEC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRegistro Brasileiro de Ensaios Cl\u0026iacute;nicos\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNIGRANRIO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversidade do Grande Rio Professor Jos\u0026eacute; de Souza Herdy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAAE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCertificado de Apresenta\u0026ccedil;\u0026atilde;o para Aprecia\u0026ccedil;\u0026atilde;o \u0026Eacute;tica\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNIFESP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversidade Federal do Estado de S\u0026atilde;o Paulo\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIV\u0026ndash;Diagnostic and Statistical Manual of Mental Disorders IV\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the institutional review board at \u003cem\u003eUniversidade do Grande Rio Professor Jos\u0026eacute; de Souza Herdy\u003c/em\u003e (UNIGRANRIO) under \u003cem\u003eCertificado de Apresenta\u0026ccedil;\u0026atilde;o para Aprecia\u0026ccedil;\u0026atilde;o \u0026Eacute;tica\u003c/em\u003e (CAAE) number 86916318.5.0000.5283, on June 28, 2018. All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVVN, DTS, CABM, and ARAB conceptualized the study and contributed to the study design and methodology. VVN conducted participant recruitment, data collection, analysis, and interpretation and drafted the original manuscript. DTS, MD, LA, CABM, and ARAB provided critical revisions and contributed to reviewing and editing the final manuscript. CABM and ARAB supervised the study. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Dr. M\u0026aacute;rio Henrique Elesb\u0026atilde;o de Borba and Dr. Renato Fernandes de Paulo for their valuable guidance and advice during the initial stages of study design and ethical review application. We would like to thank the meditation instructors, Danilo Correa and Fernanda Terra, for their dedication and essential contribution in delivering the sessions of the Mindfulness-Based Health Promotion (MBHP) program.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis. JAMA. 2016;316(21):2214\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian-Ci Quek T, Wai-San Tam W, Tran X, Zhang B, Zhang M, Su-Hui Ho Z. The Global Prevalence of Anxiety Among Medical Students: A Meta-Analysis. Int J Environ Res Public Health. 2019;16(15):2735.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006;81(4):354\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuarez DE, Cardozo AC, Ellmer D, Trujillo EM. cross sectional comparison of anxiety and depression symptoms in medical students and the general population in Colombia. Psychol Health Med. 2021;26(3):375\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoltmer E, K\u0026ouml;tter T, Spahn C. Perceived medical school stress and the development of behavior and experience patterns in German medical students. Med Teach. 2012;34(10):840\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Oliva Costa EF, Santana YS, de Abreu Santos ATR, Martins LAN, de Melo EV, de Andrade TM. Depressive symptoms among medical intern students in a Brazilian public university. Revista da Associa\u0026ccedil;\u0026atilde;o M\u0026eacute;dica Brasileira (English Edition). 2012;58(1):53\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacheco JP, Giacomin HT, Tam WW, Ribeiro TB, Arab C, Bezerra IM, et al. Mental health problems among medical students in Brazil: a systematic review and meta-analysis. Brazilian J Psychiatry. 2017;39:369\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSILVA-MENDON\u0026ccedil;A SILVAV. V. Symptoms of anxiety and depression and reasons for seeking mental health services among medical students from S\u0026atilde;o Paulo, Brazil;[S\u0026iacute;ntomas de ansiedad y depresi\u0026oacute;n y razones para buscar servicios en salud mental en estudiantes de medicina de S\u0026atilde;o Paulo, Brasil]. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003edos Santos DT, Naz\u0026aacute;rio FP, Freitas RA, Henriques VM, de Paiva IS. Alcohol abuse and dependence among Brazilian medical students: Association to sociodemographic variables, anxiety and depression. J Subst Use. 2019;24(3):285\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73(4):403\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlavin SJ. Medical Student Mental Health: Culture, Environment, and the Need for Change. JAMA. 2016;316(21):2195\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacLean L, Booza J, Balon R. The impact of medical school on student mental health. Acad Psychiatry. 2016;40:89\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEley DS, Bansal V, Leung J. Perfectionism as a mediator of psychological distress: Implications for addressing underlying vulnerabilities to the mental health of medical students. Med Teach. 2020;42(11):1301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyssen R, Vaglum P, Gr\u0026oslash;nvold NT, Ekeberg \u0026Oslash;. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Educ. 2001;35(2):110\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Burn-out an occupational phenomenon: International classification of diseases. 2019 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995\u0026ndash;1000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Ghunaim TA, Johnson J, Biyani CS, Alshahrani KM, Dunning A, O'Connor DB. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. 2022;224(1):228\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanagioti M, Geraghty K, Johnson J, Zhou A, Panagopoulou E, Chew-Graham C, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(10):1317\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStrecker EA, Appel KE, Palmer HD, Braceland FJ. Psychiatric studies in medical education: II. Neurotic trends in senior medical students. Am J Psychiatry. 1937;93(5):1197\u0026ndash;229.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWasson LT, Cusmano A, Meli L, Louh I, Falzon L, Hampsey M, et al. Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review. JAMA. 2016;316(21):2237\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUngar P, Schindler A-K, Polujanski S, Rotthoff T. Online programs to strengthen the mental health of medical students: A systematic review of the literature. Med Educ Online. 2022;27(1):2082909.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYusoff MSB. Interventions on medical students\u0026rsquo; psychological health: a meta-analysis. J Taibah Univ Med Sci. 2014;9(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro SL, Shapiro DE, Schwartz GE. Stress Management in Medical EducationTable 1. A Review of the Literature on Stress Management in Medical Education, 1969 to 1998Table 1. Continued. Table 1. Continued. Table 1. Continued. Table 1. Continued. Table 1. Continued.: A Review of the Literature. Acad Med. 2000;75(7):748\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21:581\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhitehouse WG, Dinges DF, Orne EC, Keller SE, Bates BL, Bauer NK, et al. Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school. Psychosom Med. 1996;58(3):249\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain S, Shapiro SL, Swanick S, Roesch SC, Mills PJ, Bell I, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med. 2007;33:11\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Acad Psychiatry. 2013;37:158\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eda Silva CCG, Bolognani CV, Amorim FF, Imoto AM. Effectiveness of training programs based on mindfulness in reducing psychological distress and promoting well-being in medical students: a systematic review and meta-analysis. Syst Reviews. 2023;12(1):79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaya Z, Hearn JH. Mindfulness interventions in medical education: A systematic review of their impact on medical student stress, depression, fatigue and burnout. Med Teach. 2018;40(2):146\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolle E, Gair J. Mindfulness-based stress reduction for medical students: a narrative review. Can Med Educ J. 2021;12(2):e74\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnes N, Hattan P, Black DS, Schuman-Olivier Z. An Examination of Mindfulness-Based Programs in US Medical Schools. Mindfulness. 2017;8(2):489\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabat-Zinn J, Clinic UMMCWSR. Full catastrophe living: Using the wisdom of your body and mind to face stress. pain, and illness: Delta; 1990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSipe WE, Eisendrath SJ. Mindfulness-based cognitive therapy: theory and practice. Can J Psychiatry. 2012;57(2):63\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLattimore P. Mindfulness-based emotional eating awareness training: taking the emotional out of eating. Eating and Weight Disorders-Studies on Anorexia. Bulimia Obes. 2020;25(3):649\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant S, Colaiaco B, Motala A, Shanman R, Booth M, Sorbero M, et al. Mindfulness-based relapse prevention for substance use disorders: A systematic review and meta-analysis. J Addict Med. 2017;11(5):386\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLima LC, Mendes LC. Mindfulness and psychological well-being: effects of a mindfulness-based health promotion program on healthy adults. Trends Psychol. 2020;28(2):213\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoucks EB, Neves VV, Cafferky V, Scarpaci MM, Kronish IM. Sustainability of Blood Pressure Reduction Through Adapted Mindfulness Training: The MB-BP Study. Am J Cardiol. 2024;217:31\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoucks EB, Nardi WR, Gutman R, Kronish IM, Saadeh FB, Li Y, et al. Mindfulness-based blood pressure reduction (MB-BP): Stage 1 single-arm clinical trial. PLoS ONE. 2019;14(11):e0223095.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoucks EB, Schuman-Olivier Z, Saadeh FB, Scarpaci MM, Nardi WR, Proulx JA, et al. Effect of Adapted Mindfulness Training in Participants With Elevated Office Blood Pressure: The MB‐BP Study: A Randomized Clinical Trial. J Am Heart Association. 2023;12(11):e028712.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, et al. Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA psychiatry. 2016;73(6):565\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. Guidelines. Depression in adults: recognition and management. London: National Institute for Health and Care Excellence (NICE) Copyright \u0026copy; NICE 2019.; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. 2023;80(1):13\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026oslash;llestad J, Nielsen MB, Nielsen GH. Mindfulness-and acceptance‐based interventions for anxiety disorders: A systematic review and meta‐analysis. Br J Clin Psychol. 2012;51(3):239\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraujo ACd S, CLAd, Kozasa EH, Lacerda SS, Tanaka LH. Effects of a mindfulness meditation course on healthcare students in Brazil. Acta Paulista de Enfermagem. 2020;33:eAPE20190170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDami\u0026atilde;o Neto A, Lucchetti ALG, da Silva Ezequiel O, Lucchetti G. Effects of a required large-group mindfulness meditation course on first-year medical students\u0026rsquo; mental health and quality of life: a randomized controlled trial. J Gen Intern Med. 2020;35:672\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarvalho Filho CV, Matos MTL, de Andrade MM, de Souza NCVF, Valad\u0026atilde;o AF, Cunha \u0026Acirc;GJ, et al. S\u0026eacute;rie de casos: avalia\u0026ccedil;\u0026atilde;o de uma interven\u0026ccedil;\u0026atilde;o baseada em Mindfulness no estresse percebido e qualidade de vida de estudantes de medicina: Case series: evaluation of a Mindfulness-based intervention in perceived stress and quality of life of medical students. Brazilian J Health Rev. 2022;5(5):20155\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuiroz-Gonz\u0026aacute;lez E, Lupano Perugini ML, Delgado-Abella LE, Arenas-Granada J, Demarzo M. Effects of a mindfulness-based health promotion program on mindfulness, psychological capital, compassion fatigue, and affect in healthcare workers. Front Psychol. 2024;15:1470695.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemarzo MMP, Andreoni S, Sanches N, Perez S, Fortes S, Garcia-Campayo J. Mindfulness-based stress reduction (MBSR) in perceived stress and quality of life: an open, uncontrolled study in a Brazilian healthy sample. Explore: J Sci healing. 2014;10(2):118\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemarzo M, Montero-Marin J, Puebla-Guedea M, Navarro-Gil M, Herrera-Mercadal P, Moreno-Gonz\u0026aacute;lez S et al. Efficacy of 8- and 4-Session Mindfulness-Based Interventions in a Non-clinical Population: A Controlled Study. Front Psychol. 2017;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemarzo M. Mindfulness y Promoci\u0026oacute;n de la Salud. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Lima Os\u0026oacute;rio F, Vilela Mendes A, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ‐2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care. 2009;45(3):216\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon S, Lee Y, Han C, Pae C-U, Yoon H-K, Patkar AA, et al. Usefulness of the Patient Health Questionnaire-9 for Korean medical students. Acad Psychiatry. 2014;38:661\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpitzer RL, Kroenke K, Williams JB, L\u0026ouml;we B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoreno AL, DeSousa DA, Souza AMFLPd, Manfro GG, Salum GA, Koller SH, et al. Estructura factorial, confiabilidad, y \u0026iacute;tems par\u0026aacute;metros de la versi\u0026oacute;n de portugu\u0026eacute;s brasile\u0026ntilde;o del cuestionario GAD-7. Temas em Psicologia. 2016;24(1):367\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983:385\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiqueira Reis R, Ferreira Hino AA. Rom\u0026eacute;lio Rodriguez A\u0026ntilde;ez C. Perceived stress scale: Reliability and validity study in Brazil. J Health Psychol. 2010;15(1):107\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarros VVd, Kozasa EH, Souza ICWd, Ronzani TM. Validity evidence of the Brazilian version of the Five Facet Mindfulness Questionnaire (FFMQ). Psicologia: Teoria e Pesquisa. 2014;30:317\u0026thinsp;\u0026ndash;\u0026thinsp;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePallant J. SPSS survival manual: A step by step guide to data analysis using. IBM SPSS: Taylor \u0026amp; Francis; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J. Statistical power analysis for the behavioral sciences. routledge; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D, Wolanskyj AP. The impact of a required longitudinal stress management and resilience training course for first-year medical students. J Gen Intern Med. 2017;32:1309\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAherne D, Farrant K, Hickey L, Hickey E, McGrath L, McGrath D. Mindfulness based stress reduction for medical students: optimising student satisfaction and engagement. BMC Med Educ. 2016;16:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassed C, De Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ. 2009;14:387\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhang CK, Mukhtar F, Ibrahim N, Keng S-L, Mohd. Sidik S. Effects of a brief mindfulness-based intervention program for stress management among medical students: the Mindful-Gym randomized controlled study. Adv Health Sci Educ. 2015;20:1115\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreeson JM, Toohey MJ, Pearce MJ. An adapted, four-week mind\u0026ndash;body skills group for medical students: reducing stress, increasing mindfulness, and enhancing self-care. Explore. 2015;11(3):186\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003;15(2):88\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDanilewitz M, Bradwejn J, Koszycki D. A pilot feasibility study of a peer-led mindfulness program for medical students. Can Med Educ J. 2016;7(1):e31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein RM, Mindful Practice. JAMA. 1999;282(9):833\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbert PR. Why is depression more prevalent in women? J Psychiatry Neurosci; 2015. pp. 219\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Dijk I, Lucassen PLBJ, Speckens AEM. Mindfulness training for medical students in their clinical clerkships: two cross-sectional studies exploring interest and participation. BMC Med Educ. 2015;15(1):24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWarnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45(4):381\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mindfulness, Students, Medical, Depression, Anxiety, Perceived Stress, Mental Health, Pilot Projects, Intervention Studies, Mindfulness-Based Interventions, Education, Medical","lastPublishedDoi":"10.21203/rs.3.rs-6255794/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6255794/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBACKGROUND\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMental health disorders, such as anxiety and depression, are more prevalent in medical students than in the general population. Mindfulness-based interventions (MBIs) have shown evidence of effectiveness in treating these conditions. However, findings among medical students are mixed, particularly in Brazilian samples. This study aims to evaluate the feasibility and preliminary effects of the Mindfulness-Based Health Promotion (MBHP) program on perceived stress, mindfulness, and symptoms of anxiety and depression in Brazilian medical students.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMETHODS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis single-arm pilot clinical trial involved medical students participating in the MBHP program for 2.5 hours per week over eight weeks. Outcomes were assessed at baseline and post-intervention. Feasibility was evaluated based on recruitment and retention rates. Depressive and anxiety symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7), respectively, while perceived stress and mindfulness were assessed using the Perceived Stress Scale-10 (PSS-10) and the Five Facet Mindfulness Questionnaire (FFMQ). Data were analyzed using descriptive statistics and the Wilcoxon Signed-Rank test.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRESULTS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFeasibility findings indicated that all 13 eligible participants enrolled and attended at least 50% of the program\u0026rsquo;s sessions, resulting in recruitment and retention rates of 100%. Participants (76.9% female, 92.3% Caucasian, mean age\u0026thinsp;=\u0026thinsp;23.6 years) showed significant reductions in depressive (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.62) and anxiety (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.014; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.41) symptoms post-intervention. Additionally, overall mindfulness increased significantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.62) along with four out of its five facets: observe (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.012; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.49), act with awareness (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.009; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.51), non-judgement (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.046; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.39) and non-reaction (p\u0026thinsp;=\u0026thinsp;.007; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.52). Perceived stress was not significantly reduced (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.059; \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.37).\u003c/p\u003e\u003cp\u003e\u003cb\u003eCONCLUSION\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur results suggest that the MBHP program is feasible and may be effective in reducing anxiety and depression while enhancing mindfulness in Brazilian medical students. Higher-quality randomized trials with a larger sample size and longer follow-up are needed to confirm these preliminary findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eREGISTRATION:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe trial was retrospectively registered with the \u003cem\u003eRegistro Brasileiro de Ensaios Cl\u0026iacute;nicos\u003c/em\u003e (ReBEC) on February 26, 2025, under registration number RBR-44cvfnq.\u003c/p\u003e","manuscriptTitle":"Easing the Burden: A Pilot Study on the Impact of Mindfulness on the Mental Health of Brazilian Medical Students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-25 04:27:43","doi":"10.21203/rs.3.rs-6255794/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-04T05:50:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T08:32:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-30T19:10:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201517447164659571576884477552131015116","date":"2025-06-21T18:11:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97888409124936662574960969450244849383","date":"2025-06-20T07:25:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-13T16:47:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186254787687676503778991551822224421851","date":"2025-05-06T14:39:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-29T11:19:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-04T11:30:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-04T11:30:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-03-18T18:55:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"37da8797-d865-4a3c-888d-b8160fc47377","owner":[],"postedDate":"April 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:41:56+00:00","versionOfRecord":{"articleIdentity":"rs-6255794","link":"https://doi.org/10.1186/s12909-025-07726-2","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-08-01 16:13:13","publishedOnDateReadable":"August 1st, 2025"},"versionCreatedAt":"2025-04-25 04:27:43","video":"","vorDoi":"10.1186/s12909-025-07726-2","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07726-2","workflowStages":[]},"version":"v1","identity":"rs-6255794","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6255794","identity":"rs-6255794","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}