Stress In Medical Students Research Articles

Secondary Traumatic Stress in Medical Students

Abstract There is growing clinical evidence that health professionals working with survivors of traumatic events may develop traumatic symptoms themselves. During their clinical practice, medical students are also at risk of experiencing secondary traumatic stress. 168 medical students were surveyed to determine the presence of secondary traumatic stress and explore the relations to personality factors and motivation. The findings support the need for specific training on trauma exposure and traumatic stress management in medical education. Assessment should be connected to prevention and intervention efforts.

Nitric oxide and human aging

More than in 500 17-21-year-old medical students stress reactivity (SR), biological age (BA), arterial pressure (AP) and nitric oxide (NO) metabolites excretion to the alveolar air [nitrates and nitrites concentration (NNC) in alveolar condensate] were determined in rest and before examinations during 1995-2204. AP, BA and NNC were measured in various trimesters of individual year (IY, the period from one person's birthday to another). During this period girls' AP changes insignificantly. The AP of youths is higher than in girls and increases during IV-IY trimester (10-12 months after birthday). The youths NNC decreases from the II to the IV-IY trimesters, but in girls there is a tendency to NNC increase during the IV-IY trimester their NNC negatively correlates (r = -0,34) with their systolic AP Among youths and girls with equal AP, NNC is significantly higher in girls. NNC decreases with the SR rise; this decrease develops during the examination stress too, but in girls NNC decrease is less. BA in youths is higher than in girls and increases during the IV-IY trimester. In youths BA negatively correlates (r = -0,60) with NNC. Taking into mind the "stress theory" of aging (P. Parsons, 1995) our data may be a basis to assumption that nitric oxide is a "molecule of anti-aging".

The Cost of Education: Medical Student Stress during Clerkships

Introduction: Physicians and physicians-in-training experience sustained stress, leading to increased rates of burnout, anxiety, depression, and suicide. This study explored stress patterns in third year students during clerkships at a U.S. medical school. Methods: Students completed an anonymous modified mental health professional stress survey during three successive clerkships and rated six stress factors on a Likert-type scale, from o to 3. Statistical analysis included descriptive statistics and linear mixed-effects regression models. Results: Twenty nine survey responses were collected. Overall, stress due to workload, professional self-doubt, and home-work conflicts was significantly higher than stress associated with patient-related difficulties, organizational structure, and difficulties with other healthcare workers (all p values < 0.05). On Internal Medicine and Surgery, more than 75% of students worked over 60 hours/week and reported the highest level of home-work conflicts. Women had significantly lower work-related interpersonal stress scores than men (p = 0.04). Conclusion: Medical students encounter complex Stressors during clerkships. Potential strategies to help improve the learning climate are discussed, such as duty hour limits, reduced workload, teaching time management skills, fostering emotional intelligence qualities, and team-building exercises involving all learners.

Emotional Intelligence and Stress in Medical Students Performing Surgical Tasks

Poor stress management skills can compromise performance in the operating room, particularly in inexperienced trainees. Little is known about individual differences in managing stress. This study aimed to explore the relationship between trait emotional intelligence (EI) and objective and subjective measures of stress in medical students faced with unfamiliar surgical tasks. Seventeen medical undergraduates completed an unfamiliar laparoscopic task on a simulator during January to April 2008. Subjective stress before, during (retrospectively), and after the task was measured using the self-report State-Trait Anxiety Inventory. Objective stress was measured using continuous heart rate (HR) monitoring. Participants also completed the Trait Emotional Intelligence Questionnaire short form (TEIQue-SF). The authors computed scores for global trait EI and the TEIQue-SF four factors and carried out descriptive and correlational analyses. The highest levels of subjective stress were reported during the task and correlated positively with trait EI as well as with the trait EI factors of well-being and emotionality. Objective stress (mean HR) during the task was positively related to the sociability factor of trait EI. Higher trait EI scores were also associated with better after-task recovery from stress experienced during the task. Students with higher trait EI are more likely to experience stress during unfamiliar surgical scenarios but are also more likely to recover better compared with their lower-trait-EI peers. Trait EI has implications for the design of effective stress management training tailored to individual needs and potential applications to surgical trainee selection and development.

The effects of attribution tendencies, academic stress, and coping efficacy on academic adjustment of medical students.

This study investigated the relationship among types of attribution tendencies, academic stress, coping efficacy, and academic adjustment in medical students and identified the means by which the academic adjustment of medical students can improve. Four hundred forty-two subjects from 2 medical schools in Korea were analyzed; 202 were male, 206 were female, and 34 did not identify their gender. We surveyed their academic adjustment, attribution tendencies, academic stress, and coping efficacy. The data were analyzed by descriptive statistics, t-test, and stepwise multiple regression analysis. The male group scored higher on academic adjustment, internal attribution tendency, and coping efficacy but lower on academic stress than the female group. Coping efficacy and internal attribution tendency affected the academic adjustment positively while academic stress influenced it negatively. The study indicates that students with higher scores on coping efficacy and internal attribution tendency and who have lower scores on academic stress tend to adjust better academically in medical school. Therefore, these findings may be helpful for medical schools in designing effective academic adjustment programs to improve coping efficacy and internal attribution tendency and reduce academic stress. Further, these findings have important implications for planning learning consultation programs, especially in Year 1.

Analysis of medical students' enneagram personality types, stress, and developmental level.

The purpose of this research was to examine the medical students' personality with stress and developmental level. The study explored three overarching topics: How are medical students' personality types reflected in an enneagram? Are there any differences between subtypes of stress points? How are the students' developmental levels by gender, academic level, and enneatypes? The subjects were 414 medical students in three Korean medical schools. Enneagram Personality Types Inventory (Korean version) was used. These enneatypes were divided into four subtypes: centers of intelligence, hornevian triads, self-consciousness, and harmonic group. Enneatypes and stress points were analyzed statistically by frequency and percentage of enneatypes, chi-square test, and ANOVA. Distribution of enneatypes; type 9 was the most frequent class (n=136, 32.9%). Types 1, 3, 4, and 9 had more disintegrated students than other types (chi2=59.2, p=0.000). Subtype analysis; in body-centered type more students were disintegrated than integrated or mediocre (chi2=25.8, p=0.000). In behavior patterns, aggressive and passive types showed more disintegration (chi2=25.2, p=0.000), and in self-consciousness groups only inner order types showed integration (chi2=19.3, p=0.001). In harmonic group, positive outlook types contained the most disintegrated students (chi2=20.5, p=0.000). Majority of medical students were in disintegrated developmental status. A program should be developed for students to know their ego-identity plainly and overcome their disintegration, based on their enneatypes. Such a program will help students improve their ways of thinking or their behavior and become more secure.

First cadaver dissection: Stress, preparation, and emotional experience

To evaluate the psychological preparation and stress of medical students associated with their first cadaver dissection class, covering the head and neck region. Prospective evaluation of a group of 58 second-year medical students. Participants experienced this first dissection class with little stress, with no significant gender difference. Men, however, felt better prepared than the women did. The smell and sight of the cadaver's face were their main concerns. The students were evaluated with STAI questionnaires and visual analog scales just before, immediately after, and one month after their first dissection experience. This is the first time this scheme has been used. Students suggested several improvements for advance preparation, most of them inexpensive in terms of human and material resources. The low stress caused by dissection is probably influenced by the fact that student participation is voluntary. Although they felt that they were relatively unprepared from a psychological perspective, the vast majority of students felt ready to participate in the dissections and had a very good perception of this experience.

A randomised controlled trial of the effects of mindfulness practice on medical student stress levels

This study aimed to determine whether the practice of mindfulness reduces the level of stress experienced by senior medical students. We carried out a multicentre, single-blinded, randomised controlled trial with intention-to-treat analysis in three clinical schools attached to the University of Tasmania, Hobart, Tasmania. Participants included 66 medical students in their final 2 years of study in 2009. Participants were block-randomised to either an intervention or a usual care control group. The intervention used an audio CD of guided mindfulness practice designed and produced for this trial. Participants were advised to use the intervention daily over the 8 weeks of the trial. All participants completed two self-report questionnaires, at baseline and at 8 weeks, respectively. The intervention group also completed a questionnaire at 16 weeks to provide follow-up data. The primary outcome measure was the difference over time in scores on the Perceived Stress Scale (PSS). The secondary outcome measure referred to differences over time in scores on the subscales of the Depression, Anxiety and Stress Scale (DASS). Mean baseline scores on the PSS and the stress component of the DASS were 15.7 (maximal score of 40) and 13.2 (maximal score of 42), respectively, both of which exceed scores in age-matched normative control data. Using multivariable analysis, participants in the intervention group demonstrated significant reductions in scores on the PSS (- 3.44, 95% confidence interval [CI] - 6.20 to - 0.68; p < 0.05) and the anxiety component of the DASS (- 2.82, 95% CI - 4.99 to - 0.64; p < 0.05). A borderline significant effect was demonstrated on the stress component of the DASS (- 3.69, 95% CI - 7.38 to 0.01; p = 0.05). Follow-up at 8 weeks post-trial revealed that the effect was maintained. Mindfulness practice reduced stress and anxiety in senior medical students. Stress is prevalent in medical students and can have adverse effects on both student health and patients. A simple, self-administered, evidence-based intervention now exists to manage stress in this at-risk population and should be widely utilised.

P03-413 - Stress in first-year Egyptian and Saudi female medical students: a cross cultural comparison

IntroductionCollege students, especially freshmen, are particularly prone to stress due to the transitional nature of college life. However most of studies in this context were conducted in Western Europe and North America with only few recent studies conducted in the Arab world. This study sought to determine whether there was a difference in perceived stress levels of female medical students at Mansoura University, Egypt, and King Faisal University, Saudi Arabia.MethodsThe sample consisted of first year female medical students. The self-reported questionnaire covered four categories, including 13 items, of sources of stress (stressors).Perceived stress scale and Hospital Anxiety and Depression Scale were used to measure stress, anxiety and depression.ResultsThere is no significant difference between the two groups regarding number of stressors. However, Saudi students were more likely to cite emotional problems, excessive workload and fear of future. The most common items in Egyptian students were financial and environmental problems. Prevalence of stress and clinical anxiety was higher in the Saudi sample. Logistic regression analyses of independent predictors of high level of stress among both groups combined were Saudi nationality, larger family size, clinical depression and clinical anxiety.ConclusionsPerceived stress and anxiety are frequent among Saudi students. This information could be useful in designing preventive mental health programs that should be an integral part of the routine clinical facilities caring for medical students to help them to cope with the increasing demands of medical education.

Coping with cancer: a brief report on stress and coping strategies in medical students dealing with cancer patients

This pilot study explored factors associated with stress in medical students during their initial clinical contact with cancer patients, in particular identifying stress levels and coping strategies used. A total of 80 medical students at The University of Birmingham Medical School, UK, completed retrospective self-report questionnaires measuring socio-demographics, potential stressors and coping strategies (using the Brief COPE inventory). Statistical analysis followed data collection. Of all socio-demographic categories, female gender correlated with the highest stress score (p<0.05). The most stressful situations reported related to the patient's condition, the biopsychosocial effects of the cancer on the patient and his/her family, and breaking bad news. A combination of problem- and emotion-focussed strategies were used to manage stress; and the extent of their usage was significantly related to individual stress levels (p<0.01) in both instances. Medical students in an oncology setting experience moderate stress and utilise a combination of problem- and emotion-focussed coping strategies to combat this stress. A greater use of both coping strategies was seen in students experiencing higher levels of stress. This may suggest a relative lack of effective coping skills. In light of this, the implementation of coping strategy training as a part of the medical course and/or support groups may be beneficial.

The Medical Student Stress Profile: a tool for stress audit in medical training

It is well recognised that medical training can be extremely stressful and that high stress is a risk factor for a wide range of psychological and health-related consequences. The primary aims of this study were to introduce the Medical Student Stress Profile (MSSP) and to demonstrate its psychometric quality as a specific device for auditing medical student stress. Secondary aims were to establish the reliability, construct and criterion validity of this instrument and to explore the relationships between stress, coping, personality, motivation and emotional intelligence in medical students. A battery of self-report measures including the MSSP was administered to a sample of 239 undergraduate and graduate-entry medical students. The battery included indices of stress, coping with and proneness to stress, as well as measures of emotional intelligence, motivation style, personality traits, educational environment perception and self-reported symptomatology. Psychometric evaluation of the MSSP was conducted along with a correlation analysis of stress concomitants. The MSSP revealed good psychometric properties and showed a substantial stress load in the participant sample. The pattern of correlations with concomitant measures conformed generally to expectations. Strong cohort effects were observed, which suggest the importance of future investigation into the role of the group in stress amelioration. Stress adversely affects ratings of the educational environment as measured by the Dundee Ready Education Environment Measure. The MSSP was specifically developed for the medical training context and may have utility for individual and group stress audits of medical students and as a device to inform remedial programmes in stress management in medical education.

How stressful is doctor–patient communication? Physiological and psychological stress of medical students in simulated history taking and bad-news consultations

Introduction Medical communication can be a stressful experience for both doctors and patients. In particular, inexperienced doctors facing the demanding task of a bad news consultation may experience high levels of distress. The aim of this exploratory study is to test students' differential cardiovascular reactivity to history taking and bad news consultations with a simulated patient, and to test the relation between the students' self-reported stressfulness of the consultation and their cardiovascular response. Methods Fourth and fifth year medical students ( n = 20) conducted a history taking (HT) and a bad news (BN) consultation in a randomized order with a standardized patient. Heart rate (HR), mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were assessed by way of the Finapres-technique in four conditions: rest, reading aloud, and during both consultations. Self-reported stress was assessed before and after each interview using the State and Trait Anxiety Inventory (STAI), and a visual analogue scale (VAS). Results Both HT and BN provoked more cardiovascular stress than reading. Bad-news provoked the highest HR and CO responses compared to all other conditions, and had a greater impact when it was the student's first consultation. The STAI and VAS data showed some correlations with the cardiovascular stress measures and a comparable but less significant pattern in stress response. Discussion The effect of order of the HT and BN consultations on the students' stress levels suggests an additional impact of novelty and habituation. Unfamiliarity with the patient may enhance the stressfulness of the task of breaking bad news.

Visual journaling: An intervention to influence stress, anxiety and affect levels in medical students

Research has shown that medical students have higher levels of stress and anxiety than the general population, increasing their risk of health problems, mental illness, and suicide. This study looked at the effects of visual journaling as a possible stress-reduction technique. Research took place with students and staff of Eastern Virginia Medical School, with data collected over two sessions consisting of inventory scores of the State-Trait Anxiety Inventory (STAI-Y) and the Positive and Negative Affect Schedule (PANAS-X), artwork in their visual journals, and a questionnaire. While the number of participants was not large enough to show statistical significance, there was a general decrease in anxiety and negative affect levels among nearly all participants from the pretest to the posttest. This study showed that visual journaling was a promising intervention for stress reduction in a medical environment; however, more research is needed to justify its implementation.

EXAMINATION STRESS

O b j e c t i v e : 1: To examine the effects of examination stress in young adult male and female medical students on cardiovascularsystem and thyroid gland (i.e. thyroid hormones; T3,T4).2:To find out whether the responses are sex dependent or not. S e t t i n g : Departmentof Biochemistry NMC Multan (1997-1998). Patients a n d m e t h o d : Examination stress was studied in 28 young female and 21 young malevolunteer medical students, 0.5 hour before Biochemistry examination (stress condition), at 10-12 a.m. and about six weeks after examination(control condition) at the same time in the year 1997. Estimation of Thyroxine (T4) and Triiodothyronine (T3) and T3 /T4 was done in patientsand control subjects. R e s u l t s : There were no differences in body mass index of male and female groups in control and stress group.Subsequent analysis between two sexes showed that males subjects had significantly higher systolic (124.7±40.1 mmHg) and diastolic bloodpressure (76.56±2.48 mmHg). Heart rate (84.6±2.63) increases in stress condition, in both sexes, but in males the increasing of heart rate ismore than in females. Whereas females had higher respiratory frequency in stress condition, as compared to males. The levels of T3 in femalestress group were higher than male stress group but statistically not significant. The mean values of T4 were highly significant in female stressgroup than in male stress group. C o n c l u s i o n s : Stress responses to examination are different between two sexes. The differences in responsesto examination stress between male and female showed a greater increase in systolic and diastolic blood pressure, heart rate, respiratory rateand also thyroid hormones in response to stress. It is suggested that as the examination is a stressful condition and different effects of stresson male and female medical students should be considered. The clinical presentation is palpitations, tremors, nervousness, apathy, fatigue,thirst, and emotional un-stability is due to the increase of thyroid hormones. Students are guided to remain relaxed, as neurotransmitters andhormones are released which may effect the overall performance of the students. Further study may be down to find out the effects of stresson other systems of the body which may be helpful in future to avoid the poor mental health status during the examination.

A comparison of course-related stressors in undergraduate problem-based learning (PBL) versus non-PBL medical programmes

BackgroundMedical students report high levels of stress related to their medical training as well as to other personal and financial factors. The aim of this study is to investigate whether there are differences in course-related stressors reported by medical students on undergraduate problem-based learning (PBL) and non-PBL programmes in the UK.MethodA cross-sectional study of second-year medical students in two UK medical schools (one PBL and one non-PBL programme) was conducted. A 16-question self-report questionnaire, derived from the Perceived Medical Student Stress Scale and the Higher Education Stress Inventory, was used to measure course-related stressors. Following univariate analysis of each stressor between groups, multivariate logistic regression was used to determine which stressors were the best predictors of each course type, while controlling for socio-demographic differences between the groups.ResultsA total of 280 students responded. Compared to the non-PBL students (N = 197), the PBL students (N = 83) were significantly more likely to agree that: they did not know what the faculty expected of them (Odds Ratio (OR) = 0.38, p = 0.03); there were too many small group sessions facilitated only by students resulting in an unclear curriculum (OR = 0.04, p < 0.0001); and that there was a lack of opportunity to explore academic subjects of interest (OR = 0.40, p = 0.02). They were significantly more likely to disagree that: there was a lack of encouragement from teachers (OR = 3.11, p = 0.02); and that the medical course fostered a sense of anonymity and feelings of isolation amongst students (OR = 3.42, p = 0.008).ConclusionThere are significant differences in the perceived course-related stressors affecting medical students on PBL and non-PBL programmes. Course designers and student support services should therefore tailor their work to minimise, or help students cope with, the specific stressors on each course type to ensure optimum learning and wellbeing among our future doctors.

Stress and psychological health of medical students in a Nigerian university.

Physician job satisfaction is one indicator of the overall health of our health care delivery system. Excellent but dissatisfied physicians could decide to leave the practice of medicine or highly talented students could opt for different careers if the perception that medicine is not a fulfilling career exists. This study aims to investigate the level of course satisfaction, its relationship to psychological disorder and presence/absence of stress among medical students. Physician job satisfaction is one indicator of the overall health of our health care delivery system. Excellent but dissatisfied physicians could decide to leave the practice of medicine or highly talented students could opt for different careers if the perception that medicine is not a fulfilling career exists. This study aims to investigate the level of course satisfaction, its relationship to psychological disorder and presence/absence of stress among medical students. A cross-sectional study was conducted among 410 medical students of the University of Benin, Nigeria. The respondents completed a self-administered questionnaire and a standard instrument The General Health Questionnaire (GHQ 28). The response rate was 93.9%. Two hundred and forty four (63.4%) of respondents were satisfied with their course, 331 (86.0%) of them felt medicine was stressful. There was also a statistical significant difference in the level of stress among the various levels of medical students. One hundred and twenty three (31.9%) medical students indicated that they would not study medicine again if given a second chance. One hundred and twelve (29.1%) medical students had psychological disorder. More dissatisfied students had psychological disorder than satisfied students and this difference was found to be statistically significant. The level of perceived stress among medical students was found to be high and a significant number of students had psychological morbidity. There is a need to identify and correct the causes of dissatisfaction among these groups of students in order to improve on the psychological state of the students. Stress management training is also required as majority of the medical students found the course stressful.

Well-being of medical students and their awareness on substance misuse: a cross-sectional survey in Pakistan

ObjectiveTo investigate psychological well-being and substance abuse among medical students in Pakistan.MethodsA cross-sectional questionnaire-based survey was conducted in six medical colleges across Pakistan. Final-year medical students were interviewed by either a postgraduate trainee in psychiatry or a consultant psychiatrist.ResultsA total of 540 medical students were approached; 342 participated and the response rate was 64.5%. Mean age was 23.73 years (SD 2.45 years); 52.5% were male and 90% single. Two out of every five respondents reported that work/study at medical school affected their personal health and well-being. A considerable proportion of students were aware of alcohol and smoking as coping strategies for stress in medical students. The main factors causing stress were heavy workload (47.4%), relationship with colleagues (13.5%) and staff (11.9%). A total of 30% reported a history of depression and 15% among them had used an antidepressant. More than half were aware of depression in colleagues. The majority of respondents said that teaching provided on substance misuse in the areas of alcohol and illegal drugs, management/treatment of addiction, and models of addiction was poor. There was significant association (p = 0.044) between stress and awareness about alcohol as a coping strategy for stress among medical students. A significant negative association was also found between medical colleges in public sector (p = 0.052), female gender (p = 0.003) and well-being.ConclusionThe majority of the medical students reported a negative impact of heavy workload on their psychological well-being. Significant numbers of medical students think that substance misuse is a coping strategy for stress. Teaching on addiction/addictive substances is poor at undergraduate level in Pakistani medical colleges.

P03-239 Study of stress level among medical school students of Semnan university, Iran

Background:The professional education can be stressful experience and medical students are exposed to high levels of stress in both theoretical and clinical components of their educational programme. The high level of stress often leads to disruptions in physiological and psychological health.Objective:The purpose of this study was to study stress in medical school students of Semnan university.Methods:This study was a descriptive and cross-sectional research. The sample were 211 students of general physicians (160) and paramedical (51). 206 students filled in a questionnaire.Data were collected using a stress questionnaire (R.S.Eliot). Then data were analyzed by SPSS and mean, frequency distributions. For this study were used chi-square, spearman and pearson correlation coefficient.Results:The findings showed 9.7% of students under study had high control degree, 82.5% of students had intact life but sometimes stressful situation caused anxiety for them, 6.8% of students feel depress and 1% in their life have mental crisis or conflict.Conclusion:Teaching to students in order to reduce stress level and provide educational improvement in medical students are recommended.

Depression and Its Infl uencing Factors among Korean Medical and Engineering Students in Urban Areas using Zung Self-Rating Depression Scale

Methods: The study randomly selected 640 students either majoring in medicine or engineering from two universities in Kyung-Gi province, Korea. Each of 320 students majoring in either of the two majors from each university was recruited. Among 640 students, 360 students, who were composed of 172 medical students and 188 engineering students was fi nally chosen for the analysis. The Zung Self-Rating Depression Scale was used to measure the depression state. Results: The average Zung depression score of university students was 49.2 ± 9.8. Medical students had a higher score of 52.4 ± 9.3 as compared to engineering students, who scored 46.3 ± 9.4. Overall depression rate was 42.8%. Medical students had a higher depression rate (52.3%) than engineering students (34.0%). The logistic analysis showed that infl uencing factors on depression state were sex, grade, major, stress and satisfactory sleep. The main source of stress for medical students was the grades from classes whereas job search was for engineering students. There were differences between the two groups in managing the stress. Medical students chose alcohol drinking or smoking for stress management whereas engineering students playing selected video games as their outlet. Conclusion: Medical students from urban areas seemed to be depressed more than engineering students. Their stress management methods among the subjects were drinking, smoking, and playing video games which may cause further physical and psychological problems in the future.

Symptoms of Anxiety and Depression in Medical Students and in Humanities Students: Relationship With Big-Five Personality Dimensions and Vulnerability To Stress

To evaluate the prevalence of anxiety and depression in medical students and in humanities students. To assess the relationship between symptoms of anxiety, symptoms of depression and Big-Five personality dimensions and vulnerability to stress in medical students. Randomly selected 338 medical students and 73 humanities students were evaluated for symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS), for Big-Five personality dimensions using the Ten-Item Personality Inventory (TIPI), and for vulnerability to stress using the Stress Vulnerability Scale (SVS). Symptoms of anxiety and symptoms of depression were prevalent in medical students (43% and 14%, respectively) and in humanities students (52% and 12%, respectively). In medical students the score on the HADS anxiety subscale and the score on the HADS depression subscale correlated negatively with the score on the TIPI Emotional Stability scale (r = -0.39, p < 0.01 and r = -0.2, p < 0.01, respectively) and correlated positively with the score on the SVS (r = 0.38, p < 0.01 and r = 0.44, p < 0.01, respectively). Symptoms of anxiety and depression are prevalent in medical students and in humanities students. Severity of symptoms of anxiety and symptoms of depression in medical students is negatively related to emotional stability and positively related to stress vulnerability.