How Medical Students Manage Depression, Anxiety, and Stress: A Cross-Sectional Study

Introduction

Due to the intense pressure and stress of the training process, medical students face a higher risk of burnout and depression than the general US population [Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. Mar 2014;89(3):443-451. [CrossRef] [Medline]1]. They must pursue extracurriculars, like research, to be competitive for residency applications. Common stressors include academics, peer-to-peer relationships, and finances [Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Med Educ Online. Dec 2018;23(1):1530558. [CrossRef] [Medline]2], which can impact sleep quality, physical and mental health, and academic performance [Almojali AI, Almalki SA, Alothman AS, Masuadi EM, Alaqeel MK. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health. Sep 2017;7(3):169-174. [CrossRef] [Medline]3]. Stress can lead to burnout, with some even considering leaving medicine [Rajapuram N, Langness S, Marshall MR, Sammann A. Medical students in distress: the impact of gender, race, debt, and disability. PLoS One. Dec 3, 2020;15(12):e0243250. [CrossRef] [Medline]4]. Medical students may cope with stress through healthy habits like exercise or harmful ones like alcohol abuse [Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and alcohol abuse/dependence among U.S. medical students. Acad Med. Sep 2016;91(9):1251-1256. [CrossRef] [Medline]5,Taylor CE, Scott EJ, Owen K. Physical activity, burnout and quality of life in medical students: a systematic review. Clin Teach. Dec 2022;19(6):e13525. [CrossRef] [Medline]6].

This study explores how first- and second-year medical students manage and reduce stress, to improve medical student wellness efforts.

Methods

Participants and Recruitment

Overall, 120 first-year and 126 second-year students at a California allopathic medical school were contacted via institutional email to complete an anonymous survey. One survey round was sent, with 27 responses collected.

Measures

The survey comprised 2 demographic questions (school year and gender); 24 multiple-choice questions on stress management; 1 free-response question for any unlisted stress management activities and their frequency; and 21 randomly shuffled questions from the Depression, Anxiety and Stress Scale–21 Items (DASS-21) [Lovibond SH, Lovibond PF. Depression Anxiety and Stress Scales. American Psychological Association. 1995. URL: https://psycnet.apa.org/doi/10.1037/t39835-000 [Accessed 2025-06-25] 7]. The hobbies listed were based on community observation.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics (version 28.0.1.0). Normality was assessed via the Kolmogorov-Smirnov test. For nonnormally distributed data, a Kruskal-Wallis test (via k independent samples) was conducted, with gender and school year as the grouping variables and the range being 1-2. Additionally, Spearman correlations were obtained through SPSS’s bivariate correlation function.

Ethical Considerations

This study received ethical approval from the California University of Science and Medicine Institutional Review Board (HS-2023‐56) on November 27, 2023. Informed consent was obtained from all participants included in the study for data collection and analyses. Identifying information was not collected. Participants were not compensated.

Results

The Kolmogorov-Smirnov test found that neither the questions nor the DASS-21 subscores were normally distributed. The Kruskal-Wallis results are presented in Table 1. Spearman correlations showed that school year was positively and moderately correlated with stress (r₂₇=.699; P<.001), anxiety (r₂₇=.585; P<.001), and depression (r₂₇=.408; P=.03).

Second-year medical students had mild depression (13.67), with moderate anxiety (11.17) and stress (20.50; Figure 1). In contrast, first-year medical students were in the “normal” range across all categories. This demonstrates that second-year medical students experience higher levels of distress.

Question or topic	Kruskal-Wallis H (df=1)	P value	Group 1, mean (SD)	Group 2, mean (SD)
Read books to relax	4.994	.02	.67 (.900)b	.00 (.000)c
Talk with friends	5.888	.02	2.28 (.895)b	1.44 (.726)c
Go out with friends in person	5.081	.02	1.14 (.910)d	.20 (.447)e
Painting	4.000	.046	.00 (.000)d	.75 (1.500)e
Find it harder to wind down	12.222	.001	.62 (.590)d	2.50 (.837)e
Aware of having a dry mouth	10.300	.001	.10 (.301)d	1.50 (1.225)e
Could not experience positive feelings	7.502	.006	.14 (.359)d	1.33 (1.366)e
Difficulty breathing	5.234	.02	.10 (.301)d	.67 (.816)e
Overreacting to situations	6.131	.01	.19 (.402)d	1.17 (1.169)e
Using a lot of nervous energy	13.211	.001	.57 (.676)d	2.33 (.516)e
Getting more agitated	6.911	.009	.57 (.870)d	2.00 (1.095)e
Difficult to relax	9.453	.002	.81 (.873)d	2.50 (.837)e
Felt downhearted and blue	4.374	.04	.48 (.602)d	1.33 (1.033)e
Felt close to panic	8.576	.003	.14 (.478)d	1.17 (1.169)e
Feeling scared without any good reason	5.565	.02	.24 (.539)d	1.17 (1.169)e
Stress levels (DASS-21)	12.715	.001	5.48 (4.665)d	20.50 (4.416)e
Anxiety levels (DASS-21)	8.894	.003	2.43 (3.091)d	11.17 (7.139)e
Depression levels (DASS-21)	4.336	.04	4.67 (5.677)d	13.67 (11.535)e

^aDASS-21: Depression, Anxiety and Stress Scale–21 Items.

^bFemale group.

^cMale group.

^dFirst-year group.

^eSecond-year group.

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Discussion

Female participants were more likely to read (H₁=4.994; P=.02) and talk with friends (H₁=5.888; P=.02). This aligns with the existing literature, as women have been shown to read more than men, but this could also be due to our limited sample size [Cerbara L, Ciancimino G, Tintori A. Are we still a sexist society? primary socialisation and adherence to gender roles in childhood. Int J Environ Res Public Health. Mar 14, 2022;19(6):3408. [CrossRef] [Medline]8]. Exercise habits did not significantly differ by school year (P=.09) or gender (P=.71). Prior studies have shown that exercise reduces burnout and improves quality of life [Taylor CE, Scott EJ, Owen K. Physical activity, burnout and quality of life in medical students: a systematic review. Clin Teach. Dec 2022;19(6):e13525. [CrossRef] [Medline]6], suggesting that medical schools should encourage physical activity, especially for students studying remotely.

First-year medical students were more likely to go out with friends (H₁=5.081; P=.02). Second-year medical students had varied schedules, due to rotations or professional development semesters, which at this institution are a dedicated 6-month period for self-directed activities such as research projects or studying for the United States Medical Licensing Examination (USMLE) Step exams. This may limit socialization opportunities compared to first-year medical students, who remain on a shared schedule. On the DASS-21, second-year medical students had moderate stress levels compared to first-year medical students—who had “normal” stress levels (a 15-point difference)—potentially due to clinical rotations, professional development semesters, or Step 1 exam preparation. The 6‐ to 8-week “dedicated” study period is highly stressful, and despite Step 1’s transition to a pass-or-fail grade, concerns remain about its impact on mental health. However, it is important to acknowledge that due to the limited sample size (n=27), it would be difficult to make broad generalizations. Similarly, this raises the question of validity, as students at other medical schools may have different experiences.

These findings highlight the need to focus on increasing social support through events such as mug painting, potlucks, or board game nights. This will help students build a network, better cope with stress, and reduce the negative feelings they experience [Drageset J. Social support. In: Haugan G, Eriksson M, editors. Health Promotion in Health Care – Vital Theories and Research. Springer; 2021:137-144. [CrossRef]9]. Future research should focus on optimizing such interventions not only for second-year medical students but also for third- and fourth-year medical students, who were not included in this study. Future studies should also measure stress management and stress levels longitudinally across cohorts of various institutions so that standardized approaches can be developed, which can further be adjusted to fit the cultures of individual institutions.