Assessing Mental Health and Psychological Wellbeing in Medical Students: A Systematic Review

. However, the methods used and outcomes measured in studies evaluating psychological wellbeing lack consistency given their wide and diverse array. This systematic review aims to characterise and comprehensively evaluate the outcomes measured and methods used in studies assessing psychological wellbeing among medical students. A consensus on the constructs and methods used in indexing psychological wellbeing can lead to more effective assessments and consequently more effective interventions aimed at promoting wellbeing in medical students. Methods: Multiple databases were searched, including Medline, PsycINFO, Cochrane Library


Introduction
Over the past decade, the literature on the mental health challenges faced by medical students has been rapidly expanding as the multifaceted problems experienced by medical students during their training continue to be on the rise (Bhugra et al., 2019;Dunn et al., 2008;Dyrbye et al., 2006;Fares et al., 2016;Kötter et al., 2019;Pacheco et al., 2017;Vizheh et al., 2020).Medical education is a career path intended to provide personal and professional progression opportunities within a supportive environment that fosters students' pursuit of a highly competitive career in medicine (Dyrbye & Shanafelt, 2016;Sovold et al., 2021).However, it has been alarmingly highlighted that medical students' mental health and wellbeing can be adversely affected during their program (Bhugra et al., 2019;Dyrbye & Shanafelt, 2016;Fares et al., 2016;Hope & Henderson, 2014).Crucially, acknowledging the evolving dynamics of medical education and its impact on students' mental health becomes imperative, especially in the face of global adverse events such as the COVID-19 pandemic; recent studies have highlighted a concerning trend of deteriorating mental health among medical students, calling for ongoing research and support implementation (Gold, 2020;Jia et al., 2022;Mittal et al., 2021).
The poor mental health levels associated with studying for a medical degree have been reported worldwide (Belayachi et al., 2016;Dyrbye et al., 2006;Moffat et al., 2004;Tan et al., 2023;Thiemann et al., 2020;Vizheh et al., 2020;Yusoff et al., 2010b).While a pre-diagnosis of psychopathological issues has been markedly linked with high levels of stress in medical students (Dunn et al., 2008;Farrell, Molodynski, et al., 2019;Goebert et al., 2009), several academic as well as personal factors have been also reported to contribute to psychological wellbeing and mental health problems (Chau et al., 2019;Dunn et al., 2008;Dyrbye et al., 2006;Fares et al., 2016) ranging from the academic pressures imposed by the rigorous course curriculum and structure (Dunn et al., 2008;Farrell, Molodynski, et al., 2019;Goebert et al., 2009) to financial and other personal problems such as relationship issues (Bergmann et al., 2019;Cohen et al., 2013;Ramadianto et al., 2022).Commonly reported factors causing high levels of stress in medical students have also included relationship difficulties with senior academics as well as exposure to too little or excessive responsibility and potential embarrassment during placements (Quince et al., 2012;Slavin, 2018).While maladaptive perfectionism tendencies and impostor phenomenon symptoms have also been recognised as problematic attitudes in medical students, specific personality traits, such as neuroticism, have been associated with maladaptive coping strategies that might be contributing to high levels of mental distress too (Afshar et al., 2015;Mohamed et al., 2022;Sivailango et al., 2020).
As emphasised in a recent General Medical Council report (GMC, 2013), it is highly important for UK medical schools to ensure access to appropriate academic as well as welfare support for medical students in order to actively and proactively promote their wellbeing.Enhancing students' wellbeing is fundamental to their current mental health state and academic performance.It is also critical for their future mental health and competence as doctors, as well as for the quality of patient care provision and the overall public healthcare system (West & Coia, 2019).However, the lack of consensus on defining psychological wellbeing is a challenge that has been acknowledged (Dodd et al., 2021;Macleod & Moore, 2000) with several different concepts having been applied to measure aspects pertinent to the construct of psychological wellbeing.
Additionally, the majority of studies with medical students have looked primarily at how their mental health and wellbeing levels have been adversely affected, overlooking any positive indicators of wellbeing present in medical students' lives.A limited number of studies have indicated that aspects such as self-efficacy and good quality of life may positively enhance medical students' quality of life during their medical training (Angkurawaranon et al., 2016;Haider et al., 2022;Siddiqui, 2018).Psychological wellbeing intervention studies (Hu et al., 2019;Phang et al., 2016;Slavin et al., 2014) have included measures such as the Perceived Stress Scale (PSS) (Cohen et al., 1983), General Health Questionnaire (GHQ-12) (Goldberg et al., 1997) the State-Trait Anxiety Inventory (STAI) (Spielberger, 1970) to primarily assess postintervention changes in levels of stress, anxiety and depression in medical students.Generally, though, cross-sectional and other types of studies have used different varieties of questionnaires or self-report measures to assess stress, anxiety, depression and other aspects of psychological wellbeing.Arguably, the apparent discrepancies in the use of measures or the outcomes measured may fail to depict what constitutes a robust assessment of the construct of psychological wellbeing; the different outcomes that have been assessed may not capture the full spectrum of students' mental health and psychological wellbeing consistently while in their majority they don't seem to be considering positive aspects of mental wellbeing in medical students that could be augmented through intervention-based or other curricula-based frameworks within medical education.
This review adopted the theoretical framework of The Dual Continua Model of Mental Health and Mental Illness (Keyes, 2002;Keyes, 2005;Westerhof & Keyes, 2010).Within this framework, optimal mental health is determined not just by the absence of mental illness but also by the presence of positive mental health.Aligned with the positive psychology approach (Seligman & Csikszentmihalyi, 2000) individual strengths and positive experiences, events, influences and other positive states and traits can play a pivotal role in people's optimal functioning and wellbeing.Therefore, enhancing or promoting aspects of mental health and psychological wellbeing that could positively affect the lives of medical students may be equally important as identifying and trying to reduce the impact of negative indicators of wellbeing, fostering resilience and promoting personal and professional growth.

Objectives
The current systematic review aims to identify, characterise, and comprehensively consolidate and evaluate the outcomes measured and methods employed in studies focusing on the psychological wellbeing of medical student populations.In particular, the objectives of this review will be addressed by aiming to answer the following questions: 1. What outcomes have been used as negative and/or positive indicators of mental health and psychological wellbeing in studies with medical student populations?2. What methods have these studies used in order to measure or evaluate mental health and psychological wellbeing outcomes?

Inclusion and Exclusion Criteria
This systematic review will focus on research studies published in peer-reviewed articles and relevant grey literature that primarily investigated graduate and undergraduate medical students' mental health and psychological wellbeing.Only studies published in English will be considered for inclusion.Studies that mainly focus on outcomes directly related to medical students' mental health and psychological wellbeing, such as anxiety, depression, stress, burnout and life satisfaction, will be eligible for inclusion.Other aspects can be included as long as discrete psychological wellbeing descriptions can be extracted.Both quantitative and qualitative data obtained through self-report scales or interviews respectively are applicable for inclusion.On the other hand, exclusion criteria include studies that compare medical students with other populations without providing raw data for each sample; and studies involving nonmedical students.The review protocol has been registered in the PROSPERO database with the registration number CRD42020183361.

Information Sources and Search Strategy
An initial search of selected databases was conducted before the systematic searches occurred to identify keywords relevant to the systematic review question.An information specialist contributed to refining and finalising the search terms and strategies.The electronic bibliographic databases searched were: Medline, PsycINFO, Embase through the Ovid platform, and Cochrane and Web of Science.The search spanned from inception to May 2020, with subsequent updates conducted in February 2023 and January 2024.To construct the search strategy, terms were incorporated related to the population group and wellbeing outcomes, utilising a combination of index terms (Medical Subject Headings) and free-text expressions.
Challenges persisted as existing literature demonstrated inconsistent measures and concepts relating to psychological wellbeing.Boolean terms and connectors were used to maximise the search result, and no restrictions or limitations at this stage were applied.Relevant grey literature through Google Scholar and reference lists of included studies were examined by the author (AH) (See Appendix 3 for a complete outline of search strategies).

Study Selection
This systematic review has been reported following the Preferred Reported Items for Systematic Review and Meta-Analysis statement (Moher et al., 2015).A total of 2217 studies were identified through the literature search.Studies were screened independently by two authors (AH and AD) after removing 986 duplicates.A title and abstract of the remaining 1231 studies were screened for their relevance to be considered for potential eligibility.Of these, 1187 did not meet the inclusion criteria for review.A full text of 49 papers was examined in detail against the inclusion criteria, and reference lists were hand-searched for additional relevant papers.To further lower any probability of selection bias, two authors (AH and AD) independently reviewed the retrieved full text.Seven studies were excluded due to ineligibility, and three additional studies were included by checking the reference list of identified eligible studies, resulting in a final review that included 45 studies (see Figure 1 -PRISMA Flowchart Diagram).

Data Items
Extracted data included the authors' names, year of publication, study sites, sample, population and study design.The measures and measured outcomes of psychological wellbeing studies were further extracted by AH and AD.

Assessment of Methodological Quality
Two authors (AH and AD) independently rated the study qualities using the Medical Education Research Study Quality Instrument (MERSQI) (Reed et al., 2007) and The Critical Appraisal Skills Program (CASP) Qualitative Checklist (Healthcare BV, 3 May 2020).The MERSQI tool was developed to assess the methodological quality of quantitative medical education research.MERSQI rates study quality based on study design, sampling, data type, content validity, the complexity of the analysis and outcomes.Scores of 1-3 were determined in each domain and summed to calculate an overall score that ranged from 2-18.A high-ranking score of 14 or greater indicated higher methodological quality, highlighting a high-quality study (Reed et al., 2007).The Critical Appraisal Skills Program (CASP) Qualitative Checklist (Healthcare BV, 3 May 2020) was used to assess the quality of eligible qualitative studies, which is recommended by the Cochrane Collaboration qualitative methods groups (Noyes et al., 2018).The checklist consists of 10 questions that rate the research methodology, credibility, and relevance of findings.The answers to each question can be scored as "Yes," "Can't Tell," or "No," and the total score determines the overall quality of the study.A score >9/10 "Yes" answers is considered "High" quality, a score between 8-6 /10 "Yes" answers is rated as "Moderate" quality, and a score <5/10"No" answers are classified as "Low" quality.Discrepancies in the scoring between the two reviewers, AH & AD, were resolved by consensus or discussion with a third reviewer and co-author (EN).

Methodological Quality of Included Studies
The quality of studies included in the review varied.The majority utilised quantitative methods, with one study employing mixed methods, and five studies utilising qualitative methods; for a detailed list of included studies, please refer to Tables 1 & 2. The overall quality of the quantitative studies was rated low according to the mean MERSQI score of 7.3, while the methodological quality of the qualitative studies was considered moderate, with a mean CASP quality score of 8. Ethical approval was mentioned in more than half of the studies included in the synthesis (see Tables 1 & 2).

Positive Aspects of Psychological Wellbeing
Six studies (Almaqbali, 2019;Bloodgood et al., 2009;Dyrbye et al., 2012;Machado et al., 2019;Pranita et al., 2013;Saleem & Saleem, 2017) have measured positive aspects of psychological wellbeing using six different scales (Bech, 2004;Diener et al., 1985;Dupuy, 1984;Keyes, 2009;Ryff & Keyes, 1995;Watson et al., 1988), but all have consistently indicated poor psychological wellbeing across these aspects.Pranita et al. (2013) used the WHO Five Well-being Index Questionnaire (Bech, 2004) to evaluate the positive aspects of subjective quality of life in Indian medical students, tapping on domains such as positive mood, vitality, and interest in things.Their results were consistent with those of another study (Almaqbali, 2019) that suggested a low mental quality of life in medical training, using the MSWBI (Dyrbye et al., 2010).Additional studies used various measurement tools to assess positive indicators of psychological wellbeing, including Ryff's Psychological Well-Being Scale (Ryff & Keyes, 1995), which measured autonomy, environmental mastery, selfacceptance, personal growth, positive relations with others, and purpose in life.The Dupuy General Wellbeing Schedule (Dupuy, 1984) was used to assess positive wellbeing, self-control, and general health, while the SWLS (Diener et al., 1985) measured life satisfaction.Another study (Machado et al., 2019) utilised the PANAS (Watson et al., 1988) tool to assess gratitude, appreciation, optimism, resilience, qualities, and virtues, while the MHC-SF (Keyes, 2009) was used (Dyrbye et al., 2012) to assess both flourishing and languishing.

Discussion
This systematic review examined the outcomes, outcome measures and methodological approaches used in studies to assess the psychological wellbeing of medical students.Due to the heterogeneity of the study designs and measurement approaches, it was not feasible to perform meta-analyses of the reviewed studies.Notably, the studies focused mainly on the negative indicators of psychological wellbeing, with stress, depression, anxiety, burnout, and minor psychiatric disorders being the most commonly reported.In contrast, the positive indicators of psychological wellbeing, life satisfaction, gratitude, appreciation, optimism, and resilience, were less frequently explored.The studies used a range of scales to measure negative aspects of psychological wellbeing, with the GHQ-12, OLBI, PSS, and DASS-21 being the most frequently employed.Researchers primarily used self-reported measures and quantitative designs, with convenience sampling being the most common approach for participant selection.
This review has identified various outcomes used as indicators of psychological wellbeing in medical students.However, there needs to be more precision in how these outcomes are defined and measured.It is worth noting that out of all the studies reviewed, only one (Machado et al., 2019) provided a discrete definition of psychological wellbeing or mental health.The finding bears significant implications for a lack of consistency in the measurement of psychological wellbeing, making the comparison of findings across studies problematic.Further, psychological distress was indexed as a combination of burnout, depression, fatigue, stress and low mental quality of life -all of which are outcomes that have been previously found to be directly linked with poor psychological wellbeing (Almaqbali, 2019).
Moreover, the terms used to identify aspects of psychological wellbeing have varied and have been imprecise across studies, with some using different constructs interchangeably, such as minor psychiatric disorders and psychological distress, leading to confusion and overlap among constructs.In one study (Almaqbali, 2019), mental quality of life was referred to as a direct wellbeing outcome, but the actual measurement of this construct focused on depression and anxiety.This is problematic as different labels are being used to refer to constructs that are not strictly tapped upon by the tools used to measure them (Mansfield et al., 2020).Future studies can benefit from improving the clarity and precision in defining and measuring psychological wellbeing outcomes, as well as using consistent terminology across different studies (Newson et al., 2020).This can further help improve the validity and reliability of the measures and provide a clearer overall picture of medical students' psychological wellbeing.
The methodological approaches used in studies assessing the psychological wellbeing of medical students were mixed.Around a third of the included studies showed a clear focus on measuring negative aspects of psychological wellbeing utilising multiple scales, while few studies utilised a measure or a combination of measures that tapped into positive aspects of wellbeing.This diversity in methodological emphasis raises a critical consideration: the potential oversight of the overall psychological wellbeing state of medical students when the focus is primarily placed on negative aspects per se (Diehl et al., 2011;Keyes, 2005;Westerhof & Keyes, 2010).The existing literature highlights the significance of adopting a positive psychology framework in the evaluation of global psychological wellbeing (Benoit & Gabola, 2021;Seligman, 2015;White & Eyber, 2017).Such an approach not only ensures a more holistic understanding of psychological wellbeing but also sheds light on factors contributing to resilience, personal growth, and overall positive functioning among medical students (Dyrbye et al., 2012;Van Dijk et al., 2017).Hence, embracing a positive psychology approach would help capture the complete spectrum of psychological wellbeing, thereby providing a more comprehensive perspective into the mental health of medical students (Westerhof & Keyes, 2010).In line with previous systematic reviews that have underlined the challenge of assessing wellbeing-related outcomes in the healthcare domain (Hall et al., 2016;Krishnan et al., 2022), this review also posited the necessity for more consistency in the measurement methods of psychological wellbeing used in studies with medical students; and also emphasised the importance of directing more attention towards positive as well as negative indicators of medical student psychological wellbeing.
Furthermore, in the included studies, self-reported measures were prominently employed to capture subjective experiences, often through surveys or questionnaires, reflecting a common practice in studies focusing on psychological wellbeing (Agnes Mary Khine Myint & Mohanan, 2019; Datar et al., 2017).While these measures offer direct insights into individuals' perspectives, it's crucial to acknowledge their natural subjectivity and susceptibility to biases such as social desirability and recall bias (Davis et al., 2010;Dodd et al., 2021).Alongside the use of self-reported measures, researchers frequently opted for quantitative research designs, including correlational studies and experimental designs, facilitating the statistical analysis of relationships and causal links.Convenience sampling emerged as the predominant method for participant selection, a practice that, while providing valuable insights, can introduce potential biases and may limit the generalisability of study findings to broader populations (Li et al., 2022).
While quantitative designs predominated, only a few studies utilised qualitative methods, with five employing such approaches and one adopting a mixed-methods approach.This scarcity highlighted the need to acknowledge the potential that qualitative and mixed-methods approaches can offer.Qualitative methods have the capacity to uncover nuanced aspects of psychological wellbeing from the students' perspective, providing in-depth characterisations that quantitative methods may not capture alone (Cohen et al., 2002;Rubin & Rubin, 2011).Conversely, mixed-methods approaches can integrate the strengths of both qualitative and quantitative methods, offering a comprehensive understanding of psychological wellbeing among medical students by combining rich qualitative insights with rigorous quantitative analyses (Creswell, 2015;Dawadi et al., 2021).Integrating these approaches can significantly enrich our understanding of psychological wellbeing in this context (Creswell & Creswell, 2017;Firestone, 1987;Scott et al., 2023;Wilkinson & Smith, 2003).
In light of the multitude of methodologies and outcomes used in research so far, capturing the full continuum or scope of the psychological wellbeing of medical students remains a challenge.The various questionnaires used have identified a range of wellbeing problems, some of which overlap, creating confusion about the nature of these problems and the outcomes measured.It is also unclear whether the identified problems may be indicators of clinical depression, anxiety, or general distress or measurements of transient mood or stress levels.To adequately support students' wellbeing, there is also a need for qualitative research to differentiate between reactive stress and clinical cases requiring specific intervention.
In sum, the findings are consistent across research studies in terms of denoting poor psychological wellbeing and mental health problems, particularly anxiety and depression, in the medical student population (Belayachi et al., 2016;Dyrbye et al., 2006;Moffat et al., 2004;Tan et al., 2023;Vizheh et al., 2020;Yusoff et al., 2010b).
The findings of this review complemented findings from previous reviews on the conceptualisation of wellbeing in the general student population that have identified issues with defining and measuring various domains of wellbeing (Dodd et al., 2021;Hossain et al., 2023;Hou et al., 2021).These reviews have highlighted challenges such as inconsistencies in defining wellbeing domains and selecting appropriate measures.Specifically, previous research has indicated a lack of consensus on what domains are relevant for understanding student wellbeing in general, leading to a fragmented body of work (Hossain et al., 2023).Moreover, discrepancies in the approaches used to measure wellbeing have been noted, with some studies focusing solely on subjective experiences while others incorporate broader psychological factors (Dodd et al., 2021).
Arguably, the pattern of findings that emerged from this review highlights an inconsistency in the measurement of psychological wellbeing, bringing to the fore a need to clearly index the full spectrum of medical students' psychological wellbeing within a well-defined framework of mental health and wellbeing.Identifying the factors that may positively influence medical students' psychological wellbeing is also important, as identifying positive indicators of psychological wellbeing can further inform wellbeing interventions or other tailored curriculabased programmes in medical education settings (Dyrbye et al., 2012).

Strengths, Limitations and Future Directions
To the best of the authors' knowledge, this study is one of the first attempts to systematically review the outcomes measured and methods used to assess the psychological wellbeing of medical students.With a large sample size of 16,463 participants from various countries, the study provides a broad representation of the medical student population.However, it is important to acknowledge some limitations pertinent to this review.Due to the scope of the review and limited resources available, only studies published in English were included, potentially excluding relevant studies conducted in other languages.The search strategy may have also missed some relevant studies, although efforts were made to minimise omissions by searching multiple databases, grey literature, hand-searching reference lists and having the search conducted by a second author too.The heterogeneity of study designs and measurement approaches made it impossible to conduct meta-analyses, and all studies utilised cross-sectional data, which limited the authors' ability to infer causal relationships.
Future studies should aim to ensure a more homogenous methodological approach using a set of constructs that typically index aspects of psychological wellbeing, drawing upon wellvalidated measures of psychological wellbeing.Identifying well-defined outcomes pertinent to mental health and wellbeing may also have considerable research and clinical implications for using appropriate outcome measures in interventions in order to measure their effectiveness in enhancing medical students' wellbeing.

Conclusions
This study has highlighted the need for establishing homogeneity in the measurement methods used in studies assessing psychological wellbeing in medical students and consistency in the outcomes measured to index psychological wellbeing.Addressing this need can advance our understanding of medical students' mental health problems by allowing comparisons across studies and can potentially inform the development of enhanced wellbeing support resources and interventions in educational settings.

Table 1 .
Systematic Review-Characteristics of Included Studies

Study Country Sampl e size Study design Measure of psychological wellbeing Indicators of psychological wellbeing or outcomes measured Significant wellbeing findings EA MERSQI Score
(15%) of medical students have been diagnosed with a mental health condition during medical school (91%) of them scored positive on the GHQ-12; (81%) of medical students were classified as disengaged and (89%) as suffering from exhaustion on OBI