Effects of Brief Group Mindfulness-based Cognitive Therapy for Stress Reduction among Medical Students in a Malaysian University

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1 DOI /s ORIGINAL PAPER Effects of Brief Group Mindfulness-based Cognitive Therapy for Stress Reduction among Medical Students in a Malaysian University Cheng Kar Phang 1 & Kai Chong Chiang 2 & Lai Oon Ng 3 & Shian-Ling Keng 4 & Tian Po S. Oei 5 # Springer Science+Business Media New York 2015 Abstract It has been widely reported that medical students face considerable stress in medical school. In Malaysia, a brief (four-session, 2 h per week) group Mindfulness-based Cognitive Therapy (b-gmbct/mindful-gym) was developed to help medical students cope with stress. The aim of this study was to evaluate the feasibility and effectiveness of the program in reducing stress among medical students in a Malaysian university. This was a single-group, prospective study. A total of 135 year-four medical students in psychiatric postings participated in the program (conducted in seven batches over 2 years). The following outcome variables were measured pre- and post-intervention: mindfulness, perceived stress, and general psychological distress. Intention-to-treat analyses showed significant reductions in perceived stress (M= 3.85, SD=5.70, 95 % CI, to 4.82, p<0.001) and increase in mindfulness (M=0.46, SD=0.80, 95 % CI, 0.32 to 0.59, p<0.001) with medium effect sizes from preto post-intervention. The percentage of participants who reported having significant general psychological distress * Cheng Kar Phang pckar39011@gmail.com Department of Psychiatry, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia Heath Psychology Programme, Faculty of Health Sciences, Univesiti Kebangsaan Malaysia, Selangor, Malaysia Department of Psychology, Faculty of Science and Technology, Sunway University, Selangor, Malaysia Department of Psychology, National University of Singapore, Singapore, Singapore School of Psychology & CBT Unit, Toowong Private Hospital, University of Queensland & James Cook University, Singapore, Singapore (GHQ 4) reduced (p<0.001) from 36 % (n=48) at preintervention to 10 % (n=14) after the program. Although there were significant reductions in perceived stress among Malay and non-malay medical students, Malay students had significantly lower level of perceived stress (p=0.03) after the program. This study found that the b-gmbct is potentially an effective stress reduction program for medical students in Malaysia. Keywords Mindfulness. Stress. Medical students. Psychological distress. Mental health. Cognitive therapy Introduction The level of stress in medical students is considerably high (Dyrbye et al. 2006) and can lead to various mental health problems, such as major depression, anxiety disorders, suicide, and substance abuse (Rosenthal and Okie 2005; Schwenk et al. 2010). Excessive stress in medical students can also negatively affect physical health, interpersonal relationships, academic performance, and training effectiveness in medical school (Schwenk et al. 2010). As of 2012, there are 34 medical schools in Malaysia, producing about 1700 medical graduates a year (Lum 2012; Sivanandam 2011). Using the General Health Questionnaire (GHQ-12), the prevalence of significant stress among Malaysian medical students in Universiti Sains Malaysia (USM), Universiti Putra Malaysia (UPM), and Universiti Kuala Lumpur Royal College Medicine of Perak (UniKL RCMP) were 29.6 % (Yusoff et al. 2010a), 41.9 % (Sherina et al. 2003), and 46.2 % (Zaid et al. 2007), respectively. In some studies, the level of stress among medical students was higher as compared to students in other courses, e.g., law students (Ko et al. 1999), economic and physical education students (Aktekin et al. 2001).

2 Together with the Malaysian studies, there have been hundreds of journal publications demonstrating the presence of significant psychological stress among medical students. Ironically, there were relatively few studies (less than 30) worldwide on intervention programs for medical students to cope with stress (Shapiro et al. 2000; Shiralkar et al. 2013; Yusoff and Esa 2012). The published studies in Malaysia so far focused on two very brief intervention programs consisting of a half-day (3 4 h) weekend mini lectures on concept of stress, stressors related to medical training, coping strategies, and discussion with peers and facilitators on handling stress for medical students in USM (Yusoff 2011; Yusoff and Abdul Rahim 2010). In the first study involving 38 students, there were significant improvements in the level of psychological distress from preto 4 months post-intervention (Yusoff and Abdul Rahim 2010). The second study showed that during a final examination period (Yusoff 2011), the levels of depressive and anxiety symptoms among students who had participated in the programs 6 months earlier (N=19) were significantly lower than those among students who did not participate in the program (N=29). As noted, the sample sizes are relatively small and it may be more useful to have a variety of stress management approaches for medical students with different needs. In view of that, a four-session, 2 h per week, brief Group Mindfulness-based Cognitive Therapy (b-gmbct) program was developed for this purpose. The b-gmbct program includes strategies derived from mindfulness-based and cognitive behavioral therapies, which most of the current stress management programs for medical students are based on (Yusoff and Esa 2012). The program was based on the Mindfulness-based Stress Reduction Program MBSR (Kabat-Zinn 2005) and Mindfulness-based Cognitive Therapy MBCT (Segal et al. 2002; Williams and Penman 2011). Phang and Oei (2012) had suggested further integration of mindfulness in Cognitive Behavioral Therapy (Meta- Mindfulness), which is partly applied in the intervention program of this study (e.g., cultivating gratitude and contentment). Mindfulness-based interventions have been found to be effective for reducing stress, anxiety, and depression (Hofmann et al. 2010;Khouryetal.2013)andforimproving physical health (Mars and Abbey 2010). Specifically among medical students, these interventions have been shown to reduce stress, and enhance quality of life, empathy, and spirituality (De Vibe et al. 2013;Hassedet al.2009; Jainetal.2007; Rosenzweig et al. 2003; Shapiro et al. 1998; Turakitwanakan et al. 2013; Warnecke et al. 2011). The present study aimed to evaluate the feasibility and effectiveness of the b-gmbct program in reducing stress among the medical students in a Malaysian university. Based on findings of previous studies, the following hypotheses were made: (1) Participants self-reported levels of perceived stress and general psychological distress would decrease from pre- to post-intervention, (2) Participants levels of mindfulness would increase from pre- to post-intervention, and (3) Participants improvements in mindfulness would correlate with improvements in perceived stress and general psychological distress. We also explored whether participants post-intervention perceived stress level would be predicted by age, gender, ethnicity, attendance of program, and baseline levels of mindfulness and psychological distress. Method Participants A hundred and thirty five (135) medical students from Universiti Putra Malaysia (UPM) participated in the program. They were the seven batches of year-four medical students who did their 8-week psychiatric postings between June 2010 and March Participants were informed that the program would help them to cope with stress as well as further enhance their knowledge and experience in psychiatry. The inclusion criteria were year-four medical students doing psychiatric posting and could commit to at least three out of the four sessions in the program. The exclusion criteria were students who had participated in mindfulness training. Due to ethical reasons, 31 % of the participants with high depression (DASS-D>28) and anxiety (DASS-A>20) scores (identified with depression, anxiety and stress scale by Lovibond and Lovibond 1995) were given information on places to get counseling if they deemed it was necessary. However, they were not excluded from the study. Participants ages ranged between 21 and 25 years old (M=22.23, standard deviation (SD)=0.64). There were 84 (62 %) females and 51 (38 %) males. Ethnically, 70 (52 %) were Chinese, 57 (42 %) Malays, and 8 (6 %) Indians. Procedure The b-gmbct intervention was adapted from the 8-week MBSR and MBCT programs, but shorter in duration, emphasizes more on informal practice, has a component on gratitude thinking, and with instructions tailored for medical students. It was introduced to the students as a stress management and relaxation program with the promotional name, BMindful- Gym^ (to emphasize the importance of experiential training and daily practice). The same instructor conducted the sessions for all the participants. He is a psychiatrist who practices CBT, had attended a 2-day MBCT workshop conducted by Dr. Mark Williams in Singapore, and has extensive personal mindfulness meditation practice (15 years). The program was conducted at the Department of Psychiatry at UPM. The duration of the program was 4 weeks, similar to the duration of a mindfulness-based program delivered in the study by Jain

3 et al. (2007). The number of participants in each group of the intervention was between 15 and 20. Participants met with the trainer weekly for a 2-h session for four consecutive weeks. Every session was followed by daily self-help exercises in between the sessions. The self-help exercises were based on what were introduced in the preceding lessons: mindful stretching and muscle relaxation (week 1), deep and mindful breathing±imagery (week 2), Mindful- S.T.O.P. and grateful thinking (week 3), and body scan and kindness (week 4). The program was delivered using both didactic and experiential approaches (see Table 1 for program outline). Participants were taught various techniques to help focus their attention on present-moment experiences, decrease emotional reactivity, and increase feelings of gratitude. Guided instructions were given in a booklet and compact disc to help participants carry out their self-help practice. A session would typically start off with a review of and sharing of selfhelp exercises from the preceding week. This would then be followed by introductions to a new technique, (e.g., mindful breathing, mindful stretching, body scan, and guided imagery). The instructions and guidance in the program were specially tailored for medical students. For example, the concept of BBeginner s Mind^ (a typical lesson in mindfulness-based interventions) was introduced through the newly coined word, Table 1 Outline of b-gmbct/mindful-gym program Week 1: Medical students and stress ABC of mindfulness (introduction to mindfulness) Story: Genie with unlimited wishes Mindful stretching and muscle relaxation BMindful-scope^ and beginner s mind Home-Gym (homework assignment) Week 2: Review of week 1 lessons, exercises and discussion of homework Song: Happiness is here-and-now (Malaysian version) Deep and mindful breathing Mindful imagery 4 pleasant states Home-Gym (homework assignment) Week 3: Review of week 2 lessons, exercises and discussion of homework BMindful-S.T.O.P.^a log in to mindfulness, made easy Mind-Scan mindfulness of thinking errors Gratitude workout (grateful thinking) Home-gym (homework assignment) Week 4: Review of week 3 lessons, exercises and discussion of homework Body scan and kindness Mindfulness personal practice package (MP3) customizing mindfulness practice Home-gym (homework assignment) a Mindful-S.T.O.P. is an acronym for brief informal mindfulness practice (S Stop, T Take deep and/or mindful breaths, O Observe surrounding sounds, P Proceed with activities with a smile) BMindful-scope.^ The students were explained, BTo see things which are very small, we ll need a microscope; things which are very far, we ll need a telescope. In order to see things with fresh perspectives (beginner s mind),we ll need a Mindfulscope ^ Class attendance (four sessions) was taken, but they were no measurements on adherence of trainer to program content and compliance of participants to daily self-help exercises. Measures Participants were administered four self-report questionnaires (see below) twice: (a) 1 week prior to the commencement of the program, and (b) at the end of the program (1 week after the last session). English versions of the questionnaire were used. Although English is not the first language of the participants, all are English speaking; proof of English proficiency is a basic requirement for entering the medical program in UPM. Clarifications were given whenever participants expressed difficulty in understanding some of the terminologies used in the questionnaires. The person helping with data collection (class representative) was not blinded to the intervention. A socio-demographic questionnaire was used to obtain data on age, gender, and ethnicity. The Perceived Stress Scale is a self-report instrument used to assess the degree to which an individual appraises life events as stressful during the last month (Cohen et al. 1983). Participants respond to each item using a 5-point scale ranging from 0 (never) to 4 (very often). Higher scores indicate higher levels of perceived stress. The scale has good internal reliability with coefficient alpha ranging from 0.84 to A shorter 10-item version (PSS-10) of the original scale was developed, and allows assessment of perceived stress without any loss of psychometric quality (Cohen and Williamson 1988). The Cronbach s alpha in this study was The General Health Questionnaire (GHQ-12) is a wellvalidated instrument commonly used for screening psychiatric symptoms (Golberg 1978). It is also widely used by researchers for measuring mental health status especially in detection of Bcaseness^ of significant Bemotional disturbance^ or Bpsychological distress.^ The questionnaires consist of 12 items and participants respond to the items by choosing from four responses (from least symptoms to most symptoms), i.e., Bnot at all,^ Bno more than usual,^ Brather more than usual,^ and Bmuch more than usual.^ GHQ-12 has been found to have adequate internal reliability with Cronbach s alpha ranging from 0.82 to As for Malaysian medical students, the sensitivity and specificity of the GHQ-12 score at cut-off point of four (testing against Beck Depression Inventory II for depression) were 81.3 and 75.3 %, respectively, with positive predictive value of 62.9 % (Yusoff et al. 2010b). Participants who scored GHQ-12 equal to four and above were considered

4 as having significant general psychological distress. The Cronbach s alpha in this study was 0.9. The Mindful Attention Awareness Scale (MAAS) was designed to measure the level of awareness and attention to the present-moment experience (Brown and Ryan 2003). It consists of 15 items with each item scored on a 6-point scale ranging from 1 (almost always) to 6 (almost never). Higher total scores indicate higher levels of mindfulness. The MAAS focuses on two aspects of mindfulness awareness and attention, which are considered to be foundational to mindfulness. Reliability and validity of the scale were established using samples of university students and non-college adults. Good internal reliability was found for both samples with Cronbach s alpha at 0.82 and 0.87, respectively. The Cronbach s alpha in this study was A questionnaire was used to obtain feedback on the intervention program with regards to whether the program was easy to understand, practical, beneficial, and applicable to patient care. A single-group, prospective, repeated-measures design was used in the study (See Fig. 1 for summary of study procedure). G*Power III (Faul et al. 2007) showed that the statistical powers for main outcomes (pre-post differences in MAAS, PSS- 10, GHQ) were all >99 %. For predicting post-intervention perceived stress (PSS-10) scores after controlling for preintervention PSS-10 scores, hierarchical multiple regression (HMR) was used. The dependent variable was postintervention PSS-10 scores; independent variables were preintervention PSS-10 scores (step 1), age, gender, class attendance, i.e., full attendance and non-full attendance (step 2), ethnicity, i.e., Malays and non-malays (step 3); and preintervention MAAS and GHQ-12 scores (step 4). Results A total of 135 students completed the study; 104 (77 %) had full attendance (i.e., attended four out of four sessions), 26 (19 %) attended three out of four sessions, and 5 (4 %) Data Analyses Out of 135 students who participated in the program, 130 completed the program (attended at least three out of four sessions 75 % attendance). Missing data was found in seven (5 %) of the participants (including three from those who did not complete the program), and replaced with Bfull information maximum likelihood (FIML)^ method (Schlomer et al. 2010). The full data (non-completers and replaced) was use for intention-to-treat analyses. When per-protocol analyses were conducted (non-completers and missing data were excluded from analyses), all the results were similar with intention-to-treat analyses in terms of statistical significance and effect sizes. The Statistical Package for Social Sciences Version 19 program (SPSS 19) was used to analyze the data. Normality of continuous dependent variables was determined by Kolmogorov-Smirnov test; only MAAS and PSS-10 scores were normally distributed. Homogeneity of variance was determined using Levene s test. Statistical significance was set at p<0.05. Paired sample t test was used to examine changes in MAAS and PSS-10 scores from pre- to post-intervention. Effect sizes were calculated using Cohen s d, where values of 0.2, 0.5, and 0.8 were considered as small, medium, and large, respectively. Wilcoxon signed-rank test was used to examine changes in continuous GHQ-12 scores, as the scores did not meet the assumption of normality. Effect sizes (r) were calculated using the formula (r=z/square root of N), where values of 0.1, 0.3, and 0.5 were considered as small, medium, and large, respectively. As for categorical GHQ-12 scores, a McNemar test was used. Post hoc power analysis with Fig. 1 Summary of study procedure. Asterisk indicates sociodemographic data, Mindful Attention Awareness Scale (MAAS), Perceived Stressed Scale (PSS-10), and General Health Questionnaire (GHQ-12)

5 attended two or less sessions. Ninety six percent of the participants completed the program with at least 75 % attendance. Apaired-samplest test (Table 2) showed that there was a significant reduction (M= 3.85, SD=5.70, CI, 2.88 to 4.82) in the scores of perceived stress (PSS-10) from preintervention (M=23.41, SD=6.86) to post-intervention (M= 19.56, SD=6.72), t(134)=6.67, p< A medium to large effect size (d=0.66) was found for the reduction. This confirmed the first hypothesis, that there would be a decrease in the level of perceived stress from pre- to post-intervention. As for levels of mindfulness (Table 2), there was also a significant increase (M=0.46, SD=0.80, CI, 0.32 to 0.59) in the scores of MAAS from pre-intervention (M=3.89, SD= 0.85) to post-intervention (M=4.35, SD=0.75), t(134)= 7.86, p<0.001 confirming the second hypothesis. A medium effect size (d=0.56) was found for the reduction. A McNemar test showed a significant reduction in the number of participants with categorical score of GHQ (<4 or 4) from 36 % (n=48) at pre-intervention to 10 % (n=14) at postintervention, χ 2 (1)=25.93, p< A Wilcoxon signed-rank test also showed a significant reduction in the score of GHQ from pre-intervention (median=2.00) to post-intervention (median=0), z= 6.88, p<0.001) with medium to large effect size (r) of This confirmed the first part of the first hypothesis participation in the program would be associated with significant reductions in general psychological distress. A Spearman s Rank correlation was computed to assess the relationship between the changes in the scores of PSS-10, GHQ-12, and MAAS after the program. There were significant (p=0.001) positive correlations between improvements in the scores of PSS-10 (r=0.26), GHQ-12 (r=0.29), and MAAS, with medium effect sizes. These findings supported the third hypothesis that improvements in mindfulness correlate with improvements in perceived stress and general psychological distress. The results of the HMR for predicting post-intervention PSS-10 scores are presented in Table 3. It was found that only ethnicity significantly predicted the post-intervention perceived stress scores (p=0.03). Malays compared to non- Malays, had lower post-intervention perceived stress scores, although paired t tests showed significant reductions in perceived stress in both groups (p<0.001). All independent variables together explained 47 % of the total variance in post-intervention perceived stress scores. Feedback on the intervention program is presented in Table 4. At least 90 % of the participants either strongly agree or agree that the program was easy to understand (98 %), practical (93 %), beneficial (92 %), and applicable to patient care (90 %). Discussion This study evaluated the effectiveness of a 4-week b-gmbct program in reducing stress of medical students. A total of 135 students participated in the program, with about a third of them (36 %) having significant general psychological distress (GHQ-12 scores 4), and 96 % of them completed the program with at least 75 % attendance. Participants reported significant reductions in perceived stress, general psychological distress, as well as increase in mindfulness with medium effect sizes after attending the program. At least 90 % of the participants either strongly agree or agree that the program was easy to understand (98 %), practical (93 %), beneficial (92 %), and applicable to patient care (90 %). Overall, the study suggests that the program is feasible, acceptable, and had significant effects on stress reduction among the medical students. The positive results of the present study are in line with the single-group, pre-post study on 148 first year medical students by Hassed et al. (2009), which showed significant reduction (medium effect size) in overall psychological distress (anxiety, depression, and hostility symptoms). Similar to their study whereby the mindfulness intervention (6 weeks) was embedded in a core-curriculum wellness program, the intervention in the current study (4 weeks) was embedded in a psychiatric posting curriculum. The medium effect sizes of improvements in this study are similar to the findings in two meta-analyses on effectiveness of mindfulness-based interventions (6 12 weeks program, mostly MBSR or MBCT) in uncontrolled pre-post studies for reducing anxiety and depressive symptoms (Hofmann et al. 2010), and reducing stress, anxiety, and depressive symptoms (Khoury et al. 2013). The fact that the intervention in this study could produce similar effect size (i.e., medium) of reductions in psychological distress in 4 weeks (instead of 6 12 weeks) is encouraging. Table 2 PSS-10 and MAAS scores before and after b-gmbct program Variable Pre-intervention Post-intervention Pre-post difference* Mean SD Mean SD Mean 95 % Confidence interval SD Effect size (d) PSS to MAAS to PSS-10 Perceived Stress Scale, MAAS Mindful Attention Awareness Scale, SD standard deviation *p<0.001 (one-tailed)

6 Table 3 Hierarchical multiple regression analyses on predictor variables of post-intervention perceived stress (PSS-10) scores B SE(B) β t R2 ΔR2 ΔF p Step 1 Baseline PSS <0.001 Step Baseline PSS-10 Age Gender Attendance Step Baseline PSS-10 Age Gender Attendance Ethnic Step Baseline PSS-10 Age Gender Attendance Ethnic Baseline MAAS scores Baseline GHQ scores PSS-10 Perceived Stress Scale, MAAS Mindful Attention Awareness Scale, GHQ General Health Questionnaire Bold means the p value is statistically significant The finding that participation in the program was associated with significant reductions in perceived stress is consistent with the findings by Oman et al. (2008) (using a sample of college students) and Warnecke et al. (2011) (using a sample of medical students); both are controlled studies. It is worth noting that the mindfulness interventions delivered in these studies were of a longer duration (8 weeks) compared to the intervention delivered in 4 weeks in this study. This suggests that intervention of shorter duration may be sufficient to produce a significant reduction in perceived stress. However, more definite conclusion could only be made with controlled study of the current intervention. Table 4 Feedback by participants on the b-gmbct program Number of participants (%) Statements Strongly agree Agree Not sure Overall, the program is easy to understand 59 (44 %) Overall, the exercises are practical 45 (33 %) Overall, I have benefited from the program Overall, I think I can apply what I have learned to help patients 40 (30 %) 35 (26 %) 73 (54 %) 81 (60 %) 84 (62 %) 86 (64 %) 3 (2 %) 9 (7 %) 11 (8 %) 14 (10 %) No participants chose the option of BDisagree^ or BStrongly Disagree^ in the feedback The study also showed that participation in b-gmbct was associated with significant reductions in general psychological distress. The proportion of participants with significant psychological distress (GHQ 4) decreased from 36 to 10 % from pre- to post-intervention (about 25 % reductions). Taking into consideration that between 30 and 46 % of medical students in Malaysia experience significant psychological distress, this result is encouraging. It indicates that b-gmbct has potential in meeting the urgent need of providing an effective stress management program for medical students in Malaysia. The finding that participation in b-gmbct was associated with significant increases in mindfulness suggests that b- GMBCT is effective in fostering the participants attention to and awareness of experiences in the present moment. This finding is important as all the earlier studies on mindfulness-based interventions among medical students (except the one by De Vibe et al. 2013) didnot include any measurement of mindfulness. Studies examining the effects of the 8-week MBSR/MBCT programs have, in general, found significant improvement in mindfulness and psychological well-being among participants after completion of the programs. However, other studies providing briefer forms of mindfulness-based interventions produced inconsistent findings. For instance, Agee et al. (2009) did not find a significant change in levels of mindfulness and relaxation (improvement was only in general psychological distress) among participants after a 5-week MBSR program

7 (1 h per week of group session, and 15 min of daily home practice, twice a day). The authors stated that the lack of significant change in mindfulness might have been due to insufficient duration of mindfulness training in their program. Another study involving clinical psychology trainees (Moore 2008) found that 14 weeks of brief mindfulness training (10 min weekly, during lunch time) were associated with improvements in only the observing facet of mindfulness, as measured by the Kentucky Inventory of Mindfulness Scale (KIMS). The discrepancy in the findings between these studies and the present study may have been due to various factors such as varying content of the intervention programs (e.g., BMindful-S.T.O.P.^ was taught in the program in this study, but not in studies by Agree et al. or Moore et al.), levels of proficiency in teaching mindfulness among instructors of different programs, different measurements of mindfulness (this study used MAAS), and amount of home practice that participants engaged in across the studies. Anyway, this study did not objectively measure the compliance of participants in home practice, and of trainer in delivering the lessons. Hence, definite conclusion regarding comparative effectiveness of this and other mindfulness-based interventions cannot be made. The finding that improvements in mindfulness scores correlated with improvements in perceived stress and general psychological distress scores suggests that the intervention delivered in this study works in a manner that is consistent with proposed mechanisms of mindfulness-based interventions; these interventions help by increasing participants ability to be mindful of present-moment experiences (Bränström et al. 2010; Keng et al. 2012; Nyklícek and Kuijpers 2008). The paper by Weinstein et al. (2009) discusses ways in which mindfulness may lower perceived stress. First, mindfulness may promote a less defensive, more willing exposure to challenging and threatening events and experiences which may reduce negative cognitive appraisals of those situations, thus rendering lower levels of perceived stress. Second, mindfulness may foster an enhanced capacity to adaptively cope with situations perceived as challenging. The results of Weinstein s studies showed that mindfulness predicted lower stress perception. This relationship can probably be further explained by the concept of Bstress response^ proposed by (Kabat-Zinn 2005). Mindfulness allows a person to be consciously aware of the unfolding of stressful events. Such awareness allows the person to see a range of options available in responding to the situations, instead of plunging into the automatic fight or flight reaction. This manner of response gives control to the person and helps him/her to perceive the situations as less threatening, thus lowering the perceived stress. To the authors knowledge, the present study is the first to examine the efficacy of a mindfulness-based intervention in Malaysia. One important implication of this study relates to the suitability of mindfulness-based intervention programs in the Malaysian context, which consists of diverse cultures and ethnic backgrounds. Given Malaysia s multi-cultural and multi-religious context, and the fact that mindfulness is rooted in Buddhist traditions (even though mindfulness-based programs have been implemented secularly in general), the authors initially had concerns regarding whether b-gmbct would be acceptable among Malaysian participants. In recent years, certain Malaysian religious authorities have imposed restrictions on practices that can be carried out by Muslim citizens (who constitute the majority, i.e., about 50 % of citizens in this country). For example, according to the National Islamic Fatwa Council, yoga practice (which is part of the original MBSR program) is prohibited among the Muslims (Mazwin 2008) for concerns that yoga practice and its Hindu roots might negatively impact Muslims faith and spiritual practice. Given such political and social context, the program delivered in this study has been adapted specifically for implementation in a multi-religious community in Malaysia (e.g., by removing yoga from the MBSR protocol). In the present study, participants from all three major ethnic groups in Malaysia namely, Malays (52 %), Chinese (42 %), and Indians (6 %) volunteered to participate in the program. Overall, only five (4 %) participants did not complete the program (two Malays, two Chinese, and one Indian). Although Malays had significantly lower post-intervention scores of perceived stress compared to non-malays, both groups had significant reductions in perceived stress after completing the program. The overall positive results of the study suggest that the locally adapted and culturally sensitive b-gmbct program benefitted Malaysian medical students with different socio-cultural backgrounds. In the current study, reductions in perceived stress scores were neither predicted by better class attendance nor age, gender, baseline scores of mindfulness, and general psychological distress. This concurs with the findings of a review by Carmody and Baer (2009), whereby it was found that there was no significant correlation between in-class hours of MBSR program and mean effects sizes for both clinical and non-clinical samples. More studies are needed to fine-tune the optimal duration of mindfulness-based intervention for medical students. The present study adopted a brief mindfulness training format; 4-week instead of the typical 8-week duration of MBSR/MBCT programs. The results support the findings by Jain et al. (2007)(4-week program among medical, nursing, and pre-medical students), and Agee et al. (2009)(5-week program among community adults), suggesting that a shorter program may be effective in stress reduction. This is an encouraging finding because a briefer intervention format would be less demanding on the medical students who are already facing high amounts of academic workload and a tight schedule in their daily life. As highlighted by Rosenzweig et al. (2003), the students may not be willing to devote their study time to attend a longer stress management program.

8 Compared to the traditional MBSR programs, b-gmbct adopted a more frequent but shorter duration of meditation practice, called Mindful-S.T.O.P, which is adapted from the 3-min breathing space of MBCT. Mindful-S.T.O.P can be easily practiced anytime and anywhere in their daily life, such as when stopping at the traffic light, taking a break between lectures, or waiting at the bus stop. b-gmbct also incorporates mindful stretching and muscle relaxation (similar to the progressive muscle relaxation, but with an emphasis on body awareness), and diaphragmatic breathing as components of the program to foster relaxation and awareness of body sensation. Progressive muscle relaxation and diaphragmatic breathing are exercises taught as behavioral therapy in psychiatric posting. Hence, they might be easier to teach as compared to the more formal mindfulness meditation practice such as sitting meditation and walking meditation. Another factor contributing to the effectiveness of the b- GMBCT program may be the proficiency of the instructor who has had extensive personal meditation practice (15 years). The instructors in the study by Agee et al. (2009) had approximately 6 years of personal meditation practice, and those in Jain et al. (2007) were trained in Kabat-Zinn s MBSR program which requires personal meditation practice. Segal et al. (2002), in their account of the development of MBCT, highlighted the importance of personal meditation practice in order to be an effective instructor. Mindfulness-based programs teach participants to gently embrace the difficult thoughts and feelings, instead of Bsolving^ them, and the instructors need to embody this gentle approach in guiding the participants. Such a skill can only be acquired through personal mindfulness meditation practice in addition to the systematic training on MBSR or MBCT. Even though the findings of this study seem promising, the results need to be interpreted with caution in light of several limitations of the study. First, the study did not have a control group. So, the noted improvements in outcome measures could be due to others factors other than the intervention, e.g., spontaneous improvement due to better adjustment to clinical posting, non-specific effects of intervention (e.g., attention from trainer and lecturers/supervisors), expectation bias of participants, and regression to mean of outcome scores due to repeated assessments and high baseline levels of stress (31 % had extremely severe depressive and/or anxiety symptoms). Second, there were no follow-up measurements on the effects of program, and thus the long-term effect of the program could not be assessed. Third, the instructor of the program was one of the investigators of the study, which was also a lecturer in psychiatry to the participants. This could have resulted in expectation bias from all parties instructor, investigator, and participants. Last, the present study did not collect data on the amount of home practice carried by participants. Amount of home practice may be a crucial factor that moderates the efficacy of this program. Despite the limitations, the study suggests that the b- GMBCT is potentially an effective stress reduction program for medical students in Malaysia. Randomized controlled study with long-term follow-up is suggested to further substantiate the effectiveness of the intervention. Acknowledgments This study was approved by the University Kebangsaan Malaysia s Research Ethics Committee (approval code number is NN ), and supported by the Department of Psychiatry, Faculty of Medicine & Health Sciences, Univerti Putra Malaysia. The authors would like to thank the medical students who participated in, and provided feedback for enhancement of the program. References Agee, J. 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