Mindfulness (2023) 14:1918–1929

https://doi.org/10.1007/s12671-023-02159-8

ORIGINAL PAPER

Brief Online Mindfulness‑ and Compassion‑Based Inter‑Care Program

for Students During COVID‑19 Pandemic: A Randomized Controlled
Trial
Francisco J. Villalón1,2 · Maria Ivonne Moreno1 · Rita Rivera3 · Williams Venegas1 · Javiera V. Arancibia C.1 ·
Adrian Soto1 · Alfredo Pemjean1

Accepted: 26 May 2023 / Published online: 27 June 2023

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Objectives The effects of the COVID-19 pandemic on health, economy, and social networks had an impact on the whole
population’s mental health, including students. The study aimed to evaluate the effectiveness of a brief online mindfulness- and
compassion-based inter-care intervention for medical students.
Methods A randomized controlled trial was conducted with medical students (n=360) from a Chilean university with no
prior meditation experience. An online assessment of well-being, anxiety, and depression symptoms was completed at the
beginning, 1 month, and 3 months later. A general intervention (GI) was offered to the whole group including academic
flexibility, breaks, and individual psychological help. For specific intervention, enrolled participants (n=120) were randomly
assigned to (1) mindfulness-based inter-care intervention (IBAP, n=60) or (2) psychoeducational intervention (PSE, n=60) as
an active control. Both interventions lasted 1 hr per week along 4 weeks, with homework assignments. The non-randomized
third group (n=240) received only the GI, as a treatment-as-usual control group (TAU-GI).
Results At baseline, IBAP and PSE groups had higher scores in depression symptoms than TAU-GI. IBAP and TAU-GI
showed a significant reduction in depression (F(2)=17.44, p<0.001) and anxiety symptoms (F(2)=18.06, p<0.001), but not
for the PSE group at first and 3 months. Compared to TAU-GI, IBAP showed a substantial reduction in depression symptoms
at first month (U=24.89, p<0.05). An analysis of secondary variables showed improvements in the factors of mental health
continuum and common humanity on the Self-Compassion Scale.
Conclusions Our findings suggest that brief online mindfulness- and compassion-based inter-care intervention, with academic
flexibility and break, effectively promoted mental health among medical students during the COVID-19 pandemic.
Preregistration The protocol was enrolled in Clini​caltr​ial.​gov with protocol ID NCT05011955.

Keywords Mindfulness · Self-compassion · Intervention · Medicine student · Inter-care

The outbreak of the COVID-19 pandemic in 2019, along globe. Moreover, mental health has also been adversely
with the different measures adopted by governments such compromised. For instance, a systematic review of
as lockdowns, social distancing, and restricted mobility, depression symptoms across different countries shows a
has led to financial and social consequences around the higher prevalence than anticipated from previous years before
the pandemic (14.6 to 48.3%). Additionally, the pandemic
has been associated with acute stress syndrome, insomnia,
* Francisco J. Villalón and emotional exhaustion (Brooks et al., 2020). Risk factors
francisco.villalon@mail.udp.cl
included younger age, unemployment, retirement, low
1
Centro de Educación Médica y Simulación Clínica Facultad educational level, and student status (Fernández et al., 2020;
de Medicina - Universidad Diego Portales, Santiago, Chile Wang et al., 2020; Xiong et al., 2020).
2
Programa de Postgrado en Psiquiatría y Salud Mental, Even before the pandemic, medical students reported higher
Complejo Asistencial Sótero del Río, Facultad de Medicina levels of anxiety symptoms (33.8%) (Tian-Ci Quek et al.,
- Universidad Diego Portales, Santiago, Chile 2019), depressive symptomatology (27.2%), suicidal thoughts
3
Albizu University-Miami, Doral, USA (11.1%) (Rotenstein et al., 2016), stress level, burnout,

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Mindfulness (2023) 14:1918–1929 1919

and substance abuse compared to the general population asynchronous online mindfulness and compassion pro-
(Molodynski et al., 2021). However, due to the pandemic, gram in first-year psychology students during COVID-19
students may experience higher levels of stress, loneliness, lockdown with promising results (González-García et al.,
anxiety, and depression symptoms because of the isolation, 2021). Additionally, in scenarios where there is a lack of
limited social interaction, lack of emotional support, and time for participants or providers, or limited resources,
physical contact. Additionally, uncertainty and concerns about traditional MBSR implementation may be challenging;
family health may also contribute to these symptoms (Elmer however, brief interventions could be feasible options.
et al., 2020). Specifically, in a study of 40 medicine faculties For instance, a four-session MBSR has similar effect sizes
in the USA, 30.6% and 24.3% of medicine students reported to longer versions (Demarzo et al., 2017), as have online
positive anxiety and depression symptoms, respectively adaptations (González-García et al., 2021; Kemper & Rao,
(Halperin et al., 2021). In Chile, the high presence of both 2017). However, there is no clear evidence about the effec-
symptoms in a local faculty of medicine was also reported tiveness of brief MBIs lasting fewer than 4 h in reducing
(Villalón et al., 2022). Due to this reason, there has been a anxiety and stress in health professionals (Gilmartin et al.,
growing interest in the mental health and well-being of college 2017; Howarth et al., 2019; McClintock et al., 2019).
students. This situation has promoted preventive measures Finally, criticisms have been proposed regarding
in universities to minimize the impact of psychological the representation of mindfulness practices in various
stress, especially during the COVID-19 pandemic. One contexts. For example, there is an overrepresentation of
such intervention, for instance, involves mindfulness and the developed world and an underrepresentation of Latin
compassion techniques (González-García et al., 2021). America. Additionally, concerns have been raised about
In recent years, there has been an increase in interest in the representation of ethics and/or spirituality, considering
mindfulness-based interventions (MBI), which have been the current diversity, potential barriers, and the need for
studied in different populations, conditions, and programs the integration of intercultural and spiritual competencies
(Goldberg et al., 2017; Lomas et al., 2018). Mindfulness has (Hernández-Torrano et al., 2020; Villalón, 2023).
been defined as a process of attention regulation to bring a Furthermore, a secular approach to MBI recognizes the
quality of non-elaborative awareness to current experience, importance of ethics despite the absence of explicit content
within a curiosity, experiential openness, and acceptance and that participants/instructor bring their own ethical
orientation (Bishop, 2004), and as a method to foster alter- rules. In any case, the individualized process can generate
native responses to stress and emotional distress. Potential variability in the effectiveness of mindfulness practice, so
mechanisms of change through meditation practice, involv- the possibility of guiding the process has been recommended
ing attention regulation, body awareness, and emotional and (Krägeloh, 2016). Based on this and considering the ethical
self-regulation, have also been discussed (Tang et al., 2015). aspects of medical care, an approach is proposed both of
The first-generation programs of MBI consist of eight self-care and others-care, that is, an inter-care.
weekly face-to-face group sessions lasting 2 hr each, along Care is a main part of medical practice and can be defined
with a full day of practice, meditation logs, and journal- as “commitment with heart, concern, paying attention,
ing exercises as homework. The most common standard- dedicate to something,” and can distinguish the care as (1)
ized MBIs are mindfulness-based stress reduction (MBSR) for life, (2) for human flourishing, and (3) therapeutic. It
(Kabat-Zinn, 2012) and mindfulness-based cognitive ther- can be represented by indicators of care behavior such as
apy (MBCT) (Segal et al., 2012). Before the pandemic, a attending, listening, being there with the word, the intention
study examined the use of 8 weeks of MBSR with medical of comprehension, empathy, and compassion (Mortari,
students and reported acceptable results up to 20 weeks post- 2019). This proposal defines the recognition of needs for care
intervention (van Dijk et al., 2017). Morr et al. (2020) also and communication as relevant aspects of a care theoretical
reported moderate results in their randomized controlled approach. Based on this approach and inspired by first- and
trial for an 8-week mindfulness-based virtual community second-generation mindfulness-based interventions, the
program. Furthermore, a study that used a 6-week MBSR mindfulness- and compassion-based inter-care program
adaptation reported no differences between the treatment and (IBAP) was developed. Some specific exercises of the
control group (Damião Neto et al., 2020). program include compassionate communication, reflection
In response to criticisms regarding instrumentalization, on one’s own values and purpose, gratitude practices, and
second-generation programs such as Cognitively-based active cultivation of shared resources such as social bonds
Compassion Training and Compassion Cultivation Train- (Villalón, In Press)
ing have been proposed (Gonzalez-Hernandez et al., 2019; This research aims to evaluate the effectiveness of a brief
Van Gordon et al., 2015). This program may also enhance 4-week online mindfulness- and compassion-based inter-care
well-being, mental health, and pro-social behavior. intervention in medical students to reduce anxiety and depression
Recently, a study examined the feasibility of a brief 7-hr symptoms during the COVID-19 pandemic.

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1920 Mindfulness (2023) 14:1918–1929

Method group received the general intervention only as part of the

treatment-as-usual control group (TAU-GI). Demographic
Participants and year characteristics can be found in Table 1 and a
CONSORT flow diagram in Fig. 1.
A population of 498 medical students from first to seventh
year of the Medicine Faculty of the Diego Portales Procedure
University in Santiago, Chile, were invited to voluntarily
participate through institutional email to respond to an In response to the crisis during the pandemic and periods of
online survey from April to August 2020. All students lockdown, the Faculty of Medicine established a mental health
received the general intervention (GI) during the study committee composed of faculty, administrators, and students to
period. evaluate and implement mental health support measures. The
Three hundred and sixty responses (n=360) were main goals were to assess the impact of the pandemic on mental
received (response rate 72%). All respondents with interest health of medicine students, implement general organizational
in the specific intervention trial (n=120) were randomly and educational interventions for whole student body, and
included in a mindfulness- and compassion-based inter-care provide specific interventions for student in need. The study
intervention (IBAP, n=60) as an intervention group or in was planned and conducted within this context.
a psychoeducation-based intervention (PSE, n=60) as an A non-blinded randomized controlled trial was conducted
active control group. Randomization was conducted using between April and November 2020, with assessments at the
a random-number table. Students were not aware of their beginning of the study, post-intervention 1 month later, and
group allocation until all participants had completed the a follow-up 3 months later.
online baseline assessment. The remaining 240 participants All assessments were done through an electronic survey
who were not interested in the specific intervention trial platform, guaranteeing confidentiality. The survey included
but were interested in participating in the follow-up cohort questions on demographic characteristic, as well as validated

Table 1  The sample Variable Indicator TAU-GI IBAP PSE

characteristics of the TAU-GI,
IBAP, and PSE arms, broken Gender Female 129 (50.4%/−0.8) 37 (62.7%/0.9) 28 (62.2%/0.8)
down by gender and year.
Year 1 39 (15.2%/0.7) 2 (03.4%/−2.1) 8 (17.8%/0.8)
Chi-squared analysis reveals
no significant difference in 2 28 (10.9%/−2.1) 29 (49.2%/6.3) 1 (02.2%/−2.3)
gender at baseline, but there is 3 32 (12.5%/−2.0) 25 (42.4%/4.5) 7 (15.6%/−0.4)
a significant difference in the 4 50 (19.5%/0.7) 3 (05.1%/−2.3) 11 (24.4%/1.1)
year distribution across arms.
5 31 (12.1%/0.8) 0 (00.0%/−2.5) 7 (15.6%/1.0)
N represents the number of
participants, and percentages 6 42 (16.4%/1.1) 0 (00.0%/−2.9) 8 (17.8%/0.7)
and standardized residuals (%/ 7 34 (13.3%/1.5) 0 (00.0%/−2.5) 3 (06.7%/−0.8)
SR) are reported. Mean and Total 256 59 45
standard deviation (SD) were
Depression (PHQ-9) 10.77 (6.28) 13.46 (5.18) 12.73 (5.52)
also reported. The treatment
arms are labeled as follows: Anxiety (GAD-7) 8.29 (5.15) 10.69 (4.78) 9.87 (4.66)
TAU-GI, treatment-as-usual Emotional well-being (MHC) 3.99 (0.97) 3.74 (1.03) 3.82 (0.82)
with general intervention Social well-being (MHC) 3.06 (1.24) 2.82 (1.00) 2.90 (1.02)
only; IBAP, mindfulness- and
Psychological well-being (MHC) 3.79 (1.15) 3.56 (1.07) 3.43 (1.15)
compassion-based inter-
care intervention; PSE, Observation (FFMQ) 3.42 (0.93) 3.31 (1.10) 3.02 (0.79)
psychoeducational intervention Description (FFMQ) 3.38 (0.68) 3.10 (0.67) 3.01 (0.75)
Awareness (FFMQ) 3.20 (0.96) 3.11 (0.91) 2.80 (0.85)
Non-judgment (FFMQ) 2.71 (0.89) 2.60 (0.85) 2.52 (0.72)
No-reactivity (FFMQ) 2.95 (0.90) 2.78 (0.82) 2.68 (0.85)
Overidentification (SCS) 2.50 (1.07) 2.38 (0.84) 2.14 (0.94)
Self-kindness (SCS) 2.99 (0.85) 2.88 (0.65) 2.76 (0.70)
Mindfulness (SCS) 3.42 (0.90) 3.45 (0.78) 3.18 (0.90)
Isolation (SCS) 2.66 (1.14) 2.44 (0.90) 2.38 (1.01)
Common humanity (SCS) 2.89 (0.91) 2.62 (0.83) 2.56 (0.91)
Self-judgment (SCS) 3.04 (1.10) 2.86 (0.84) 2.50 (1.06)

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Mindfulness (2023) 14:1918–1929 1921

Assessed for eligibility (N= 360)

Enrollment

Non Randomized but included as GI

(n=240)
Excluded (n=0)
Not meeting inclusion criteria (n= 0)
Declined to participate (n=0)
Other reasons (n=0)

Randomized (n=120)

Allocation
Allocated to intervention (n= 60) Allocated to intervention (n= 60)
Received allocated intervention (n=59) Received allocated intervention (n= 45)
Did not receive allocated intervention – Time Did not receive allocated – Time
incompatibility (n=1) incompatibility (n=15)

Follow-Up
Lost to follow-up (Non responders) (n= 17-27) Lost to follow-up (Non responders) (n= 9-29)

Discontinued intervention (n= 0) Discontinued intervention (n=0)

Analysis
Analysed (n=42-32) Analysed (n= 32-16)
Excluded from analysis (Non responders) Excluded from analysis (Non responders)
(n=17-27) (n= 9-29)

Fig. 1  CONSORT flow diagram

questionnaires about depressive and anxiety symptoms, mental treatment-as-usual group and received only the general
health, mindfulness, and self-compassion variables (details in intervention (TAU-GI).
the “Measures” section), and were completed by participants Mindfulness- and compassion-based inter-care
at the beginning, post-intervention, and 3-months follow-up. intervention, the intervention was a brief version of the
General intervention (GI), academic breaks of 2 weeks mindfulness- and compassion-based inter-care program
per semester (apart from holidays), and academic flexibility or intercuidado basado en atención plena y compasión
in submitting work, attending practical activities, and in Spanish (IBAP) (Villalón, In Press). It consists of four
examination dated were offered to the student body. weekly synchronic group sessions via Zoom of 1 hr each
Four to eight individual counseling sessions were offered and home practice. A total of four groups, 15 students each,
if they reported a high score on depression or anxiety were conducted by one certified mindfulness teacher. The
symptoms, and, if necessary, were then referred to continue IBAP program is based on the care theoretical approach
mental health services in the university student’s welfare (Mortari, 2019) and was inspired by first- and second-
system and/or in the respective personal insurance health generation mindfulness-based interventions, such as
system. Participants who were not willing to participate in mindfulness-based cognitive therapy, and Cognitively-based
the specific intervention trial were considered part of the Compassion Training. The program focuses on actively

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cultivating inter-care resource, including recognizing care Anxiety symptoms were evaluated using the General
needs for oneself, others, and the community; training in Anxiety Disorder 7 (GAD-7) validated in Spain (García-
compassionate communication skills; reflection on one’s Campayo et al., 2010) for anxiety disorder screening
own values; and purpose and planning mutual care resource. with a sensitivity and specificity of 86.8% and 93.4%. It
Each module consists of meditation practices, inquiry, contains 7 items on a 5-point Likert scale (0–3) to evaluate
and self- or group-reflections on topics such as mindfulness, frequency of symptoms from Never to Almost every day.
automatic pilot, mind wandering, acceptance, gratitude and The cut-off points are 5, 10, and 15 for mild, moderate,
compassion, care resources, and inter-care. The summary of and severe anxiety symptoms. A high level of reliability
modules and components is available in Table 2. is indicated by McDonald’s omega reliability estimate of
Psychoeducational intervention (PSE), the PSE 0.94 for the GAD-7.
intervention was designed for this study. It consists of Mental health can be defined as a state in which an
four synchronic group sessions via Zoom of 1 hr each, individual realizes their own abilities, can cope with
one per week, and home practice. A total of four groups the stresses of life, can work productively, and can
were conducted with 15 students each. Two psychologists make a positive contribution to society. Keyes (2002)
facilitated these interventions. describes mental health in 3 main dimensions: emotional,
The objective of the intervention was to develop the psychological well-being, and social well-being. Keyes
following self-care habits and skills: (1) time management, developed the Mental Health Continuum Scale-Long Form
(2) stress management, (3) effective communication, and (4) (MHC-LF) composed of 40 items. In 2009, Keyes developed
health habits such as exercise, sleep hygiene, and diet. a shorter 14-item version which was translated and validated
in Chilean adults in 2017 by Guadalupe Echeverría et al.
Measures (2017). The MHC-14 dimensions showed high reliability
with McDonald’s omega estimates of ω=0.87 for emotional
The primary outcomes were depression and anxiety symptoms well-being, ω=0.85 for social well-being, and ω=0.91 for
scales. Secondary variables were gender, university level, mental psychological well-being.
health, mindfulness, and self-compassion traits. Mindfulness is defined as the ability to pay attention to
Depression symptoms were evaluated using the our own experiences without judging them, and recently, it
Patient Health Questionnaire–9 (PHQ9), which is used has been incorporated into many programs for the treatment
for depression screening with a sensibility and specificity of recurrent depressive and anxiety disorders. Baer et al.
of 88% and 92%. It contains 9 items on a 5-point Likert (2006) developed the Five Facet Mindfulness Questionnaire
scale (0–4) to evaluate frequency of symptoms from Never (FFMQ), which consists of 39 questions that examine 5
to Almost every day. It has been translated and validated facets of mindfulness: observe, describe, act aware, non-
in Spanish and Chilean populations (Baader et al., 2012; judge, and non-react. A 15-item version was validated in
Saldivia et al., 2019). The cut-off points are 5, 10, 15, and 20 Chile in 2021 by Villalón et al. (In Press). The FFMQ-15
for mild, moderate, moderate-severe, and severe depression has acceptable reliability with Cronbach’s alpha estimates
symptoms. McDonald’s omega reliability estimate for the of 0.86 for non-react, 0.79 for act aware, 0.68 for describe,
PHQ9 is 0.9, indicating high reliability. 0.76 for non-judge, and 0.73 for observe.

Table 2  The name and main topic of each module, as well as the corresponding meditation practices, habits formation exercises, and homework
assignments
Module Main topic Meditation practices Habits exercises Homework

Mindfulness Introduction to the program, Raisin meditation, body Habit exercise: Body scan, informal practice,
orientation, and presenta- scan meditation What’s my purpose and pleasant diary.
tion for this program?
The experience Pleasant diary, across the Body scan meditation, Habit exercise: Goal Breath meditation, informal
street exercise breath meditation of the week, if “x” practice, unpleasant and
then “y” plan for needs diary.
barrier.
Common humanity and Unpleasant diary and needs Yoga, gratitude meditation N/A Breath meditation, informal
gratitude recognition, reflection on based on one fulfilled practice, and communica-
common resources need. tion diary.
Compassion and intercare Compassion communication Reflection on self-care N/A N/A
exercise, acceptance medi- resources and activities
tation, Metta meditation

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Self-compassion is understood as maintaining full Table 3  The number of participants in each study arm (n) at each
attention and opening without disconnecting from self’s time point, as well as the corresponding dropout rates and standard-
ized residuals (%/SR). Chi-squared test results indicate statistical sig-
suffering with the desire to alleviate pain in a non- nificance at Time 1 (p<0.001**) and Time 2 (p<0.05*). The treat-
judgmental way, comprehending the own experience ment arms are labeled as follows: TAU-GI, treatment-as-usual with
as a part of the human experience. Evidence describes general intervention only; IBAP, mindfulness- and compassion-based
that those with higher self-compassion present fewer inter-care intervention; PSE, psychoeducational intervention
points in anxiety and depression symptoms (Germer & Baseline 1 month post intervention 3-month follow-up
Neff, 2019; Neff, 2003; Neff et al., 2007). A scale with
TAU-GI 256 127 (50%/1.7)** 79 (69%/0.9)*
6 subdomains was developed by Neff (2003) and for this
IBAP 59 42 (29%/−1.6)** 32 (46%/−1.9)*
study, a translation of the “Self-Compassion Scale Short
PSE 45 36 (20%/−2.3)** 16 (64%/−0.1)*
Form – 12” was made according to the Ramadilla-Rodilla
Total 360 205 (43%) 127 (65%)
proposed method (Ramada-Rodilla et al., 2013). The
Spanish 12-item version was validated in Chile in 2021
by Villalón et al. (in press). Neither Cronbach’s alpha
nor a reported reliability estimate was provided, as it is rates in IBAP and PSE at first month (χ2(2) = 19.41, p
a 2-item scale. <0.001) and IBAP in third month (χ2(2) = 11.82, p =0.003)
compared to TAU-GI.
There are differences between school year distribution
Data Analyses between three groups (χ2(12) = 112.95, p <0.001, Monte
Carlo p <0.001 CI 0.000–0.000) and no gender differences
Since all variables showed a non-normal distribution, as (χ2(4) = 7.68, p=0.103). Demographics and differences
assessed by the Kolmogorov-Smirnov Test (p<0.001 on all are exposed on Table 1 and medians for primary outcomes
variables), and due to small samples and unequal sample (Mdn) on Table 4 and Fig. 2. A Kruskal-Wallis test
sizes, non-parametric analyses were conducted (Nwobi & showed that at baseline there are significant differences
Akanno, 2021; Skovlund & Fenstad, 2001). between the three groups in depression and anxiety
For continuous variables, medians were compared; the symptoms (H(2)= 13.32, p <0.001). Participants in
Kruskal-Wallis (H) test was used for independent samples IBAP and PSE group show higher depression (Mdn=13.5
and Friedman test (F) for dependent samples. Post hoc and 13) and anxiety symptoms (Mdn=10 and 11) than
analyses were made using the Dunn test with Bonferroni TAU-GI (Mdn=10 and 8). A post hoc Dunn-Bonferroni
correction (Z). To assess baseline differences, we compared test using a Bonferroni-adjusted alpha level was used to
pre-post differences between groups (Campbell & Stanley, compare all pairs of groups. The difference in depression
1963). Size effect was calculated using Kendall’s coefficient symptoms between IBAP/TAU-GI (Z = −47.79, IBAP (n
of concordance (W) (Tomczak & Tomczak, 2014). For = 59), TAU-GI (n = 256), p <0.001) and PSE/TAU-GI
nominal variables, χ2 tests were used. A Monte Carlo (Z= −38.5, PSE (n=45), TAU-GI (n= 256), p=0.022)
simulation was used as an alternative when the conditions was significant. Only IBAP/TAU-GI difference was
for a χ2 test were not met. To manage missing data, a nearest maintained after Bonferroni adjustment (p = 0.004).
neighbor imputation was made, and then a sensitivity analysis There is no difference between IBAP and PSE at baseline.
was conducted (Beretta & Santaniello, 2016). Analyses were
performed on IBM SPSS 25 and RStudio. Intervention Efficacy
The hypotheses in the study were (1) the IBAP, PSE, and
TAU-GI as interventions are effective in reducing symptoms A Friedman test was performed for each group in time.
of depression and anxiety in medical students over time. (2) For IBAP, it showed the time affects depression (F(2)=
The IBAP intervention is more effective in reducing anxiety 17.44, p<0.001) and anxiety symptoms (F(2)= 18.06,
and depression compared to PSE and TAU-GI. p<0.001). Effect size were W=0.26 and W=0.27. At
first month (Mdn=9 and 6) and third month (Mdn=8 and
6), participants showed lower depression and anxiety
Results symptoms than baseline (Mdn= 13.5 and 10). Post hoc
Dunn’s test using a Bonferroni-adjusted alpha level was
Of a total of 498 medical students, 360 completed the first used to compare all pairs of groups. The difference in
assessment (72% response rate), 205 the second assessment depression symptoms between baseline-first month
1 month later (43% dropout), and 127 3 months later (65% (z=0.82, p=0.001) and baseline-third month (z=0.86,
dropout). Response rate and dropout of each group and time p=0.001) was significant and it was maintained after
are reported in Table 3. There were significant lower dropout Bonferroni adjustment (p=0.001 and p=0.003). The

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1924 Mindfulness (2023) 14:1918–1929

Table 4  Depression symptom scores (PHQ-9) and anxiety symp- * for p<0.05 and ** for p<0.001 in the column between time points
tom scores (GAD-7) by study arm at baseline, first month, and third for the same arm group. The treatment arms are labeled as follows:
month, as well as the changes between baseline and first month (Mdn. TAU-GI, treatment-as-usual with general intervention only; IBAP,
Dif 0–1) and third month (Mdn. Dif 0.2). Significant Kruskal-Wallis mindfulness- and compassion-based inter-care intervention; PSE,
tests are marked with * for p<0.05 and ** for p<0.001 in the row psychoeducational intervention
between arm groups, and significant Friedman tests are marked with

Baseline 1st month 3rd month

Depression (PHQ-9) Mdn Mdn. Dif 0–1 Mdn Mdn. Dif 0–2 Sig

TAU-GI 10 8 −1 8 −3 **
IBAP 13.5 9 −4 8 −5.5 **
PSE 13 10 −2.5 9 −4.5 *
Sig ** *
Anxiety (GAD-7)
TAU-GI 8 6 −1 5 −3 **
IBAP 10 6 −3 6 −4 **
PSE 11 8 −1 8 −1
Sig. ** * *

Fig. 2  Depression symptom

scores (PHQ-9)
14

12

10

0
Baseline 1st month 3rd month

TAU-GI IBAP PSE

difference in anxiety symptoms between baseline-first higher symptoms reduction (Mdn=−4.0 and −3.0) than
month (z=0.85, p=0.000) and baseline-third month PSE (Mdn=−2.5 and −1.0) or TAU-GI (Mdn=−1.0
(z=0.92, p=0.001) was significant and it was maintained and −1.0). A post hoc test showed that the difference
after Bonferroni adjustment (p.=0.001 and p.=0.002). in depression symptoms changes between IBAP and
Similar results were found for TAU-GI. There is no TAU-GI was significant (U=24.89, IBAP (n=42), TAU-GI
significant difference in anxiety or depression symptoms (n=127), p=0.016), and it was maintained after Bonferroni
after Bonferroni adjustment at any time for PSE group. adjustment (p=0.049). For anxiety symptoms, the post
Results including size effect (W) can be found in Table 5. hoc test showed a difference between IBAP and TAU-GI
The Kruskal-Wallis test showed that studied arms (U=22.34, IBAP (n=42), TAU-GI (n=127), p=0.031), and
significantly affect at first month changes in depression IBAP and PSE (U= −29.58, IBAP (n=42), PSE (n=36),
(H(2)= 6.26, p=0.044) and anxiety symptoms (H(2)= p=0.025). None of the other comparisons were significant
6.08, p=0.044). Participants in the IBAP group show after Bonferroni adjustment (all p>0.05) (Table 6).

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Mindfulness (2023) 14:1918–1929 1925

Table 5  Presents the results Variables F(df) z

of the Friedman test (F) for
each group between baseline, 1 Depression (PHQ-9) IBAP (n=33 / W=0.26) 17.44 (2)**
month, and 3 months, and the
1st - 3rd 0.05
Wilcoxon test (z) results were
reported only for significant Bl - 3rd 0.86 **/**
tests. Kendall’s effect size Bl - 1st 0.82 **/*
(W) was also calculated. Anxiety (GAD-7) IBAP (n=33 / W=0.27) 18.06 (2)**
Significance (Sig.) and adjusted
1st - 3rd –0.08
significance (adj. Sig.) were
reported separately by a “/” Bl - 3rd 0.94 **/*
representing *p < 0.05 and Bl - 1st 0.85 **/**
**p < 0.001. The treatment Depression (PHQ-9) PSE (n=16 / W=0.19) 6.20 (2)*
arms were labeled as follows:
1st - 3rd –0.28
TAU-GI, treatment-as-usual
with general intervention Bl - 3rd 0.56
only; IBAP, mindfulness Bl - 1st 0.84 */
and compassion-based Anxiety (GAD-7) PSE (n=16 / W=0.05) 1.46 (2)
inter-care intervention; PSE,
Depression (PHQ-9) TAU (n=77 / W=0.10) 14.72 (2)**
psychoeducational intervention.
Time was represented by Bl, 1st - 3rd 0.22
baseline; 1st, 1st month; and Bl - 3rd 0.58 **/**
3rd, 3rd month Bl – 1st 0.36 */*
Anxiety (GAD-7) TAU (n=77 / W=0,15) 23.36 (2)**
1st - 3rd 0.06
Bl - 3rd 0.66 **/**
Bl - 1st 0.60 **/**

Table 6  Results of the Kruskal- Variables h (df) U

Wallis test (H) and post hoc
Mann-Whitney U test (U) for Depression (PHQ-9) Baseline (n=360) 13.33 (2)**
the PHQ-9 and GAD-7 scores
TAU-PSE –38.50 */
and differences between groups
at baseline, 1 month, and 3 TAU-IBAP –47.79 **/*
months. The U Mann-Whitney PSE-IBAP 9.29
test is reported only when Anxiety (GAD-7) Baseline (n=360) 13.68 (2)**
the Kruskal-Wallis test was
TAU-PSE –35.40 */
significant. Significance (Sig.)
and adjusted significance (adj. TAU-IBAP –50.23 **/*
Sig.) are reported separately PSE-IBAP 14.83
by a “/” representing *p < Depression (PHQ-9) 1st month (n=205) 0.87 (2)
0.05 and **p < 0.001. The
Anxiety (GAD-7) 1st month (n=205) 4.71 (2)
treatment arms are labeled as
follows: TAU-GI, treatment-as- Depression (PHQ-9) 3rd month (n=127) 0.90 (2)
usual with general intervention Anxiety (GAD-7) 3rd month (n=127) 6.33 (2)*
only; IBAP, mindfulness TAU-PSE –25.26 */*
and compassion-based
TAU-IBAP –5.28
inter-care intervention; PSE,
psychoeducational intervention. PSE-IBAP –20.00
Time was represented by Bl, Depression (PHQ-9) Difference Baseline – 1st month (n=199) 6.27 (2)*
baseline; 1st, 1st month; and TAU-PSE 13.76
3rd, 3rd month
TAU-IBAP 24.89 */*
PSE-IBAP –11.13
Anxiety (GAD-7) Difference Baseline – 1st month (n=199) 6.09 (2)*
TAU-PSE –7.42
TAU-IBAP 22.34 */
PSE-IBAP –29.58
Depression (PHQ-9) Difference Baseline – 3rd month (n=132) 1.03 (2)
Anxiety (GAD-7) Difference Baseline – 3rd month (n=132) 1.57 (2)

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1926 Mindfulness (2023) 14:1918–1929

Attrition Analysis 3-month follow-up. Compared to both control groups,

there were significant changes in anxiety at 1 month, and
Attrition analysis shows differences between groups at in depression only compared to TAU-GI. Also, there are
first month (χ 2(2) = 19.45, p=0.001) and third month important effects of academic flexibility, breaks, and other
(χ 2(2) = 11.82, p=0.003). Post hoc analysis shows less possible factors as shown in the treatment-as-usual general
dropout rate at first month in PSE (standardized residual intervention group. The intervention also had an impact on
(SR) = −2.3) and IBAP (SR= −1.6), and in third month secondary variables, such as the common humanity factor
in IBAP (SR= −1.9). Dropout rates are in Table 3. There of the Self-Compassion Scale, as well as emotional and
is a difference between participants who dropped out social well-being.
the study year at first month for gender (χ 2(2) = 7.37, Based on this, the results of this study support the
p = 0.025) and school year (χ 2(6) = 33.88, p=0.001), effectiveness of brief 4-hr mindfulness- and compassion-
and third month only for school year (χ 2 (6) = 29.83, based interventions for medical students, along with
p=0.001). At first month, males (SR=1.5), 5th (SR=1.7), the use of organizational interventions. The baseline
6th (SR=1.4), and 7th (SR=2.1) grade had higher dropout differences between the IBAP/PSE groups compared
rates. At third month, 6th (SR=2.0) and 7th (SR=1.6) to TAU-GI may be explained by the selection method.
grade had higher dropout rates. Participants who perceive themselves as having a higher
After conducting a nearest neighbor imputation sensitivity burden, fewer resilience resources, and a greater desire
analysis on the completed data, similar results as before were for support may have enrolled for randomization in the
obtained. The Kruskal-Wallis test showed that the studied specific intervention study to receive additional support
intervention arms significantly affected changes in depression beyond the general intervention. Regarding the groups with
(H(2)= 15.16, p<0.001) and anxiety symptoms (H(2)= 12.70, a higher prevalence of anxiety and depression symptoms,
p=0.002) at the first month. Post hoc tests, with Bonferroni IBAP could accelerate the reduction of symptomatology.
adjustment, revealed significant differences in depression It has previously been reported that organizational
symptom changes between the IBAP and TAU-GI groups interventions associated with groups or individuals have
(p<0.001), as well as in anxiety changes between the IBAP greater effectiveness and the possibility of maintaining the
and TAU-GI groups (p=0.006) and between the IBAP and change over time in health professionals (Wiederhold et al.,
PSE groups (p=0.02). 2018). It may be feasible to offer this kind of intervention
specifically for those with higher burdens, in addition to
Effects on Secondary Variables organizational interventions.
The high dropout rate of this study in the three groups
A Friedman test was conducted to analyze the secondary vari- stands out. Although the mindfulness-based intervention
ables in the IBAP group. Significant changes were observed in had a lower dropout rate, it was close to 50%. At the same
EWB (F(2) = 7.26, p=0.026), SWB (F(2) = 9.07, p=0.011), time, the participation in the workshops was higher than
and the common humanity factor of the SCS (F(2) = 14.3, the survey response rate. There are several possible factors
p=0.001). None of the other secondary variables was found to that explain this, such as the high academic demand, the
be significant. At baseline, there were no differences between stress caused by the pandemic, and laxity in reviewing
the PSE and IBAP groups in these variables (p>0.05). The the institutional mail or survey mail that arrives in a spam
Mann-Whitney U test revealed a significant difference only folder. Also, during the study period, there were two studies
in the common humanity factor of the SCS at the third month taking place at the same time with the same population;
compared to the PSE group (p=0.021). one of them had two main surveys, which may have led
to exhaustion in answering surveys or confusion between
the studies. Unfortunately, the other investigation did not
Discussion individualized responses, making it impossible to cross-
reference the databases. Nevertheless, future studies should
The goal of the current study was to evaluate the evaluate the reasons for dropout and assess maintenance
effectiveness on depression, anxiety symptoms, and well- incentives, considering that participation was voluntary
being of a brief online mindfulness- and compassion- and outside of the academic curriculum. Similar studies
based inter-care intervention for medical students during with lower dropout rates have incorporated the intervention
the COVID-19 pandemic. Overall, the results showed that into the curriculum (Damião Neto et al., 2020; van Dijk
a brief 4-hr IBAP intervention, combined with a general et al., 2017) or have offered financial incentives or academic
intervention consisting of academic breaks and flexibility, benefits (Morr et al., 2020). Although, we must consider
was effective in reducing anxiety and depression that mandatory activities can be less effective for mental
symptoms both at the end of the intervention and at the health (Damião Neto et al., 2020).

13
Mindfulness (2023) 14:1918–1929 1927

Another relevant point is effect on self-compassion. The The implication of this study is that a brief online
results show an increase of common humanity as a factor of self- mindfulness- and compassion-based intervention of 4 hr, in
compassion. Previous studies describe an increase in the Self- addition to organizational interventions, may be effective in
Compassion Scale in 16-hr or short 7-hr programs, but it was not reducing anxiety or depression symptoms during a critical
broken down by factors (González-García et al., 2021; Jazaieri situation. Furthermore, in case of limited resources, this
et al., 2013). Regarding the SCS-12 scale used in the study, it intervention could be targeted towards those with higher
has been described that it presents better psychometric properties levels of symptomatology.
when using the six-factor model (Villalón et al., In press).
In relation to previous studies, there is no clear evidence Limitations and Future Directions
that mindfulness- and compassion-based interventions are
effective for medical students, as there have been contra- The data must be interpreted with caution given the high
dictory findings. For instance, some studies have reported rate of dropout of the sample during follow-up, sample
that the classical MBSR program of 8 weeks was effective size, and the notion that the same team that carried out
for clinical clerkship students, with positive effects lasting the workshops was the one who was asked to answer the
up to 20 months post-intervention (van Dijk et al., 2017). survey. This can influence positive responses, particularly
However, other studies suggest that compulsory, large-group in MBI (Davidson & Kaszniak, 2015). Future research is
6-week modified student programs have no effect, even necessary to replicate this study. We recommend including
though this intervention was mandatory (Damião Neto et al., an extended version of the intervention, such as a standard
2020). Our results suggest that a voluntary intervention, in 8-week mindfulness intervention, a larger sample size, and
addition to organizational support, may be effective for a multicenter evaluation with different instructors, assessing
specific group. It is important to consider that this interven- more participants and incorporating a more comprehensive
tion may not be suitable for everyone, but for those who follow-up to ensure more robust results and generalizability
are in greater need of help. Furthermore, more evidence is of findings. Additionally, surveys to collect and analyze
needed for brief interventions, especially during the COVID- results with blinded assessment should be considered.
19 crisis. However, as reviewed, to date, there is no clear evi-
dence of the effectiveness of brief mindfulness interventions
Author Contribution Francisco J. Villalón L: study conception and design.
over time, nor is there a standardized definition of “brief.” Material preparation, data collection and analysis. Writing — original draft
Nevertheless, interventions lasting more than 4 hr have been preparation. Writing — review and editing. Methodology. Formal analysis
found to be effective at reducing anxiety symptomatology and investigation. Williams Venegas Gonzalez: writing — original draft
(Gilmartin et al., 2017; Howarth et al., 2019; McClintock preparation. Writing — review and editing. Javiera Arancibia: writing —
original draft preparation. Writing — review and editing. Formal analysis
et al., 2019). Brief interventions are important in the context and investigation. Adrian Soto: writing — original draft preparation.
of limited time or resources. During the COVID-19 pan- Writing — review and editing. Formal analysis and investigation. Maria
demic, such interventions can offer a rapid response in addi- Ivonne Moreno: formal analysis and investigation. Supervision. Rita
tion to other organizational interventions. For instance, an Rivera: writing — review and editing. Alfredo Pemjean: writing — review
and editing. Supervision.
8-week mindfulness-based community online intervention
has been reported to be effective in reducing symptoms of Data Availability The data that support the findings of this study are
anxiety and depression (Morr et al., 2020), as well as a brief available from the corresponding author upon reasonable request. The
online intervention through videos totaling 7 hr plus exer- data are not publicly available due to them containing information
that could compromise the privacy of research participants. However,
cises at home (González-García et al., 2021). Nonetheless, the authors are committed to making the data available to interested
randomized controlled trials are still needed. Our results researchers in a responsible and transparent manner, in compliance
support previous evidence that a brief online intervention with all relevant ethical and legal requirements.
may be effective in reducing anxiety and depression.
To our knowledge, this is the first study during the Declarations
COVID-19 pandemic that uses a randomized controlled trial Ethics Statement This study was performed in line with the principles
to evaluate the efficacy on a brief online mindfulness-based of the Declaration of Helsinki. Approval was granted by the Ethics
intervention. Considering access to the entire population of Committee of University Diego Portales University in Santiago, Chile
students at the Diego Portales University and a high initial (N 06-2020) on May 14, 2020. The protocol was enrolled in Clini​caltr​
ial.​gov with protocol ID NCT05011955.
response rate, the participants are a representative sample. At
the same time, having randomization with a control group that Informed Consent Statement Informed consent and consent to publish
also received an intervention of the same duration allowed were obtained from all individual participants included in the study.
us to distinguish common factors that are related to the
intervention, such as the Hawthorne effect and group support. Conflict of Interest The authors declare no competing interests.

13
1928 Mindfulness (2023) 14:1918–1929

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