Can positive emotional writing improve the emotional health level of international medical students? Evidence from a randomized controlled trial

Depression and anxiety are highly prevalent among university students and may be especially pronounced in medical students due to long training, clinical pressures, and concerns about future career demands. International medical students studying in China face additional stressors, including cross-cultural adaptation, separation from family, and language barriers, leading to elevated rates of depression and anxiety and associated adverse academic and behavioral outcomes. Addressing both negative emotions (depression, anxiety) and promoting positive experiences (well-being) is therefore important. Positive emotional writing—writing about positive life experiences—integrates positive psychology with expressive writing and has shown benefits in reducing negative affect and enhancing well-being in various populations. This study asks whether an 8-week positive emotional writing intervention, added to routine psychological care, improves depression, anxiety, and subjective well-being in international medical students compared with routine care alone.

Expressive writing, first examined by Pennebaker and colleagues, has demonstrated health benefits but with variable effects influenced by context and individual differences. Greater use of positive emotional words during expressive writing has been linked to better outcomes. Building on this, positive emotional writing focuses on writing about positive life experiences to evoke positive emotions, broaden cognition, and build enduring coping resources (broaden-and-build theory). Prior studies across clinical and non-clinical samples have reported that positive emotional writing reduces depression and anxiety, lowers stress and trait anxiety, and increases positive affect and well-being. Examples include randomized trials showing reductions in anxiety and stress after brief multi-day interventions, benefits for students (including reduced test anxiety and increased positive emotion), and online interventions demonstrating decreased depression among socially inhibited individuals. Despite these findings, evidence in international medical student populations in China has been limited, motivating the present randomized controlled trial.

Design: Two-arm, single-blind randomized controlled trial with pre-test and post-test assessments comparing positive emotional writing plus routine psychological care versus routine care alone. Ethics approval: Medical ethics committee of Wuhan University of Science and Technology (No. 2024119); registered at Chinese Clinical Trial Registry (ChiCTR2400087815). Setting and participants: International medical students at a comprehensive university in central China were recruited via convenience sampling. Inclusion criteria: full-time international medical students with >1 year of schooling; no prior positive emotional writing intervention; voluntary participation; no history of mental illness or psychological treatment in the past 6 months. Randomization and blinding: Ninety-two eligible students were randomized (simple randomization via random number table by a non-author) to experimental (n=46) or control (n=46). Participants were single-blinded (not informed of group assignment). Attrition: Experimental 2 dropouts (4.34%); control 1 dropout (2.17%); 89 completed (experimental n=44; control n=45). Sample characteristics (completers): Age 21–28 (mean 23.67); 46 male, 43 female; 65 Christian, 24 Muslim. Groups did not differ at baseline by age, gender, or religion. Interventions: • Routine psychological care (both groups): Weekly counselor check-ins on living, academic, and psychological status; timely counseling as needed. • Positive emotional writing (experimental group only): 8-week program, once per week. Each session involved writing about positive experiences/themes for that week. Weekly themes included: Week 1—plans/visions for studying medicine in China and proud/satisfying moments; Week 2—events in medical study that brought happiness/pride/satisfaction and associated feelings; Week 3—people/things providing love/care/help and feelings/reciprocity; Week 4—helping others during clinical practice and learned skills; Week 5—personal growth during COVID-19; Weeks 6–7—positive events that made them happy that week; Week 8—hopes, plans, and good wishes for the future. Duration/frequency: once weekly over 8 weeks, in-person administration alongside routine care. Measures: • Depression: Self-Rating Depression Scale (SDS; 20 items, 4-point Likert; higher scores = more severe depression). Reliability: pre α=0.876; post α=0.845. • Anxiety: Self-Rating Anxiety Scale (SAS; 20 items; standard score = total×1.25; higher scores = more severe anxiety). Reliability: pre α=0.823; post α=0.836. • Well-being: General Well-Being Schedule (GWB; 33 items assessing health concerns, energy, life satisfaction/interest, depressed vs. happy mood, emotional/behavioral control, relaxation/tension; higher scores = greater well-being). Reliability: pre α=0.835; post α=0.876. Qualitative component: Structured interviews (experimental group) with five open-ended questions on recent emotions, changes in anxiety/depression, emergence of positive emotions, changes in happiness, and willingness to continue/recommend the practice. Analysis: SPSS 26.0. Normality and homogeneity assumptions were met. Continuous variables as mean±SD; categorical as counts/percentages. Baseline between-group differences: independent-samples t-test (SDS, SAS, GWB) and chi-square tests (demographics). Within-group pre-to-post changes: paired-samples t-tests. Between-group differences in change scores: independent-samples t-tests. Qualitative responses underwent thematic analysis by an independent psychology expert; frequencies summarized descriptively. Timeline: Recruitment near end of month 1 of spring semester; pre-test; 2-month intervention; post-test two months after trial start (total duration ≈3 months).

Sample and baseline: Of 92 randomized students, 89 completed (experimental n=44; control n=45). Groups were comparable at baseline in age, gender, religion (all p>0.05) and in outcome scores: SDS 45.43±14.20 vs 42.98±13.63 (t=0.83, p>0.05); SAS 54.57±11.22 vs 54.04±11.92 (t=0.21, p>0.05); GWB 68.66±6.87 vs 70.16±7.31 (t=-0.99, p>0.05). Within-group changes: • Experimental group (positive emotional writing + routine care): Significant improvements from pre to post. SDS decreased (t=10.27, p<0.01; Cohen’s d=1.55). SAS decreased (t=14.84, p<0.01; d=2.24). GWB increased (t=-41.58, p<0.01; d=6.26). • Control group (routine care only): SAS decreased modestly (t=7.61, p<0.01; d=1.13). SDS change not significant (t=1.93, p>0.05; d=0.29). GWB decreased slightly (t=2.31, p<0.05; d=0.34). Between-group differences in change: Experimental group showed greater improvement than control. SDS change: 6.05±3.91 vs 1.29±4.48 (t=5.33, p<0.01; d=1.13). SAS change: 8.16±3.65 vs 2.53±2.23 (t=8.80, p<0.01; d=1.87). GWB change favored experimental with a larger increase (t=-26.63, p<0.01; d≈-5.70; change values reported as -9.39±1.50 vs 0.69±2.00, reflecting scoring direction). Qualitative findings (experimental group): Most reported recent negative emotions (e.g., anxiety, depression) but noted positive changes after the intervention—reduced negative emotions (90.9%), increased positive emotions (86.4%), and higher happiness (93.2%). About two-thirds were willing to continue the practice (65.9%), and nearly half would recommend it to others (47.7%). Overall: Positive emotional writing produced large, clinically meaningful reductions in depression and anxiety and a substantial increase in well-being beyond routine psychological care.

The randomized controlled design demonstrates that adding positive emotional writing to routine care significantly improves emotional health among international medical students relative to routine care alone. Findings align with the broaden-and-build theory: writing about positive experiences likely elicited positive affect, broadened cognition, and fostered adaptive coping resources, helping students reappraise stressors and address academic and acculturative challenges more flexibly. The substantial effect sizes, especially for well-being, suggest this low-cost, easily implemented strategy can be integrated into student support services. The qualitative data corroborate quantitative improvements, with students describing stress relief, reduced depressive feelings, enhanced energy, and a more positive outlook on studying and living in China. These results support the utility of incorporating structured positive emotional writing into counseling and wellness programs for international medical students.

This study provides the first randomized evidence among international medical students in China that an 8-week positive emotional writing intervention significantly reduces depression and anxiety and enhances subjective well-being beyond routine psychological care. Given its low cost and ease of delivery, positive emotional writing is a practical addition to student mental health services. Future research should replicate in larger, multi-institution samples; include multimodal assessments (self, peer, objective); and analyze written content to elucidate mechanisms of change.

• Single-university, relatively small sample limits generalizability; findings are exploratory. • Outcomes relied on self-report scales, potentially influenced by social desirability; future work should adopt multimodal assessments (self, peer, subjective/objective). • Mechanisms were not directly tested; content analysis of writings and mediational designs are needed to clarify how positive emotional writing exerts effects on depression, anxiety, and well-being.