Graduate students suffer from issues with mental and emotional wellbeing at a high rate. While most commonly understood as an individual issue, the high prevalence of mental health problems suggests that their causes may extend beyond personal factors. A closer look at the environment that a graduate student operates in suggests systemic or organizational factors that exert notable pressures that students have to cope with. This article examines four levels of systems that create a structural environment that negatively impacts mental health and wellbeing among graduate students: (1) the academic system, (2) the institutional and departmental systems, (3) lab or cohort systems, and (4) the social‐economic system. In light of this analysis, we propose a model of how systemic stress affects mental health. This model sheds light on the systems‐level process improvements that can be instituted to help universities prevent mental health issues among graduate students.

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Objective Standard predictors do not fully explain variations in the frequency and timing of heart failure (HF) adverse events (AEs). Psychological stress can trigger acute cardiovascular (CV) events, but it is not known whether stress can precipitate AEs in HF patients. We investigated prospective associations of psychological stress with AEs in patients with HF. Methods 144 HF patients (77% male; 57.5±11.5, range 23–87 years, LVEF≤40%) were longitudinally evaluated for psychological stress (Perceived Stress Scale; PSS) and AEs (CV hospitalizations/death) at 2-week intervals for 3 months, and at 9-month follow- up. Results 42 patients (29.2%) had at least one CV hospitalization and 9 (6.3%) died. Patients reporting high average perceived stress across study measurements had a higher likelihood of AEs during the study period compared to those with lower stress (OR=1.10, 95% CI=1.04, 1.17). In contrast to average levels, increases in stress did not predict AEs (p=.96). Perceived stress was elevated after a CV hospitalization (B=2.70, SE=0.93, p=.004) suggesting that CV hospitalizations increase stress. Subsequent analysis indicated that (24 of 38; 63%) of patients showed a stress increase following hospitalization. However, a prospective association between stress and AEs was present when accounting for prior hospitalizations (B=2.43, SE=1.23, p=.05). Conclusions Sustained levels of perceived stress are associated with increased risk of AEs, and increased distress following hospitalization occurs in many, but not all, HF patients. Patients with chronically high stress may be an important target group for HF interventions aimed at reducing hospitalizations.

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Objective This study compares sensory-biological, cognitive-emotional, and cognitive-interpretational factors in predicting angina on an exercise treadmill test (ETT). Methods 163 patients with ETT-induced ischemia and coronary artery disease (CAD) in the NHLBI Psychophysiological Investigations of Myocardial Ischemia (PIMI) study were given an ETT, and 79 patients reported angina during the ETT. We assessed the following as predictors of self-reported anginal pain: sensory-biological factors (β-endorphin reactivity, hot pain threshold, and maximum ST-segment depression), cognitive-emotional factors (negative affect and symptom perception), and cognitive-interpretation (self-reported history of exercise-induced angina). Models were covariate-adjusted with predictors examined individually and as part of component blocks. Results Logistic regression revealed that history of angina (OR=17.41, 95% CI=7.16–42.34) and negative affect (OR=1.65, 95% CI=1.17–2.34), but not maximum ST-segment depression, hot pain threshold, β-endorphin reactivity, nor symptom perception were significant predictors of angina on the ETT. The component block of sensory-biological variables was not significantly predictive of anginal pain (chi2block = 5.15, p = 0.741). However, the cognitive-emotional block (chi2block = 11.19, p = 0.004) and history of angina (cognitive-interpretation) (chi2block = 54.87, p < 0.001) were predictive of ETT angina. A model including all variables revealed that only history of angina was predictive of ETT pain (OR = 16.39, p < 0.001), although negative affect approached significance (OR = 1.45, p = 0.07). Conclusion These data suggest that in patients with ischemia, cognitive-emotional and cognitive-interpretational factors are important predictors of exercise angina.