ReviewInterventions to reduce stress in university students: A review and meta-analysis
Introduction
On September 5, 2012, a Canadian national news magazine ran a cover story entitled “Mental Health Crisis on Campus: Canadian students feel hopeless, depressed, even suicidal” (Lunau, 2012). The story highlighted a 2011 survey at University of Alberta in which over 50% of 1600 students reported feeling hopeless and overwhelming anxiety over the past 12 months. The story continued by recounting incidents of suicide across Canadian campuses. The following month, the CBC reported a survey conducted at another Canadian university indicating that 88.8% of the students identified feeling generally overwhelmed, 50.2% stated that they were overwhelmed with anxiety, 66.1% indicated they were very sad, and 34.2% reported feeling depressed (Craggs, 2012).
Other studies confirm concerning rates of anxiety and depression in university students. The American Foundation for Suicide Prevention sponsored a suicide screening project at Emory University in the United States between 2002 and 2005 (Garlow et al., 2008). Of the sample of 729 student participants, only 16.5% reported no symptoms of depression, while 30.6% reported moderate depression and an additional 23.2% reported moderately severe or severe depression using the Physician Health Questionnaire (PHQ-9). Among the 5689 American university students who participated in a 2007 Healthy Minds Survey, 50.7% tested positive for major depression, panic disorder and/or generalized anxiety using the PHQ-9 (Keyes et al., 2012). A study of 1,616 Turkish university students revealed rates of moderate depression in 27.1%, anxiety in 47.1%, and stress in 27.1% of the sample (Bayran and Bilgel, 2008). A large study in the United Kingdom involving 16,460 undergraduate students charted the longitudinal course of anxiety and depression over the course of their university careers (Bewick et al., 2010). This study revealed that student anxiety scores peaked in the first term of second year and final year, whereas depression scores rose steadily over time, peaking at the end of the final year. Nevertheless, anxiety symptoms were significantly higher than depression scores at all time points, and at no time during university did psychological distress fall to pre-admission levels (Bewick et al., 2010).
Students with mental health problems report poorer relationships with other students and faculty members, lower levels of engagement in campus clubs and activities, lower grade averages, and lower rates of graduation than students not suffering from mental health problems (Byrd and McKinney, 2012, Keyes et al., 2012, Salzer, 2012, Storrie et al., 2010). Furthermore, 11.1% of the Emory University students reported suicidal ideation over the preceding 4 weeks, and 16.5% reported a life-time incidence of suicide or self-harm behavior (Garlow et al., 2008). In a random sample of 8155 students from 15 US universities, 6.75% reported suicidal ideation and 0.5% reported an attempt in the past year (Downs and Eisenberg, 2012). Thus, stress and its mental health implications amongst students is a significant issue for universities.
Studies indicate that few students experiencing stress-related mental health problems receive treatment. Garlow et al. (2008) reported that only 15% of the students with moderately severe or severe depression or with suicidal ideation in their sample were receiving treatment. Downs and Eisenberg (2012) reported that just over half (51.5%) of the students with suicidal ideation received some type of treatment. In part, low treatment rates are related to help-seeking behaviors among students. In the Downs and Eisenberg (2012) study, the most commonly reported barriers to seeking treatment were: (1) a preference for dealing with stress alone (73.3%); (2) the belief that stress is normal in university (52.2%); (3) not seeing their needs as serious (52.1%); and (4) not having time for treatment (46.7%).
In light of repeated studies that suggest that approximately 50% of the student body experiences significant levels of stress in the form of anxiety and/or depression, we conclude that universities must employ preventative interventions that have the potential to reach larger groups of students and not merely rely on individual counseling services to meet student needs. This paper is a meta-analysis of such interventions with the aim of providing an evidence-based approach for interventions to reduce stress in university students. While meta-analyses have previously been conducted on the use of various models of invention for mixed groups of people suffering from anxiety and depression (Hunot et al., 2007, Jorm et al., 2008, Krisanaprakornkit et al., 2006), previous meta-analyses and reviews have not shed light on whether such interventions are effective for university students.
Section snippets
Method
Studies in this analysis included experimental and parallel cohort quasi-experimental evaluations of psychological intervention programs to reduce stress in university students. Studies were eligible for the review if they used: (1) random assignment to create treatment and comparison or control groups or (2) parallel cohort designs in which groups were assessed at the same points in time. Single-group designs were excluded from the analysis but are included in the summary of studies (Table 1).
Search strategy
Searches were conducted on electronic databases, including the Cochrane database on systematic reviews, Medline, Embase, PsychINFO, ERIC, Applied Social Science Abstracts, Social Sciences Abstracts, PsycInfo, and Dissertation Abstracts International. Reviewers checked the reference lists of all relevant articles that were obtained, including those from previously published reviews. Potentially relevant articles were identified, retrieved, and assessed for possible inclusion in the review.
Data analysis
A meta-analysis was conducted to pool change in the primary outcome (self-reported anxiety) and secondary outcomes (self-reported depression and salivary cortisol level) from baseline to the post-intervention period using Comprehensive Meta-analysis software, version 2.0. All data were continuous and analyzed by measuring the standard mean difference between the treatment and comparison groups based on the reported means and standard deviations for each group. Standard mean differences (SMD)
Results
Twenty-nine controlled trials on stress interventions for university students met the criteria for inclusion in the meta-analysis. Three additional studies using single-group designs are included in the summary table (Table 1) in order to provide full information to readers (Burns et al., 2011, Caldwell et al., 2010, Collard et al., 2008). Controlled trial studies covered students in a wide range of disciplines, including nursing, medical science, medicine, economics, social work, law,
Discussion
A range of studies conducted in various jurisdictions reveal that approximately half of the university students report moderate levels of stress-related mental health concerns, including anxiety and depression (Bayran and Bilgel, 2008, Garlow et al., 2008, Keyes et al., 2012, Lunau, 2012). Students experiencing these symptoms also report lower levels of engagement, lower GPA, and suicidal ideation (Byrd and McKinney, 2012, Downs and Eisenberg, 2012, Garlow et al., 2008). Clearly, this is a
Conclusions
Results from this review and meta-analysis provide strong support that cognitive, behavioral, and mindfulness-based approaches are effective in reducing the effects of stress on university students, including reducing levels of anxiety, depression, and cortisol response. Given the high rates of stress-related mental health problems reported by university students, universities are advised to examine means to provide opportunities for a larger number of students to access these interventions.
Conflict of interest
No conflict declared.
Role of funding source
Nothing declared.
Acknowledgements
The authors do not have any acknowledgements to declare.
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