Review
Interventions to reduce stress in university students: A review and meta-analysis

https://doi.org/10.1016/j.jad.2012.11.026Get rights and content

Abstract

Background

Recent research has revealed concerning rates of anxiety and depression among university students. Nevertheless, only a small percentage of these students receive treatment from university health services. Universities are thus challenged with instituting preventative programs that address student stress and reduce resultant anxiety and depression.

Method

A systematic review of the literature and meta-analysis was conducted to examine the effectiveness of interventions aimed at reducing stress in university students. Studies were eligible for inclusion if the assignment of study participants to experimental or control groups was by random allocation or parallel cohort design.

Results

Retrieved studies represented a variety of intervention approaches with students in a broad range of programs and disciplines. Twenty-four studies, involving 1431 students were included in the meta-analysis. Cognitive, behavioral and mindfulness interventions were associated with decreased symptoms of anxiety. Secondary outcomes included lower levels of depression and cortisol.

Limitations

Included studies were limited to those published in peer reviewed journals. These studies over-represent interventions with female students in Western countries. Studies on some types of interventions such as psycho-educational and arts based interventions did not have sufficient data for inclusion in the meta-analysis.

Conclusion

This review provides evidence that cognitive, behavioral, and mindfulness interventions are effective in reducing stress in university students. Universities are encouraged to make such programs widely available to students. In addition however, future work should focus on developing stress reduction programs that attract male students and address their needs.

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.

References (67)

  • A. Beck et al.

    Manual for the Beck Depression Inventory

    (1996)
  • B. Bewick et al.

    Changes in undergraduate students' psychological well-being as they progress through university

    Studies in Higher Education

    (2010)
  • Bisson, J., Andrew, M., 2007. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of...
  • B. Bittman et al.

    Recreational music-making: an integrative group intervention for reducing burnout and improving mood states in first year associate degree nursing students; insight and economic impact

    International Journal of Nursing Education Scholarship

    (2004)
  • B. Bittman et al.

    Group Empowerment Drumming

    (2001)
  • J. Burns et al.

    The effect of meditation on self-reported measures of stress, anxiety, depression, and perfectionism in a college population

    Journal of College Student Psychotherapy

    (2011)
  • D. Byrd et al.

    Individual, interpersonal, and institutional level factors associated with the mental health of college students

    Journal of American College Health

    (2012)
  • K. Caldwell et al.

    Developing mindfulness in college students through movement-based courses: effects on self-regulatory self-efficacy, mood, stress, and sleep quality

    Journal of American College Health

    (2010)
  • E. Charlesworth et al.

    Stress management skill for nursing students

    Journal of Clinical Psychology

    (1981)
  • E. Chiauzzi et al.

    MyStudentBody-Stress: an online stress management intervention for college students

    Journal of Health Communication

    (2008)
  • A. Chiesa et al.

    Mindfulness-Based Stress Reduction for stress management in healthy people: a review and meta-analysis

    Journal of Alternative and Complementary Medicine

    (2009)
  • S. Cohen et al.

    A global measure of perceived stress

    Journal of Health and Social Behavior

    (1983)
  • P. Collard et al.

    Teaching mindfulness based cognitive therapy (MBCT) to students: the effects of MBCT on the levels of mindfulness and subjective well-being

    Counselling Psychology Quarterly

    (2008)
  • Craggs, S., 2012. One-third of McMaster students battle depression: survey. CBC News. Available from:...
  • G. Deckro et al.

    The evaluation of a mind/body intervention to reduce pychological distress and perceived stress in college students

    Journal of American College Health

    (2002)
  • T. Dowd et al.

    Comparison of a healing touch, coaching, and a combined intervention on comfort and stress in younger college students

    Holistic Nursing Practice

    (2007)
  • M. Downs et al.

    Help seeking and treatment use among suicidal college students

    Journal of American College Health

    (2012)
  • S. Dziegielewski et al.

    Addressing stress with social work students: a controlled evaluation

    Journal of Social Work Education

    (2004)
  • M. Enright et al.

    The efficacy of eye movement desensitization and reprocessing therapy technique in the treatment of test anxiety of college students

    Journal of College Counseling

    (2000)
  • R. Fehring

    Effects of biofeedback-aided relaxation on the psychological stress symptoms of college students

    Nursing Research

    (1983)
  • S. Garlow et al.

    Depression, desperation, and suicidal ideation in college students: results from the American Foundation for Suicide Prevention College Screening Project and Emory University

    Depression and Anxeity

    (2008)
  • G. Guyatt et al.

    Users' Guides to the Medical Literature: a Manual for Evidence-Based Clinical Practice

    (2008)
  • A. Hamdan-Mansour et al.

    Effectiveness of cognitive-behavioral therapy on depressive symptomatology, stress and coping strategies among Jordanian university students

    Issues in Mental Health Nursing

    (2009)
  • Cited by (570)

    View all citing articles on Scopus
    View full text