Regehr 等 - 2013 - Interventions to reduce stress in university stude

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Regehr 等 - 2013 - Interventions to reduce stress in university stude

ReviewInterventions to reduce stress in university students: A review andmeta-analysisCheryl Regehr a,n, Dylan Glancy b, Annabel Pitts ca Factor-Inwentash Faculty of Social Work Vice-Provost, Academic Programs, University of Toronto, 27 King’s College Circle, Toronto, Canada M5S 1A1b Queens University, Kingston, Canadac Factor-Inwentash Faculty of Social Work, University of Toronto, Canadaarticle infoArticle history:Received 14 October 2012Accepted 6 November 2012Available online 13 December 201... [收起]
Regehr 等 - 2013 - Interventions to reduce stress in university stude
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Interventions to reduce stress in university students: A review and


Cheryl Regehr a,n

, Dylan Glancy b

, Annabel Pitts c

a Factor-Inwentash Faculty of Social Work Vice-Provost, Academic Programs, University of Toronto, 27 King’s College Circle, Toronto, Canada M5S 1A1

b Queens University, Kingston, Canada

c Factor-Inwentash Faculty of Social Work, University of Toronto, Canada

article info

Article history:

Received 14 October 2012

Accepted 6 November 2012

Available online 13 December 2012





University student




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


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.

& 2012 Elsevier B.V. All rights reserved.


1. Introduction ........................................................................................................2

2. Method . . ..........................................................................................................2

3. Search strategy......................................................................................................2

4. Data analysis .......................................................................................................5

5. Results . . ..........................................................................................................6

5.1. Stress interventions ............................................................................................6

5.2. Meta-analysis results ...........................................................................................7

6. Discussion .........................................................................................................7

6.1. Limitations ...................................................................................................9

7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Conflict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Contents lists available at SciVerse ScienceDirect

journal homepage:

Journal of Affective Disorders

0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved.

n Corresponding author. Tel.: þ1 416 978 2122.

E-mail address: (C. Regehr).

Journal of Affective Disorders 148 (2013) 1–11


Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1. 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,


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


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.

2. 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).

Study participants included undergraduate, graduate, and professional students who had participated in interventions aimed at

reducing their levels of stress. Any type of psychological, psychoeducational, and/or psychosocial intervention aimed at reducing

stress in university students was eligible for inclusion in the

review. Studies that exclusively examined pharmacological interventions; that compared psychosocial, psychological, or psychoeducational treatments to pharmacological treatment; or studies

that combined these treatments with pharmacological treatments, were excluded.

The assessment of the primary outcome of psychological stress

and anxiety symptoms included various standardized measures

such as the Spielberger State-Trait Anxiety Inventory (STAI)

(Spielberger, 1983) and the Perceived Stress Scale (PSS) (Cohen

et al., 1983). Secondary outcomes were decreased levels of

depression and physiological stress responses. Secondary outcome measures included: severity of depressive symptoms using

scales such as the Beck Depression Inventory (BDI) (Beck and

Steer, 1996) and physiological arousal as measured by salivary


3. 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

2 C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11


Table 1

Summary of stress interventions for university students studies.

Study Design and N Population Nature of intervention Length of intervention Stress outcome



Controlled trials cognitive/behavioral/mindfulness-based interventions

Astin (1997) Randomized Behavioral medicine

undergraduate students, USA

Mindfulness-based stress

reduction (MBSR)

8–2 h sessions over 8 weeks SCL-90 (depression and



12 int/7 controls Depression

1 male/18 females

Charlesworth et al.


Parallel cohort Med-Surg nursing students,


Relaxation training 5–2 h sessions over 5 weeks State-Trait Anxiety

Inventory (STAI)


10 int/8 controls Visual imagery

1 males/17 females Modified systematic


Deckro, et al. (2002) Randomized Undergraduate students, USA Relaxation response 6–90 min training sessions STAI Anxiety

63 int/65 controls CBT skills PSS

51 males/77 females SCL-90

Dehghan-Nayeri and



Parallel cohort Medical science students,


Simple relaxation 30 min session, 15 min daily practice 8 weeks STAI Anxiety

100 int/100 control Progressive muscle relaxation

0 male/200 females

Enright et al. (2000) Randomized Students with test anxiety, USA Eye-movement desensitization


2–1 h sessions Test anxiety inventory Anxiety

18 int/17 controls

11 males/24 females

Fehring (1983) Randomized Undergraduate students, USA Bio-feedback and relaxation


1 session, independent daily practice with


STAI Anxiety

26 per group POMS

17 males/61 females

C. Regehr et al. / Journal of Aff


Gaab et al. (2003) Randomized Institute of Technology

students, Switzerland

Stress inoculation training (SIT)

and CBSM

2–7 h sessions PSS Anxiety

24 int/24 controls Salivary cortisol Depression

All male CES depression scale Biological arousal

Gaab et al. (2006) Randomized Economic students taking

qualifying exam, Switzerland

Cognitive-Behavioral Stress

Management (CBSM)

4 weekly sessions, 1 booster session STAI Anxiety

13 int/15 controls Salivary cortisol Biological arousal

17 males/11 females

Godbey and Courage


Parallel cohort Nursing students, USA Stress management techniques 6 week individual counseling STAI Anxiety

7 int/12 controls

All women

Hamdan-Mansour et al.


Randomized Students suffering from

depression, Jordan


therapy—teaching kids to cope

10–45 min weekly sessions PSS Anxiety

44 int/40 controls BDI Depression

46 males/38 females

Hammerfald et al. (2006) Randomized UG psychology students,


Cognitive-behavioral stress

management (CBSM)

2–5 h sessions Salivary cortisol Biological arousal

42 int/41 controls

14 males/59 females

Heaman (1995) Randomized Nursing students, USA Bio-feedback aided relaxation


5–90 min sessions STAI Anxiety

21 int/19 controls

All female

Jain et al. (2007) Randomized Medical, nursing or premed

students, USA

1. MBSR 4–1.5 h sessions Brief symptom inventory



27/24/30 controls 2. Relaxation POMS

15 males/66 females

Jones and Johnston


Randomized Student nurses, Scotland Multi-modal stress management 6–2 h sessions GHQ Anxiety

40 int/30 controls STAI Depression


fective Disorders 148 (2013) 1–11



Kooken and Hayslip


Randomized Elderly undergrad students,


SIT 3 weekly sessions STAI Anxiety

11 int/9 controls Test anxiety scale

9 males/20 females Fear of negative

evaluation scale

Lynch et al. (2011) Parallel cohort Undergraduate students,


Mindfulness-based coping with

university life (from MSBR)

8–1.5 h sessions, weekly PSS Anxiety

10 int/6 controls Hospital anxiety and

depression scale (HADS)


4 males/26 females Salivary cortisol

Oman et al. (2008) Randomized Undergraduate students, USA MBSR and eight point program


8–90 min sessions PSS Anxiety

28/15 control

9 males/35 females

Russler (1991) Randomized Nursing students, USA Multi-modal stress management 2–8 h sessions STAI Anxiety

19 int/19 controls reported emotions


Gender not reported

Shapiro et al. (1998) Randomized Paramedic and medical

students, USA

MSRB 7–2.5 h sessions STAI Anxiety

37 int/36 controls SCL-90 Depression

32 males/41 females

Shapiro et al. (2011) Randomized Undergraduate students, USA MSRB PSS Anxiety

15 int/15 controls

4 males/26 females

Sheehy and Horan

Randomized Law students, USA SIT 4–90 min sessions STAI Anxiety

Table 1


Study Design and N Population Nature of intervention Length of intervention Stress outcome measures Meta-analyses

C. Regehr et al. / Journal of Affecti





, y

11 int/11 controls symptoms of stress

inventory (SSI)

6 males/16 females Derogatis sress profile

Stephens (1992) Randomized Nursing students, USA Imagery and relaxation Audiotaped imagery 15 min per day for 5 days,

then 3 times per week for 3 weeks

STAI Anxiety

62/38 controls

All female

St. Lawrence et al. (1983) Parallel cohort Law students, USA Multi-model stress management 6–90 min sessions Stressful situations



11 int/10 controls

Gender not reported

Warnecke et al. (2011) Parallel cohort Medical students, Tasmania MSRB Audio tape daily for 8 weeks PSS Anxiety

24 int/32 controls Depression and anxiety

stress scale


14 males/42 females

Controlled trials educational interventions

Chiauzzi et al., 2008 Randomized Mixed undergraduate students,


Website with stress strategies

tailored to the student

20 min at least 4 times over 2 weeks Perceived stress scale


Insufficient data

80 int/80 controls for meta-analysis

107 males/113 females

Dziegielewski et al.


Randomized Social work students, USA Educational: signs of stress,

measures to address stress

45 min seminar Stressful situations

questionnaire (SSQ)

No comparators

25 int/23 controls

9 males/39 females

Controlled trials art-based interventions

Bittman et al. (2004) Parallel cohort Nursing students, USA Recreational music making


6–1 h sessions over six weeks Profile of mood states


Insufficient data

for meta-analysis

38 int/37 controls Maslach burnout

inventory (MBI)

11 males/64 females

ive Disorders 148 (2013) 1–11


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.

Screening of the studies was carried out by a three-stage

procedure. The first stage of screening determined whether a

study might be appropriate for the review based on the study’s

title and abstract. During the second stage of screening, full copies

of articles were reviewed to determine whether studies should

remain in the review based on the inclusion and exclusion

criteria. The assessment of the methodological quality of each

study was based on criteria established in the Cochrane Collaboration Handbook (Higgins and Green, 2011). The third stage

consisted of data extraction from the articles that passed the two

previous screenings. Where data was not available in the study

report of eligible studies, the reviewers corresponded with investigators requesting further information.

The searches were conducted between February 10 and March

1, 2012 and yielded 3138 potentially relevant studies (see Fig. 1).

Once duplicates were removed, 442 titles and abstracts were

saved to a spread sheet and subjected to more detailed evaluation. During the second screen, studies were excluded because the

intervention included pharmacological approaches; or because

the focus of intervention was with another population including

mental health counselors, persons with trauma histories, prisoners, elementary or adolescent aged children, or persons exclusively dealing with racial identity. The second screen of titles and

abstracts resulted in 63 studies that were selected for full text

analysis. Thirty-four studies were screened out at this stage as

they were not intervention studies, or they did not have stress

and/or anxiety as an outcome measure. In the end, 29 controlled

studies on stress interventions for university students were

deemed to be appropriate meta-analyses (Table 1). Twenty-four

studies contained sufficient information for meta-analysis or had

comparators in order to allow for meta-analysis. Three additional

single-group design studies are included in the table in order to

provide more complete information on the range of studies in

this area.

4. Data analysis

A meta-analysis was conducted to pool change in the primary

outcome (self-reported anxiety) and secondary outcomes (selfreported 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)

allowed for comparisons to be made across studies when scales

measured the same outcomes using different standardized instruments, such as administering the STAI or the PSS to measure

anxiety. Standard mean differences were determined by calculating the Hedges’ g (Hedges, 1982). The Hedges’ g is preferable to

Cohen’s d in this instance, as it includes an adjustment for small

sample bias. To pool SMDs, inverse variance methods were used

to weigh each effect size by the inverse of its variance to obtain an

overall estimate of effect size. Standard differences in means

(SDMs) point estimates and 95% confidence intervals (CIs) were

computed using a random effects model. Heterogeneity between

studies was calculated using I

2 (Higgins et al., 2003). This statistic

provides an estimate of the percentage of variability in results

across studies that are likely due to treatment effect rather than

chance (Guyatt et al., 2008).

Mohammadian et al.


Randomized Undergraduate students in

residence, Iran

Poetry 7–90 minute sessions Depression anxiety stress


No comparators

14 int/14 controls

All female

Controlled trials other interventions

Dowd, et al. (2007) Randomized Undergraduate students, USA Healing touch and coaching 3 weekly sessions Stress test 26 No comparators

12/14/13/13 controls

12 males/40 females

Single group design studies cognitive/behavioral/mindfulness-based interventions

Burns et al. (2011) Pre-test/post-test Undergraduate students, USA Transcendental meditation (TM) 6–45 min sessions over 6 days PSS No control group

No control Beck anxiety inventory

43 int CES depression scale

18 males/25 females

Caldwell et al. (2010) Pre-test/post-test Undergraduate students, USA Mindfulness-based movement


150 min per week for 15 weeks PSS-4 No control group

3 int 4 Dimension mood


166 int

25 males/141 females

Collard et al. (2008) Pre-test/post-test Post-Graduate Mindfulness-based cognitive

therapy (MBCT)

8 weeks Positive and negative

affect scale (PANAS)

No control group

16 int Counseling students, England

2 males/14 females

C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11 5


5. Results

Twenty-nine controlled trials on stress interventions for university students met the criteria for inclusion in the metaanalysis. 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, psychology, technology,

and general arts and science. While the majority of controlled

trial studies (19) involved students in the United States, studies

also included students in Tehran (Dehghan-Nayeri and AdibHajbaghery, 2011), Switzerland (Gaab et al., 2003, 2006;

Hammerfald et al., 2006), Jordan (Hamdan-Mansour et al.,

2009), Scotland (Jones and Johnston, 2000), England (Lynch

et al., 2011), Iran (Mohammadian et al., 2011), and Tasmania

(Warnecke et al., 2011). The combined controlled trials had 1802

student participants. Of the total number of participants in these

studies, 24.7% were male, 72.4% were female, and in 2.8% of the

cases gender was not reported. Thus in the reported cases 25.5%

of participants were male.

5.1. Stress interventions

For the purposes of meta-analysis, stress interventions were

grouped into three broad categories: (1) arts-based interventions;

(2) psycho-educational interventions; and (3) cognitive/behavioral/mindfulness-based interventions. One controlled trial

(Dowd et al., 2007) was not classified as appropriate to any of

the three categories and thus was not included in the metaanalysis. The one study classified in the other interventions

category used a combination of energy therapy through healing

touch and self-care coaching based on comfort theory. Dowd and

colleagues concluded that a healing touch provided greater

reduction in stress immediately after intervention; however,

when combined with the coaching intervention it had better

carryover effects. These findings have not been replicated and a

Cochrane Review conducted in 2007 was unable to locate randomized or quasi-randomized trials for inclusion in a meta-analysis

(Robinson et al., 2007).

Two studies were classified as arts-based interventions. Bittman and colleagues tested the efficacy of Group Empowerment

Drumming, a form of recreational music making (Bittman et al.,

2004). This intervention followed the HealthRHYTHMS protocol

(Bittman et al., 2001) and used drumming to enhance social

support, provide exercise and intellectual stimulation, and

heighten spirituality. The intervention was conducted on a

group basis, one hour each week for six weeks. The published

version of this paper did not contain sufficient data for metaanalysis, and given the time elapsed since the study was conducted, the authors were unable to provide the required

data (Bittman, 2012 personal communication). Mohammadian

and colleagues tested a seven-session Poetry Therapy intervention with students in Iran. In this intervention, Persian poetry

was read to students and used as a means to elicit emotions,

analyze feelings, and promote collaborative writing. Poetry Therapy is described as a means to express feelings and thoughts that

might otherwise be repressed. While this study reported depression and anxiety as outcomes, it was not included in the metaanalysis due to an absence of comparators (Mohammadian et al.,


Two controlled trials examined psycho-educational interventions. Chaiuzzi and colleagues created an online stress intervention, MyStudentBody-Stress, tailored to provide tools, strategies

and stories related to stress management and individual feedback

on personal stress management strategies. In the intervention

condition, students were instructed to spend at least 20 min on

the website on four occasions over a two-week period (Chiauzzi

et al., 2008). The authors report that there was no significant

condition-by-time interaction effect on anxiety as measured by

the Perceived Stress Scale; however, there was insufficient data to

include the study in a meta-analysis. Dziegielewski, Turnage, and

Roest-Marti provided a 45-min seminar for social work students

covering personality styles and behavior, signs of stress, and

concrete methods for managing stress. While this study reported

significant reduction in stress in the intervention as measured by

the Stress Situations Questionnaire, it was not included in the

meta-analysis due to an absence of comparators (Dziegielewski

et al., 2004).

Twenty-four studies examined the effects of various models of

cognitive, behavioural, and/or mindfulness-based techniques on

stress in university students. All of these studies had sufficient

data for inclusion in the meta-analysis. Cognitive-behavioral

therapy incorporates cognitive, behavioral, and social learning

theory components to explain functioning as a product of reciprocal interactions between personal and environmental variables. In the realm of stress, behavioral interventions often focus

on control of physical stress reactions through controlled breathing or muscle relaxation. Cognitive therapy components aim to

assist individuals in identifying and modifying dysfunctional

beliefs that influence response to stimuli and subsequent physiological and psychological distress. The studies in this analysis

used a variety of strategies in the broad category of cognitive

behavioral interventions. Most interventions involved 4–8 weekly

sessions. However, some interventions (Dehghan-Nayeri and

Adib-Hajbaghery, 2011; Fehring, 1983) involved only one session,

followed by independent practice with relaxation tapes (see

Table 1).

Total Hits (n=3,138)

Potentially relevant studies

screened for retrieval (n=442)

Potentially appropriate studies to be

included in the meta-anlaysis (n=63)

Studies appropriate for meta

analysis (n=29)

Studies with useable outcome data

for meta-analysis (n=24)

Fig. 1. Search results.

6 C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11


Five studies (Gaab et al., 2003, 2006; Hammerfald et al., 2006;

Kooken and Hayslip, 1984; Sheehy and Horan, 2004) examined

interventions based on Stress Inoculation Training (SIT). First developed

by Meichenbaum in 1977, this model of intervention involves three

interlocking and overlapping phases: (1) education regarding sources

of stress, including irrational thinking, and ways to reduce psychological and physiological stress; (2) coping skills, including relaxation

training and cognitive restructuring; and (3) application of new

strategies to real or simulated situations (Meichenbaum, 1977,

1993; Meichenbaum and Deffenbacher, 1988). While originally

developed for clinical populations, stress inoculation training has

increasingly been used in a variety of populations to assist with the

management of occupational stress and enhance performance under

stress (Saunders et al., 1996). Meichenbaum (1993) describes SIT as a

flexible, multifaceted form of cognitive-behavioral therapy that can

be modified to suit the specific situation. In this vein, Gaab and

colleagues explicitly state they have slightly adapted SIT into a model

they call Cognitive-Behavioral Stress Management (CBSM) for use on

Swiss students.

Other studies in this review use a combination of techniques

encompassed in SIT, including psycho-educational elements,

relaxation training, and cognitive restructuring. Four studies

(Dehghan-Nayeri and Adib-Hajbaghery, 2011; Fehring, 1983;

Heaman, 1995; Stephens, 1992) used combinations of relaxation

training, education, and imagery. Commonly, these models incorporate group training sessions and homework practice, often

through the use of relaxation and guided imagery tapes. Seven

studies incorporated relaxation techniques and education with

various forms of cognitive restructuring, entitling their

approaches multidimensional or multi-modal (Charlesworth

et al., 1981; Deckro et al., 2002; Godbey and Courage, 1994;

Hamdan-Mansour et al., 2009; Jones and Johnston, 2000; Russler,

1991; St. Lawrence et al., 1983). One study (Enright et al., 2000)

used Eye-Movement Desensitization and Reprocessing (EMDR) with

students experiencing test anxiety. EMDR incorporates cognitivebehavioral interventions with desensitization through therapeutic exposure and saccadic eye movements. During treatment, the

client’s attention is directed to the external stimulus (usually eye

movements) while simultaneously concentrating on the source of

emotional distress (Shapiro, 1996).

An approach that has been gaining increased attention over

the last two decades is Mindfulness-Based Stress Reduction (MBSR).

While there are intersections between mindfulness-based

approaches and cognitive therapy, most explicitly in

Mindfulness-Based Cognitive Therapy (Segal et al., 2002), the

studies included in this review do not specifically describe the

integration of cognitive-behavioral techniques into their

approaches. Nevertheless, it is difficult to draw clear distinctions

between the approaches using imagery and relaxation and those

using mindfulness. As a result, meta-analyses were conducted

that combined cognitive-behavioral and mindfulness interventions and that examined their effectiveness separately.

Developed by Kabat-Zinn, MBSR incorporates three mindfulness practices: (1) sweeping, or an awareness of the body

focussing on breath awareness and relaxation; (2) mindfulness

of breath; and (3) hatha yoga postures. Sessions generally cover

mindfulness in stressful situations and social interactions, and

acceptance of self and others. In this model, weekly MBSR

sessions are augmented by audio cassettes that lead to practice

at home. Originally designed as a behavioral medicine technique

for patients with chronic pain (Kabat-Zinn, 1982), the model has

subsequently been tested on people with a broad spectrum of

issues, including anxiety disorders (Kabat-Zinn et al., 1991). In

this review, seven studies examined approaches based on MBSR

(Astin, 1997; Jain et al., 2007; Lynch et al., 2011; Oman et al.,

2008; Shapiro et al., 1998, 2011; Warnecke et al., 2011).

5.2. Meta-analysis results

Twenty-four studies including 1431 participants contained sufficient information and had comparators for meta-analysis. Of those

included in the meta-analysis, 24.0% of the participants were male.

Twenty-three cognitive, behavioural, and mindfulness-based studies contributed data to a pooled analysis for the primary outcome of

self-reported anxiety. Results are significant for treatment against the

control group (Standard Difference in Means point estimate 0.77;

95% CI 0.88 to 0.58). Heterogeneity as assessed by the I

2 is

moderate (29.4%; see Fig. 2). In addition, cognitive, behavioural, and

mindfulness-based approaches were assessed independently for the

impact on anxiety. The pooled results for 16 cognitive behavioral

interventions (SDM 0.77; 95% CI 0.97 to 0.57; I

2¼43.0%) and 9

mindfulness-based interventions (SDM 0.73; 95% CI 1.00 to

0.45; I

2¼36.9%) showed significant improvement over control

groups (see Figs. 3 and 4). Despite the differences in approach,

moderate heterogeneity suggests a considerable degree of similarity.

Two analyses were conducted for secondary outcomes. Six

cognitive behavioral and mindfulness-based studies contributed

to a pooled analysis for depression. Results are significant for

treatment against the control group (SDM 0.81; 95% CI 1.49 to

0.13; see Fig. 5). Heterogeneity in this analysis is high


2¼86.6%). In one study of a self-directed intervention using

mindfulness-based audio recordings, the intervention did not

result in lower levels of depression (Warnecke et al., 2011). Three

studies contributed to a pooled analysis for salivary cortisol (SDM

0.52; 95% CI 0.83 to 0.20). Heterogeneity as assessed by the


2 is 0% in this analysis, which speaks to the consistency in the

approach used across trials (see Fig. 6).

6. 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 critical

issue for universities to address. This paper reports a systematic

review and meta-analysis of 24 controlled studies that examine

the effectiveness of interventions aimed at reducing stress in

university students.

The findings of the meta-analysis suggest that cognitive,

behavioral, and mindfulness-based interventions focused on

stress reduction significantly reduce symptoms of anxiety.

Further, despite variations in approaches in terms of length of

intervention and specific components of the intervention (including such aspects as cognitive restructuring, relaxation, and meditation) with students in different programs and in different

countries, these results are remarkably consistent. In five of six

studies, depression scores were also significantly reduced in the

intervention group. Furthermore, three studies that assessed the

impact of a stress inoculation training-based intervention demonstrated significant impact on salivary cortisol levels, suggesting

that the intervention has an impact not only on individual

appraisal of stress symptoms, but also on biological arousal.

These findings are supported by meta-analyses conducted

with other populations. A Cochrane Review based on an analysis

of 22 studies reported that CBT approaches are effective in

addressing generalized anxiety disorders in mixed populations

with a mean overall age of 47.2 years (Hunot et al., 2007). Other

systematic reviews have established that cognitive-behavioral

C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11 7


Fig. 3

Study name Statistics for each study Std diff in means and 95% CI

Std diff Standard Lower Upper

in means error Variance limit limit Z-Value p-Value

Astin, 1997 -1.263 0.518 0.268 -2.278 -0.248 -2.439 0.015

Charlesworth, 1981 -0.440 0.480 0.230 -1.381 0.500 -0.918 0.359

Deckro et al, 2002 -0.663 0.217 0.047 -1.087 -0.238 -3.060 0.002

Dehghan-Nayeri, 2011 -0.995 0.150 0.022 -1.289 -0.702 -6.639 0.000

Enright, 2000 -0.841 0.353 0.124 -1.533 -0.150 -2.384 0.017

Fehrang, 1983 -0.817 0.289 0.083 -1.382 -0.251 -2.829 0.005

Gaab, 2003 -0.663 0.296 0.088 -1.244 -0.082 -2.235 0.025

Gaab, 2006 -0.743 0.392 0.153 -1.510 0.025 -1.896 0.058

Godbey, 1994 -0.195 0.477 0.227 -1.129 0.739 -0.409 0.683

Hamdan-Mansour, 2009 -1.149 0.236 0.056 -1.611 -0.687 -4.872 0.000

Heaman, 1995 -0.992 0.335 0.113 -1.649 -0.334 -2.957 0.003

Jain et al, 2007 -0.734 0.274 0.075 -1.271 -0.197 -2.677 0.007

Jones et al, 2000 -1.481 0.272 0.074 -2.014 -0.948 -5.444 0.000

Kooken, 1984 -0.272 0.452 0.204 -1.157 0.613 -0.602 0.547

Lynch, 2007 -0.657 0.529 0.280 -1.695 0.380 -1.242 0.214

Oman, 2008 -0.335 0.322 0.104 -0.966 0.296 -1.041 0.298

Russler, 1991 -0.026 0.324 0.105 -0.662 0.610 -0.080 0.937

Shapiro, 1998 -0.475 0.237 0.056 -0.940 -0.009 -1.999 0.046

Shapiro, 2011 -0.532 0.372 0.138 -1.260 0.197 -1.431 0.153

Sheehy, 2004 -1.302 0.469 0.220 -2.223 -0.382 -2.774 0.006

Stephens, 1992 -0.343 0.207 0.043 -0.749 0.064 -1.653 0.098

StLawrence, 1983 -0.814 0.455 0.207 -1.705 0.077 -1.790 0.073

Warnecke, 2012 -0.758 0.279 0.078 -1.305 -0.210 -2.712 0.007

-0.733 0.077 0.006 -0.883 -0.583 -9.565 0.000

-1.00 -0.50 0.00 0.50 1.00

Favours Intervention Favours Control

Anxiety in Cognitive/ Behavioral / Mindfulness-Based Interventions

Meta Analysis

Fig. 2

8 C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11


approaches including SIT and EMDR are effective in reducing

symptoms of post-traumatic stress disorder in populations ranging from accident victims to emergency responders, veterans,

and victims of sexual violence (Bisson and Andrew, 2007; Regehr

et al., 2012; Sherman, 1998). Jorm, Morgan, and Hetrick conclude

in a Cochrane review of 15 trials that relaxation techniques are

more effective in reducing depression than no treatment, but less

effective than other CBT techniques (Jorm et al., 2008). Krisanaprakornkit and colleagues report the results of a Cochrane review

with two controlled studies and concluded that mediation is

comparable to other relaxation techniques in reducing anxiety

(Krisanaprakornkit et al., 2006). This is confirmed by a more

recent review that found MSBR and relaxation are both effective

in reducing stress associated with a number of mental and

physical disorders (Chiesa and Serretti, 2009). An additional

review on mindfulness interventions similarly concluded that

this approach reduces stress in individuals with a range of health

conditions (Grossman et al., 2004). This corroboration further

adds to the compelling results of the current review and metaanalysis.

6.1. Limitations

Despite these strong findings, this review and meta-analysis

has limitations. Studies in this analysis are limited to those

published in the English language in peer-reviewed journals.

The students represented in these studies were enrolled in a

variety of academic programs including health sciences, general

undergraduate, technology, and law. The intervention studies

were conducted in a number of countries; however, the preponderance of research has been conducted in English-speaking

Western countries and thus generalizability to other cultural

contexts may be limited. In addition, the majority of participants

in these studies were women. That being said, one study

Study name Statistics for each study Std diff in means and 95% CI

Std diff Standard Lower Upper

in means error Variance limit limit Z-Value p-Value

Astin, 1997 -1.671 0.547 0.300 -2.744 -0.598 -3.052 0.002

Hamdan-Mansour, 2009 -1.446 0.245 0.060 -1.927 -0.965 -5.896 0.000

Jones, 2000 -1.191 0.262 0.068 -1.703 -0.678 -4.550 0.000

Lynch, 2011 -0.626 0.528 0.279 -1.661 0.409 -1.185 0.236

Shapiro, 1998 -0.670 0.241 0.058 -1.141 -0.198 -2.783 0.005

Warnecke, 2012 0.585 0.276 0.076 0.045 1.125 2.122 0.034

-0.810 0.347 0.120 -1.490 -0.130 -2.336 0.020

-1.00 -0.50 0.00 0.50 1.00

Favours Intervention Favours Control

Depression in Cognitive/ Behavioral / Mindfulness-Based Interventions

Meta Analysis

Fig. 5

Study name Statistics for each study Std diff in means and 95% CI

Std diff Standard Lower Upper

in means error Variance limit limit Z-Value p-Value

Astin, 1997 -1.263 0.518 0.268 -2.278 -0.248 -2.439 0.015

Jain et al, 2007 -0.734 0.274 0.075 -1.271 -0.197 -2.677 0.007

Jones et al, 2000 -1.481 0.272 0.074 -2.014 -0.948 -5.444 0.000

Kooken, 1984 -0.272 0.452 0.204 -1.157 0.613 -0.602 0.547

Lynch, 2007 -0.657 0.529 0.280 -1.695 0.380 -1.242 0.214

Oman, 2008 -0.335 0.322 0.104 -0.966 0.296 -1.041 0.298

Shapiro, 1998 -0.475 0.237 0.056 -0.940 -0.009 -1.999 0.046

Shapiro, 2011 -0.532 0.372 0.138 -1.260 0.197 -1.431 0.153

Warnecke, 2012 -0.758 0.279 0.078 -1.305 -0.210 -2.712 0.007

-0.728 0.140 0.020 -1.003 -0.453 -5.182 0.000

-1.00 -0.50 0.00 0.50 1.00

Favours Intervention Favours Control

Anxiety in Mindfulness-Based Trials

Meta Analysis

Fig. 4

C. Regehr et al. / Journal of Affective Disorders 148 (2013) 1–11 9


(Gaab et al., 2003) was conducted exclusively with male students

and reported positive results in terms of anxiety, depression, and

cortisol response when compared with the control condition.

Nevertheless, focusing on strategies that will appeal to young

men is an area for further development.

Finally, the meta-analysis in this review was limited to studies

examining the effectiveness of cognitive, behavioral, and

mindfulness-based interventions. While controlled studies were

conducted with respect to arts-based and educational interventions, there was insufficient data to perform meta-analyses of

these types of interventions. This represents an area for further


7. 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. The

favorable outcomes benefit not only individual students, but have

the potential to provide wide-spread benefits to universities in

terms of both enhancing student experience and reducing health

service costs resulting from student mental health problems.

Conflict of interest

No conflict declared.

Role of funding source

Nothing declared.


The authors do not have any acknowledgements to declare.


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