Journal of Affective Disorders 244 (2019) 196–208

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Predictors of depressive symptoms in college students: A systematic review T

and meta-analysis of cohort studies
Liu Yana, ,1, Zhang Ninga,1, Bao Guangyia,1, Huang Yubeib, Ji Bingyuana, , Wu Yilia,
⁎ ⁎

Liu Chuanxina, Li Gongyinga,

⁎

a
School of Mental Health, Shandong Key Laboratory of Behavioral Medicine, Jining Medical University, No. 133 Hehua Road, Jining, PR China
b
Cancer Molecular Epidemiology and Biostatistics Laboratory, Tianjin Medical University Cancer Institute & Hospital, Tianjin, PR China

ARTICLE INFO ABSTRACT

Keywords: Background: To explore predictors of depressive symptoms in college students.

College student Methods: We performed a systematic review and meta-analysis on the predictors of depressive symptoms.
Depressive symptom PubMed/Medline, Embase, Springerlink, EBSCOhost, Cochrane review, PsycINFO, China Knowledge Resource
Predictor Integrated Database, Weipu database and Wanfang database were searched for cohort or longitudinal studies.
Stata version 13.1 was used for statistical meta-analysis.
Results: Among 30 cohort studies, 24 studies covering 25,154 college students with the NOS of 6 and over were
selected for systematic review and 15 studies met the inclusion criteria for meta-analysis. The predictors of
depressive symptoms in college students were gender, baseline depression, neuroticism or psychoticism, nega-
tive automatic thoughts or negative rumination, dysfunctional attitude, childhood abuse, sex abuse, and stressful
life events. The combined risk ratios and its 95% confidence interval (CI) of each previous predictors were 1.11
(95% CI: 1.02, 1.21), 1.28 (95% CI: 1.10, 1.45), 1.25 (95% CI: 1.04, 1.45), 1.03 (95% CI: 1.01,1.05), 1.17 (95%
CI: 1.05, 1.29), 1.05(95% CI: 1.02,1.08), 1.01 (95% CI: 1.00,1.02), and 1.16 (95% CI: 1.04, 1.27), respectively.
Perceived social support and family function did not displayed significant predictive effects. Funnel plots showed
that publication bias was possible.
Limitations: Screening tools for depressive symptoms do not have the power or specificity of the gold standard
measures for depression like the Structured Clinical Interview (SCID) or the Composite International Diagnostic
Interview (CIDI) based on Diagnostic and Statistical Manual of Mental Disorders (DSM), which would influence
the study validity and the combined estimates.
Conclusions: Specific biological, psychological and environmental factors contribute to depressive symptoms in
college students. Consideration of these prognostic factors might be conducive to improve understanding and
management of future interventions against depressive symptoms among college students. Due to the highly
sophisticated course of depression, it is crucial to summarize theoretical frameworks for depressive symptom
interventions among college students.

1. Introduction
Depressive symptoms are extremely prevalent in college students
nowadays which is typically characterized by sad, loss of interest,
hopeless, nervous or anxious feelings and even suicidal ideation
(Kessler et al., 2003; Ceyhan et al., 2009; Tomoda et al., 2000; Wang
et al., 2017). According to the results of different meta-analyses, the
prevalence of depressive symptoms is higher among college students
compared to the general population or non-college students (Ibrahim
et al., 2013; Mikolajczyk et al., 2008; Blanco et al., 2008; Rotenstein
et al., 2016; Lei et al., 2016; Ovuga et al., 2006). The prevalence ap-
pears to be increasing (Acharya et al., 2018). College students in higher
education institutions are subjected to stressors not only from daily
lives, but from additional unique stressors to their curriculum and
campus lives. They are specifically a vulnerable group due to their
unique developmental stage in life, the nature of adjustment to the new
environment on campus, academic expectations, and the higher edu-
cation program (Ibrahim et al., 2013; Acharya et al., 2018).
Systematic reviews and meta-analysis on depressive symptoms in
college students have just focused on the prevalence. It showed that the

⁎
Corresponding authors.
E-mail addresses: hakunaly@163.com (Y. Liu), jby2006@126.com (B. Ji), ligongying2005@126.com (G. Li).
1
Yan Liu, Ning Zhang and Guangyi Bao were the Co-first authors in this study due to their equivalent contributions.

https://doi.org/10.1016/j.jad.2018.10.084
Received 16 July 2018; Received in revised form 11 September 2018; Accepted 5 October 2018
Available online 06 October 2018
0165-0327/ © 2018 Elsevier B.V. All rights reserved.
Y. Liu et al.
prevalence of depressive symptoms among college students was esti-
mated to be 33% (95% CI: 32% to 34%) (Sarokhani et al., 2013;
Ibrahim et al., 2013) and it was 27.2% (95% CI: 24.7% to 29.9%)
among medical students (Rotenstein et al., 2016). The overall pre-
valence of depression among Chinese university students was 23.8%
(95% CI: 19.9% to 28.5%) (Lei et al., 2016).
Previous researches indicate that a combination of genetic, biolo-
gical, psychological, interpersonal, environmental factors might be re-
sponsible for depressive symptoms in college students via a complicated
interaction pathway (Byrd and McKinney, 2012; Bulo and Sanchez,
2014; Deatherage et al., 2014; CONVERGE consortium., 2015; Major
Depressive Disorder Working Group of the Psychiatric GWAS
Consortium., 2013; Hyde et al., 2016; Xiao et al., 2018). In terms of
genetic factors, besides sex differences, family history and individual
depression history are the most powerful indices for future risk of de-
pressive symptoms or major depressive disorders (Maji, 2018; Adewuya
et al., 2018). Women's unique attachment patterns, relational self-
construal, as well as gender and personality traits, play important roles
in gender difference in depressive symptoms (Maji, 2018). Of these
factors, environmental and psychological factors such as immediate
surroundings (e.g., family raising and campus environmental factors),
life experiences and events, thoughts or attitude style, and resultant life
stressors are well known to affect the risk of depressive symptoms (Byrd
and McKinney, 2012; Bulo and Sanchez 2014; Deatherage et al., 2014;
Yu et al., 2015). Low financial condition, single living, low level of
closeness with parents or peers were also risk factors for depressive
symptoms among university students (Lee et al., 2013). However, there
was no systematic review and meta-analysis to discuss predictive fac-
tors of depressive symptoms among college students yet.
It is crucial to develop a better understanding of the predictive
factors that impede or facilitate onset of depressive symptoms in college
students. This would help to guide the development and formulation of
potential interventions and fast and sustained policies for students’
depression.
Therefore, the aim of this review is to systematically examine cur-
rent scientific evidence with respect to all the predictive factors from
cohort, prospective, followed-up and longitudinal studies for depressive
symptoms in college students.
2. Methods
2.1. Protocol and registration
This systematic review and meta-analysis were conducted in ac-
cordance with PROSPERO (International Prospective Register of
Systematic Reviews) guidelines. A protocol was developed and also
registered at the PROSPERO with a registered number of
CRD42018082554 (http://www.crd.york.ac.uk/PROSPERO).
2.2. Information source and literature search
A comprehensive search of electronic medical and psychological
databases was conducted to seek relevant articles on prognostic factors
for depressive symptoms among college students on May 10, 2018. We
carried out Boolean search techniques, e.g., (university student* OR
college student* OR undergraduate* OR academician OR university
man OR college-goer*) AND (depressi* OR depressive symptom* OR
depressive disorder* OR major depressive disorder* OR MDD OR de-
pressive state) AND (cohort OR follow-up OR followed-up OR panel OR
longitudinal OR prospective). The keywords and combinations of key-
words were listed in Table 1. Related references were also searched.
197
Journal of Affective Disorders 244 (2019) 196–208
2.3. Selection of studies
Two independent reviewers (N.Z. and G.B.) screened all articles.
And the two reviewers determined whether a study would be selected
in this systematic review and meta-analysis. Any discrepancy was re-
solved and figured out by a third reviewer (Y.L.). All studies reached a
consensus by discussion if there was any disagreement.
Inclusion criteria for this study were: (1) Participants consisted of
college students, who were18 years or older; (2) Studies included de-
pressive symptoms as a main or secondary outcome; (3) Studies de-
signed of longitudinal or retrospective cohort, followed-up or pro-
spective studies were included; (4) Languages and published periods
were not restricted.
Exclusion criteria for this study were: (1) Non-college students as
participants; (2) Cross-sectional studies, case-control studies, rando-
mized clinical trials were excluded; (3) No reports on depressive
symptoms in articles; (4) Risk ratios or relative risks (RR) and its 95%
CI (confidence interval) could not be calculated by information ex-
tracted from selected articles.
2.4. Definition of depressive symptoms and predictive factors
The main outcome was depressive symptoms, although it was
commonly reported as depression in most of the researches without
clinical diagnosis from psychiatrists. Most studies just used these de-
pression screen tools. We used the term of depressive symptoms as
outcome in this study. Depressive symptoms were usually based on self-
report and assessed by Center for Epidemiologic Studies Depression
Scale (CES-D) (Radloff, 1977; Whisman et al., 2000), Beck Depression
Inventory (BDI) (Beck, 1996; Smarr and Keefer, 2011), Patient Health
Questionnaire (PHQ-9 mostly) (Kroenke and Spitzer, 2002), Self-Rating
Depression Scale (SDS, Zung 1965) and Hamilton Rating Scale for De-
pression (HAMD) (Leucht et al., 2013; Melzer et al., 2012).
CES-D drawn up by Radloff (1977) consists of 20 items with four-
pointed scale (0 = almost none, 3 = almost always) with a range score
of 0–60. If CES-D scores are less than 16 it is defined as no depressive
symptoms, scores of 16–19 as potential depressive symptoms and more
than 19 as depressive symptoms.
BDI (BDI-II) is made up of 21 items with a score range from 0–63
based on four-pointed scale. The severities of depression are as follows:
no depression of scores less than 13, the mild depression is 14–19, the
moderate depression is 20–28 and the severe depression is 29–63.
PHQ-9 consists of 9 items with four-points criteria (0 = not at all,
3 = nearly every day). The cutoff point of no depression, mild de-
pression, moderate depression and severe depression is 5, 10, 15 and
20. While screening for depression, the Patient Health Questionnaire
(PHQ-2) can also be used with a cutoff point of 2.
SDS is a widely used instrument to measure depression. There are
20 items with a four-pointed scale (1 = not true at all, 4 = true all the
times) with a range score of 20–80. Standard scores for evaluation of
the severity of depression are as follows: normal scores with upper
limitation is 53, the moderate depression is 53–62, the severe depres-
sion is 62–72 and the extremely severe depression is higher than 72.
HAMD consists of 17 or 24 items (HAMD-17 or HAMD-24). For
some specific items, the scale is five-pointed (0–4). However, it is three-
pointed (0–2) for the other items. In terms of HAMD-17, the score
ranges of no depression, mild depression, moderate depression and
severe depression is <7, 7–17, 18–24 and >24, respectively. In terms
of HAMD-24, the related score ranges is <8, 8–20, 21–35 and >35.
In summary, the cutoff point for depressive symptoms of CES-D,
BDI, PHQ-9, SDS, HAMD-24 and HAMD-17 is 16, 13, 5, 53, 8 and 7,
respectively.
Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Table 1 The predictive factors identified in selected studies included de-

Keywords and key word combinations used in literature searching. mographic factors (gender), psychiatric factors (baseline depression,
Keywords-student related Keywords-depression Keywords-study design and SF12-mental function), psychological factors (neuroticism or psychoti-
related methods cism, dysfunctional attitude, negative automatic thoughts or negative
rumination, attribution style, coping style, perceived or utility of social
University student* Depressi* Cohort
support, low self-esteem, savoring, self-compassion) and environmental
College student* Depressive symptom* Followed-up
Undergraduate* Depressive disorder* Follow-up
factors (childhood abuse, sex abuse, stressful life events, family func-
Academician Major depressive Panel tion).
disorder*
University man MDD Longitudinal 2.5. Quality assessment- NOS criteria
College-goer* Depressive state Prospective

The quality of included studies was assessed by Newcastle–Ottawa

Scale (NOS) (Stang, 2010). It consists of eight items, divided into four

Fig. 1. Flow chart of selection process.

198
 Table 2
Characteristics of the studies included with NOS scores.
Y. Liu et al.

Study Published year Country Language Study design Follow-up period Sample size Outcome Inventorya Predictors Quality Meta-
Scores (9/ analysis
NOS) included

Chen et al. 2011 China Chinese Longitudinal 6 months 1427 Depressive PHQ-9 negative automatic thoughts, attribution 8 Yes
(Dissertation) symptoms style, SF 12-mental functioning,
psychological history, perceived social
support, neuroticism
Chou et al. 2018 Taiwan English Prospective 1 year 324 Significant BDI-II age, gender, psychological inflexibility/ 8 Yes
depression experiential avoidance (PI/EA)
including Problem-focused coping,
Emotion-focused coping and Less
effective coping
Ding et al. 2012 China Chinese Followed-up 6 months 254 Depressive CES-D gender, attribution style, coping style, 7 Yes
symptoms dysfunctional attitude, stressful life
events, social support
Ford et al. 2016 United States English Followed-up 5 weeks 133 Depressive CES-D baseline depressive symptoms, stressful 7 Yes
symptoms life events, savoring, self-compassion
He et al. 2014 China Chinese Followed-up 6 months 1427 Depressive PHQ-9 baseline depressive symptoms, 7 Yes
symptoms neuroticism, psychoticism, negative
automatic thoughts, attribution style, SF
12-mental functioning
Ito et al. 2006 Japan English Longitudinal 8 months 346 Depression Inventory to diagnose sex, baseline depressive symptoms, 7 Yes
depression-lifetime ruminative response, distractive
version, SDS response, negative rumination trait
Kassel et al. 2006 United States English Followed-up 8 weeks 322 Depressive Inventory to Diagnose age, sex, baseline depressive symptoms, 7 No
symptomatology Depression coping style, negative mood regulation

199
expectancies (NMRE)
Kelly et al. 2007 United States English Longitudinal 9 weeks 60 MDDb DSM-IV self-esteem 5 No
Kleiman et al. 2015 United States English Longitudinal 4 weeks 209 Depressive BDI-II negative cognitive style, hopelessness, 6 No
symptoms negative life events
Krahé and 2016 Germany English Longitudinal 12 months, 24 2425 Depressive BDI sex victimization 7 Yes
Berger months symptoms
Lara et al. 2000 United States English Longitudinal 6 months 84 MDDb DSM-IV, HAMD age, sex, race, education, age of onset, 6 No
prior MDEs, Axis Ⅰ comorbidity
Meghani and 2016 United States English Cohort 9 months 114 Depressive Boston 4 CES-D acculturation and enculturation 6 No
Harvey symptoms patterns, social support, coping strategy,
academic and financial concerns,
perceived degree of adjustment
Peñate et al. 2009 Spain Spanish Cohort 6 months 414 Depressive BDI-II need of achievement (a dysfunctional 7 Yes
symptoms attitude), neuroticism
Piumatti 2017 Switzland English Longitudinal 12 months 705 Depressive PHQ-2 baseline depression, positive motivation 6 Yes
symptoms attitudes
Sun 2013 China Chinese Longitudinal 6 months, 12 10,340 Depressive BDI grade, sex, satisfaction with major, 7 Yes
(Dissertation) months symptoms stressful life events, objective social
support, utility of social support, family
assessment device
Wang 2010 China Chinese Followed-up 1 month, 3 months 447 Depressive SDS sex, major 6 No
symptoms
Wang 2012 China English Followed-up Not reported 350 Depressive CES-D perceived family perfectionism, self- 6 No
symptoms esteem, achievement motivation
Yao et al. 2009 China Chinese Longitudinal 2, 4, 6, 8, 10, and 659 Depressive CES-D baseline depression, stressful life events, 7 Yes
12 months symptoms neuroticism
Yi et al. 2012 China English Followed-up 6 months 662 Depressive Mood and Anxiety anxious attachment, social hassles 7 No
symptoms Symptoms
(continued on next page)
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 Y. Liu et al.

Table 2 (continued)

Study Published year Country Language Study design Follow-up period Sample size Outcome Inventorya Predictors Quality Meta-
Scores (9/ analysis
NOS) included

Questionnaire—-Short
Form
Zhang et al. 2013 China Chinese Followed-up 4 months 206 Depressive BDI discrepancy, social prescribed 7 No
symptoms perfectionism subscales of maladaptive
perfectionism
Zheng et al. 2014 China English Followed-up 1 month, 2 659 Depressive CES-D daily hassles, low self-esteem 7 Yes
months, 3 months, symptoms
4 months, 5
months, 6 months
Zhong 2014 China Chinese Retrospective 4 years 569 Depressive CES-D childhood abuse (physical neglect) 8 Yes
cohort symptoms
(Dissertation)
Zhu et al. 2011 China Chinese Retrospective not reported 2374 Depressive BDI childhood abuse, neuroticism 6 Yes
cohort, cross- symptoms

200
sectional
Zhu et al. 2011 China Chinese Followed-up 1 month, 2 644 Depressive CES-D sex, baseline depression, stressful life 7 Yes
months, 3 months, symptoms events, dysfunctional attitude
4 months, 5
months, 6 months

PHQ-2: Patient Health Questionnaire-2

CES-D: Center for Epidemiologic Studies Depression Scale
DSM: Diagnostic and Statistical Manual of Mental Disorders
BDI: Beck Depression Inventory
HAMD: Hamilton rating scale for depression
SDS: Self-rating Depression Scale
a
PHQ-9: Patient Health Questionnaire-9
b
MDD: Major depressive disorder
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Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Table 3
The summary of meta-analysis results of different risk factors for depressive symptoms in college students.
Factors Pooled RR* 95% CI p value for Heterogeneity test Numbers of reports for
(Inverse-squared) meta-analysis
Lower level Upper level

Biological factors
Gender 1.11 1.02 1.21 0.067 4
Baseline depression 1.28 1.10 1.45 <0.001 7
SF12-mental function – – – – –
Psychological factors
Neuroticism or psychoticism 1.26 1.06 1.47 <0.001 6
Dysfunctional attitude 1.17 1.05 1.29 0.006 3
Negative automatic thoughts or negative rumination 1.03 1.01 1.05 0.10 3
Attribution style – – – – –
Coping style – – – – –
Perceived/utility of social support 0.93 0.85 1.02 <0.001 3
Low self-esteem – – – – –
Savoring – – – – –
Self-compassion – – – – –
Environmental factors
Childhood abuse (emotional or physical neglect, emotional or 1.05 1.02 1.08 <0.001 7
physical abuse, sex abuse included)
Sex abuse 1.01 1.00 1.02 0.52 3
Stressful life events 1.16 1.04 1.27 <0.001 4
Family function 0.96 0.91 1.01 0.052 5

⁎
Random effect model was used.

dimensions: (1) Selection of the study (4 items); (2) Comparability (1 for RR estimates. LBM was as follows:
item); (3) Exposure for case and control studies (2 items); (4) Outcomes
for cohort studies (1 item). All the studies can be awarded a maximum log P (Y = 1 | x1, …, x p) = 0 + 1 x1+…+ p x p

of one star for each item. And a maximum of two stars can be given for
comparability. Studies with the NOS ≥ 7 were recognized as high
quality. Studies with scores of 4–6 were recognized as moderate and
articles with NOS < 4 scores were considered as low quality and were
excluded.
In this study, we selected 6 as a cutoff point. Studies with NOS of 6
and over were selected for further analysis and studies with NOS < 6
were excluded.
2.6. Data synthesis
Using the selected articles after screening and NOS assessment, two
authors (Y.L. and N.Z.) made a data sheet independently and assessed
each studies included for the final combination. If there were any dis-
pute, the third person's (B.J.) proposal would be considered.
2.7. Statistical analysis
All statistical analyses were completed in Stata version 13.1 (Stata
Corporation, College Station, TX, USA) and Microsoft Excel 2013
(Microsoft Corporation, Redmond, WA, USA). For each predictor, if
there were more than 3 articles reported the same or related index, we
conducted a meta-analysis for this factor. Sensitivity analyses were also
conducted. Funnel plot of each factor was made to display the potential
publication bias (Biljana et al., 1999). All potential prognostic factors
for depressive symptoms in college students were reported in-
dependently.
The results of the meta-analysis on predictors of depressive symp-
toms were reported as pooled RR and associated 95% confidence in-
terval (CI). A two-sided p < 0.05 was considered statistically sig-
nificant. If the RR and its 95% CI were not reported directly in articles,
we calculated them by the coefficient and standardized error (SE) from
equations. The log binomial model (LBM) (Skov et al., 1998) was used
P = RR/ PR
In this study, we used ln(x) as the connection function. PR
(Prevalence ratio) meant the ratio of exposure population prevalence
and non-exposed group. In this study, we assumed PR = 1.
The calculation of 95% CI: ln(RR) ± u × SE(lnRR). So, the lower
level and upper level were calculated by: exp[ln(RR) ± u × SE(lnRR)]
and u = 1.96. Not only the logistic regression coefficients but also the
linear ones would be refined accordingly.
The heterogeneity of the included studies was evaluated using the
Cochran's Q test and the I2 test (Higgins and Thompson, 2002). I2 is the
proportion of total variation attributable to between-study hetero-
geneity as opposed to random error or chance. I2 values of over 25%,
50% and 75% were considered as low, moderate, and high hetero-
geneity, respectively. Given the outcomes included measured by dif-
ferent methods, we used the random effect model to calculate the
overall effect size and its 95% CI. The random effect meta-analysis as-
sumed that each study was estimated a study-specific true effect which
could be due to the between-study heterogeneity.
3. Results
3.1. Description of the included studies
5980 peer-reviewed articles were retrieved from eight electronic
databases using pre-defined search terms. The titles and abstracts of
these articles were screened and, as a result, 30 cohort articles were
selected for full text reading. With the NOS assessment, six articles were
excluded. 24 articles were collected for this systematic review (13 in
English, 1 in Spanish and 10 in Chinese included). And 15 articles were
used for meta-analysis ultimately, covering 6 in English, 1 in Spanish
and 8 in Chinese. No RCT and case-control studies were eligible. The
flow chart of screening process was showed in Fig. 1.

201
Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Fig. 2. Pooled estimates with 95% CI of predictive factors for depressive symptoms in college students (A: gender; B: baseline depression; C: neuroticism or
psychoticism; D: negative automatic thoughts or negative rumination; E: perceived or utility of social support; F: dysfunctional attitude; G: childhood abuse; H: sex
abuse; I: stressful life events; J: family function).
202
Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Fig. 2. (continued)

203
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Fig. 2. (continued)

204
Y. Liu et al.
Fig. 2. (continued)
The final 24 articles selected with the NOS of 6 and over totally
covered 25,154 college students. The publication period ranged from
2000 to 2018. 13 studies were conducted in China, 6 in United States,
and 1 in Japan, Spain, Taiwan, Switzerland, and Germany, respectively.
The longitudinal periods ranged from one month to four years. The
mean period of followed-up was 6.45 months (standard deviation,
SD = 3.86 months) without the extreme value of 4 years.
Actually, there was only 4 studies reported depression or major
depressive disorders. And all the others just reported depressive
symptoms, although it was also called depression in most of the studies.
Different inventories were used to measure depressive states, e.g.,
CES-D (Center for Epidemiologic Studies Depression Scale; 8 studies),
BDI (Beck Depression Inventory; 7 studies), PHQ (Patient Health
Questionnaire; 3 studies), SDS (Self-rating Depression Scale; 2 studies)
and HAMD (Hamilton rating scale for depression; 1 study), etc. Detailed
information is displayed in Table 2. The NOS quality scores are also
displayed in Table 2.
3.2. Predictors for depressive symptoms
Table 3 shows the results of predictive factors associated with de-
pressive symptoms in college students. Forest plots of predictors were
displayed in Fig. 2 (A–I). After the sensitivity analysis, all combined
effects of random effect models were shown independently (Table 3 and
Fig. 2). The meta-analysis results showed that gender (female), baseline
depression, neuroticism or psychoticism, negative automatic thoughts
or negative rumination, dysfunctional attitude, childhood abuse (emo-
tional or physical neglect, emotional or physical abuse, sex abuse in-
cluded), sex abuse independently, and stressful life events positively
predict depressive symptoms. The combined effects of corresponding
previous predictors via random effect models were as follows: 1.11
(95% CI: 1.02, 1.21), 1.28 (95% CI: 1.10, 1.45), 1.25 (95% CI: 1.04,
1.45), 1.03 (95% CI: 1.01, 1.05), 1.17 (95% CI: 1.05, 1.29), 1.05 (95%
CI: 1.02, 1.08), 1.01 (95% CI: 1.00, 1.02) and 1.16 (1.04, 1.27).
The combined effect of gender by fixed effect model was 1.06 (95%
CI: 0.73, 1.39) after excluding the Ding's study (Ding et al., 2012) based
on a sensitivity analysis.
Female college students with baseline depression, specific person-
ality characteristics (neuroticism or psychoticism), specific response
coping style (negative automatic thoughts, negative rumination), stress
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Journal of Affective Disorders 244 (2019) 196–208
coping (dysfunctional attitude) and the adverse childhood experience
were more susceptible to depressive symptoms.
Perceived or utility of social support (pooled effect = 0.93, 95% CI:
0.85, 1.02) and family function (pooled effect = 0.96, 95% CI: 0.91,
1.01) did not display significant associations with depressive symptoms
in college students. The heterogeneity of each prognostic factor is also
presented in Table 3. Random effect model were used for all the com-
bined effects.
We did not have sufficient numbers of studies to analyze the in-
fluence of SF 12-mental function, dysfunctional attitude, attribution
style, coping style, self-esteem, savoring, self-compassion and any other
predictive variables.
Table 4 displays the datasets we used for meta-analysis.
3.3. Funnel plots of predictors
Fig. 3 shows the publication bias for each predictive factor. Al-
though there were not enough studies for meta-analysis, we still re-
vealed the funnel plots of each predictor with 3 and over studies. There
were obvious publication biases for most of the predictive factors. We
should make cautious interpretation of the results of this study. 7 stu-
dies were included for the meta-analysis of baseline depression and
childhood abuse (emotional or physical neglect, emotional or physical
abuse, and sex abuse included), respectively. 6 reports were used for the
meta-analysis of neuroticism or psychoticism, 5 for family function
(abstracting from one study from five dimensions) and 4 for stressful
life events. There were only 3 studies were taken for the meta-analysis
of gender, negative automatic thoughts or negative rumination, dys-
functional attitude, perceived or utility of social support and sex abuse,
respectively.
4. Discussion
This systematic review and meta-analysis investigated the pre-
dictive factors for depressive symptoms among college students. The
pooled results showed that female students were more likely to suffer
from depressive symptoms. Students with previous depressive episodes,
neurotically or psychotically personality traits and negative coping
style with stressful life events were much prone to depressive symp-
toms.
Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Table 4 2018; Yi et al., 2012; Wang, 2012; Krahé and Berger, 2017; Peñate
Datasets of predictive factors (RR with 95% CI) for meta-analysis. et al., 2009; Lara et al., 2000).
Factors Study Year RR 95% CI Females were more vulnerable to depressive symptoms. Maybe this
LL UL could explain why nursing students have a higher prevalence (34.0%,
95% CI: 28.0%, 40%) (Tung et al., 2018) than that of general medical
Gender
students (27.2%, 95% CI: 24.7%, 29.9%) (Rotenstein et al., 2016).
Ito et al. 2006 1.120 0.440 2.870
Sun 2013 1.138 1.039 1.245
Baseline depressive states accounted for the greatest weight for the
Zhu et al. 2011 1.522 1.008 2.297 prediction of future depressive symptoms, followed by personality traits
Ding et al. 2012 0.390 0.230 0.690 (e.g., neuroticism and psychoticism), stressful life events, gender,
Chou et al. 2018 0.669 0.392 1.141 childhood abuse (sex abuse included), and negative thoughts or rumi-
Baseline depression
nation (Adewuya et al., 2018; Yu et al., 2015; Chou et al., 2018; Ito
He et al. 2014 1.130 1.020 1.260
Ford et al. 2014 1.840 1.492 2.248 et al., 2006; Kassel et al., 2006; Piumatti, 2018; Yi et al., 2012; Wang,
Ito et al. 2006 1.060 0.980 1.140 2012; Krahé and Berger, 2017; Peñate et al., 2009; Lara et al., 2000).
Piumatti 2017 1.350 1.046 1.742 Sexual abuse was also an independent predictor for depressive symp-
Yao et al. 2009 27.380 16.130 46.480
toms among college students. All these factors could predict in-
Zheng et al. 2014 1.323 1.272 1.376
Zhu et al. 2011 43.380 27.102 69.436
dependently depressive symptoms.
Neuroticism or psychoticism As the protective factors, perceived social support and family
He et al. 2014 1.040 1.010 1.070 function did not display significant predictive effects in this study. We
He et al. 2014 1.040 1.010 1.070 assumed that it was due to not enough studies included. And the results
Chen 2011 1.023 0.991 1.055
of family functions were abstracted from only one study. For other
Peñate et al. 2009 1.568 1.434 1.715
Yao et al. 2009 6.110 3.600 10.373 predictors, such as dysfunctional attitude, attribution style, coping
Zhu et al. 2011 1.586 1.543 1.630 style, self-esteem and self-compassion, we should conduct further re-
Negative automatic thoughts or negative rumination searches.
He et al. 2014 1.020 1.000 1.040 To our knowledge, this is the first meta-analysis for predictive fac-
Chen 2011 1.026 1.008 1.044
Ito et al. 2006 1.090 1.000 1.120
tors of depressive symptoms among college students. However, there
Dysfunctional attitude are some limitations the meta-analysis may come across that might
Peñate et al. 2009 1.150 1.038 1.275 affect the outcomes. First, limited databases were searched for litera-
Zhu et al. 2011 3.456 2.159 5.531 tures collection, although there were no languages and publication
Ding et al. 2012 2.390 1.400 4.080
period restrictions. Secondly, different screening methods for depres-
Perceived/uutility of social support
Chen 2011 1.029 0.996 1.063 sive symptoms were utilized, such as BDI, CES-D, SDS, etc., which may
Sun 2013 0.936 0.923 0.949 be inadequately sensitive to the recent phenomenon in college setting
Sun 2013 0.842 0.821 0.863 and subsequently affected the pooled effects. These tools do not have
Childhood abuse the power or specificity of the gold standard measures for depression
Krahé and Berger 2016 1.017 1.006 1.036
Krahé and Berger 2016 1.009 1.001 1.023
like the Structured Clinical Interview (SCID) or the Composite
Zhong 2014 1.078 0.920 1.263 International Diagnostic Interview (CIDI) based on Diagnostic and
Zhong 2014 1.143 0.981 1.332 Statistical Manual of Mental Disorders, the third revision (DSM-Ⅲ-R)
Zhong, 2014 1.067 0.993 1.272 (Acharya et al., 2018; Smarr and Keefer, 2011). Finally, we used not
Zhong 2014 1.145 1.020 1.285
only logistic regression coefficients but the linear regression coefficients
Zhu et al. 2011 1.146 1.085 1.210
Sex abuse for the translation of RR and its 95% CI calculations, which would in-
Krahé and Berger 2016 1.017 1.006 1.036 fluence the pooled effects.
Krahé and Berger 2016 1.009 1.001 1.023 Biological, psychological and environmental factors contribute to
Zhong 2014 1.078 0.920 1.263 depressive symptoms in college students accordingly. Consideration of
Sressful life events
Ford et al. 2014 1.259 1.185 1.350
these prognostic factors may be conducive to improve understanding
Sun 2013 1.297 1.259 1.336 and management of future interventions against depressive symptoms
Yao et al. 2009 1.041 1.021 1.061 among college students. Due to the highly sophisticated course of de-
Zhu et al. 2011 1.041 1.021 1.061 pression, it is crucial to summarize theoretical frameworks for depres-
Family function
sive symptoms interventions among college students according to these
Sun 2013 0.982 0.908 1.063
Sun 2013 1.024 0.947 1.106 predictors. Without proper and prompt treatment or intervention, de-
Sun 2013 0.901 0.836 0.970 pressive symptoms may lead to severe adverse effects in life
Sun 2013 0.897 0.825 0.975 (Jiang et al., 2015).
Sun 2013 1.005 0.922 1.096 The study results of predictors of depressive symptoms in college
students would be crucial to potential interventions against depression.
More cohort studies are needed to verify the causal relationships be-
tween predictive factors and depressive symptoms among college stu-
Previous studies have consistently revealed the impacts of in- dents. Future researches should also determine whether interventions
dividual characteristics (e.g., gender), clinical characteristics (e.g., that reduce depression in college students carry over in their effec-
previous depression), psychological factors (e.g., neuroticism or psy- tiveness when those students transition to workplaces (Rotenstein et al.,
choticism, negative automatic thoughts or negative rumination, dys- 2016).
functional attitude) and environmental or social factors (e.g., abuse
experience, stress experience) on depressive symptoms in college stu-
dents (Chou et al., 2018; Ito et al., 2006; Kassel et al., 2006; Piumatti,

206
Y. Liu et al. Journal of Affective Disorders 244 (2019) 196–208

Fig. 3. A: Funnel plots of gender and depressive symptoms studies. B: Funnel plots of baseline depression and depressive symptoms studies. C: Funnel plots of
neuroticism or psychoticism and depressive symptoms studies. D: Funnel plots of negative automatic thoughts or negative rumination and depressive symptoms
studies. E: Funnel plots of perceived or utility of social support and depressive symptoms studies. F: Funnel plots of dysfunctional attitude and depressive symptoms
studies; G: Funnel plots of childhood abuse and depressive symptoms studies. H: Funnel plots of sex abuse and depressive symptoms studies. I: Funnel plots of
stressful life events and depressive symptoms studies. J: Funnel plots of family function and depressive symptoms studies.

Acknowledgments Supplementary materials

This study was funded by the National Natural Science Foundation
Cultivation Project of Jining Medical University (Grant number:
JYP201701, PI: Yan Liu), the Natural Science Foundation of Shandong
Province (Grant number: ZR2011HM023, PI: Gongying Li) and the
National Natural Science Fund (Grant number: 81571334, PI: Gongying
Li). The funders had no role in the design and conduction of this study.
Contributors
Yan Liu, Ning Zhang and Guangyi Bao, the first authors, take the
responsibility of writing this manuscript. Yan Liu, Bingyuan Ji,
Chuanxin Liu and Gongying Li contribute hugely in the study design.
Ning Zhang and Guangyi Bao do mainly literature searches and
screening. Ning Zhang and Yubei Huang conduct the meta-analysis
construction. Yili Wu and Gongying Li proofread the English revision.
Yan Liu, Bingyuan Ji and Gongying Li, the corresponding authors, take
all the responsibility of collecting all the information from the other
authors, revise the manuscript, and submit the manuscript.
Ethical standards
The manuscript does not contain patients or population data.
Conflict of interest
The authors report no conflicts of interest.
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2018.10.084.
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