Accepted Manuscript

Interventions for common mental health problems among university and college
students: A systematic review and meta-analysis of randomized controlled trials

Junping Huang, Yeshambel T. Nigatu, Rachel Smail-crevier, Xin Zhang, Jianli Wang

PII: S0022-3956(17)31362-6
DOI: 10.1016/j.jpsychires.2018.09.018
Reference: PIAT 3470

To appear in: Journal of Psychiatric Research

Received Date: 12 December 2017

Revised Date: 28 September 2018
Accepted Date: 28 September 2018

Please cite this article as: Huang J, Nigatu YT, Smail-crevier R, Zhang X, Wang J, Interventions for
common mental health problems among university and college students: A systematic review and
meta-analysis of randomized controlled trials, Journal of Psychiatric Research (2018), doi: https://
doi.org/10.1016/j.jpsychires.2018.09.018.

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3 Interventions for Common Mental Health Problems among University and College

4 Students: A Systematic Review and Meta-analysis of

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5 Randomized Controlled Trials

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7 Junping Huang1, Yeshambel T. Nigatu2, Rachel Smail-crevier2, Xin Zhang1, Jianli Wang2,3,4,5

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8

9
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10 1. Department of Child and Adolescent Health, School of Public Health, Tianjin Medical University, China
11 2. Work & Mental Health Research Unit, The Royal’s Institute of Mental Health Research.
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12 3. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa

13 4. School of Psychology, Faculty of Social Sciences, University of Ottawa
14 5. Department of Psychiatry, Faculty of Medicine, University of Ottawa.
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19 Correspondence:
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20 Jianli Wang
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21 Work & Mental Health Research Unit,

22 University of Ottawa Institute of Mental Health Research.
23 1145 Carling Ave, Ottawa, ON K1Z 7K4
24 Canada
25 Email: Jianli.Wang@theroyal.ca
26 Phone number: +1(613)722-6521 ext. 6057

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28
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29 ABSTRACT:

30 Common mental health problems (CMHPs), such as depression, anxiety disorder, obsessive-compulsive disorder (OCD),

31 and post-traumatic stress disorder (PTSD) are internalizing disorders with high comorbidity. University and college

32 students are under many stressors and transitional events, and students fall within the age range when CMHPs are at their

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33 developmental peak. Compared to the expanded effort to explore and treat CMHPs, there has been no a meta-analysis

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34 that comprehensively reviewed the interventions for CMHPs and examined the effects of interventions for CMHPs in

35 college students. The objective of this review is to conduct a systematic review and meta-analysis of randomized

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36 controlled trials (RCTs) examining interventions for CMHPs among university and college students and to estimate their

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post-intervention effect size (ES), as well as follow-up ES, for depression, anxiety disorder, OCD and PTSD separately.
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38 Meta-analytic procedures were conducted in accordance with PRISMA guidelines. We reviewed 7768 abstracts from

39 which 331 full-text articles were reviewed and 51 RCTs were included in the analysis. We found moderate effect sizes
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40 for both depression (Hedges’ g = -0.60) and anxiety disorder (Hedges’ g = -0.48). There was no evidence that existing
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41 interventions for OCD or PTSD were effective in this population. For interventions with high number of papers, we
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42 performed subgroup analysis and found that cognitive behavioral therapy (CBT) and mindfulness-based interventions

43 were effective for both depression and generalized anxiety disorder (GAD), and attention/perception modification was
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44 effective for GAD; other interventions (i.e. art, exercise and peer support) had the highest ES for both depression and
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45 GAD among university and college students.

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46

47 Keywords:

48 Intervention; depression; anxiety disorder; obsessive-compulsive disorder (OCD); post-traumatic stress disorder (PTSD);

49 meta-analysis

50
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51 INTRODUCTION

52 Common mental health problems (CMHPs), including depression, anxiety disorder, obsessive-compulsive disorder

53 (OCD) and post-traumatic stress disorder (PTSD) are internalizing disorders, which represent overlapping variations of

54 emotional distress in response to life stressors and difficulties (Nigatu et al., 2016). Anxiety disorders including

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55 generalized anxiety disorder (GAD), social anxiety, panic disorder, agoraphobia and specific phobia share the features of

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56 excessive fear and anxiety. CMHPs can negatively affect the entire life course of patients, causing substantial

57 psychological, cognitive, social and occupational impairments (APA, 2013). CMHPs are also associated with significant

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58 long-term disability. Individuals with CMHPs usually experience a lifelong pattern of relapse and remission (NICE,

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2011). Seventy-five percent of those who have a mental disorder had their first onset by the age of 25 years (Kessler et
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60 al., 2007), which is a pivotal time period of one’s life course in terms of pursuing post-secondary education and entering

61 the work force.

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63 CMHPs are common and highly comorbid disorders. Of those aged 16 to 64 years who meet the diagnostic criteria for at
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64 least one CMHP, more than half experience comorbid anxiety or depressive disorders (NICE, 2011). In the Netherlands
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65 Study of Depression and Anxiety (NESDA), among persons with a depressive disorder, 67% had a current and 75% had
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66 a lifetime comorbid anxiety disorder. Of persons with a current anxiety disorder, 63% had a current and 81% had a

67 lifetime depressive disorder (Lamers et al., 2011). Research has also indicated that greater levels of anxiety sensitivity are
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68
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a higher-order cognitive risk-factor for both OCD and PTSD (Olatunji and Wolitzky-Taylor, 2009). It is practical, as well

69 as important, to aggregate common mental health problems to find out how effectively the interventions work.

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71 University and college students may be at higher risk of developing CMHPs because they are often under significant

72 stress, are in a transitional period, and fall within the age range when CMHPs are at their developmental peak (Cuijpers

73 et al., 2016). Cumulative data from the American College Health Association (ACHA) surveys conducted from 1998
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74 through 2008 suggested that the prevalence of clinically significant depression among university and college students is

75 rising over time (ACHA, 2009). The same prevalence trend was found by the Center for Collegiate Mental Health, which

76 reported year-over-year increases in the frequency of anxiety and depression (CCMH, 2017). In addition, according to

77 the 2016 survey by the Association for University and College Counseling Center Directors (AUCCCD) among 529

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78 counseling centers, anxiety continues to be the most predominant concern among college students with an annual

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79 prevalence of 51%, followed by depression with a annual prevalence of 41% (AUCCCD, 2016). A systematic review of

80 studies among university and college students found that reported depression prevalence rates ranged from 10% to 85%

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81 with a weighted mean prevalence of 30.6% (Ibrahim et al., 2013). OCD and PTSD were also often reported among

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college and university students. Sulkowski et al. (2011) found that, although only 5% of students displayed clinically
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83 significant OCD symptoms, obsessive-compulsive spectrum disorder (OCSD) symptoms were relatively common in

84 college students (22%~42%), and those with OCSD symptoms had higher anxiety. Similarly, a study of community
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85 college students indicated that 12.6% of non-veteran students were above the cut-off score on a PTSD screening
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86 instrument (Fortney et al., 2016). CMHPs that are left untreated in students could result in negative outcomes, including
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87 lower self-esteem, social withdrawal, poor academic performance, and, in severe cases, suicide. CMHPs also have a

88 negative impact on later occupational trajectories and as well as an enormous economic impact over the life course
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89 (Blanco et al., 2014).

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91 The mental health challenges faced by university and college students call for effective interventions for CMHPs.

92 Various interventions have been developed, including antidepressant medication, psychotherapies, physical exercise, art

93 therapy, etc. Interventions can be delivered individually, in a group, in a guided self-help, or Internet-based format. These

94 interventions differ from each other with regard to content, methods, and results. Increasingly, various interventions for

95 the treatment of CMHPs have been explored in the past 2 decades, yet there has been no a meta-analysis that
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96 comprehensively reviewed or examined the effectiveness of interventions for CMHPs in college and university students.

97 It is unclear whether the current interventions are effective for the vast majority of students that suffer from CMHPs and,

98 for this reason, a review of these interventions is essential in order to establish interventions that are appropriate for

99 college students. .

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100

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101 There have been several systematic (Reavley and Jorm 2010; Farrer et al., 2013; Shiralkar et al., 2013; Fernandez et al.,

102 2016) and meta-analytic (Davies et al., 2014) reviews on preventive interventions in university and college students’

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103 mental health problems. For example, a meta-analytic review on psychological intervention to decrease depression

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among college students was recently published (Cuijpers et al., 2016). In this meta-analysis, 8 of the 15 included papers
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105 were published between 1977~1993 and the author noted that the risk of bias in these studies was high and the number of

106 studies was relatively low, reducing the ability to carry out powerful moderator analyses. Based on these findings and
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107 upon the high comorbidity of CMHPs, we propose to conduct a systematic review and meta-analysis to examine the
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108 effects of interventions for CMHPs in college students after 2000. In our paper, we will calculate the post-intervention
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109 ES for depression, anxiety, OCD and PTSD separately, as well as follow-up ES. We will also seek to identify factors that

110 may contribute to the intervention effect.

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111
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112 METHOD
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113 Protocol and registration

114 This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for

115 Systematic Reviews and Meta-analyses (PRISMA) guidelines (Moher et al., 2010) and the Consolidated Standards of

116 Reporting Trials Statement (CONSORT) (Schulz et al., 2010). A protocol was developed prior to this review and was

117 registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/ (CRD42017064487).

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119 Data Sources and Study Selection

120 We selected randomized controlled trials (RCTs) of interventions in university or college students with depression,

121 anxiety disorder (including GAD, social anxiety, panic disorder, agoraphobia and specific phobia), obsessive-compulsive

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122 disorder (OCD) or post-traumatic stress disorder (PTSD) using a comprehensive search strategy. We searched the

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123 following databases: Pubmed/Medline, Embase, ERIC, PsycARTICLES, PsycINFO and CENTRAL (see Supplementary

124 Appendix for search terms). Two authors independently reviewed the abstracts and articles with a 97.7% level of

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125 agreement (Kappa = 0.713). In the event of a difference in opinion among authors, the authors discussed until reaching

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an agreement. In addition, we searched GreyOpen, GreyMatters and used advanced searches in Google and Yahoo to
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127 find unpublished reports, abstracts, briefs and preliminary reports. We also screened the reference lists of identified

128 articles and published reviews in this field.

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129
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130 Inclusion Criteria

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131 Studies meeting the following inclusion criteria were selected for the meta-analysis: 1) target population were university

132 or college students; 2) health conditions intervened included: depression, anxiety disorder, OCD or PTSD; 3) randomized
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133 controlled trial design; 4) control was no treatment, waitlist or placebo control; 5) outcomes (depression, anxiety, OCD,
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134 PTSD) were assessed with a validated instrument; 6) a minimum of 10 participants in each experimental group; 7) being
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135 written in English and published between Jan, 2000 - May, 2018. Excluded from the review and meta-analysis were: 1)

136 studies with controlled clinical trials (CCT) or quasi-experimental design; 2) interventions for high stress,

137 test/performance anxiety, bipolar disorders or psychotic symptoms; 3) pilot studies.

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139 Methodological quality

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140 We used the Consolidated Standards of Reporting Trials (CONSORT) statement 2010 (Schulz et al., 2010) to assess the

141 methodological quality of included RCTs. CONSORT 2010 contains 25-items, including detailed description of trial

142 design, detailed description of rigorous randomization methodology, power analysis, etc. Methodological quality was not

143 used as a criterion to select studies.

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144

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145 Data Extraction, Coding, and Processing

146 Data extraction was performed using a template based on the Cochrane Review template (Higgins and Green, 2011). We

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147 extracted the following data from each article using a data extraction form: study characteristics (title, author, publishing

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year, geographic location, category of CMHP), participants (age, gender, grade, ethnicity distribution, inclusion and
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149 exclusion criteria, incentive of participation or not), study design (RCT design, number of trial arms, method of

150 randomization, allocation sequence concealment, blinding, sample size and number allocated to each trial arm, attrition),
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151 intervention (intervention name, number of sessions, format and control conditions), results (outcome name and
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152 definition, pre-, post- and follow-up results). Most of these variables were included in this meta-analytic review, except a
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153 few omitted variables (e.g., grade and ethnicity which were poorly reported). Double check was also applied with high

154 level of agreement (correlation = 0.921~1.0). If there were multiple reports of the same study, we extracted data from all
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155 reports directly into a single data extraction form. If the study adopted placebo as well as no treatment/waitlist as control,
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156 we chose placebo control, excluding other control conditions. Based on the number of included studies, only depression
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157 and generalized anxiety disorder (GAD) had sufficient papers to conduct subgroup and moderator analysis. Moderators

158 are described below. Geographic location was distributed among these 4 regions: North America, Europe, Asia, and

159 Australia. Interventions were classified into 4 categories: 1) cognitive and behavioral related interventions (interventions

160 based on cognitive or behavioral therapy (CBT), as well as comprehensive therapy based on CBT); 2) mindfulness-based

161 interventions; 3) attention/perception modifications; 4) other interventions (e.g., supplement, exercise, music, peer
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162 support and personalized feedback). Interventions were also classified as easy to disseminate or not. Those with a

163 single-session intervention, bibliotherapy, unguided online CBT intervention, homework, self-help intervention,

164 personalized feedback, and writing sessions were defined as easy to disseminate, while face-to-face interventions and

165 guided online interventions with several sessions were classified as not. Incentive of participation includes those who

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166 received research certificates, course certificates or financial offsets from attending the research.

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167

168 Risk of bias of the randomized studies was assessed using a modified version of the Cochrane Collaboration’s risk of bias

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169 tool (Higgins and Green, 2011). The tool provides a checklist to aid understanding of trial quality and does not calculate

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an overall quality score. It assesses study biases, including random sequence generation (selection bias), allocation
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171 concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment

172 (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias) and other biases. We coded
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173 according to the principles written in the Cochrane Handbook for Systematic Reviews of Intervention (Higgins and
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174 Green, 2011). All of the studies used a self-reported scale as an outcome measure, so performance bias was similar to
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175 detection bias. For those using placebo controls, we classified blinding as low risk. If the study allocated participants on

176 the basis of a random table using a computer system, sequence generation and allocation concealment were both rated as
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177 low risk.

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178
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179 Effect Size Calculation

180 The Standardized Mean Difference (SMD) is a version of ES typically calculated in reviews and is expressed as Hedges’

181 g. SMDs were calculated for each included study by subtracting the post-intervention mean of the intervention condition

182 from the post-intervention mean of the comparison condition, and dividing this by the pooled standard deviation from

183 both conditions (Higgins and Green, 2011). When an intervention reduced negative emotions more than the control,
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184 Hedges’ g had a negative value. The use of SMD allows comparisons across studies where different psychometric

185 measures were used to assess the same outcomes (Higgins and Green, 2011). Hedges’ g yields an unbiased estimate even

186 though the sample size is small (Hedges and Olkin, 1985). Inferences of Hedges’ g can be made using Cohen’s d

187 conventions as small (0.2), medium (0.5), and large (0.8) (Cohen, 1998).

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188

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189 The intervention effect for depression, anxiety, OCD and PTSD was calculated separately by pooling the corresponding

190 estimates using random-effects meta-analyses that accounted for between-study heterogeneity. Pooled follow-up effects

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191 were calculated using the same approach. Standard χ2 tests and the I2 statistic were used to assess between-study

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heterogeneity. I2 statistic means the percentage of variability in intervention estimates due to heterogeneity rather than
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193 sampling error, or chance, with the values of 25% indicating low heterogeneity, 50% suggesting moderate, and 75%

194 indicating considerable heterogeneity (Higgins et al., 2003). Subgroup analysis and random-effects meta-regression (van
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195 Houwelingenet al., 2002) were performed to further explore the heterogeneity and to identify the moderators. Geographic
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196 location, intervention type, easy to disseminate or not, control conditions and the inclusion of participation incentive or
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197 not were the main factors that were considered. Forty-six out of 51 studies over-represented female participants, so we

198 did not include gender as a moderator. Publication bias was investigated using funnel plots and the Egger and
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199 trim-and-fill tests. All analyses were performed using STATA 15.0.
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200
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201 RESULTS

202 Description of included studies

203 Figure 1 presents a flow diagram of the study selection process. We retrieved 7768 peer-reviewed articles from 6 main

204 databases. The titles and abstracts of these articles were examined, and 331 articles were selected. The full texts of these

205 papers were subsequently examined and 51 RCT studies were retained. Supplementary Table 1 presents the studies
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206 included in this review and meta-analysis. We organized the data according to CMHPs categories, e.g. depression,

207 anxiety, OCD or PTSD. Studies that included either depression or anxiety with both depression and anxiety outcome

208 measures were listed first. Within each category, we organized according to publishing year and alphabetically by the

209 first author’s family name.

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211 Three studies (Wu, 2002; Day et al., 2013; Falsafi, 2016) included interventions for students with either depression or

212 anxiety, all of which had outcome measures of both depression and anxiety; 6 studies (Clore, 2008; Hinton and Gaynor,

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213 2010; Ellis et al., 2011; Lintvedt et al., 2013; Kim et al., 2016; Levin et al., 2016) included students with psychological

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distress, 3 of which (Ellis et al., 2011; Kim et al., 2016; Levin et al., 2016) had outcome measures of both depression and
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215 anxiety, with the latter 3 having only outcome measure of depression; 22 studies (Peden et al., 2001; Gawrysiak et al.,

216 2009; Geisner et al., 2009; Hamdan-Mansour et al., 2009; McMakin, 2009; Wells and Beevers, 2010; Armento, 2011;
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217 McMakin et al., 2011; Charbonneau, 2012; Penton-Voak et al., 2012; Moldovan et al., 2013; Walker and Lampropoulos,
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218 2014; Chen et al., 2015; Geisner et al., 2015; Ginty and Conklin, 2015; Yang et al., 2015; Li et al., 2016; McIndoo et al.,
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219 2016; Takagaki et al., 2016; López-Rodríguez et al., 2017; Mastikhina and Dobson, 2017; Yang et al., 2018) included

220 only students with depression. Fifteen papers included students with anxiety disorders, among them, 6 studies (Kenardy
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221 et al., 2003; Smits et al., 2008; Morris et al., 2016; Richards et al., 2016; Chaló et al., 2017; Xu et al., 2017) included
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222 students with GAD, 6 studies (Beard and Amir, 2008; Bjornsson et al., 2011; Lee and Kwon, 2013; Yao et al., 2015;
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223 Norton and Abbott, 2016; Ye, 2017) included students with social anxiety, and 3 studies (Vansteenwegen et al., 2007;

224 Olatunji et al., 2012; Cougle et al., 2016) included students with specific anxiety. One study (Timpano et al, 2016)

225 included students with OCD, and 4 studies (Lange et al., 2001; Sloan et al., 2011; Callinan et al., 2014; Allan et al.,

226 2015) included students with PTSD. Five of the studies including students with depression (Gawrysiak et al., 2009;

227 Armento, 2011; Yang et al., 2015; Li et al., 2016; McIndoo et al., 2016), and 4 of the studies that included students with
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228 GAD (Kenardy et al., 2003; Smits et al., 2008; Morris et al., 2016; Richards et al., 2016) reported both depression and

229 anxiety outcome measures. For these papers, because their pre-intervention anxiety (depression) mean was also above

230 their corresponding cut-off, we included the latter as an independent ES. For papers dealing with social/specific anxiety,

231 OCD or PTSD, we only chose its specific corresponding outcome measure. In total, we included 51 studies, 59

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232 interventions and 77 post-intervention ESs for this review. We analyzed intervention effect for depression, anxiety, OCD

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233 and PTSD separately.

234

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235 Seventeen studies (Peden et al., 2000; Wu, 2002; Kenardy et al., 2003; Smits et al., 2008; Hamdan-Mansour et al., 2009;

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Wells and Beevers, 2010; Armento, 2011; Charbonneau, 2012; Moldovan et al., 2013; Allan et al., 2015; Yang et al.,
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237 2015; Yao et al., 2015; Falsafi, 2016; McIndoo et al., 2016; Timpano et al., 2016; Mastikhina and Dobson, 2017; Yang et

238 al., 2018) reported long-term follow-up results. Long-term follow-up results indicate whether the intervention effect is
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239 sustained over time following the completion of the intervention. The duration of follow-up ranged from 2 weeks to 7
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240 months post-intervention. Of the 51 studies that were included, 26 were from North America, 10 from Europe, 12 from
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241 Asia and 3 from Australia. There were a total of 3396 university or college students included in the studies. One study on

242 depression (Yang et al., 2018) and 3 studies on social anxiety (Bjornsson, 2010; Lee and Kwon, 2013; Norton and
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243 Abbott, 2016) included participants that met M.I.N.I. or DSM-IV criteria for the disorder, whereas in the remaining
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244 studies, participants were included if they met criteria for depression or anxiety disorder based on self-reported scales.
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245 The age of participants ranged from 16 to 50 years old, and the mean age was between 18.9 and 28.2 years old. Forty-six

246 of the 51 studies over-represented females with the percentage ranging from 62% to 100%. Further characteristics of the

247 studies are shown in Table 1 in the supplementary appendix and more information about included studies is available

248 upon request.

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250 Many studies examined the effect of cognitive-behavioral related interventions on depression and GAD (24/42 ESs were

251 for depression and 11/21 ESs were for GAD). Interventions for social anxiety included attention/perception modification

252 (Beard and Amir, 2008; Yao et al., 2015), imagery rescript (Lee and Kwon, 2013; Norton and Abbott, 2016),

253 mindfulness (Ye, 2017) and cognitive behavioral group therapy (CBGT) (Bjornsson et al., 2011; Norton and Abbott,

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254 2016). Among the studies targeting specific anxiety, all interventions were exposure-based. One paper (Keough and

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255 Schmidt, 2012) targeting OCD symptoms adopted anxiety sensitivity education and reduction training. Interventions that

256 targeted posttraumatic stress included attention training (Callinan et al., 2014), anxiety sensitivity education and

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257 reduction training (Allan et al., 2015), Interapy treatment (Lange et al., 2001) and written emotional disclosure (Sloan et

258 al., 2011). US

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260 Methodological quality

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261 The average overall compliance with the CONSORT checklist of the included studies was 55.5% (95% CI, 53.2~57.7%).
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262 Ten papers (19.6%) had a compliance of over 60% and 4 papers (7.8%) had a compliance of less than 45%. Most
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263 relevant descriptors from the checklist were determined to be methodologically adequate except identification as a

264 randomised trial in the title (51.9%), sample size (27.5%), sequence generation (56.9%), allocation concealment (39.2%),
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265 implementation (27.5%), blinding (35.3%), baseline database (43.1%), registration (5.9%) and funding (35.3%). Only 1
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266 paper reported its protocol (2.0%).

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267

268 Interventions for depression

269 Figure 2 shows meta-analysis results of intervention for depression by different interventions. Hedges’ g for overall

270 post-intervention for depression was -0.60 (95% CI: -0.74, -0.46). The pooled ES (Hedges’ g) of other interventions (i.e.

271 art, exercise and peer support) was higher (-0.76, 95% CI: -1.19, -0.32) than cognitive-behavioral related interventions
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272 (-0.59, 95% CI: -0.72, -0.45), mindfulness-based interventions (-0.52, 95% CI: -0.88, -0.16) and attention/perception

273 modification (-0.46, 95% CI: -1.06, 0.13). The ESs were statistically significant for cognitive-behavioral related

274 interventions, mindfulness-based interventions and other interventions for depression. We failed to find statistical

275 significance for the intervention of attention/perception modification for depression (p > 0.05).

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276

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277 As for subgroup analysis, Hedges’ g for easy to disseminate interventions (-0.37, 95% CI: -0.58,-0.17) was smaller than

278 that of not easy to disseminate interventions (-0.70, 95% CI: -0.88, -0.52). For geographic location, Hedges’ g for

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279 depression intervention was largest in Asia: -0.94 (95% CI: -1.27, -0.62), followed by Australia: -0.77 (95% CI: -1.16,

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-0.38), North America: -0.58 (95% CI: -0.77, -0.38), and Europe: -0.29 (95% CI: -0.53, 0.04). For control condition, no
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281 treatment had the largest effect (-0.68, 95% CI: -0.93, -0.43), followed by the waitlist (-0.55, 95% CI: -0.71, -0.39), and

282 placebo control (-0.52, 95% CI: -0.87, -0.18). Hedges’ g for interventions with incentive (-0.58, 95% CI: -0.79, -0.37)
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283 was similar with interventions without incentive (-0.63, 95% CI: -0.84, -0.43). To further explore the possible factors that
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284 caused heterogeneity, we performed meta-regression analysis by moderators. We failed to find any moderators that
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285 affected the effect size of the intervention with statistical significance.

286
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287 Hedges’ g for overall long term follow-up intervention for depression was -0.68 (95% CI: -0.89, -0.48). The follow-up
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288 pooled ES (Hedges’ g) of cognitive-behavioral related interventions (-0.75, 95% CI: -0.95, -0.54) and other interventions
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289 (-1.09, 95% CI: -1.57, -0.60) had a higher and significant effect. Mindfulness-based interventions and

290 attention/perception modification had a lower and insignificant effect, with their Hedges’ g being -0.56 (95% CI: -1.22,

291 0.11), -0.42 (95% CI: -1.02, 0.19) respectively. Long term follow-up effect (Hedges’ g) for easy to disseminate

292 interventions (-0.46, 95% CI: -0.88, -0.04)] was lower than not easy to disseminate interventions (-0.72, 95% CI: -0.95,

293 -0.50).
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295 Interventions for anxiety disorders

296 Figure 3 shows meta-analysis results of intervention for anxiety by category. The overall ES (Hedges’ g) for anxiety

297 disorder was -0.48 (95% CI: -0.62, -0.34). The ESs were statistically significant for GAD interventions (Hedges’ g =

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298 -0.49, 95% CI: -0.62, -0.37). There was no statistical significance for interventions for social anxiety (Hedges’ g = -0.32,

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299 95% CI: -0.69, 0.04) and specific anxiety (Hedges’ g = -0.51, 95% CI: -1.42, 0.40).

300

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301 When examining the interventions by each anxiety categories, only GAD had high number of studies, thus subgroup and

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moderator analysis was only done in studies targeting GAD. The pooled ES (Hedges’ g) of other interventions (peer
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303 support, music) for GAD had a higher effect (-0.84, 95% CI: -1.19, -0.49) than CBT related interventions (-0.39, 95% CI:

304 -0.55, -0.22) and mindfulness (-0.49, 95% CI: -0.84, -0.15). There were only 2 papers to assess the effect of
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305 attention/perception modification on GAD, so we didn’t calculate the pooled ES. Interventions with no treatment control
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306 had higher ES (Hedges’ g = -0.81, 95% CI: -1.18, -0.43) than interventions with waitlist (Hedges’ g = -0.42, 95% CI:
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307 -0.58, -0.27) and interventions with placebo control (Hedges’ g = -0.55, 95% CI: -0.90, -0.21). Intervention effect

308 favoured those with longer and guided interventions (Hedges’ g for easy to disseminate interventions was -0.54, 95% CI:
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309 -0.69, -0.38) and Hedges’ g for not easy to disseminate interventions was -0.41 (95% CI: -0.66, -0.16)]. We also
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310 performed meta-regression analysis, yet failed to find any statistical significant moderators that affect the effect size of
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311 the intervention for GAD.

312

313 Hedges’ g for overall long term follow-up intervention for any anxiety disorders was -0.44 (95% CI: -0.71, -0.17). The

314 Hedges’ g for interventions with no treatment control (-0.90, 95% CI: -1.35, -0.45) and interventions with waitlist control

315 (-0.60, 95% CI: -1.00, -0.21) were higher than interventions with placebo control (-0.02, 95% CI: -0.33, 0.29).
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316

317 Interventions for OCD and PTSD

318 There was only 1 article related to OCD intervention. As such, the ES related to OCD was not calculated. For the three

319 papers that examined post-traumatic stress disorder (PTSD) interventions, the Hedges’ g for overall post-intervention

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320 was -0.50 (95% CI: -1.15, 0.16), which was not statistically significant.

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321

322 Publication bias and study quality

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323 To test the robustness of the estimated effects, we assessed publication bias and study quality. Figure 1 and 2 in the

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Supplementary Appendix show the funnel plots of included studies for depression and anxiety disorders separately. In
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325 addition, we confirmed the funnel plot result with the Egger’s regression test, which was statistically significant

326 indicating asymmetry for both depression and anxiety disorders (t = -2.86, p = 0.007 for depression; t = -3.47, p = 0.003
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327 for anxiety). We also performed the trim-and-fill procedure. No studies were filled or trimmed, suggesting minimal
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328 impact of publication bias and the robustness of our results.

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329

330 The included papers had considerably high quality. Seven of 51 papers met all criteria for low risk of bias (Beard and
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331 Amir 2008; Sloan et al., 2011; Penton-Voak et al., 2012; Lee and Kwon, 2013; Ginty and Conklin, 2015; Yang et al.,
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332 2015; Norton and Abbott, 2016). As shown in figure 4, 57.0% of ESs adopted low risk of sequence generation, and
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333 46.8% of ESs adopted low risk of allocation. Blinding of the participants was at 44.3%. Due to author’s poor reporting

334 clarity, 40.5% of sequence generation and 48.1% of allocation were rated as “unclear risk” and 13.9% were judged to be

335 at high risk of attrition bias. Additionally, 6.3% were rated as high risk of reporting bias, while 8.9% had other biases,

336 including baseline imbalance and separate interventions combined.

337
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338 DISCUSSION

339 To our knowledge, this is the first meta-analysis to comprehensively estimate the efficacy of interventions for college and

340 university students with CMHPs. We adopted a detailed systematic search strategy, clearly defined inclusion criteria, and

341 the objective assessment of the methodological rigor for each included study. We found moderate intervention effect for

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342 both depression (Hedges’ g = -0.60) and anxiety disorders (Hedges’ g = -0.48). The overall ESs for PTSD had no

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343 statistical significance. Even though interventions based on CBT, attention/perception modification and

344 mindfulness-based intervention were found to be effective, other interventions, i.e. art, exercise, and peer support had the

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345 highest ESs for both depression and GAD among college and university students (Hedges’ g = -0.76 for depression,

346 US
Hedges’ g = -0.84 for GAD). For those with long term follow-up data, interventions for depression and anxiety showed
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347 statistically significant effects.

348
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349 1. Effect size

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350 The moderate post-intervention effect and the statistically significant long-term effect found in our study for depression
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351 and anxiety disorders further verified the effectiveness of specialized clinical services targeting individuals with

352 depression or anxiety. The effect size for depression found in our study (Hedges’ g = -0.60) was higher than that found in
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353 a computer-delivered and web-based intervention meta-analysis among university students (Hedges’ g = -0.43 for
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354 depression) (Davies et al., 2014) and a review of technology-based interventions for mental health in tertiary students
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355 (Hedges’ g = 0.48) (Farrer et al., 2013). This is in agreement with the results of research that compared the effect of

356 iCBT to face-to-face CBT, which found that face-to-face CBT was somewhat more effective (Sethi, 2012). The effect

357 size for depression found in our study was lower than that found in the meta-analysis results of psychological treatment

358 among college students (Hedges’ g = 0.89) (Cuijpers et al., 2016). The latter included lower quality studies, and thus had
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359 higher ESs. This is consistent with the conclusion that larger effects sizes are found when inclusion criteria are less strict

360 and a greater number of papers are included in the analysis.

361

362 It is difficult to compare the ES for anxiety disorder found in our study with other studies because inclusion criteria differ

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363 across studies. The ES (Hedges’ g = -0.48) found in our study was similar to the results of the meta-analytic study by

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364 Davies who assessed the effect of computer-delivered and web-based interventions to improve anxiety among university

365 students (Hedges’ g = -0.56 for anxiety) (Davies et al., 2014), and it was lower than the results found in the

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366 technology-based interventions in tertiary students (Hedges’ g = -0.77) (Farrer et al., 2013). Social and specific anxiety

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disorders were included in this study and there was no statistically significant effect of intervention for either of these
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368 disorders in college and university students. These results emphasize the necessity to develop more reliable and efficient

369 interventions for social anxiety and specific anxiety disorder. Compared to a meta-analysis that reported the effects of
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370 psychological interventions on symptoms of anxiety delivered via smartphone, our results were higher (Hedges’ g =
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371 -0.325) (Firth et al., 2017).

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372

373 2. Moderators
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374 Compared with placebo control or waitlist, intervention effect favoured those with control being no treatment which is
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375 consistent with other meta-analyses (Mohr et al., 2009; Davies, et al., 2014; Cuijpers et al., 2016). There are a number of
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376 non-specific intervention effects that account for improvement in mental illness, such as working alliance, placebo, and

377 natural remission (Stek et al., 2006; Bertisch et al., 2009). However these non-specific effects can be controlled by

378 including a placebo condition. Because “no treatment” and “waitlist control” groups are only capable of controlling for

379 the natural course of mental health problems, we set placebo control as our first choice in this meta-analysis.

380
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381 Easy to disseminate interventions, including single-session intervention, bibliotherapy, unguided online CBT, homework,

382 self-help intervention, and personalized feedback had smaller ESs compared to more complex, longer and guided

383 interventions for depression in our meta-analysis. The Center for Collegiate Mental Health 2017 Annual Report also

384 found a relationship between symptom reduction and length of treatment (CCMH, 2017). Theoretically, longer

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385 interventions provide more opportunities for presentation of information concerning attitudinal and behavioral change

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386 skills, allow participants to reflect on intervention material between sessions, and give participants more opportunities to

387 practice new skills and then return to the group for trouble-shooting advice (Stice and Shaw, 2004). Therefore, it is

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388 unsurprising that complex interventions show larger effects.

389 US
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390 Even though ESs were not significantly associated with intervention type, other interventions had a higher effect size for

391 both depression and anxiety. This conclusion should be considered with caution. To some extent this suggests that there
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392 currently may not be a leading intervention for college students with CMHPs.
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393
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394 This systematic review and meta-analysis had several limitations. 1) Similar to the findings from former reviews, studies

395 included in our review over-represent interventions with female students in Western countries. 2) Generally,
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396 interventions in the included studies lasted for a short period of time and some web-based interventions had low
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397 adherence, which could attenuate the intervention effect. 3) Participants included in the studies were almost all students
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398 with mild ~ moderate mental health problems, thus caution should be used when extrapolating these results to clinical

399 populations with severe symptoms. 4) The amount of data included in this study was rather small once it was divided into

400 subgroups. This is especially true for the anxiety subgroups, therefore some of the results should be considered with

401 caution.

402
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403 In conclusion, consistent with former findings, we also found a moderate intervention effect for both depression and

404 anxiety among college and university students. Other interventions, i.e. art, exercise, peer support, etc. had the highest ES

405 for both depression and GAD. It would thus seem practical as well as useful to offer more support programs in colleges

406 and universities to improve students’ mental health. We also feel that more rigorously designed RCTs among university

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407 and college students are needed. Although complex interventions based on CBT and mindfulness principles are more

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408 effective than interventions that are easy to disseminate, future studies must examine effectiveness, as well as the

409 acceptability, sustainability, and cost-effect ratio of these interventions.

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411 FUNDING: US
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412 This research is supported by the China Scholarship Council.

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626 meditation in anxious individuals. Conscious Cogn 51, 157-165.

627 Yang, W., Ding, Z., Dai, T., Peng, F., Zhang, J. X., 2015. Attention Bias Modification training in individuals with
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628 depressive symptoms: A randomized controlled trial. J Behav Ther Exp Psychiatry 49(Pt A), 101-111.

629 Yang, X., Zhao, J., Chen, Y., Zu, S., 2018. Comprehensive self-control training benefits depressed college
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630 students: A six-month randomized controlled intervention trial. J Affect Disord 226, 251-260.

631 Yao, N., Yu, H., Qian, M., Li, S., 2015. Does attention redirection contribute to the effectiveness of attention
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632 bias modification on social anxiety? J Anxiety Disord 36, 52-62.

633 Ye, H., 2017. Impact of Mindfulness-Based Stress Reduction (MBSR) on Students' Social Anxiety: A
634 Randomized Controlled Trial. NeuroQuantology 15, 101-106.
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Appendix

Methods 1. Search strategy used in the current systematic review and meta-analysis.

Pubmed:
1. Mood Disorder [MeSH]
2. Depression [MeSH]

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3. Depressive Disorder, Major[MeSH]
4. Anxiety [MeSH]
5. Anxiety Disorder [MeSH]

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6. “common mental health disorders” [text]
7. OR / 1-6
8. Randomized Controlled Trial [MeSH Terms]
9. Controlled Clinical Trial [MeSH Terms]

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10. Random Allocation [MeSH Terms]
11. randomized controlled trial [publication type]

13. Single-blinded Method [MeSH Terms]

14. Double-blinded Method [MeSH Terms]
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12. controlled clinical trial [publication type]
AN
15. random* [Ti/Ab] AND control
16. OR / 8-15
17. University [MeSH]
18. Students [MeSH] AND (college OR university)
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19. Young adult [MeSH] AND (college OR university)

20. OR/17-19
21. 7 AND 16 AND 20
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(Note: OCD,PTSD is included in the “anxiety disorder[MeSH]”)

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Embase(OVID):
1.exp/mood disorder
2. exp/mental health
3. exp/emotional disorder
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4. exp/depression
5. exp/atypical depression
6. exp/anxiety
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7. exp/anxiety disorder
8. exp/generalized anxiety disorder
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9. exp/anxiety neurosis
10. exp/panic
11. exp/phobia
12. exp/social phobia
13. exp/obsessive compulsive disorder
14. exp/posttraumatic stress disorder
15. (trauma and stressor-related disorders).mp.
16. OR / 1-15
17. randomized controlled trial.mp.
18. controlled clinical trial.mp.
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19. randomization.mp.
20. double-blind procedure .mp.
21. single-blind procedure .mp.
22. crossover procedure .mp.
23. OR / 17-22
24. exp/college
25. exp/college student

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26. exp/university
27. exp/university student
28. exp/student AND (college.ab, tw. OR university.ab, tw.)

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29. exp/young adult AND (college.ab, tw. OR university.ab, tw.)
30. university-based. ab, tw.
31. OR /24-30
32. 16 AND 23 AND 31

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ERIC(OVID):
1.exp/emotional disturbances
2. exp/depression(psychology)
3. exp/anxiety
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4. exp/anxiety disorders
5. exp/mental health
6. exp/fear
7. exp/panic
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8. exp/posttraumatic stress disorder

9. OR /1-8
10. exp/randomized controlled trials
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11. random*.tw. ab.

12. blind*.tw. ab.
13. assign*.tw. ab.
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14. OR /10-13
15. exp/(college OR university)
16.exp/(college students OR university students)
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17. exp/students AND(college.tx. OR university.tx.)

18. exp/young adult AND(college.tx. OR university.tx.)
19. OR / 15-18
20. 9 AND 14 AND 19
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(Note: obsessive-compulsive disorder is included in the “anxiety disorder”)

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PsycARTICLES:
1. (depress* OR anxiety OR phobia* OR “phobic disorder” OR “agoraphobia” OR “fear” OR “panic
disorder” OR “obsessive-compulsive disorder” OR “posttraumatic stress disorder” OR “mental
health”OR “emotional health” OR “emotional disturbances” OR “mood disorder”OR “affective
disorder” OR “internalizing disorder”OR “social withdrawal”).ab.
2. random* control* trial* OR randomization OR “single-blinded” OR “double-blinded” OR “cross
over*” OR “clinical trial*”
3. random*.ab.
4. 2 OR 3
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5. “college student*” OR “university student*” OR “tertiary education” OR “university-based” OR

undergraduate* OR “post-secondary education”
6. 1 AND 4 AND 5

PsycINFO:
1. exp/mental health
2. exp/affective disorder

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3. exp/emotional disturbances
4. exp/depression (emotion)
5. exp/major depression

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6. exp/atypical depression
7. exp/anxiety
8. exp/anxiety disorder
9. exp/generalized anxiety disorder

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10. exp/social anxiety
11. exp/social phobia
12. exp/phobias
13. exp/agoraphobia
14. exp/panic disorder
US
AN
15. exp/obsessive-compulsive disorder
16. exp/traumatic neurosis
17. exp/posttraumatic stress disorder
18. OR/1-17
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19. random* control* trial*.af.

20. “clinical trial*”.af.
21. randomization .af.
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22. single-blind*.af.
23. double-blind* .af.
24. cross-over*.af.
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25. cross over* .af.

26. random* .ab.
27. OR/19-26
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28. exp/college
29. exp/university
30. exp/college students
31. exp/undergraduates
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32. exp/students AND (college OR university).af.

33. (young adult*).ab. AND (college OR university).af.
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34. (old adolescent*) AND (college OR university).af.

35. university-based. af.
36. OR/28-35
37. 18 AND 27 AND 36

CENTRAL:
1. MeSH descriptor: [Mood Disorders] explode all trees
2. MeSH descriptor: [Mental Health] explode all trees
3. MeSH descriptor: [Depression] explode all trees
4.MeSH descriptor: [Depressive Disorder, Major] explode all trees
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5.MeSH descriptor: [Anxiety] explode all trees

6. MeSH descriptor: [Anxiety Disorders] explode all trees
7. MeSH descriptor: [Trauma and Stressor Related Disorders] explode all trees
8. OR/1-7
9. MeSH descriptor: [young adult] explode all trees
10. college student*
11. university student*

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12. university-based
13. undergraduate*
14. “higher education”

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15. “tertiary education”
16. OR/9-15
17. 8 AND 16

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AN
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Results: Table 1 Studies included in the systematic review

Study Participates CMHD Intervention Control Measures Follow-up Country

Wu et al. (2002) 12 females/ 12 males; Anxiety or Music therapy (10 sessions; once every week; each No treatment SDS 2 month Taiwan
Age range: 19-21 years Depression session lasts 2-hr) SAS (Zung's self- follow-up (China)
rating anxiety scale)

T
Day et al. (2013) 59 females/7 males; Anxiety or Web-based guided CBT intervention (standard CBT Waitlist DASS-21 anxiety, No follow-up Canada
Age: 23.55±4.89 Depression principal and includes 5 modules; trained students depression

P
provide support and engagement but no therapeutic

I
advice)
Falsafi et al. 67 students(86.4% Anxiety or ①Mindfulness and self-compassion intervention No treatment BDI-II 1 month USA

R
(2016) females); Depression group (8 weeks of mindfulness training, including Hamilton anxiety follow-up
Age range: 18-50 years self-compassion +20 min practice each day) scale

C
with age mean 22.1 ②Hatha Yoga intervention (8 weeks of yoga
training+20 min practice each day)

S
Clore et al. (2007) 39 students (67% female ) Psychological Cognitive therapy (building positive self-thoughts Placebo BDI- II No follow-up USA
Age: 22±5.24 distress and disputing negative self-thoughts; six 1-hr weekly control

U
sessions)
Hinton et al. 22 students (73% female); Psychological Cognitive defusion(ACT); 3 sessions + homework; 1 Waitlist BDI No follow-up USA

N
(2010) Age: 20.09±2.56 distress session every week

A
Ellis et al. (2011) 31 females/9 males; Psychological ①MoodGym (online CBT; 5 modules of CBT; 3- No treatment DASS-21 anxiety, No follow-up Australia
Age range: 18-25 years distress sessions) depression
②Moodgarden(3 60-min sessions; online peer

M
support)
Lintvedt et al. 163 students(76.7% Psychological MoodGYM(CBT, interpersonal therapy, relaxation Waitlist CES-D No follow-up Norway
(2013) females) distress techniques)+BluePage(psychoeducation);

D
Age: 28.2±7.4

E
Kim et al. (2016) 84 females Psychological Integrated stress management program(ISMP; eight Waitlist SCL-90 anxiety, No follow-up Korean

T
Age range: 19-29 years distress 2-hr sessions over 4 weeks; CBT) depression

P
Levin et al. (2016) 79 students (66% female); Psychological Web-based ACT self-help Program (6 self-help Waitlist Counselling Center No follow-up USA
Age: 20.51±2.73 distress sessions over 4 weeks) Assessment of

E
Psychological
Symptoms (CCAPS)-

C
anxiety, depression
Peden et al. 92 females; Depressive 6-week cognitive-behavioral group intervention No treatment BDI-II 6 month UK
(2001) Age range:18 -24 years symptoms follow-up

AC
Geisner et al. 168 students (70% Depressive Personalized feedback about depression symptoms Attention BDI No follow-up USA
(2008) female); symptoms and a depression tips brochure placebo
Age: 19.28±1.97
McMakin et al. 41 females; Depressive Positive Emotion Regulation Coaching(3 separate Attention BDI-II No follow-up USA
(2008) Age range:18-25 years symptoms writing sessions within 2 weeks; cognitive treatment) placebo
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Study Participates CMHD Intervention Control Measures Follow-up Country

Gawrysiak et al. 24 females/6 males; Depressive Brief behavioral activation(single-session Placebo BDI-II No follow-up USA
(2009) Age: 18.4±0.81 symptoms intervention and 2-week treatment interval) control BAI

Hamdan- 38 females/46 males; Depressive Modified Teaching Kids to Cope No treatment BDI-Arabic version 3 month Jordan
Mansour et al. Age range: 17-24 years symptoms (psychoeducation+part of cognitive-behavioral follow-up

T
(2009) intervention programs)
Wells (2010) 24 females/10 males Depression 4 attention training session during 2 weeks No treatment BDI- II 2 week USA

P
Age: 19.1±1.7 follow-up

I
Armento et al. 50 students (62% female); Depressive Behavioral activation of religious behavior (a Placebo BDI 1 month USA

R
(2011) Age: 20±2.75 symptoms session+2-week activation interval) control BAI follow-up

C
Charbonneau et 72 females; Depressive Mindfulness-based intervention(relaxation, No treatment CES-D 5 month USA
al. (2011) Age range:17-19 years symptoms meditation, mindfulness; eight 1-hr manualized follow-up

S
intervention sessions)

McMakin et al. 27 females; Depressive Positive Affect Stimulation and Sustainment (PASS) Placebo BDI-II No follow-up USA

U
(2011) Age range: 18-19 years symptoms Module; 3 separate writing sessions within a 2-week control
period, with at least 48 h between sessions;

N
behavioral activation
Penton-Voak et 80 students (70% female); Depressive emotion perception training(four times over Placebo BDI-II No follow-up UK

A
al. (2012) Age range:18-40 years symptoms consecutive days) control

M
Moldovan et al. 42 students (87.5% Depressive CBT-based bibliotherapy along with explicit Placebo BDI-II 3 month Romania
(2013) female); symptoms instructions control follow-up
Age: 22.42±2.68(E);

D
23.08±2.14(C)

E
Walker et al. 59 females/27 males; Depressive ①More than 4 hours of CBT homework assignments No treatment CES-D No follow-up USA
(2014) Age range: 18-25 years symptoms spread over 2 weeks

T
②CBT+Interpersonal (homework)
③Positive psychology (homework);

P
Chen et al. (2015) 69 females/2 males; Depression Chinese five-element music therapy (40-min music No treatment DMSRIA(Depression No follow-up China
Age range: 16-20 years therapy; twice a week for 10 weeks) Mood Self-Report

E
Inventory for
Adolescence)

C
Geisner et al. 167 students (62.4% depressed brief web-based, personalized feedback and coping Placebo BDI-II No follow-up USA
(2015) female) mood with strategies based on literature on treatment of control

C
Age: 20.14±1.34 alcohol depression and alcohol
problem

A
Ginty et al. (2015) 23 students (78% female); Depressive Supplementation(1000 mg EPA and 400 mg DHA Placebo BDI-II No follow-up USA
Age: 20.2±1.25 symptoms daily for 21-days) control

Yang et al. (2015) 37 females/17 males; Depressive Attentional bias modification (ABM); eight 12-min Placebo BDI 7 month China
Age: 19.57±0.87 symptoms training across 2 weeks control STAI follow-up
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Study Participates CMHD Intervention Control Measures Follow-up Country

Li et al. (2016) 41 females; Depressive Attentional bias modification (ABM); 28 sessions Placebo BDI No follow-up China
Age range: 18-24 years symptoms across 4 weeks control STAI
McIndoo et al. 31 females/ 19 males; Depressive ①Abbreviated MBT(mindful-base therapy; 4 weekly Waitlist BDI-II 1 month USA
(2016) Age: 19.2±1.67 symptoms 1-hr session) BAI follow-up
②Behavioral activation (abbreviated BATD; 4

T
weekly 1-hr session)
Takagaki et al. 45 females/73 males; Depressive Behavioral activation (five 60-min session; one each No treatment BDI-II No follow-up Japan

P
(2016) Age range:18-19 years symptoms week)

I
López-Rodriguez 95 students (74.7% Depression Biodanza sessions for 90 min a week, over a period Waitlist CES-D No follow-up Spain

R
(2017) female) of 4 weeks
Age:22.07±4.71

C
Mastikhina et al. 45 students (86.7% Depressive Attentional retraining for 4 sessions during a two- No treatment BDI-II 2 week USA
(2017) female) symptoms week period Follow-up

S
Age: 20±2.07
Yang et al. (2018) 44 females/30 males Depressive 8-week comprehensive self-control training (CSCT) No treatment BDI-II 4-month China
Age range:16-21 years disorder follow-up

U
Kenardy et al. 83 students(61.7% Anxiety Online anxiety prevention program(6 sessions of Waitlist The Anxiety 6 month Australia

N
(2003) female); web-based integrated CBT) Sensitivity Index follow-up
Age: 20.73±6.29 (ASI)

A
CES-D
Smits et al. 49 students (75% female); Anxiety ①Exercise(six 20-min exercise over 2-week period; Waitlist BDI 3-week USA

M
(2008) Age: 20.68±5.8 exercise intensity=70% Hrmax) BAI follow-up
②Exercise+cognitive restructuring
Morris et al. 93 females/ 45 males; Anxiety Unguided 6-week internet-delivered Cognitive Waitlist BDI-II No follow-up UK

D
(2016) Age range:18-34 years Behavioural Therapy (iCBT) STAI-S

E
Xu et al. (2017) 55 females/27 males Anxiety 1 session of meditation Placebo Positive and No follow-up Canada
Age: 20±1.8 control Negative Affect

T
Schedule(negative
affect)

P
Richards et al. 137 students (77% Anxiety Calming Anxiety(psychologist guided internet Waitlist BDI-II No follow-up Ireland
(2016) female); delivered CBT intervention) GAD-7

E
Age:23.82±7.05

C
Chaló et al. 39 female/5 males Anxiety Biofeedback Group took a 15 min session Waitlist STAI No follow-up Portugal
(2017) Age range:18-24 years per week, over 8 weeks

C
Beard et al. 27 students (93% female); Social anxiety Computerized Interpretation Modification Program; Placebo The Social No follow-up USA

A
(2008) Mean age: 20 years old 8 computer sessions over 4 weeks control Phobia and Anxiety
Inventory-Social
Phobia subscale
Bjornsson et al. 39 students (77% female); Social anxiety CBGT(eight 2-hr group sessions; psychoeducation, in- Attention LSAS No follow-up USA
(2008) Age range: 18-25 years session exposure, cognitive restructuring) placebo
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Study Participates CMHD Intervention Control Measures Follow-up Country

Lee et al. (2013) 18 females/ 5 males; Social phobia Imagery rescript(Imagery Placebo Social Avoidance No follow-up South
Age: 23.92±3.35 interview+Cognitiverestructuring+ImageryRescriptin control and Distress Scale Korea
g for 3 weeks) (SADS)

Norton et al. 60 students (85% female); Social anxiety ①Imagery rescript (30-45 min single session) Placebo Social Interaction No follow-up Australia

T
(2016) Age: 20.83±3.99 ②Cognitive restructuring (30-45 min single session) control Anxiety Scale (SIAS)

P
Yao et al. (2015) 40 females/28 males; Social anxiety ①Attention bias modification; non-valence-specific Placebo Liebowitz Social 2 week China

I
Age range: 17-28 years attend-to-geometrics (AGC) control Anxiety Scale (LSAS) follow-up
②Attention modification(AMC)

R
Ye (2017) 27 students Social anxiety 8-week Mindfulness-Based Stress Reduction (MBSR) Treat as usual LSAS No follow-up China
Age: 16–40 years program

C
Cougle et al. 34 females; Spider phobia Contamination-Focused Exposure Waitlist FSQ No follow-up USA
(2016) Age: 19.12±2.1

S
Vansteenwegen 52 females and 2 males Spider phobia multiple extinction group (videotapes of the same Attention FSQ No follow-up Belgium
(2007) Age:18-28 years with a spider in three different locations of a house) placebo
mean of 19.2.

U
Olatunji et al. 44 students (80% female); Blood- Repeated Exposure to Threat-Relevant Stimuli Attention TheDisgust No follow-up USA
(2012) Age range: 18–21 years Injection- placebo Sensitivity Scale-

N
Injury Phobia Revised (DS-R)
Timpano et al. 104 students (83.7% Obsessive Brief Anxiety Sensitivity Reduction Intervention(a Placebo STAI 7 month USA

A
(2016) female); compulsive single 50-min session, computer-assisted AS control follow-up
Age: 18.9±1.42 spectrum intervention)

M
symptoms
Lange et al. 16 females/ 9 males; Posttraumatic On-line therapy(self- Waitlist The impact of No follow-up Netherland
(2001) Age: 22±4.9 stress confrontation+cognitivereappraisal+sharing and events scale ( IES-

D
farewell ritual) Avoidance)
Sloan et al. 42 students; Posttraumatic Written Emotional Disclosure(WED) for 3 Placebo PTSD symptom scale No follow-up USA

E
(2011) Age: 18.9±1.1 stress consecutive days control (PSS-I)
disorder

T
Allan et al. (2015) 82 students (82.9% traumatic Anxiety Sensitivity Education and Reduction Training Placebo The Posttraumatic 1 month USA
female); stress (ASERT; single 50-min computer-assisted session; control Stress Disorder follow-up

P
Age: 18.84±1.5 symptom psychoeducation and a brief interoceptive exposure) Checklist-
Civilian Version

E
(PCL-C)
Callinan et al. 12 males/ 48 female; traumatic Attention Training (two 12 min training and practice Placebo The Impact of No follow-up USA

C
(2015) Age range: 18-28 years stress the technique at least twice for homework) control Events Scale (IES)
symptom

AC
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Funnel plot with pseudo 95% confidence limits

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se(SMD)

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Figure 1 Funnel plot of included studies for depression intervention

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Funnel plot with pseudo 95% confidence limits

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.2
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Figure 2Funnel plot of included studies for generalized anxiety disorder (GAD) intervention
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7768 records identified through database searching
7 2564 Pubmed
8 2118 Embase

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291 Eric
9 562 PsycARTICLES
10 1950 PsycINFO
283 CENTRAL
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7437 records excluded based on
13 review of title and abstract

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349 duplicates
14 7088 wrong population or outcome

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17
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331 articles screened from the database
9 articles from Google advanced search
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18
Not college students: 90
19 Not CMHPs: 72
Not RCT or not intervention: 48
20 No demanded control: 19
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No demanded outcome: 3
21 Else: 17
22
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23 91 RCT, CCT, pilot RCT studies

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Pilot RCT: 14
25 CCT: 17
26 RCT preventive program with high risk data: 6
Less than 10 in the intervention: 1
27 Abnormal value: 2
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29 51 RCT studies
59 interventions
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31 Figure 1.PRISMA flowchart outlining process for systematic review/meta-analysis.

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48 Figure 2 Forest plot of intervention for depression among college students
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63 Figure 3 Forest plot of intervention for anxiety disorders among college students
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79 Figure 4 Risk assessment of bias presented as percentages across all included studies.
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