MANAGEMENT OF DEPRESSION AND ANXIETY

Management of Depression and Anxiety in College Students

McKenzie Luknis, Makayla Durkin, Kaitlyn Chambers, Riley Campbell, Phantashia Freeman

Youngstown State University

NURS 3749: Nursing Research

Ms. Heasley

April 5, 2021
MANAGEMENT OF DEPRESSION AND ANXIETY
2

Abstract

The purpose of this research was to look at how depression affects the college population and

identify the different pharmacological and nonpharmacological coping mechanisms. This

research was based on nine sources. It was found that antidepressants are an effective

pharmacological treatment plan to cope with depression. Although, when patients were

prescribed antidepressants some of them were found to stop their medications within the first

month and they would relapse. Some of the medications that were tested were Citalopram,

Fluoxetine, and Flouxetine with Cognitive Behavioral Therapy (CBT). Nonpharmacological

interventions can also serve as promising complementary and alternative approaches in reducing

anxiety symptoms and depression as found in several of the articles used. Some

nonpharmacological treatments were diaphragmatic breathing relaxation exercises and

aromatherapy combined with music therapy. Overall, the research done showed that depression

and anxiety among college students can be managed and/or coped with by using

pharmacological and nonpharmacological treatments.

MANAGEMENT OF DEPRESSION AND ANXIETY
3
Management of Depression and Anxiety in College Students

Introduction

Depression in college students is a common problem. When going to college students

may be leaving home for the first time, living on their own, facing challenges, pressures, and

anxieties, and not getting an adequate amount of sleep. Depression is considered a mood

disorder that causes a constant feeling of sadness and loss of interest for at least two weeks or

longer. It is not something you can snap out of, and it is more than just the blues or a sign of

weakness. Some symptoms of depression are feelings of sadness, loss of interest or pleasure in

most or all normal activities, sleep disturbances, fatigue, and lack of energy, changes in appetite,

anxiety, trouble thinking or making decisions, and suicidal thoughts (“College Depression”

2020). Some students may already be diagnosed with depression and are getting help, but many

students may be undiagnosed and afraid to get help. It is very important for students to talk to

someone and get the help they may need. Many campuses have counselors that any student can

talk to for free. There are pharmacological and nonpharmacological treatments that can be used

for students with depression. We will discuss later what these terms mean and how they may

affect different students. The question we will be answering is how does depression affect the

college population, and what are pharmacological and nonpharmacological coping mechanisms?

Pharmacological Treatments

Antidepressants are medications that can help relieve symptoms of depression. When an

individual is depressed, there are three neurotransmitters that are affected: Dopamine,

Norepinephrine, and Serotonin. Antidepressant medications help restore the balance of these

brain chemicals and alleviate the symptoms of depression. With any medication, there are side
MANAGEMENT OF DEPRESSION AND ANXIETY
4
effects. For example, in Citalopram, some side effects are nausea, dry mouth, loss of appetite,

drowsiness, and sweating.

A study was conducted by Adrian and Martin Jones in 2009. It consisted of 2,876

patients; some took the antidepressants, and the others took the placebo. This study showed that

60% of people who adhered to the pharmacological treatment had a positive response. On the

other hand, it was found that 50% of people who were prescribed an antidepressant, discontinued

their treatment within the first month. The rate of response was measured finding 27.5% of

patients achieved remission following a 14-week program taking Citalopram. 38% of patient’s

failed to achieve a response in 12 weeks of treatment. Within the placebo group, two thirds

relapsed within two years. The authors concluded that patients who have been prescribed

antidepressants needed to continue with the treatment for six months after remission. In

addition, for patients who had a relapse in their depression on two or more occasions, treatment

may need to be indefinite (Jones, M., & Jones, A. 2009).

Overall, this study showed that the longer the patient was on the medication regimen, the

better the chance they had of having a positive response. College students might be embarrassed

to admit they are depressed. Most universities have campus counseling centers for free and can

refer to off campus services and recommendations.

In the next study, there were 2,731 patients with Treatment-Resistant Depression, who

were included in ten randomized control trials. Treatment-Resistant Depression (TRD) is a

depression where medications are not enough to treat it. The medication might not help the

patient at all, or it will improve their symptoms temporarily. The purpose of this study was to

seek out if augmentation with a second antidepressant or an antipsychotic medication would be

MANAGEMENT OF DEPRESSION AND ANXIETY
5
effective for TRD (Arnold, M. J., Fulleborn, S., & Farrell, J. 2021). Buspirone is an

antipsychotic medication that affects neurotransmitters in the brain such as serotonin and

dopamine. The most common baseline antidepressant found was Fluoxetine, and it decreased

depression score by 50% by itself. Some side effects of this medication are nervousness,

insomnia, nausea, heartburn, and anxiety. Some other antidepressants that were used were

Mirtazapine and Mianserin.

When Fluoxetine and Mianserin were augmented together it increased both response and

remission rates, without increasing the drop-out rates. Fluoxetine with Mirtazapine failed to

improve depression symptoms, response rates, or remission rates after 12, 24, or 52 weeks.

Also, switching from Fluoxetine to Mianserin did not improve depression scores, response rates

or remission rates either (Arnold, M. J., Fulleborn, S., & Farrell, J. 2021). Institute for Clinical

Systems Improvement (ICSI) and the National Institute for Health and Care Excellence (NICE)

recommended augmenting antidepressant therapy to manage TRD. ICSI suggested

augmentation with bupropion, buspirone, mirtazapine, thyroxine, stimulants, lithium, or atypical

antipsychotics. Whereas NICE suggested switching antidepressant medications or augmenting

with lithium, an antipsychotic, or mirtazapine if the patient was willing to tolerate increased

adverse effects. An example of an atypical antipsychotic is Quetiapine. Bupropion and

Quetiapine augmented together showed more evidence of a benefit. Overall, this study shows

the effectiveness of antidepressant medication augmented with antipsychotic medications.

Fluoxetine and Cognitive Behavioral Therapy (CBT) have shown to benefit patients with

anxiety and depression. Fluoxetine is an anti-depressant of the Selective Serotonin Reuptake

Inhibitor (SSRI) class. SSRIs are meant to increase the levels of serotonin in the brain.

Serotonin is a neurotransmitter that is often referred to as the “feel good hormone”. Fluoxetine is
MANAGEMENT OF DEPRESSION AND ANXIETY
6
used to treat depression, Obsessive-Compulsive Disorder (OCD), bulimia nervosa, and panic

disorder. CBT is a psycho-social intervention that is aimed to improve mental health. CBT

focuses on changing cognitive distortions and behaviors, improving emotional regulation, and

the development of personal coping strategies that target solving current problems. CBT could

be self-directed or done with another person.

A randomized controlled trial was done by David Kupfer in 2005 on patients with

depression using Fluoxetine along with CBT, Fluoxetine alone, CBT alone, and a placebo.

Major depression is characterized by having symptoms for a minimum of two weeks. Symptoms

include loss of interest, irritability, anxiety, changes in sleep and appetite, poor memory, and

inability to enjoy oneself. Responses were measured and showed patients who took Fluoxetine

along with CBT and reported a response of 71%. Patients who took Fluoxetine alone showed a

response of 60.6% and patients who only used CBT showed a response of 43.2%. Patients

taking a placebo showed a response of 34.8% (Kupfer, D. J. 2005). The greatest response

measured was taking Fluoxetine as prescribed along with CBT. When treating depression in

adolescents it is recommended to start off by giving half of the dose, then to slowly increase to a

dose that works for the patient. When starting Fluoxetine, 10 mg is initially given for the first

week. After one week 20 mg is given as a maintenance dose. It will take three weeks to start to

see results. SSRIs are typically the first-line of acute treatment. It usually takes more than one

form of treatment to find which one works best.

A study was conducted in the United States by Mark Olfson and Marcus Steven between

the years of 1996 to 2005 to measure the usage and effectiveness of antidepressants to treat and

manage depression in the household setting. Patients that were included in this study were at

least six years old and taking at least one antidepressant. Results showed that the rate of
MANAGEMENT OF DEPRESSION AND ANXIETY
7
antidepressant treatment increased from 5.84% in 1996 to 10.12% in 2005, or from 13.3 to 27.0

million persons (Olfson, M., and Steven, M. 2005). The number of people using an

antidepressant to treat depression had doubled in those nine years studied. The percentage of

antidepressants used and the rate ratios of each year affected the amount of antidepressants that

were used. They were adjusted individually based on the patient’s age, sex, race/ethnicity,

annual family income, self-perceived mental health, and insurance status. The amount of people

with depression hardly changed. Every patient was individualized by being prescribed different

antidepressants along with different dosages.

There are a number of different pharmacologic measures that could be used to treat and

manage depression. Antidepressants are a common form of treatment. There are several types

of antidepressants as well, including Selective Serotonin Reuptake Inhibitors (SSRI), Serotonin-

noradrenaline reuptake inhibitors (SNRI), Noradrenaline and specific serotonergic

antidepressants (NASSA), Tricyclic antidepressants (TCA), and Monoamine Oxidase Inhibitors

(MAOI). Each class targets different neurotransmitters in the brain to stimulate a response.

Dosing varies among these medications as well. It typically takes six to eight weeks to fully see

a response to the medication. Although, every person is unique and different medications work

better for different people. Sometimes patients may have to try different types to find what

works best for them.

Nonpharmacological Treatments

Many college students face mental health issues, such as depression and anxiety, during

the semester due to stress. The good news is there are a few ways symptoms of depression and

anxiety can be decreased in college students. Previously, pharmacological treatments were

mentioned, but there are also nonpharmacological techniques that can be implemented as well.
MANAGEMENT OF DEPRESSION AND ANXIETY
8
Some techniques include aromatherapy, music therapy, physical exercise, healthy eating, pet

therapy, decreased intake of caffeine, and deep breathing. There has been research conducted

regarding aromatherapy combined with music therapy and diaphragmatic deep breathing

relaxation exercises.

As mentioned by author Yu-Fren Chen (2016), “Diaphragmatic breathing relaxation

(DBR) exercises have been shown to be effective at reducing the perceptions and symptoms of

anxiety.” Diaphragmatic breathing involves taking deep breaths during times of stress to help

bring down your heart rate and prevent hyperventilation, which would only increase anxiety.

Often headaches can be a physiological side effect of anxiety. As reported by Chen, not only

does deep breathing help decrease anxiety, but it also helps reduce pain associated with

migraines. Studies were conducted by Chen and associates to demonstrate the effects of

diaphragmatic breathing relaxation exercises to decrease anxiety. The authors compared two

study groups, a control group that did not participate in diaphragmatic breathing and the other

group that actively participated in diaphragmatic breathing. According to the research by Chen,

results showed significant differences between the groups, proving that diaphragmatic breathing

relaxation exercises did indeed decrease anxiety. Deep breathing helps relax the body and mind,

which allows students to focus distinctly on schoolwork.

Other nonpharmacological techniques that can help decrease anxiety include

aromatherapy, which involves smelling pleasurable scents, “sweet marjoram, which is effective

in relieving stress, soothing, and emotional relaxation, and citrus sinensis (orange), which is

effective in reducing nervousness and stress” ( Son, 2019). As a result distracting the individual

from anxiety. Another technique used is music therapy. This therapy requires listening to

music, which soothes the patient’s mind and returns them back to a calm state. “Combining
MANAGEMENT OF DEPRESSION AND ANXIETY
9
these two techniques together showed better results with relieving a patient's anxiety” (Son,

2019).

Among college students, nursing is one of the more challenging majors to complete due

to the strenuous amounts of workload, clinical hours that are required, and critical thinking skills

to apply on exams. Test anxiety is common and causes more stress. As reported by Hae Kyoung

Son (2019), nursing students experience high levels of stress and anxiety. Engaging in music

and aromatherapy can help decrease their stress and anxiety.

Son and his colleagues conducted a study comparing how aromatherapy, music therapy,

and the two therapies combined affected anxiety levels in nursing students. The authors tested

each therapy separately in control groups; an aromatherapy group, a music therapy group and a

combination of the therapies. Consistent with Son’s theory, “aromatherapy combined with

music therapy had a significant effect on test anxiety, state anxiety, stress and performance of

fundamental nursing skills compared to aromatherapy and music therapy as separate

interventions”. In their study they tested sophomores in the nursing program on their capabilities

of inserting indwelling catheters after partaking in the anxiety relieving therapies. After

participating in these relaxing exercises before inserting the indwelling catheters, the students'

were more confident due to their relaxed state of mind. Overall, this study showed that

participating in nonpharmacological techniques helped to relieve anxiety and depression in

college students.

There are no shortage of options when it comes to nonpharmacological treatments for

depression and anxiety. Many techniques involve relaxation and stress management, which are

important skills for nursing students to master. Not only will nonpharmacological interventions
MANAGEMENT OF DEPRESSION AND ANXIETY
10
for depression benefit the students directly, but these interventions will benefit patients as well.

A student who practices depression management themselves, will be more effective at

implementing these interventions for their patients because the student has firsthand knowledge.

Early recognition and treatment of depressive symptoms is important when considering the

effectiveness of nonpharmacological interventions. One common nonpharmacological treatment

is cognitive therapy, in which patients are taught to manage their negative thoughts. If

depression and anxiety can be managed with cognitive therapy alone, patients experience fewer

side effects than pharmacological depression management (Chen, D., Sun, W., Liu, N., Wang, J.,

Guo, P., Zhang, X., & Zhang, W. 2019). Side effects are an important consideration pertaining

to the discussion of depression management. According to Chen et al. 2019, “Although

antidepressants have positive therapeutic effects in depression, patients often discontinue

pharmacotherapy due to side effects and high cost.” The goal for management of depression and

anxiety is to find a treatment regimen that works for the individual patient. Each case should be

evaluated on its own and the benefits of nonpharmacological interventions should be considered

when determining a plan of care.

According to the meta-analysis performed by Chen et al. 2019, “Among these

nonpharmacological interventions, four studies reported that mindfulness interventions had small

positive effects on depressive symptoms and depression post intervention compared with the

control group.” Additionally, Chen et al. 2019, mentioned that stress management techniques

also had small positive effects on the participants. Between mindfulness and stress management

strategies, patients with depression and anxiety can either supplement or replace their current

treatment methods with effective nonpharmacological symptom management.

MANAGEMENT OF DEPRESSION AND ANXIETY
11
When considering nursing students as the population in question, perhaps one of the

most easily accessible interventions for depression management is internet intervention. In the

article by Harrer et al. 2019, interventions like virtual simulations, educational websites, and

mindfulness applications were evaluated for effectiveness on management of depressive

symptoms in university students. The authors completed a meta-analysis of forty-eight studies

on this topic to determine the effectiveness of internet based interventions. Specifically, the

benefits of internet based therapy include anonymity, cost-effectiveness, and scalability (Harrer,

M., Adam, S. H., Baumeister, H., Cuijpers, P., Karyotaki, E., Auerbach, R. P., Kessler, R. C.,

Bruffaerts, R., Berking, M., & Ebert, D. D. 2019). The internet is readily accessible on

university campuses and therefore gives students the opportunity to take advantage of online

counseling and stress management. Internet resources can handle a high volume of users which

contributes to the cost-effectiveness of this style of intervention. In addition to being financially

conscious, university students need flexible schedules to accommodate classes and part-time

jobs. Internet delivery of psychological interventions is ideal for students’ schedules, so there is

no need to find the time to visit a therapist in person. Studies have found that internet

interventions are effective. According to Harrer et al. 2019; evaluation of “Internet‐based

cognitive behavioural therapy (CBT; 93%), [ . . . ] found moderate to large effects on depression,

anxiety, and stress (standardized mean difference [SMD] = 0.43– 0.73) compared with inactive

control groups but no superiority of these interventions compared with active controls.”

University students dealing with depression and anxiety can benefit from the use of Internet-

based cognitive therapy and other virtual depression interventions.

Conclusion
MANAGEMENT OF DEPRESSION AND ANXIETY
12
In conclusion, it was found that both pharmacological and nonpharmacological

treatments are effective in treating and managing depression. It was found that it is important

that patients continue their medications and nonpharmacological treatments to get the full effect

and avoid a relapse. Depression in college students is very common and should not be taken

lightly. It is very important for patients to get the treatment they need to live a normal and

successful life. Not everyone may need pharmacological treatment and may just need

nonpharmacological treatment but it is important for patients to check with their doctor and see

what will help them. Everyone is different and certain treatments affect everyone differently but

for the majority of students it was found in these studies used that both treatments are very

effective and should be utilized.

MANAGEMENT OF DEPRESSION AND ANXIETY
13
References

Arnold, M. J., Fulleborn, S., & Farrell, J. (2021). Medications for Treatment-Resistant

Depression in Adults. American Family Physician, 103(1), 16+.

https://link.gale.com/apps/doc/A646776132/PPNU?

u=ohlink104&sid=PPNU&xid=84b302bf.

Chen, D., Sun, W., Liu, N., Wang, J., Guo, P., Zhang, X., & Zhang, W. (2019). Effects of

nonpharmacological interventions on depressive symptoms and depression among

nursing students: A systematic review and meta-analysis. Complementary Therapies

in Clinical Practice, 34, 217–228. https://doi.org/10.1016/j.ctcp.2018.12.011

Chen, Y.-F., Huang, X.-Y., Chien, C.-H., & Cheng, J.-F. (2017). The Effectiveness of

Diaphragmatic Breathing Relaxation Training for Reducing Anxiety. Perspectives in

Psychiatric Care, 53(4), 329–336. https://doi-org.eps.cc.ysu.edu/10.1111/ppc.12184.

“College Depression: What Parents Need to Know.” Mayo Clinic, Mayo Foundation for

Medical Education and Research, 14 Feb. 2020,

www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/college-dep

ression/art-20048327.

Harrer, M., Adam, S. H., Baumeister, H., Cuijpers, P., Karyotaki, E., Auerbach, R. P.,

Kessler, R. C., Bruffaerts, R., Berking, M., & Ebert, D. D. (2019). Internet

interventions for mental health in university students: A systematic review and meta-
MANAGEMENT OF DEPRESSION AND ANXIETY
14
analysis. International Journal of Methods in Psychiatric Research, 28(2), e1759.

https://doi.org/10.1002/mpr.1759

Jones, M., & Jones, A. (2009). Pharmacological developments in the treatment of

depression. Nursing Standard, 23(32), 40+.

https://link.gale.com/apps/doc/A198849299/PPNU?

u=ohlink104&sid=PPNU&xid=0f06fe07.

Kupfer, D. J. (2005). The pharmacological management of depression. Dialogues Clin

Neurosci,7(3), 191-205. doi:10.31887/DCNS.2005.7.3/dkupfer.

Olfson, Mark, and Steven C. Marcus. “National Patterns in Antidepressant Medication

Treatment.” Archives of General Psychiatry, vol. 66, no. 8, 2009, p. 848.,

doi:10.1001/archgenpsychiatry.2009.81.

Son, H. K., So, W.-Y., & Kim, M. (2019). Effects of Aromatherapy Combined with Music

Therapy on Anxiety, Stress, and Fundamental Nursing Skills in Nursing Students: A

Randomized Controlled Trial. International Journal of Environmental Research and

Public Health, 16(21). https://doi-org.eps.cc.ysu.edu/10.3390/ijerph16214185.