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Interventions for common mental

health problems among university
and college students: A systematic
review and m...
Junping Huang, Yeshambel T Nigatu

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 Journal of Psychiatric Research 107 (2018) 1–10

Contents lists available at ScienceDirect

Journal of Psychiatric Research

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

T
Interventions for common mental health problems among university and
college students: A systematic review and meta-analysis of randomized
controlled trials
Junping Huanga, Yeshambel T. Nigatub, Rachel Smail-Crevierb, Xin Zhanga, Jianli Wangb,c,d,e,∗
a
Department of Child and Adolescent Health, School of Public Health, Tianjin Medical University, China
b
Work & Mental Health Research Unit, The Royal's Institute of Mental Health Research, Canada
c
School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Canada
d
School of Psychology, Faculty of Social Sciences, University of Ottawa, Canada
e
Department of Psychiatry, Faculty of Medicine, University of Ottawa, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: Common mental health problems (CMHPs), such as depression, anxiety disorder, obsessive-compulsive disorder
Intervention (OCD), and post-traumatic stress disorder (PTSD) are internalizing disorders with high comorbidity. University
Depression and college students are under many stressors and transitional events, and students fall within the age range
Anxiety disorder when CMHPs are at their developmental peak. Compared to the expanded effort to explore and treat CMHPs,
OCD
there has been no a meta-analysis that comprehensively reviewed the interventions for CMHPs and examined the
Obsessive-compulsive disorder
effects of interventions for CMHPs in college students. The objective of this review is to conduct a systematic
PTSD
Post-traumatic stress disorder review and meta-analysis of randomized controlled trials (RCTs) examining interventions for CMHPs among
Meta-analysis university and college students and to estimate their post-intervention effect size (ES), as well as follow-up ES,
for depression, anxiety disorder, OCD and PTSD separately. Meta-analytic procedures were conducted in ac-
cordance with PRISMA guidelines. We reviewed 7768 abstracts from which 331 full-text articles were reviewed
and 51 RCTs were included in the analysis. We found moderate effect sizes for both depression (Hedges'
g = −0.60) and anxiety disorder (Hedges' g = −0.48). There was no evidence that existing interventions for
OCD or PTSD were effective in this population. For interventions with high number of papers, we performed
subgroup analysis and found that cognitive behavioral therapy (CBT) and mindfulness-based interventions were
effective for both depression and generalized anxiety disorder (GAD), and attention/perception modification was
effective for GAD; other interventions (i.e. art, exercise and peer support) had the highest ES for both depression
and GAD among university and college students.

1. Introduction significant long-term disability. Individuals with CMHPs usually ex-

Common mental health problems (CMHPs), including depression,
anxiety disorder, obsessive-compulsive disorder (OCD) and post-trau-
matic stress disorder (PTSD) are internalizing disorders, which re-
present overlapping variations of emotional distress in response to life
stressors and difficulties (Nigatu et al., 2016). Anxiety disorders in-
cluding generalized anxiety disorder (GAD), social anxiety, panic dis-
order, agoraphobia and specific phobia share the features of excessive
fear and anxiety. CMHPs can negatively affect the entire life course of
patients, causing substantial psychological, cognitive, social and occu-
pational impairments (APA, 2013). CMHPs are also associated with
perience a lifelong pattern of relapse and remission (NICE, 2011). Se-
venty-five percent of those who have a mental disorder had their first
onset by the age of 25 years (Kessler et al., 2007), which is a pivotal
time period of one's life course in terms of pursuing post-secondary
education and entering the work force.
CMHPs are common and highly comorbid disorders. Of those aged
16–64 years who meet the diagnostic criteria for at least one CMHP,
more than half experience comorbid anxiety or depressive disorders
(NICE, 2011). In the Netherlands Study of Depression and Anxiety
(NESDA), among persons with a depressive disorder, 67% had a current
and 75% had a lifetime comorbid anxiety disorder. Of persons with a

∗
Corresponding author. Work & Mental Health Research Unit, University of Ottawa Institute of Mental Health Research, 1145 Carling Ave, Ottawa, ON K1Z 7K4,
Canada.
E-mail address: Jianli.Wang@theroyal.ca (J. Wang).

https://doi.org/10.1016/j.jpsychires.2018.09.018

0022-3956/ © 2018 Elsevier Ltd. All rights reserved.

Received 12 December 2017; Received in revised form 28 September 2018; Accepted 28 September 2018
J. Huang et al.
current anxiety disorder, 63% had a current and 81% had a lifetime
depressive disorder (Lamers et al., 2011). Research has also indicated
that greater levels of anxiety sensitivity are a higher-order cognitive
risk-factor for both OCD and PTSD (Olatunji and Wolitzky-Taylor,
2009). It is practical, as well as important, to aggregate common mental
health problems to find out how effectively the interventions work.
University and college students may be at higher risk of developing
CMHPs because they are often under significant stress, are in a transi-
tional period, and fall within the age range when CMHPs are at their
developmental peak (Cuijpers et al., 2016). Cumulative data from the
American College Health Association (ACHA) surveys conducted from
1998 through 2008 suggested that the prevalence of clinically sig-
nificant depression among university and college students is rising over
time (ACHA, 2009). The same prevalence trend was found by the
Center for Collegiate Mental Health, which reported year-over-year
increases in the frequency of anxiety and depression (CCMH, 2017). In
addition, according to the 2016 survey by the Association for University
and College Counseling Center Directors (AUCCCD) among 529 coun-
seling centers, anxiety continues to be the most predominant concern
among college students with an annual prevalence of 51%, followed by
depression with an annual prevalence of 41% (AUCCCD, 2016). A
systematic review of studies among university and college students
found that reported depression prevalence rates ranged from 10% to
85% with a weighted mean prevalence of 30.6% (Ibrahim et al., 2013).
OCD and PTSD were also often reported among college and university
students. Sulkowski et al. (2011) found that, although only 5% of stu-
dents displayed clinically significant OCD symptoms, obsessive-com-
pulsive spectrum disorder (OCSD) symptoms were relatively common
in college students (22%–42%), and those with OCSD symptoms had
higher anxiety. Similarly, a study of community college students in-
dicated that 12.6% of non-veteran students were above the cut-off score
on a PTSD screening instrument (Fortney et al., 2016). CMHPs that are
left untreated in students could result in negative outcomes, including
lower self-esteem, social withdrawal, poor academic performance, and,
in severe cases, suicide. CMHPs also have a negative impact on later
occupational trajectories and as well as an enormous economic impact
over the life course (Blanco et al., 2014).
The mental health challenges faced by university and college stu-
dents call for effective interventions for CMHPs. Various interventions
have been developed, including antidepressant medication, psy-
chotherapies, physical exercise, art therapy, etc. Interventions can be
delivered individually, in a group, in a guided self-help, or Internet-
based format. These interventions differ from each other with regard to
content, methods, and results. Increasingly, various interventions for
the treatment of CMHPs have been explored in the past 2 decades, yet
there has been no a meta-analysis that comprehensively reviewed or
examined the effectiveness of interventions for CMHPs in college and
university students. It is unclear whether the current interventions are
effective for the vast majority of students that suffer from CMHPs and,
for this reason, a review of these interventions is essential in order to
establish interventions that are appropriate for college students. .
There have been several systematic (Reavley and Jorm, 2010; Farrer
et al., 2013; Shiralkar et al., 2013; Fernandez et al., 2016) and meta-
analytic (Davies et al., 2014) reviews on preventive interventions in
university and college students' mental health problems. For example, a
meta-analytic review on psychological intervention to decrease de-
pression among college students was recently published (Cuijpers et al.,
2016). In this meta-analysis, 8 of the 15 included papers were published
between 1977 and 1993 and the author noted that the risk of bias in
these studies was high and the number of studies was relatively low,
reducing the ability to carry out powerful moderator analyses. Based on
these findings and upon the high comorbidity of CMHPs, we propose to
conduct a systematic review and meta-analysis to examine the effects of
interventions for CMHPs in college students after 2000. In our paper,
we will calculate the post-intervention ES for depression, anxiety, OCD
and PTSD separately, as well as follow-up ES. We will also seek to
2
Journal of Psychiatric Research 107 (2018) 1–10
identify factors that may contribute to the intervention effect.
2. Method
2.1. Protocol and registration
This systematic review and meta-analysis was conducted in ac-
cordance with the Preferred Reporting Items for Systematic Reviews
and Meta-analyses (PRISMA) guidelines (Moher et al., 2010) and the
Consolidated Standards of Reporting Trials Statement (CONSORT)
(Schulz et al., 2010). A protocol was developed prior to this review and
was registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/
(CRD42017064487).
2.2. Data sources and study selection
We selected randomized controlled trials (RCTs) of interventions in
university or college students with depression, anxiety disorder (in-
cluding GAD, social anxiety, panic disorder, agoraphobia and specific
phobia), obsessive-compulsive disorder (OCD) or post-traumatic stress
disorder (PTSD) using a comprehensive search strategy. We searched
the following databases: Pubmed/Medline, Embase, ERIC,
PsycARTICLES, PsycINFO and CENTRAL (see Supplementary Appendix
for search terms). Two authors independently reviewed the abstracts
and articles with a 97.7% level of agreement (Kappa = 0.713). In the
event of a difference in opinion among authors, the authors discussed
until reaching an agreement. In addition, we searched GreyOpen,
GreyMatters and used advanced searches in Google and Yahoo to find
unpublished reports, abstracts, briefs and preliminary reports. We also
screened the reference lists of identified articles and published reviews
in this field.
2.3. Inclusion criteria
Studies meeting the following inclusion criteria were selected for
the meta-analysis: 1) target population were university or college stu-
dents; 2) health conditions intervened included: depression, anxiety
disorder, OCD or PTSD; 3) randomized controlled trial design; 4) con-
trol was no treatment, waitlist or placebo control; 5) outcomes (de-
pression, anxiety, OCD, PTSD) were assessed with a validated instru-
ment; 6) a minimum of 10 participants in each experimental group; 7)
being written in English and published between Jan, 2000–May, 2018.
Excluded from the review and meta-analysis were: 1) studies with
controlled clinical trials (CCT) or quasi-experimental design; 2) inter-
ventions for high stress, test/performance anxiety, bipolar disorders or
psychotic symptoms; 3) pilot studies.
2.4. Methodological quality
We used the Consolidated Standards of Reporting Trials (CONSORT)
statement 2010 (Schulz et al., 2010) to assess the methodological
quality of included RCTs. CONSORT 2010 contains 25-items, including
detailed description of trial design, detailed description of rigorous
randomization methodology, power analysis, etc. Methodological
quality was not used as a criterion to select studies.
2.5. Data extraction, coding, and processing
Data extraction was performed using a template based on the
Cochrane Review template (Higgins and Green, 2011). We extracted
the following data from each article using a data extraction form: study
characteristics (title, author, publishing year, geographic location, ca-
tegory of CMHP), participants (age, gender, grade, ethnicity distribu-
tion, inclusion and exclusion criteria, incentive of participation or not),
study design (RCT design, number of trial arms, method of randomi-
zation, allocation sequence concealment, blinding, sample size and
J. Huang et al.
Fig. 1. PRISMA flowchart outlining process for systematic review/meta-analysis.
number allocated to each trial arm, attrition), intervention (interven-
tion name, number of sessions, format and control conditions), results
(outcome name and definition, pre-, post- and follow-up results). Most
of these variables were included in this meta-analytic review, except a
few omitted variables (e.g., grade and ethnicity which were poorly
reported). Double check was also applied with high level of agreement
(correlation = 0.921–1.0). If there were multiple reports of the same
study, we extracted data from all reports directly into a single data
extraction form. If the study adopted placebo as well as no treatment/
waitlist as control, we chose placebo control, excluding other control
conditions. Based on the number of included studies, only depression
and generalized anxiety disorder (GAD) had sufficient papers to con-
duct subgroup and moderator analysis. Moderators are described
below. Geographic location was distributed among these 4 regions:
North America, Europe, Asia, and Australia. Interventions were classi-
fied into 4 categories: 1) cognitive and behavioral related interventions
(interventions based on cognitive or behavioral therapy (CBT), as well
as comprehensive therapy based on CBT); 2) mindfulness-based
3
Journal of Psychiatric Research 107 (2018) 1–10
interventions; 3) attention/perception modifications; 4) other inter-
ventions (e.g., supplement, exercise, music, peer support and persona-
lized feedback). Interventions were also classified as easy to dis-
seminate or not. Those with a single-session intervention,
bibliotherapy, unguided online CBT intervention, homework, self-help
intervention, personalized feedback, and writing sessions were defined
as easy to disseminate, while face-to-face interventions and guided
online interventions with several sessions were classified as not. In-
centive of participation includes those who received research certifi-
cates, course certificates or financial offsets from attending the re-
search.
Risk of bias of the randomized studies was assessed using a modified
version of the Cochrane Collaboration's risk of bias tool (Higgins and
Green, 2011). The tool provides a checklist to aid understanding of trial
quality and does not calculate an overall quality score. It assesses study
biases, including random sequence generation (selection bias), alloca-
tion concealment (selection bias), blinding of participants and per-
sonnel (performance bias), blinding of outcome assessment (detection
J. Huang et al.
bias), incomplete outcome data (attrition bias), selective reporting
(reporting bias) and other biases. We coded according to the principles
written in the Cochrane Handbook for Systematic Reviews of Inter-
vention (Higgins and Green, 2011). All of the studies used a self-re-
ported scale as an outcome measure, so performance bias was similar to
detection bias. For those using placebo controls, we classified blinding
as low risk. If the study allocated participants on the basis of a random
table using a computer system, sequence generation and allocation
concealment were both rated as low risk.
2.6. Effect size calculation
The Standardized Mean Difference (SMD) is a version of ES typically
calculated in reviews and is expressed as Hedges' g. SMDs were calcu-
lated for each included study by subtracting the post-intervention mean
of the intervention condition from the post-intervention mean of the
comparison condition, and dividing this by the pooled standard de-
viation from both conditions (Higgins and Green, 2011). When an in-
tervention reduced negative emotions more than the control, Hedges' g
had a negative value. The use of SMD allows comparisons across studies
where different psychometric measures were used to assess the same
outcomes (Higgins and Green, 2011). Hedges' g yields an unbiased es-
timate even though the sample size is small (Hedges and Olkin, 1985).
Inferences of Hedges' g can be made using Cohen's d conventions as small
(0.2), medium (0.5), and large (0.8) (Cohen, 1998).
The intervention effect for depression, anxiety, OCD and PTSD was
calculated separately by pooling the corresponding estimates using
random-effects meta-analyses that accounted for between-study het-
erogeneity. Pooled follow-up effects were calculated using the same
approach. Standard χ2 tests and the I2 statistic were used to assess
between-study heterogeneity. I2 statistic means the percentage of
variability in intervention estimates due to heterogeneity rather than
sampling error, or chance, with the values of 25% indicating low het-
erogeneity, 50% suggesting moderate, and 75% indicating considerable
heterogeneity (Higgins et al., 2003). Subgroup analysis and random-
effects meta-regression (van Houwelingen et al., 2002) were performed
to further explore the heterogeneity and to identify the moderators.
Geographic location, intervention type, easy to disseminate or not,
control conditions and the inclusion of participation incentive or not
were the main factors that were considered. Forty-six out of 51 studies
over-represented female participants, so we did not include gender as a
moderator. Publication bias was investigated using funnel plots and the
Egger and trim-and-fill tests. All analyses were performed using STATA
15.0.
3. Results
3.1. Description of included studies
Fig. 1 presents a flow diagram of the study selection process. We
retrieved 7768 peer-reviewed articles from 6 main databases. The titles
and abstracts of these articles were examined, and 331 articles were
selected. The full texts of these papers were subsequently examined and
51 RCT studies were retained. Supplementary Table 1 presents the
studies included in this review and meta-analysis. We organized the
data according to CMHPs categories, e.g. depression, anxiety, OCD or
PTSD. Studies that included either depression or anxiety with both
depression and anxiety outcome measures were listed first. Within each
category, we organized according to publishing year and alphabetically
by the first author's family name.
Three studies (Wu, 2002; Day et al., 2013; Falsafi, 2016) included
interventions for students with either depression or anxiety, all of
which had outcome measures of both depression and anxiety; 6 studies
(Clore, 2008; Hinton and Gaynor, 2010; Ellis et al., 2011; Lintvedt
et al., 2013; Kim et al., 2016; Levin et al., 2017) included students with
psychological distress, 3 of which (Ellis et al., 2011; Kim et al., 2016;
4
Journal of Psychiatric Research 107 (2018) 1–10
Levin et al., 2017) had outcome measures of both depression and an-
xiety, with the latter 3 having only outcome measure of depression; 22
studies (Peden et al., 2000; Gawrysiak et al., 2009; Geisner et al., 2015;
Hamdan-Mansour et al., 2009; McMakin, 2009; Wells and Beevers,
2010; Armento, 2011; McMakin et al., 2011; Charbonneau, 2012;
Penton-Voak et al., 2012; Moldovan et al., 2013; Walker and
Lampropoulos, 2014; Chen et al., 2015; Geisner et al., 2015; Ginty and
Conklin, 2015; Yang et al., 2015, 2018; Li et al., 2016; McIndoo et al.,
2016; Takagaki et al., 2016; López-Rodríguez et al., 2017; Mastikhina
and Dobson, 2017) included only students with depression. Fifteen
papers included students with anxiety disorders, among them, 6 studies
(Kenardy et al., 2003; Smits et al., 2008; Morris et al., 2016; Richards
et al., 2016; Chaló et al., 2017; Xu et al., 2017) included students with
GAD, 6 studies (Beard and Amir, 2008; Bjornsson, 2010; Lee and Kwon,
2013; Yao et al., 2015; Norton and Abbott, 2016; Ye, 2017) included
students with social anxiety, and 3 studies (Vansteenwegen et al., 2007;
Olatunji et al., 2012; Cougle et al., 2016) included students with spe-
cific anxiety. One study (Timpano et al., 2016) included students with
OCD, and 4 studies (Lange et al., 2001; Sloan et al., 2011; Callinan
et al., 2014; Allan et al., 2015) included students with PTSD. Five of the
studies including students with depression (Gawrysiak et al., 2009;
Armento, 2011; Yang et al., 2015; Li et al., 2016; McIndoo et al., 2016),
and 4 of the studies that included students with GAD (Kenardy et al.,
2003; Smits et al., 2008; Morris et al., 2016; Richards et al., 2016)
reported both depression and anxiety outcome measures. For these
papers, because their pre-intervention anxiety (depression) mean was
also above their corresponding cut-off, we included the latter as an
independent ES. For papers dealing with social/specific anxiety, OCD or
PTSD, we only chose its specific corresponding outcome measure. In
total, we included 51 studies, 59 interventions and 77 post-intervention
ESs for this review. We analyzed intervention effect for depression,
anxiety, OCD and PTSD separately.
Seventeen studies (Peden et al., 2000; Wu, 2002; Kenardy et al.,
2003; Smits et al., 2008; Hamdan-Mansour et al., 2009; Wells and
Beevers, 2010; Armento, 2011; Charbonneau, 2012; Moldovan et al.,
2013; Allan et al., 2015; Yang et al., 2015, 2018; Yao et al., 2015;
Falsafi, 2016; McIndoo et al., 2016; Timpano et al., 2016; Mastikhina
and Dobson, 2017) reported long-term follow-up results. Long-term
follow-up results indicate whether the intervention effect is sustained
over time following the completion of the intervention. The duration of
follow-up ranged from 2 weeks to 7 months post-intervention. Of the 51
studies that were included, 26 were from North America, 10 from
Europe, 12 from Asia and 3 from Australia. There were a total of 3396
university or college students included in the studies. One study on
depression (Yang et al., 2018) and 3 studies on social anxiety
(Bjornsson, 2010; Lee and Kwon, 2013; Norton and Abbott, 2016) in-
cluded participants that met M.I.N.I. or DSM-IV criteria for the disorder,
whereas in the remaining studies, participants were included if they
met criteria for depression or anxiety disorder based on self-reported
scales. 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 of the 51
studies over-represented females with the percentage ranging from 62%
to 100%. Further characteristics of the studies are shown in Table 1 in
the supplementary appendix and more information about included
studies is available upon request.
Many studies examined the effect of cognitive-behavioral related
interventions on depression and GAD (24/42 ESs were for depression
and 11/21 ESs were for GAD). Interventions for social anxiety included
attention/perception modification (Beard and Amir, 2008; Yao et al.,
2015), imagery rescript (Lee and Kwon, 2013; Norton and Abbott,
2016), mindfulness (Ye, 2017) and cognitive behavioral group therapy
(CBGT) (Bjornsson, 2010; Norton and Abbott, 2016). Among the studies
targeting specific anxiety, all interventions were exposure-based. One
paper (Keough and Schmidt, 2012) targeting OCD symptoms adopted
anxiety sensitivity education and reduction training. Interventions that
targeted posttraumatic stress included attention training (Callinan
J. Huang et al.
Fig. 2. Forest plot of intervention for depression among college students.
et al., 2014), anxiety sensitivity education and reduction training (Allan
et al., 2015), Interapy treatment (Lange et al., 2001) and written
emotional disclosure (Sloan et al., 2011).
3.2. Methodological quality
The average overall compliance with the CONSORT checklist of the
included studies was 55.5% (95% CI, 53.2–57.7%). Ten papers (19.6%)
had a compliance of over 60% and 4 papers (7.8%) had a compliance of
less than 45%. Most relevant descriptors from the checklist were de-
termined to be methodologically adequate except identification as a
randomized trial in the title (51.9%), sample size (27.5%), sequence
generation (56.9%), allocation concealment (39.2%), implementation
(27.5%), blinding (35.3%), baseline database (43.1%), registration
(5.9%) and funding (35.3%). Only 1 paper reported its protocol (2.0%).
3.3. Interventions for depression
Fig. 2 shows meta-analysis results of intervention for depression by
5
Journal of Psychiatric Research 107 (2018) 1–10
different interventions. Hedges' g for overall post-intervention for de-
pression was −0.60 (95% CI: 0.74, −0.46). The pooled ES (Hedges' g) of
other interventions (i.e. art, exercise and peer support) was higher
(−0.76, 95% CI: 1.19, −0.32) than cognitive-behavioral related in-
terventions (−0.59, 95% CI: 0.72, −0.45), mindfulness-based inter-
ventions (−0.52, 95% CI: 0.88, −0.16) and attention/perception
modification (−0.46, 95% CI: 1.06, 0.13). The ESs were statistically
significant for cognitive-behavioral related interventions, mindfulness-
based interventions and other interventions for depression. We failed to
find statistical significance for the intervention of attention/perception
modification for depression (p > 0.05).
As for subgroup analysis, Hedges' g for easy to disseminate inter-
ventions (−0.37, 95% CI: 0.58,-0.17) was smaller than that of not easy
to disseminate interventions (−0.70, 95% CI: 0.88, −0.52). For geo-
graphic location, Hedges' g for depression intervention was largest in
Asia: 0.94 (95% CI: 1.27, −0.62), followed by Australia: 0.77 (95% CI:
1.16, −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 treatment had the
largest effect (−0.68, 95% CI: 0.93, −0.43), followed by the waitlist
J. Huang et al.
(−0.55, 95% CI: 0.71, −0.39), and placebo control (−0.52, 95% CI:
0.87, −0.18). Hedges' g for interventions with incentive (−0.58, 95%
CI: 0.79, −0.37) was similar with interventions without incentive
(−0.63, 95% CI: 0.84, −0.43). To further explore the possible factors
that caused heterogeneity, we performed meta-regression analysis by
moderators. We failed to find any moderators that affected the effect
size of the intervention with statistical significance.
Hedges' g for overall long term follow-up intervention for depression
was −0.68 (95% CI: 0.89, −0.48). The follow-up pooled ES (Hedges' g)
of cognitive-behavioral related interventions (−0.75, 95% CI: 0.95,
−0.54) and other interventions (−1.09, 95% CI: 1.57, −0.60) had a
higher and significant effect. Mindfulness-based interventions and at-
tention/perception modification had a lower and insignificant effect,
with their Hedges' g being −0.56 (95% CI: 1.22, 0.11), −0.42 (95% CI:
1.02, 0.19) respectively. Long term follow-up effect (Hedges' g) for easy
to disseminate interventions (−0.46, 95% CI: 0.88, −0.04)] was lower
than not easy to disseminate interventions (−0.72, 95% CI: 0.95,
−0.50).
Fig. 3. Forest plot of intervention for anxiety disorders among college students.
6
Journal of Psychiatric Research 107 (2018) 1–10
3.4. Interventions for anxiety disorders
Fig. 3 shows meta-analysis results of intervention for anxiety by
category. The overall ES (Hedges' g) for anxiety disorder was −0.48
(95% CI: 0.62, −0.34). The ESs were statistically significant for GAD
interventions (Hedges' g = −0.49, 95% CI: 0.62, −0.37). There was no
statistical significance for interventions for social anxiety (Hedges'
g = −0.32, 95% CI: 0.69, 0.04) and specific anxiety (Hedges'
g = −0.51, 95% CI: 1.42, 0.40).
When examining the interventions by each anxiety categories, only
GAD had high number of studies, thus subgroup and moderator analysis
was only done in studies targeting GAD. The pooled ES (Hedges' g) of
other interventions (peer support, music) for GAD had a higher effect
(−0.84, 95% CI: 1.19, −0.49) than CBT related interventions (−0.39,
95% CI: 0.55, −0.22) and mindfulness (−0.49, 95% CI: 0.84, −0.15).
There were only 2 papers to assess the effect of attention/perception
modification on GAD, so we didn't calculate the pooled ES.
Interventions with no treatment control had higher ES (Hedges'
g = −0.81, 95% CI: 1.18, −0.43) than interventions with waitlist
(Hedges' g = −0.42, 95% CI: 0.58, −0.27) and interventions with
placebo control (Hedges' g = −0.55, 95% CI: 0.90, −0.21).
J. Huang et al.
Intervention effect favoured those with longer and guided interventions
(Hedges' g for easy to disseminate interventions was −0.54, 95% CI:
0.69, −0.38) and Hedges' g for not easy to disseminate interventions
was −0.41 (95% CI: 0.66, −0.16)]. We also performed meta-regression
analysis, yet failed to find any statistical significant moderators that
affect the effect size of the intervention for GAD.
Hedges' g for overall long term follow-up intervention for any an-
xiety disorders was −0.44 (95% CI: 0.71, −0.17). The Hedges' g for
interventions with no treatment control (−0.90, 95% CI: 1.35, −0.45)
and interventions with waitlist control (−0.60, 95% CI: 1.00, −0.21)
were higher than interventions with placebo control (−0.02, 95% CI:
0.33, 0.29).
3.5. Interventions for OCD and PTSD
There was only 1 article related to OCD intervention. As such, the ES
related to OCD was not calculated. For the three papers that examined
post-traumatic stress disorder (PTSD) interventions, the Hedges' g for
overall post-intervention was −0.50 (95% CI: 1.15, 0.16), which was
not statistically significant.
3.6. Publication bias and study quality
To test the robustness of the estimated effects, we assessed pub-
lication bias and study quality. Figs. 1 and 2 in the Supplementary
Appendix show the funnel plots of included studies for depression and
anxiety disorders separately. In addition, we confirmed the funnel plot
result with the Egger's regression test, which was statistically significant
indicating asymmetry for both depression and anxiety disorders
(t = −2.86, p = 0.007 for depression; t = −3.47, p = 0.003 for an-
xiety). We also performed the trim-and-fill procedure. No studies were
filled or trimmed, suggesting minimal impact of publication bias and
the robustness of our results.
The included papers had considerably high quality. Seven of 51
papers met all criteria for low risk of bias (Beard and Amir, 2008; Sloan
et al., 2011; Penton-Voak et al., 2012; Lee and Kwon, 2013; Ginty and
Conklin, 2015; Yang et al., 2015; Norton and Abbott, 2016). As shown
in Fig. 4, 57.0% of ESs adopted low risk of sequence generation, and
46.8% of ESs adopted low risk of allocation. Blinding of the participants
Fig. 4. Risk assessment of bias presented as percentages across all included studies.
7
Journal of Psychiatric Research 107 (2018) 1–10
was at 44.3%. Due to author's poor reporting clarity, 40.5% of sequence
generation and 48.1% of allocation were rated as “unclear risk” and
13.9% were judged to be at high risk of attrition bias. Additionally,
6.3% were rated as high risk of reporting bias, while 8.9% had other
biases, including baseline imbalance and separate interventions com-
bined.
4. Discussion
To our knowledge, this is the first meta-analysis to comprehensively
estimate the efficacy of interventions for college and university students
with CMHPs. We adopted a detailed systematic search strategy, clearly
defined inclusion criteria, and the objective assessment of the metho-
dological rigor for each included study. We found moderate interven-
tion effect for both depression (Hedges' g = −0.60) and anxiety dis-
orders (Hedges' g = −0.48). The overall ESs for PTSD had no statistical
significance. Even though interventions based on CBT, attention/per-
ception modification and mindfulness-based intervention were found to
be effective, other interventions, i.e. art, exercise, and peer support had
the highest ESs for both depression and GAD among college and uni-
versity students (Hedges' g = −0.76 for depression, Hedges' g = −0.84
for GAD). For those with long term follow-up data, interventions for
depression and anxiety showed statistically significant effects.
4.1. Effect size
The moderate post-intervention effect and the statistically sig-
nificant long-term effect found in our study for depression and anxiety
disorders further verified the effectiveness of specialized clinical ser-
vices targeting individuals with depression or anxiety. The effect size
for depression found in our study (Hedges' g = −0.60) was higher than
that found in a computer-delivered and web-based intervention meta-
analysis among university students (Hedges' g = −0.43 for depression)
(Davies et al., 2014) and a review of technology-based interventions for
mental health in tertiary students (Hedges' g = 0.48) (Farrer et al.,
2013). This is in agreement with the results of research that compared
the effect of iCBT to face-to-face CBT, which found that face-to-face CBT
was somewhat more effective (Sethi, 2012). The effect size for de-
pression found in our study was lower than that found in the meta-
J. Huang et al.
analysis results of psychological treatment among college students
(Hedges' g = 0.89) (Cuijpers et al., 2016). The latter included lower
quality studies, and thus had higher ESs. This is consistent with the
conclusion that larger effects sizes are found when inclusion criteria are
less strict and a greater number of papers are included in the analysis.
It is difficult to compare the ES for anxiety disorder found in our
study with other studies because inclusion criteria differ across studies.
The ES (Hedges' g = −0.48) found in our study was similar to the results
of the meta-analytic study by Davies who assessed the effect of com-
puter-delivered and web-based interventions to improve anxiety among
university students (Hedges' g = −0.56 for anxiety) (Davies et al.,
2014), and it was lower than the results found in the technology-based
interventions in tertiary students (Hedges' g = −0.77) (Farrer et al.,
2013). Social and specific anxiety disorders were included in this study
and there was no statistically significant effect of intervention for either
of these disorders in college and university students. These results
emphasize the necessity to develop more reliable and efficient inter-
ventions for social anxiety and specific anxiety disorder. Compared to a
meta-analysis that reported the effects of psychological interventions on
symptoms of anxiety delivered via smartphone, our results were higher
(Hedges' g = −0.325) (Firth et al., 2017).
4.2. Moderators
Compared with placebo control or waitlist, intervention effect fa-
voured those with control being no treatment which is consistent with
other meta-analyses (Mohr et al., 2009; Davies et al., 2014; Cuijpers
et al., 2016). There are a number of non-specific intervention effects
that account for improvement in mental illness, such as working alli-
ance, placebo, and natural remission (Stek et al., 2006; Bertisch et al.,
2009). However these non-specific effects can be controlled by in-
cluding a placebo condition. Because “no treatment” and “waitlist
control” groups are only capable of controlling for the natural course of
mental health problems, we set placebo control as our first choice in
this meta-analysis.
Easy to disseminate interventions, including single-session inter-
vention, bibliotherapy, unguided online CBT, homework, self-help in-
tervention, and personalized feedback had smaller ESs compared to
more complex, longer and guided interventions for depression in our
meta-analysis. The Center for Collegiate Mental Health 2017 Annual
Report also found a relationship between symptom reduction and
length of treatment (CCMH, 2017). Theoretically, longer interventions
provide more opportunities for presentation of information concerning
attitudinal and behavioral change skills, allow participants to reflect on
intervention material between sessions, and give participants more
opportunities to practice new skills and then return to the group for
trouble-shooting advice (Stice and Shaw, 2004). Therefore, it is un-
surprising that complex interventions show larger effects.
Even though ESs were not significantly associated with intervention
type, other interventions had a higher effect size for both depression
and anxiety. This conclusion should be considered with caution. To
some extent this suggests that there currently may not be a leading
intervention for college students with CMHPs.
This systematic review and meta-analysis had several limitations. 1)
Similar to the findings from former reviews, studies included in our
review over-represent interventions with female students in Western
countries. 2) Generally, interventions in the included studies lasted for
a short period of time and some web-based interventions had low ad-
herence, which could attenuate the intervention effect. 3) Participants
included in the studies were almost all students with mild ∼ moderate
mental health problems, thus caution should be used when extra-
polating these results to clinical populations with severe symptoms. 4)
The amount of data included in this study was rather small once it was
divided into subgroups. This is especially true for the anxiety sub-
groups, therefore some of the results should be considered with caution.
In conclusion, consistent with former findings, we also found a
8
Journal of Psychiatric Research 107 (2018) 1–10
moderate intervention effect for both depression and anxiety among
college and university students. Other interventions, i.e. art, exercise,
peer support, etc. had the highest ES for both depression and GAD. It
would thus seem practical as well as useful to offer more support pro-
grams in colleges and universities to improve students' mental health.
We also feel that more rigorously designed RCTs among university and
college students are needed. Although complex interventions based on
CBT and mindfulness principles are more effective than interventions
that are easy to disseminate, future studies must examine effectiveness,
as well as the acceptability, sustainability, and cost-effect ratio of these
interventions.
Declarations of interest
none
Funding
This research is supported by the China Scholarship Council.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jpsychires.2018.09.018.
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