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International Journal of StressManagementMeta-Analytic Evaluation of Stress ReductionInterventions for Undergraduate and Graduate StudentsMiryam Yusufov, Jennifer Nicoloro-SantaBarbara, Natalie E. Grey, Anne Moyer, and Marci LobelOnline First Publication, May 3, 2018. http://dx.doi.org/10.1037/str0000099
CITATIONYusufov, M., Nicoloro-SantaBarbara, J., Grey, N. E., Moyer, A., & Lobel, M. (2018, May 3). Meta-Analytic Evaluation of Stress Reduction Interventions for Undergraduate and Graduate Students.International Journal of Stress Management. Advance online publication.http://dx.doi.org/10.1037/str0000099
Meta-Analytic Evaluation of Stress Reduction Interventions forUndergraduate and Graduate Students
Miryam Yusufov, Jennifer Nicoloro-SantaBarbara, Natalie E. Grey, Anne Moyer,and Marci Lobel
Stony Brook University
Growing numbers of students in college or graduate school experience high stress,resulting in adverse emotional, academic, and health outcomes. A variety of stressreduction interventions have been used with students, but their effectiveness has notbeen systematically examined. We used meta-analysis to evaluate the efficacy of stressreduction interventions for undergraduate and graduate students. Studies (k � 43) thatused an appropriate control group and assessed distress before and after interventionwere aggregated using a random-effects model. Most studies were conducted in theUnited States; others were from Asia, Europe, and Australia. Standardized mean gaindifference effect sizes were calculated for anxiety and perceived stress for six inter-vention techniques. Moderators examined included student type (undergraduate andgraduate) and duration of intervention. Results indicate that most interventions areeffective in decreasing both outcomes in students. Cognitive–behavioral therapy,coping skills, and social support interventions were more effective in reducing per-ceived stress, whereas relaxation training, mindfulness-based stress reduction, andpsychoeducation were more effective in reducing anxiety. Graduate students experi-enced greater reduction in anxiety than did undergraduates for relaxation training andpsychoeducation interventions. Participants in both long- and short-term interventionsshowed significant reduction in anxiety and perceived stress relative to control groups,but for relaxation training, long-term interventions were more effective in reducinganxiety than were short-term interventions. Although all six techniques were effectivein reducing at least one of the stress-related outcomes, the few differences in effec-tiveness suggest there is value in tailoring interventions toward the particular group andoutcome being targeted.
Keywords: stress reduction intervention, anxiety, distress, students, meta-analysis
Distress among young adult students is risingprecipitously. Undergraduate students are pre-senting to counseling centers with mental healthconcerns in growing numbers, and poor self-rated emotional health has become increasingly
common among students (American Psycholog-ical Association, 2013; Center for CollegiateMental Health, 2014; Reetz, Krylowicz, & Mis-tler, 2014; Watkins, Hunt, & Eisenberg, 2012).Stress is often a precursor to depression, anxi-ety, and other mental health disorders in stu-dents (Augner, 2015; Beiter et al., 2015; Iqbal,Gupta, & Venkatarao, 2015; Watkins et al.,2012). In the past 25 years, students’ percep-tions of their own mental health have beendeclining, with a 13% decline from 2009 to2010 (Pryor, Hurtado, DeAngelo, Blake, &Tran, 2010). Research has also suggested thatthe current generation of students struggles withstress management far more than did previousgenerations (Bland, Melton, Welle, & Bigham,2012).
Miryam Yusufov, Jennifer Nicoloro-SantaBarbara, Nata-lie E. Grey, Anne Moyer, and Marci Lobel, Department ofPsychology, Stony Brook University.
Miryam Yusufov is now at Harvard Medical School.Natalie E. Grey is now at California State University, Chan-nel Islands.
Correspondence concerning this article should be ad-dressed to Marci Lobel, Department of Psychology, StonyBrook University, 100 Nicolls Road, Stony Brook, NY11794-2500. E-mail: [email protected]
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International Journal of Stress Management© 2018 American Psychological Association 2018, Vol. 1, No. 999, 0001072-5245/18/$12.00 http://dx.doi.org/10.1037/str0000099
1
Undergraduates report a wide range of stres-sors including academic pressures, social chal-lenges, family strains, and financial concerns(Beiter et al., 2015). At the same time, thesestudents are undergoing a transition from ado-lescence to adulthood (Arnett, 2014). Manystruggle to solidify their identities, attitudes,and values, and some have not yet developedappropriate skills to cope well with stress (Ar-nett, 2014; London, Rosenthal, Levy, & Lobel,2011). During their later college years, studentsalso begin to make career decisions and pursuegraduate training or occupational prospects thatcan engender stress (Beiter et al., 2015). Fur-thermore, some research attributes studentstress increases to increasing numbers of peopleenrolling in degree-granting institutions. Col-lege enrollment increased by 11% between1991 and 2001 and by 32% between 2001 and2011 (National Center for Education Statistics,2011). As the population of people who areattending college and graduate school has ex-panded, more of them may be underprepared.Students from diverse backgrounds also reportexperiences of stress on college campuses re-lated to their racial and ethnic identity (Arbona& Jimenez, 2014). In addition, the cost ofhigher education has risen much more rapidly—260% from 1980 to 2014—than other commod-ities (�120% over the same period; Jackson,2015). Consequently, students and their fami-lies are facing greater financial stress and morestudents are working while attending school(Heckman, Lim, & Montalto, 2014). Finally,older students are more numerous than in pre-vious generations, and they may simultaneouslybe facing other stressors (Chung, Turnball, &Chur-Hansen, 2017). For example, the numberof single mothers in college more than doubledfrom 1999 to 2012, and now accounts for 11%of all undergraduates (Institute for Women’sPolicy Research, 2017).
Graduate students also face substantial stress,particularly in medical, helping, and clinicallyoriented graduate programs. These students notonly engage in rigorous theoretical learning butare also responsible for patients and simultane-ously deal with a lack of knowledge and expe-rience in a novel environment (Seibel, 2014).Some graduate nursing students, for example,report low confidence and an inability to com-plete tasks, which lead to increases in anxiety,perceived stress, and depression (Reeve, Shu-
maker, Yearwood, Crowell, & Riley, 2013;Wolf, Stidham, & Ross, 2015). Like their un-dergraduate counterparts, both clinically andnonclinically oriented graduate students alsoexperience numerous other stressors, includingtest anxiety (Augner, 2015) and financial strains(Ho, Wong, Chow, & Cheng, 2015).
Facing this number and variety of challengeswith insufficient coping skills can adversely af-fect students’ psychological and physical health(Augner, 2015; Klainin-Yobas et al., 2014; Li &Yang, 2009). Stress and maladaptive copingstrategies are related in students to poor sleep(Sawah et al., 2015), psychiatric disorders(Iqbal et al., 2015), substance abuse (Jackson,Shanafelt, Hasan, Satele, & Dyrbye, 2016;Moore, Burgard, Larson, & Ferm, 2014), phys-ical health decrements (Klainin-Yobas et al.,2014), attrition, and poor academic perfor-mance (Sohail, 2013). A qualitative study ofcollege administrators revealed that increases inmental health severity and psychosocial differ-ences in the college population partly accountedfor increased demand for college mental healthservices (Watkins et al., 2012). The trends aresimilar across countries and settings. For exam-ple, one study of Saudi Arabian medical stu-dents revealed that the prevalence of stress was63%, and the prevalence of severe stress was25% (Abdulghani, AlKanhal, Mahmoud, Pon-namperuma, & Alfaris, 2011). School-relatedstress has been associated with high rates ofsuicide in Asian Americans and in Asian coun-tries (Leong, Leach, Yeh, & Chou, 2007), andnumerous French studies have identified highrates of student distress, often associated with orleading to psychological disorders and suicidalideation (Saleh, Camart, & Romo, 2017). Giventhe extent of deleterious outcomes associatedwith stress, identifying effective approaches tomanaging stress in undergraduate and graduatestudents is imperative.
Stress Reduction Interventions for Students
A variety of interventions have been createdto alleviate stress in students. These interven-tions incorporate several techniques, either sin-gly or in combination, most commonly includ-ing psychoeducation, relaxation training,cognitive– behavioral therapy (CBT), socialsupport, coping skills training, or mindfulnesstraining. The goal of psychoeducation is to in-
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crease knowledge of the causes of stress and itsemotional, cognitive, behavioral, and physio-logical effects (Steinhardt & Dolbier, 2008).Relaxation training includes techniques such asprogressive muscle relaxation, guided imagery,meditation, and biofeedback, and is designed toreduce or alter the physiological stress response(Henriques, Keffer, Abrahamson, & Horst,2011; Ratanasiripong, Ratanasiripong, &Kathalae, 2012; Zargarzadeh & Shirazi, 2014).Cognitive–behavioral strategies aim to identifyand change maladaptive thinking and behavior,such as catastrophizing and alcohol use (Or-bach, Lindsay, & Grey, 2007). Interventionsthat employ social support provide environ-ments where individuals are encouraged tocommunicate their experiences, thoughts, andfeelings to one another (Ando, 2011; Kim, Lee,Kim, Noh, & Lee, 2016). Coping skills trainingfocuses on tailoring skills to deal with specificstressors (Jones, 2004; Sheehy & Horan, 2004).Finally, mindfulness-based stress reduction(MBSR; Kabat-Zinn, 1990) is based on thepremise that enhancing one’s ability to attend topresent moment experiences in a receptive wayreduces self-focused thoughts and emotions thatlead to poor mental health (Call, Miron, & Or-cutt, 2014; Chen, Yang, Wang, & Zhang, 2013;Phang, Mukhtar, Ibrahim, Keng, & Sidik, 2015;Warnecke, Quinn, Ogden, Towle, & Nelson,2011). The selection of techniques incorporatedinto stress reduction interventions is based onassumptions about their likely effectiveness in agiven context.
Various meta-analyses and systematic re-views have evaluated such stress reduction in-terventions. However, most studies have evalu-ated one intervention only, such as meditation(Sedlmeier et al., 2012), mindfulness (Gross-man, Niemann, Schmidt, & Walach, 2004;Khoury, Sharma, Rush, & Fournier, 2015; Ze-nner, Herrnleben-Kurz, & Walach, 2014; Zoog-man, Goldberg, Hoyt, & Miller, 2015), relax-ation training (Bastani, Hidarnia, Kazemnejad,Vafaei, & Kashanian, 2005), or CBT (Hofmann& Smits, 2008; Regehr, Glancy, & Pitts, 2013;Stewart & Chambless, 2009). CBT, for exam-ple, has been shown in several analyses to bemoderately (Hofmann & Smits, 2008) orstrongly (Stewart & Chambless, 2009) effec-tive, although the findings are based primarilyon nonstudent samples. Benefits of relaxationtraining were demonstrated in a unique nonstu-
dent population, namely, pregnant women (Bas-tani et al., 2005). In this study, relaxation train-ing produced reductions both in anxiety and inperceived stress, with stronger effects on anxi-ety. MBSR interventions have also been usedsuccessfully in a variety of populations, includ-ing healthy adults (Chiesa & Serretti, 2009) aswell as patients (Grossman et al., 2004), al-though there have been some contradictoryfindings regarding the specific benefits of thistype of intervention. A meta-analysis by Goyaland colleagues (2014), for example, indicatedthat mindfulness interventions had moderateimpact on anxiety (d � .38 at 8 weeks; .22 at3–6 months), and little impact on stress or dis-tress in adult clinical samples, whereas a differ-ent meta-analysis indicated that MBSR hadlarger effects on stress than on anxiety (Khouryet al., 2015).
Of research that has investigated stress inter-ventions among students, most studies haveevaluated either undergraduate (Regehr et al.,2013) or graduate (Galbraith & Brown, 2011)students exclusively. For instance, a meta-analysis of stress interventions with nursing stu-dents revealed that coping skills and changingmaladaptive cognitions were effective in reduc-ing perceived stress in this population (Gal-braith & Brown, 2011). To our knowledge, nometa-analysis has examined which techniquesare most effective in reducing distress amongundergraduate and graduate students, andwhether effectiveness varies depending on stu-dent population. Undergraduate and graduatestudents both experience a large number andvariety of stressors during their education.Many interventions have been developed forboth undergraduate and graduate student popu-lations. However, it is not known whether un-dergraduate and graduate students benefit dif-ferentially from these interventions.
It is also important to examine whether inter-ventions are differentially effective based ontheir duration. Van Daele, Hermans, VanAudenhove, and Van den Bergh (2012), forexample, found that brief psychoeducation in-terventions to reduce stress were more effectivethan psychoeducation interventions of longerduration. Stress reduction interventions for stu-dents range from single-day programs to pro-grams lasting several weeks. One of the briefestinterventions is the 1-day outdoor experientialtraining program (Kanters, Bristol, & Attarian,
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2002) that often incorporates coping skills train-ing and social support in orientation programs atcolleges and universities (Padilla-Meléndez,Fernández-Gámez, & Molina-Gómez, 2014).This intervention has been shown to reduceanxiety in graduate veterinary students (Kanterset al., 2002). Many other interventions last 8weeks or more. For example, a multidimen-sional intervention in which nursing studentsmet for 2 hours weekly for 12 weeks was ef-fective in reducing their anxiety (Sharif & Ar-mitage, 2004). Longer interventions may bemore resource-intensive and require greatercommitment from participants; however, ifbriefer interventions are not as efficacious, thengreater investment may be worthwhile.
The Present Study
We used meta-analytic techniques to exam-ine the effectiveness of interventions in reduc-ing students’ anxiety and perceived stress incomparison with control conditions. Examiningchanges in both anxiety and perceived stressoffers a more comprehensive analysis of theimpact of interventions. According to one of themost prominent theoretical frameworks for con-ceptualizing stress, cognitive appraisal is theprocess by which individuals evaluate whethera situation is stressful or benign (Lazarus &Folkman, 1984). Anxiety is a common emo-tional response to a situation perceived asstressful, although some emotion experts sug-gest that anxiety can be a more immediate re-sponse, not necessarily preceded by a cognitiveappraisal or perception of stress (cf. Lazarus,1999). Thus, it is valuable to examine perceivedstress and anxiety independently and to deter-mine whether interventions reduce one or bothof these.
The aim of the present study was to evaluatethe effectiveness of interventions in reducingstudents’ anxiety and perceived stress. We usedmeta-analysis to examine effectiveness of sixtypes of evidence-based interventions: CBT,coping skills training, relaxation training,MBSR, psychoeducation, and social support. Inaddition to identifying effective interventions,we also explored whether effectiveness is influ-enced by duration of the intervention or bystudent level (i.e., undergraduate vs. graduate).
Intervention Type
We compared changes in anxiety or per-ceived stress from before to after an interven-tion based on the type of intervention techniqueused: CBT, coping skills training, MBSR, re-laxation training, psychoeducation, or socialsupport. Because some interventions used morethan one technique, some studies were includedin multiple analyses. We tested the followinghypotheses:
Hypothesis 1: Interventions that incorpo-rate techniques that aim to alter cognitiveappraisals of stressors, specifically thosethat use CBT or coping skills training, willhave robust effect sizes for perceived stressand smaller effect sizes for anxiety.
Hypothesis 2: Interventions that aim to re-duce negative emotional responses tostressors, specifically those that use relax-ation training, will have robust effect sizesfor anxiety and smaller effect sizes forperceived stress.
Hypothesis 3: Interventions using MBSR,social support, or psychoeducational tech-niques will have similar effect sizes forboth outcomes (perceived stress and anxi-ety) because such techniques focus both oncognitive appraisal and emotionalresponses.
Study hypotheses were evaluated by examin-ing effect sizes for alleviation of anxiety andperceived stress, respectively. See Method sec-tion below.
Student Type
We also explored whether the efficacy ofinterventions varies depending on whether it isused with undergraduate or graduate students.Whereas both types of students face a variety ofstressors during their education, undergraduatestudents experience a transitional period be-tween late adolescence and early adulthood inwhich their identities, attitudes, and values maybe unstable (Arnett, 2014). They may also haveunderdeveloped or untested coping skills andcould therefore benefit differently than rela-tively older graduate students from interven-tions aimed at improving these skills. Becausethere is insufficient existing evidence to ad-
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vance a specific hypothesis, these analyses wereexploratory.
Intervention Duration
Duration of intervention is also an importantmoderator to examine to determine whetherthere is justification for investing greater re-sources and participant time in longer lastinginterventions, or whether briefer interventionsare equally effective and more resource effi-cient. This analysis was also exploratory.
Method
Study Selection and Data Extraction
According to guidelines of the Preferred Re-porting Items for Systematic Reviews andMeta-Analyses (PRISMA; Moher, Liberati,Tetzlaff, Altman, & the PRISMA Group, 2009),a systematic literature search was conducted bysearching bibliographic databases PsycINFOand PubMed (Medline). For both databases, theexact search date was 1 January 1980 through31 December 2015. This period begins aroundthe time of important developments in stressresearch and evidence-based interventions, in-cluding establishment by Hans Selye of theAmerican Institute of Stress in 1978, the found-ing of John Kabat-Zinn’s MBSR clinic (Kabat-Zinn, 1982), the integration of cognitive thera-pies and behavioral therapies to form CBT andthe founding of the CBT special interest groupby the Association for Advancement of Behav-ior Therapy (now the Association for Behav-ioral and Cognitive Therapies), and the growthand popularization of applications of psychoe-ducation by C.M. Anderson (Anderson, Hog-arty, & Reiss, 1981). In addition, through cov-ering a 35-year period, we strived to improvethe reliability of meta-analysis results by in-cluding a larger number of studies than havebeen included in previous analyses of stressinterventions. A Boolean search strategy wasconducted with the following keywords andlogic: (stress management program OR stressmanagement intervention OR stress inoculationtraining OR coping skills training OR mindful-ness-based stress reduction OR relaxationtraining OR meditation) AND (stress OR dis-tress OR anxiety) AND (cope OR coping) AND(student OR undergraduate OR graduate OR
college OR university). We also conducted ahand search of relevant journals. After remov-ing duplicates, this process identified abstractsof 254 human studies published in English (Fig-ure 1). Based upon examination of abstracts,196 inappropriate articles were excluded (e.g.,those lacking interventions), yielding 58 poten-tially eligible studies. Inclusion criteria werethen examined. Studies were eligible for inclu-sion if they were published in a peer-reviewedjournal (i.e., dissertations were excluded), useda prospective design with perceived stress oranxiety quantitatively assessed with a standard-ized measure both before and after the interven-tion, included undergraduate or graduate stu-dent participants, used a control group, andreported results needed to calculate an effectsize. A total of 43 eligible articles were identi-fied and included in the meta-analysis. Themain outcome of interest was change in per-ceived stress and/or anxiety. The followingwere also extracted from articles: lead author,year of publication, country, intervention tech-nique(s), sample size, intervention duration,study design, and subgroup (i.e., gender andyear in school).
Psychological Distress Constructsand Measures
Some studies reported multiple relevant mea-sures (e.g., two different anxiety measures), andtheir inclusion would violate statistical assump-tions about independence. In these cases, a sin-gle measure was chosen a priori (Lipsey &Wilson, 2001). To maximize consistency, thefrequency of use of psychological distress mea-sures in the entire sample was calculated, andthe most frequently used measure was chosenfor the primary analysis.
Anxiety. Measures of anxiety included theState Anxiety subscale of the State–Trait Anx-iety Inventory (Spielberger, Gorsuch, Lushene,Vagg, & Jacobs, 1983), the Tension-Anxietysubscale of the Profile of Mood States (McNair,Lorr, & Droppleman, 1992), the Test AnxietyScale (Sarason, 1978), the Test Anxiety Inven-tory (Spielberger, 1980), the Hamilton AnxietyRating Scale (Hamilton, 1959), the Anxietysubscale of the Depression, Anxiety, and StressScale (Lovibond & Lovibond, 1995), the Symp-tom Checklist–90–Revision (Derogatis, Rick-els, & Rock, 1976), the Endler Multidimen-
5INTERVENTIONS FOR STUDENT DISTRESS
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sional Anxiety Scale–State (Endler, Edwards, &Vitelli, 1991), the General Distress, Anxioussubscale of the Mood and Anxiety SymptomQuestionnaire (Watson & Clark, 1991; Watsonet al., 1995), and the Apprehension in Social/Academic Failure subscale of the Stressful Sit-uations Questionnaire (Fischer & Corcoran,1994).
Perceived stress. Measures of perceivedstress included the Perceived Stress Scale (Co-hen & Williamson, 1988), the Symptoms ofStress Inventory (Leckie & Thompson, 1979),the Brief Symptom Inventory (Derogatis,1993), the Perceived Stress of Medical School(Vitaliano, Russo, Carr, & Heerwagen, 1984),the Stress subscale of the Depression, Anxiety,and Stress Scale (Lovibond & Lovibond, 1995),the General Distress, Mixed subscale of theMood and Anxiety Symptom Questionnaire(Watson & Clark, 1991; Watson et al., 1995),the Revised Life Stress Scale for College Stu-dents (Chon, Kim, & Yi, 2000), and the Psy-chosocial Wellbeing Index–Short form (Chang,2000).
Data Abstraction and Statistical Analyses
Typically, means and standard deviations foreach anxiety and/or perceived stress outcomemeasure in each condition and time point wereextracted for each study. In cases in whichthe mean, standard deviation, and sample sizescores were not available, effect sizes were cal-culated using effect size estimates (e.g., F, t, orp values). The standardized mean gain differ-ence effect size (d) was used to examinechanges in psychological distress before andafter intervention in the treatment group com-pared with a control group. This statistic iscalculated by subtracting the control group gainscore (posttest score minus pretest score) fromthe treatment group gain score and dividing thedifference by the pooled pretest standard devi-ation (Reardon-Anderson, Stagner, Macomber,& Murray, 2005). A positive effect size indi-cates that the treatment group had a larger re-duction in psychological distress than the con-trol group. The individual effect sizes were thenweighted by the inverse of their variance andaveraged to obtain an aggregate effect size. De-
Figure 1. The process of study selection. The process is modeled after Moher et al. (2009).
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scriptive information for each study was alsoabstracted for moderator variables, includingthe type of student (sample included only un-dergraduates vs. sample included graduate stu-dents) and duration of the intervention (�8weeks vs. 8� weeks). Analyses were conductedwith Comprehensive Meta-Analysis Version2.0 (Borenstein, Hedges, Higgins, & Rothstein,2005). Random-effects aggregate effect sizesare reported.
Results
A description of the studies analyzed appearsin Table 1. From the 43 studies, we extracted 35effect sizes for anxiety and 20 for stress. Treat-ment group sample sizes ranged from 7 to 195(M � 45.8, SD � 38.1). Control group samplesizes ranged from 12 to 162 (M � 43.6, SD �32.2), resulting in a total of 4,400 treatment andcontrol participants with sample mean agesranging from 18.8 (SD � 1.4) to 36.1 (SD �10.7) years. Thirty studies were conducted inthe United States, two in the United Kingdom,two in Korea, two in Iran, and one each inAustralia, China, India, Japan, Jordan, Malay-sia, and Thailand. The majority of interventions(k � 22) used a combination of interventiontechniques. In such cases, studies were includedin multiple analyses based on the types of tech-niques included in their interventions. Of the 43studies, 23 used relaxation training, 18 usedpsychoeducation, 17 used coping skills training,13 used CBT, 11 used MBSR, and four usedsocial support. Twenty-one studies used a singletechnique, namely, MBSR, relaxation training,psychoeducation, or CBT. Twenty-six interven-tions were short-term (1 day to 6 weeks), and 17were of long-term duration (8 weeks to 12weeks). The majority of studies (28) used un-dergraduate student samples; 15 were studies ofgraduate students. Anxiety and perceived stressaggregate effect sizes are presented for each ofthe six intervention components in Table 2. Weevaluated the magnitude of aggregate effectsizes in terms of Cohen’s (1988) recommenda-tions: d � 0.20, small; d � 0.50, medium; andd � 0.80, large.
Anxiety
Individual effect sizes ranged from �0.64 to4.17. Assuming a random-effects model, the
inverse-variance weighted mean effect size foranxiety was 0.62, 95% confidence interval (CI)[0.37, 0.87], p � .001. These positive effectsizes indicate that participants receiving an in-tervention evidenced larger decreases in anxietythan the control group. The aggregate effect sizefor this analysis is considered an effect of me-dium size.
To test Hypotheses 1 through 3, effect sizesfor reduction of anxiety based on each interven-tion technique separately were calculated. All ofthe aggregate effect sizes for anxiety based ontechnique used were positive. All were statisti-cally significant except for social support (Table2). Aggregate effect sizes were small for studiesusing CBT and for those using coping skillstraining, medium for studies using MBSR orpsychoeducation, and large for relaxation train-ing. Analyses supported Hypotheses 1 and 2,but not the hypothesis that social support wouldreduce anxiety (Hypothesis 3).
Effect sizes were significantly heterogeneous,Q(34) � 370.47, p � .01. Therefore, to explorewhether the efficacy of interventions for anxietyvaries depending on their duration and whetherthey are used with undergraduate or graduatestudents, two mixed-effects moderator analyseswere conducted using an analogue-to-analysisof variance for categorical variables. Moderatoranalysis revealed that neither duration of inter-vention (short-term vs. long-term) nor type ofstudent (undergraduate vs. graduate) was a sta-tistically significant moderator of anxiety,Q(1) � 2.02, p � .16; Q(1) � .99, p � .32,respectively. Moderation analyses of interven-tion duration and student type on anxiety-related effects of specific intervention type werealso conducted to offer a more fine-tuned test ofthese exploratory ideas. Duration was a signif-icant moderator for relaxation training interven-tions only, indicating that the duration of inter-vention significantly reduced the level ofheterogeneity, Q(1) � 3.97, p � .05. Althoughparticipants in both long- and short-term relax-ation training interventions experienced a sig-nificant reduction in anxiety relative to partici-pants in the control group, long-term relaxationtraining interventions (d � 1.58, 95% CI [0.74,2.42], p � .01) were more effective for reducinganxiety than were short-term relaxation traininginterventions (d � 0.63, 95% CI [0.20, 1.05],p � .05). Type of student was a significantmoderator for psychoeducation and for relax-
7INTERVENTIONS FOR STUDENT DISTRESS
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Tab
le1
Sum
mar
yof
the
Stud
ies
Incl
uded
inth
eA
naly
sis
Stud
yC
ount
ryIn
terv
entio
nte
chni
ques
NIn
terv
entio
ndu
ratio
nD
esig
nSt
uden
tty
peO
utco
me
Subg
roup
And
o(2
011)
aJa
pan
Cop
ing
skill
str
aini
ng,
psyc
hoed
ucat
ion,
soci
alsu
ppor
t22
211
wee
ksE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyFe
mal
eM
ale
Cal
l,M
iron
,an
dO
rcut
t(2
014)
Uni
ted
Stat
esM
BSR
/rel
axat
ion
trai
ning
91T
hree
45-m
inse
ssio
nsE
xper
imen
tal
Und
ergr
adua
teA
nxie
ty,
perc
eive
dst
ress
NA
Che
n,Y
ang,
Wan
g,an
dZ
hang
(201
3)C
hina
MB
SR60
30m
inda
ilyfo
r7
days
Exp
erim
enta
lG
radu
ate
Anx
iety
NA
Chi
auzz
i,B
reva
rd,
Thu
m,
Dec
embr
ele,
and
Lor
d(2
008)
Uni
ted
Stat
esC
opin
gsk
ills
trai
ning
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
235
20m
in,
4tim
esov
er2
wee
ksE
xper
imen
tal
Und
ergr
adua
tePe
rcei
ved
stre
ssN
A
Dec
kro
etal
.(2
002)
Uni
ted
Stat
esC
BT
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
128
6w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
,pe
rcei
ved
stre
ssN
A
Dol
bier
and
Rus
h(2
012)
Uni
ted
Stat
esR
elax
atio
ntr
aini
ng12
820
min
sE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
AD
zieg
iele
wsk
i,T
urna
ge,
and
Roe
st-
Mar
ti(2
004)
Uni
ted
Stat
esC
BT
,co
ping
skill
str
aini
ng,
psyc
hoed
ucat
ion,
rela
xatio
ntr
aini
ng48
45m
ins
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Ero
gul,
Sing
er,
McI
ntyr
e,an
dSt
efan
ov(2
014)
Uni
ted
Stat
esM
BSR
57w
eekl
y75
-min
sess
ions
for
8w
eeks
and
afu
llda
yre
trea
t
Exp
erim
enta
lG
radu
ate
Perc
eive
dst
ress
NA
Fehr
ing
(198
3)U
nite
dSt
ates
Rel
axat
ion
trai
ning
788
wee
ksE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
AFi
nkel
stei
n,B
row
nste
in,
Scot
t,an
dL
an(2
007)
Uni
ted
Stat
esPs
ycho
educ
atio
n72
10w
eeks
Qua
si-e
xper
imen
tal
Gra
duat
eA
nxie
ty,
perc
eive
dst
ress
NA
Flin
chba
ugh,
Moo
re,
Cha
ng,
and
May
(201
2)U
nite
dSt
ates
Rel
axat
ion
trai
ning
,co
ping
skill
str
aini
ng11
712
wee
ksQ
uasi
-exp
erim
enta
lU
nder
grad
uate
Perc
eive
dst
ress
NA
Font
ana,
Hyr
a,G
odfr
ey,
and
Cer
mak
(199
9)U
nite
dSt
ates
CB
T,
copi
ngsk
ills
trai
ning
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
36Si
x45
-min
sess
ions
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Fraz
ier
etal
.(2
015)
Uni
ted
Stat
esC
opin
gsk
ills
trai
ning
194
2w
eeks
Exp
erim
enta
lU
nder
grad
uate
Perc
eive
dst
ress
,an
xiet
yN
A
God
bey
and
Cou
rage
(199
4)U
nite
dSt
ates
CB
T,
copi
ngsk
ills
trai
ning
,ps
ycho
educ
atio
n19
6w
eeks
Qua
si-e
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
A
Ham
dan-
Man
sour
,Pu
skar
,an
dB
anda
k(2
009)
Jord
anC
BT
,co
ping
skill
str
aini
ng84
10w
eeks
Exp
erim
enta
lU
nder
grad
uate
Perc
eive
dst
ress
NA
Hea
man
(199
5)U
nite
dSt
ates
CB
T,
psyc
hoed
ucat
ion,
rela
xatio
ntr
aini
ng40
5w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Hen
riqu
es,
Kef
fer,
Abr
aham
son,
and
Hor
st(2
011)
Uni
ted
Stat
esR
elax
atio
ntr
aini
ng35
4w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
,pe
rcei
ved
stre
ssN
A
Hin
tz,
Fraz
ier,
and
Mer
edith
(201
5)U
nite
dSt
ates
Cop
ing
skill
str
aini
ng19
514
,10
-min
sess
ions
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
,pe
rcei
ved
stre
ssN
A
Jain
etal
.(2
007)
Uni
ted
Stat
esM
BSR
,re
laxa
tion
trai
ning
834
wee
ksE
xper
imen
tal
Gra
duat
ePe
rcei
ved
stre
ssN
AJo
hans
son
(199
1)a
Uni
ted
Stat
esC
BT
,co
ping
skill
str
aini
ng,
psyc
hoed
ucat
ion,
rela
xatio
ntr
aini
ng76
3w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
Seni
ors
Soph
omor
es
Jone
s(2
004)
Uni
ted
Stat
esC
opin
gsk
ills
trai
ning
,ps
ycho
educ
atio
n,so
cial
supp
ort
588
wee
ksE
xper
imen
tal
Und
ergr
adua
tePe
rcei
ved
stre
ssN
A
Kan
g,C
hoi,
and
Ryu
(200
9)K
orea
MB
SR41
8w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
,pe
rcei
ved
stre
ssN
A
Kan
ji,W
hite
,an
dE
rnst
(200
4)U
nite
dK
ingd
omR
elax
atio
ntr
aini
ng93
8w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Kan
ters
,B
rist
ol,
and
Atta
rian
(200
2)U
nite
dSt
ates
Cop
ing
skill
str
aini
ng,
soci
alsu
ppor
t13
51-
day
sess
ion
Qua
si-e
xper
imen
tal
Gra
duat
eA
nxie
tyN
AK
im,
Lee
,K
im,
Noh
,an
dL
ee(2
016)
Kor
eaC
opin
gsk
ills
trai
ning
84E
ight
2-hr
sess
ions
over
4w
eeks
Exp
erim
enta
lU
nder
grad
uate
Anx
iety
,pe
rcei
ved
stre
ssN
A
(tab
leco
ntin
ues)
8 YUSUFOV ET AL.
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
Tab
le1
(con
tinu
ed)
Stud
yC
ount
ryIn
terv
entio
nte
chni
ques
NIn
terv
entio
ndu
ratio
nD
esig
nSt
uden
tty
peO
utco
me
Subg
roup
McW
hirt
er,
Oke
y,R
oth,
and
Her
lach
e(1
995)
Uni
ted
Stat
esC
BT
,co
ping
skill
str
aini
ng,
psyc
hoed
ucat
ion,
rela
xatio
ntr
aini
ng33
45
wee
ksQ
uasi
-exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Nid
ich
etal
.(2
009)
Uni
ted
Stat
esPs
ycho
educ
atio
n,re
laxa
tion
trai
ning
298
12w
eeks
Exp
erim
enta
lG
radu
ate
Anx
iety
NA
Om
an,
Shap
iro,
Tho
rese
n,Pl
ante
,an
dFl
inde
rs(2
008)
Uni
ted
Stat
esM
BSR
448
wee
ksE
xper
imen
tal
Und
ergr
adua
tePe
rcei
ved
stre
ssN
A
Orb
ach,
Lin
dsay
,an
dG
rey
(200
7)U
nite
dK
ingd
omC
BT
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
908
wee
ksE
xper
imen
tal
Gra
duat
eA
nxie
tyN
A
Phan
g,M
ukht
ar,
Ibra
him
,K
eng,
and
Moh
dSi
dik
(201
5)M
alay
sia
MB
SR75
5w
eeks
Exp
erim
ent
Gra
duat
ePe
rcei
ved
stre
ssN
A
Rat
anas
irip
ong,
Rat
anas
irip
ong,
and
Kat
hala
e(2
012)
Tha
iland
Rel
axat
ion
trai
ning
605
wee
ksE
xper
imen
tal
Gra
duat
eA
nxie
ty,
perc
eive
dst
ress
NA
Rau
sch,
Gra
mlin
g,an
dA
uerb
ach
(200
6)U
nite
dSt
ates
Rel
axat
ion
trai
ning
387
30m
inE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
A
Ros
enzw
eig,
Rei
bel,
Gre
eson
,B
rain
ard,
and
Hoj
at(2
003)
Uni
ted
Stat
esM
BSR
302
10w
eeks
Qua
si-e
xper
imen
tal
Gra
duat
eA
nxie
tyN
A
Rus
sler
(199
1)U
nite
dSt
ates
CB
T,
copi
ngsk
ills
trai
ning
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
5716
hrov
er2
wee
ksE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
A
Shan
kara
pilla
i,N
air,
and
Geo
rge
(201
2)In
dia
Rel
axat
ion
trai
ning
100
60m
inE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
ASh
apir
o,Sc
hwar
tz,
and
Bon
ner
(199
8)U
nite
dSt
ates
MB
SR78
8w
eeks
Exp
erim
enta
lG
radu
ate
Anx
iety
NA
Shap
iro,
Bro
wn,
and
Bie
gel
(200
7)U
nite
dSt
ates
MB
SR54
8w
eeks
Qua
si-e
xper
imen
tal
Gra
duat
eA
nxie
ty,
perc
eive
dst
ress
NA
Shar
ifan
dA
rmita
ge(2
004)
Iran
CB
T,
psyc
hoed
ucat
ion,
rela
xatio
ntr
aini
ng10
012
wee
ksQ
uasi
-exp
erim
enta
lU
nder
grad
uate
Anx
iety
NA
Shee
hyan
dH
oran
(200
4)U
nite
dSt
ates
CB
T,
copi
ngsk
ills
trai
ning
,ps
ycho
educ
atio
n,re
laxa
tion
trai
ning
224
wee
ksE
xper
imen
tal
Gra
duat
eA
nxie
ty,
perc
eive
dst
ress
NA
Smith
(198
9)U
nite
dSt
ates
Cop
ing
skill
str
aini
ng,
psyc
hoed
ucat
ion
365
hrov
er2
wee
ksE
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
ASt
einh
ardt
and
Dol
bier
(200
8)U
nite
dSt
ates
CB
T,
copi
ngsk
ills
trai
ning
,ps
ycho
educ
atio
n,so
cial
supp
ort
574
wee
ksE
xper
imen
tal
Gra
duat
ePe
rcei
ved
stre
ssN
A
War
neck
e,Q
uinn
,O
gden
,T
owle
,an
dN
elso
n(2
011)
Aus
tral
iaM
BSR
668
wee
ksE
xper
imen
tal
Gra
duat
eA
nxie
ty,
perc
eive
dst
ress
NA
Zar
garz
adeh
and
Shir
azi
(201
4)Ir
anR
elax
atio
ntr
aini
ng99
4,30
-min
sess
ions
Qua
si-e
xper
imen
tal
Und
ergr
adua
teA
nxie
tyN
A
Not
e.M
BSR
�m
indf
ulne
ss-b
ased
stre
ssre
duct
ion;
CB
T�
cogn
itive
–be
havi
oral
ther
apy;
NA
�no
tav
aila
ble.
aSt
udie
sw
ithsu
bgro
ups
cont
ribu
ted
two
effe
ctsi
zes
toan
alys
es.
9INTERVENTIONS FOR STUDENT DISTRESS
Thi
sdo
cum
ent
isco
pyri
ghte
dby
the
Am
eric
anPs
ycho
logi
cal
Ass
ocia
tion
oron
eof
itsal
lied
publ
ishe
rs.
Thi
sar
ticle
isin
tend
edso
lely
for
the
pers
onal
use
ofth
ein
divi
dual
user
and
isno
tto
bedi
ssem
inat
edbr
oadl
y.
ation training interventions, Q(1) � 6.77, p �.01; Q(1) � 8.36, p � .01, respectively. Grad-uate students experienced greater reduction inanxiety than did undergraduate students forboth types of interventions. For the relaxationtraining intervention, both undergraduates andgraduate students experienced a statistically sig-nificant reduction in anxiety relative to partici-pants in the control group (graduate students:d � 1.81, 95% CI [1.06, 2.56], p � 001; un-dergraduate students: d � 0.57, 95% CI [0.20,0.95], p � .05). For the psychoeducation inter-vention, graduate students experienced a signif-icant reduction in anxiety relative to controlgroup participants (d � 1.78, 95% CI [0.84,2.73], p � .001), whereas undergraduates re-ceiving this intervention experienced a margin-ally significant reduction in anxiety (d � 0.40,95% CI [�0.05, 0.84], p � .08).
To rule out the possibility of bias by date ofpublication, moderator analyses of publicationdate on anxiety and anxiety-related effects ofspecific intervention type were conducted. Pub-lication date was examined as a continuous vari-able as well as a categorical variable (compar-ing articles published through 2005 with thosepublished after 2005 to create similar cell sizes).Meta-regressions revealed that publication datedid not influence the effect sizes for anxiety oranxiety-related effects of specific interventiontypes.
Perceived Stress
Individual effect sizes for perceived stressranged from �0.62 to 1.29. Assuming a ran-dom-effects model, the aggregate effect sizewas of small to medium size, 0.44, 95% CI[0.24, 0.64], p � .01. These positive effect sizesindicate that participants receiving an interven-tion evidenced larger decreases in perceivedstress than the control group.
To test Hypotheses 1 through 3, effect sizesfor reduction of perceived stress based on eachintervention technique separately were calcu-lated. All of the aggregate effect sizes for per-ceived stress based on technique used were pos-itive. All were statistically significant except forMBSR (Table 2). Studies using CBT and socialsupport had medium aggregate effect sizes; theaggregate effect sizes for coping skills training(0.45), psychoeducation (0.43), and relaxationtraining (0.36) were small to medium. AnalysesT
able
2A
naly
sis
ofO
utco
mes
Fol
low
ing
Inte
rven
tion
Inte
rven
tion
tech
niqu
eD
istr
ess
cons
truc
tk
dR
ange
95%
CI
Mod
erat
oran
alys
es(m
ixed
-eff
ects
mod
el)
Hom
ogen
eity
test
Stud
ent
type
Dur
atio
n
CB
TA
nxie
ty12
0.38
���
�0.
63to
1.01
[0.1
5,0.
60]
Q(1
1)�
23.5
5�Q
b(1
)�
1.45
Qb(1
)�
0.27
PS4
0.71
���
0.41
to1.
15[0
.37,
1.04
]Q
(3)
�5.
54C
opin
gsk
ills
trai
ning
Anx
iety
140.
29��
�0.
63to
.89
[0.0
6,0.
52]
Q(1
3)�
40.2
9���
Qb(1
)�
0.63
Qb(1
)�
1.53
PS8
0.45
��
�0.
22to
1.15
[0.1
5,0.
75]
Q(7
)�
26.9
1���
Qb(1
)�
0.34
Qb(1
)�
0.08
Rel
axat
ion
trai
ning
Anx
iety
200.
82��
0to
4.17
[3.6
7,4.
67]
Q(1
9)�
287.
10���
Qb(1
)�
8.36
��
Qb(1
)�
3.97
�
PS8
0.36
��
�0.
08to
0.72
[0.1
3,0.
58]
Q(7
)�
11.5
5M
BSR
Anx
iety
80.
50��
�0.
64to
1.23
[0.1
1,0.
88]
Q(6
)�
29.1
4���
Qb(1
)�
0.52
Qb(1
)�
0.04
PS7
0.40
�0.
62to
1.29
[�0.
12,0
.92]
Q(6
)�
36.3
8���
Psyc
hoed
ucat
ion
Anx
iety
170.
64��
�0.
63to
4.17
[0.1
5,1.
13]
Q(1
6)�
253.
02���
Qb(1
)�
6.77
��
Qb(1
)�
1.92
PS6
0.43
��
�0.
05to
0.63
[0.1
5,0.
70]
Q(5
)�
10.0
0So
cial
supp
ort
Anx
iety
30.
24�
0.43
to0.
89[�
0.56
,1.0
3]Q
(2)
�24
.12�
�
PS2
0.62
��
0.62
to0.
63[0
.25,
1.00
]Q
(1)
�0�
��
Qb(1
)�
0Q
b(1
)�
0
Not
e.C
I�
confi
denc
ein
terv
al;
CB
T�
cogn
itive
–be
havi
oral
ther
apy;
PS�
perc
eive
dst
ress
;Q
b�
betw
een-
grou
pshe
tero
gene
ityfo
rca
tego
rica
lm
oder
ator
s;M
BSR
�m
indf
ulne
ss-b
ased
stre
ssre
duct
ion.
�p
�.0
5.��
p�
.01.
���
p�
.001
.
10 YUSUFOV ET AL.
Thi
sdo
cum
ent
isco
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supported Hypotheses 1 and 2, but not the hy-pothesis that MBSR would reduce perceivedstress (Hypothesis 3).
Effect sizes were significantly heterogeneous,Q(19) � 62.81, p � .01. Therefore, to explorewhether the efficacy of interventions for per-ceived stress varies depending on their durationand whether they are used with undergraduateor graduate students, two mixed-effects moder-ator analyses were conducted using an ana-logue-to-analysis of variance for categoricalvariables. Moderator analysis revealed that nei-ther duration of intervention nor type of studentwas a significant moderator of perceived stress,Q(1) � .01, p � .93; Q(1) � .11, p � .74,respectively. To offer a more fine-tuned test,moderation analyses of duration and studenttype on stress-related effects of specific inter-vention type were also conducted; none wassignificant.
As for anxiety, additional moderator analysesof publication date on perceived stress and per-ceived stress-related effects of specific interven-tion type were conducted with publication datetreated as a continuous and categorical variable.These meta-regressions revealed that publica-tion date did not influence effect sizes for per-ceived stress or perceived stress-related effectsof specific intervention types.
Publication Bias
To assess publication bias, Rosenthal’s fail-safe N values (Rosenthal, 1979) were calculatedfor significant effect sizes. For anxiety, �1,965studies would be needed to render the effect sizestatistically nonsignificant; for perceived stress,298 studies would be needed to render the effectsize statistically nonsignificant. Therefore, pub-lication bias does not appear to pose a problemfor the findings involving either anxiety or per-ceived stress.
Discussion
Because of the rising prevalence and seriousconsequences of stress among students, stressreduction interventions are an important tool forcolleges and universities. However, no previousreview has systematically examined the efficacyof such interventions by student level, type ofintervention technique, or duration. Results ofthe present meta-analysis indicate that many
types of stress intervention techniques are ef-fective in reducing perceptions (perceivedstress) and emotional responses to stress (anxi-ety) among students.
Coping Skills Training and CBT
Hypothesis 1 was the prediction that inter-ventions using coping skills training or CBTwould have greater impact on perceived stressthan on anxiety because these techniques aredesigned to alter cognitive appraisals of stres-sors. Results of the meta-analysis offer supportfor this hypothesis. This finding advances exist-ing research examining such interventions, bothin students and in nonstudent populations. Al-though CBT evidenced only a small-to-mediumeffect size (d � 0.38) for reduction of anxiety inthe present investigation, meta-analyses of CBTinterventions conducted with groups other thanstudents have revealed stronger effects for anx-iety reduction (Hofmann & Smits, 2008; Stew-art & Chambless, 2009). Collectively, theseanalyses suggest that CBT may be a more ef-fective intervention for anxiety in nonstudentthan student populations, although direct com-parisons of these groups would be necessary toconfirm this possibility.
Relaxation Training
Supporting Hypothesis 2, which predictedthat interventions using relaxation trainingwould have stronger effect sizes for anxietythan for perceived stress because these types ofinterventions aim to reduce negative emotionalresponses to stressors, we found that studies thatincluded a relaxation training technique in theirintervention did appear to be more effective inreducing anxiety than perceived stress. Relax-ation training directly addresses psychologicaland somatic consequences of stress rather thaninstilling stress management skills. A similarpattern of effects was found in pregnant womenby Bastani et al. (2005) who reported that re-laxation training produced larger reductions inanxiety than in perceived stress.
Psychoeducation, Social Support,and MBSR
We hypothesized that interventions involvingpsychoeducation, social support, or MBSR
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would reduce perceived stress and anxiety be-cause these techniques aim to influence bothcognitive appraisal and emotional responses tostress (Hypothesis 3). Findings for psychoedu-cation were consistent with this hypothesis:Psychoeducation did reduce both perceivedstress (small effect) and anxiety (medium ef-fect). A previous meta-analysis also found thatpsychoeducation had small effects on stress(mean posttest effect size � 0.27); that meta-analysis did not examine effects on anxiety,however (Van Daele et al., 2012).
In contrast, findings for social support andMBSR did not support the hypothesis that theseinterventions would reduce both perceivedstress and anxiety. Interventions promoting so-cial support reduced perceived stress only andhad no effect on anxiety, whereas interventionsusing MBSR were moderately effective in re-ducing anxiety but did not reduce perceivedstress. There is a considerable body of researchdemonstrating that social support can buffer theimpact of stress on numerous outcomes, partic-ularly when the type and amount of supportoffers good fit to recipient needs (see review byUchino & Birmingham, 2011). It is not clearwhy social support interventions conductedwith students did not reduce anxiety, but closeinspection of these interventions might revealwhether they provided types or amounts of sup-port appropriate to the needs of their studentsamples. In addition, the small number of stud-ies (k � 3, k � 2) for social support interven-tions suggests that these findings are less likelyto be precise and thus should be interpreted withcaution.
As for MBSR, previous meta-analyses of-fer mixed findings about the benefits of thistype of intervention across heterogeneoussamples. Some indicate benefits of mindful-ness meditation in reducing both stress andanxiety (Chiesa & Serretti, 2009), or im-provements in a range of mental health vari-ables including anxiety and depression(Grossman et al., 2004). Two more recentmeta-analyses offer contradictory findings,with the results of one indicating moderateimpact on anxiety and little impact on stress(Goyal et al., 2014), and the results of theother indicating that MBSR had larger effectson stress than on anxiety (Khoury et al.,2015).
Impact of Student Type andIntervention Duration
Most of the interventions evaluated here wereequally effective for undergraduate and gradu-ate students. To our knowledge, no previousstudy has explored differential treatment re-sponse for undergraduate and graduate students.The impact of each intervention on perceivedstress was equivalent for both groups of stu-dents; for anxiety, graduate students evidenceda greater reduction than did undergraduate stu-dents from psychoeducation and relaxationtraining, but derived equivalent benefit from theremaining interventions. Although undergradu-ate and graduate students may be in differentdevelopmental stages and experience some dif-ferent challenges, both groups face stress intheir respective environments and both may beopen to learning new, effective techniques toreduce feelings of distress. In fact, with theexception of one study, all participants werevolunteers rather than required to participate inan intervention, suggesting that students may beparticularly motivated to learn strategies to al-leviate stress.
In addition, results suggest that most inter-ventions lasting 8 weeks or more were no moreeffective in reducing anxiety or perceived stressthan were interventions lasting fewer than 8weeks, although for relaxation training inter-ventions only, long-term interventions weremore effective at reducing anxiety than wereshort-term interventions. Briefer interventionsare usually less expensive, entail less participantburden, and have higher compliance than longerinterventions. For most types of interventions,short-term versions may be sufficiently effec-tive. This finding extends existing research onintervention duration. For example, Van Daeleet al. (2012) found that briefer psychoeduca-tional interventions generated better results, andVirgili (2015) reported that brief MBSR inter-ventions were as effective as standard 8-weekinterventions. However, there is some evidencethat longer interventions result in sustainedchange in various populations (Proeschold-Bellet al., 2017). Brief interventions may be effec-tive with students because they can be incorpo-rated easily into the time course of academicterms.
One must be cautious in drawing conclusionsabout the impact of sample and intervention
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characteristics on intervention efficacy. Bothoverall aggregate analyses yielded significantheterogeneity across studies. Thus, it is possiblethat moderators other than the ones evaluated inthis study are accounting for overall heteroge-neity. One potential moderator is gender com-position of the sample. There was not sufficientstatistical power to examine this factor in thegroup of studies analyzed. An important issuefor future research is determining what types ofinterventions work best with what types of peo-ple. For example, there is reason to predict thatinterventions that increase social support (Dit-zen & Heinrichs, 2014; Walen & Lachman,2000) or those that involve psychoeducation(Van Daele et al., 2012) may be more effectivefor women than for men. Ethnicity, race, andcultural background may also be significantmoderators of the efficacy of interventions.These possibilities can only be tested as morestudies of diverse types of interventions withdiverse samples become available for analysis.Nevertheless, it is notable that this researchidentified benefits of interventions for studentsfrom a variety of backgrounds and countries.
Study Limitations, Strengths,and Implications
One limitation of this analysis involves thenumber of studies included. Many studies wereexcluded because they did not administer stan-dardized measures of anxiety or perceived stressboth before and after an intervention or did notinclude a control group. Fail-safe N values pro-vide little support for the presence of publica-tion bias. The limited number of studies is par-ticularly relevant to the moderator analyses,however, which should be considered cau-tiously. Only a modest portion of studies as-sessed perceived stress as an outcome; a major-ity of studies assessed anxiety. Meta-analysis ismost powerful in testing moderators when thenumber of studies, and therefore the number ofeffect size estimates, is large. This means thatthe influence of moderators may have been un-derestimated because of limited power to detectdifferences.
The issue of independence is also important.Although the current analysis examined effectson perceived stress and anxiety based on inter-vention technique used, a majority of studiesused multidimensional interventions and as-
sessed both perceived stress and anxiety in asingle study, so there is an overlap betweenmany of the aggregate effects. When multipleoutcomes are measured for the same individu-als, effect sizes for those outcomes are not in-dependent. Furthermore, if a technique reducesperceived stress, then reduction in anxiety mayalso occur, as cognitive appraisal often precedesemotional response (Lazarus & Folkman,1984). Many studies also combined techniquesthat could have interacted to affect outcomes(Ando, 2011; Chiauzzi, Brevard, Thurn, De-cembrele, & Lord, 2008). To examine whethereffectiveness was associated with exposure to agreater number of intervention techniques, weconducted an exploratory simulated regressionanalysis of the moderating effect of number oftechniques. It was not significant (p � .73).Nevertheless, caution is advisable in directlycomparing one intervention technique with an-other based on our analytic approach.
It is also important to note the heterogeneityof measures of anxiety and perceived stress.The State–Trait Anxiety Inventory was the mostfrequently used measure of anxiety, accountingfor 34.9% of all studies (k � 15). Six studiesused the Profile of Mood States (POMS), fourstudies used the Depression Anxiety StressScales (DASS-21), and four used the SymptomChecklist (SCL-R-90). Other measures were theHamilton Anxiety Rating Scale and the SarasonTest Anxiety Scale. Perceived stress was mostcommonly measured using the Perceived StressScale, which accounted for 30.2% of all studies.Heterogeneity of measurement may have con-strained our ability to find effects, but the pres-ent meta-analysis revealed effects for both per-ceived stress and anxiety despite this constraint.
Because a majority of studies did not reportlong-term follow-up data, we cannot draw con-clusions about how long the effects of interven-tions last. Students may show improvements instress and anxiety immediately following astress reduction intervention, but over time mayreturn to baseline levels, especially without con-tinued help. Alternatively, students may learnlifelong skills during interventions that can beused to combat stress long after interventionshave been completed. Studies are needed thatinclude longer term follow-up data. Similarly,because distress is related to other adverse out-comes in students, it would be valuable forfuture studies to examine physical health and
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academic outcomes such as retention in pro-grams, grade point average, or board certifica-tion and licensing exam scores. Psychosocialoutcomes such as academic self-efficacy andsatisfaction with fields of study may also beworthwhile to assess in future studies.
Given that the majority of control groupsincluded in this review did not receive anyintervention, but were merely assigned to wait-lists or received nothing, a plausible conclusionfrom these results is that students benefit fromany type of help, regardless of its content. Be-cause few studies included in this meta-analysishad control groups assigned to an alternativeintervention, a moderator analysis of the type ofcontrol group could not be conducted. How-ever, as additional intervention studies are con-ducted and become available to evaluation bymeta-analytic techniques, analyses examiningcontrol groups who engage in alternative activ-ities rather than controls who receive nothingshould be performed to determine the impact ofparticipating in any intervention or participatingin a particular stress reduction intervention.
Despite its limitations, results of the presentstudy are encouraging and offer several impli-cations for research as well as clinical applica-tion. All of the techniques were effective inreducing at least one of the stress-related out-comes (i.e., perceived stress, anxiety) in bothshort-term and long-term interventions. Of theinterventions examined, relaxation training ap-peared to be the most effective intervention toreduce anxiety for undergraduates; relaxationtraining and psychoeducation appeared to be themost effective interventions against anxiety forgraduate students. CBT, coping skills training,psychoeducation, and social support interven-tions were effective to reduce perceived stressin both groups of students. These findings sug-gest there is value in tailoring interventionstoward the particular group and outcome beingtargeted.
In addition, given that stress is thought toprecede anxiety (Lazarus & Folkman, 1984),targeting stress before its escalation and mani-festation as anxiety may be an especially effec-tive approach. We did not directly test the tem-poral precedence of stress and anxiety, but thisis an important avenue for further research. Fi-nally, a more detailed understanding of differ-ences between students and other populationsmight help to explain whether and why they
respond to interventions differently. Results ofthe present meta-analysis highlight that somedisparities may exist in the effectiveness ofstress interventions such as CBT for studentsand nonstudents. Such differences may be at-tributable to the unique stressors that studentsface or to their age, maturity, or life stage.Research addressing these important issues mayhelp to inform and tailor interventions to theneeds of students and can be used as a basis toallocate resources more effectively for interven-tions that will alleviate distress in students at alllevels.
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Received July 10, 2017Revision received February 27, 2018
Accepted February 27, 2018 �
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