Prevention of Depression in the College Student Population: A Review of the Literature

Article Outline

• Abstract
• Background
  • Incidence and Prevalence
  • Significance, Morbidity, and Mortality
  • Cost
• Depression-prevention research
  • Methods
    • Search Process
    • Inclusion and Exclusion Criteria
  • Leveling and Grading the Literature
• Results
  • Students
  • Types of Depression-Prevention Interventions
  • Intervention Format and Evaluation
• Research implications
  • Gaps in the Literature
  • Implications for Future Research
• Recommendations
  • Academic Setting Change Recommendations
  • Nursing Practice Change Recommendations
• Conclusion
• Acknowledgments
• Appendix A. Depression-Prevention in the College Student Population: Research Studies
• References
• Copyright

The National Institute of Mental Health recommends that interventions be designed to prevent the onset of clinical depression in at-risk groups. College students are included in those groups identified as at risk. This article reports on 16 U.S. clinical trials, conducted with samples of college-aged students between 1987 and 2011, to identify effective depression-prevention strategies. Recommendations from the review of these studies include additional research to determine prevention strategies for the college student population and the use of evidence-based prevention strategies in nursing practice to improve the quality of life for this at-risk population.

APPROXIMATELY HALF OF the young adults living in the United States enroll in and receive some form of postsecondary education (U.S. Department of Education, 2005). Many have health needs. In 1998, the American College Health Association (ACHA) implemented the National College Health Assessment (NCHA) to identify the nationwide mental and physical health needs of the college student population. The NCHA study provides the largest sample and most comprehensive data available on the mental health status of college students. Findings from this study have helped identify the mental health needs of college students nationwide. Assessment and understanding are essential for campus officials and health providers to respond by cultivating healthy and safe campus communities (ACHA-NCHA, 2009). The purpose of this article is to synthesize findings of clinical trials performed in the United States within the college student population from 1987 to 2011, emphasizing findings about effective depression-prevention strategies for this at-risk group. The background on incidence and prevalence frames the study.

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Background 

Incidence and Prevalence 

In the spring of 2008, the most recent data available to the public, the ACHA-NCHA surveyed a random sample of 80,121 college students from 106 postsecondary education institutions. Data from this survey, and previous surveys from the ACHA-NCHA, have indicated that depressive disorders may be the most prevalent psychological conditions experienced by college students (see Table 1). Of the students surveyed in 2009, 14.9% (n = 11,777) reported a previous diagnosis of depression within their lifetime. Of those with a history of depression within their lifetime, 32% (n = 3,746) reported being diagnosed with depression within the previous school year (ACHA-NCHA, 2009). At the time of the study, the percentage of students who were being treated for depression was 24.5% (n = 2,870), and the percentage of students who were taking medication for depression was 35.6% (n = 4,157; ACHA-NCHA, 2009). In addition, cumulative data from the NCHA surveys conducted from 1998 through 2008 suggest that the prevalence of diagnosable depression rates among college students is rising. The surveys reveal a 4.6% increase in the number of college students diagnosed with depression over the past 10 years, shifting from 10.3% in 1998 to 14.9% in 2008 (American College Health Association-National College Health Assessment [ACHA-NCHA], 2000, American College Health Association-National College Health Assessment [ACHA-NCHA], 2009).

Table 1. Data Summary From the ACHA's 2009 NCHA Survey Results (N = 80,121)

Survey-related question	No. of students	Percentage of students
Of all participating students, those with a diagnoses of depression within their lifetime	11,777	14.9
Of students with lifetime depression diagnoses (above), those having ever been diagnosed with depression who were:
• Diagnosed within the previous school year	3,746	32
• Undergoing therapy for depression at time of study	2,870	24.5
• Taking medication for depression at time of study	4,157	35.6
Of all participating students, those who had at least once within the previous school year:
• Seriously considered suicide	7,141	9
• Attempted suicide	1,004	1.3
• “Felt so depressed it was difficult to function”	34,040	43
• “Felt hopeless”	49,208	62.1

Note. Adapted from ACHA-NCHA (2009). Copyright 2009 by the American College Health Association.

In addition to those identified as having been diagnosed with depression, others were identified as at-risk for depression based on responses to a series of depression symptom-related questions. To note, 43% (n = 34,040) of the respondents reported that at least once or more within the previous school year they had “felt so depressed it was difficult to function,” and more than 62% (n = 49,208) revealed they had “felt hopeless” (ACHA-NCHA, 2009, p. 485). Also significant, 9.0% (n = 7,141) of the survey respondents reported seriously considering suicide at least once in the previous school year, whereas 1.3% (n = 1,004) of students had actually attempted suicide (ACHA-NCHA, 2009).

Other studies also suggest an increase in prevalence of depressive symptoms and other psychological conditions among college students. To assess access to and utilization of mental health services for students enrolled in postsecondary education programs, a national survey of college and university counseling centers is conducted annually by the American College Counseling Association. In the most recent 2009 national survey of college and university counseling center directors, which included data collection from 302 institutions, 89.4% (n = 253) reported an increase among students who had been treated for severe psychological problems within the preceding 5 years, up from 85.8% (n = 265) reported in the 2004 survey (Gallagher, 2004, Gallagher, 2009). Similarly, Voelker (2003) found increases in the use of health care services for college students with depressive symptoms at Kansas State University. Findings indicated that there had been a 20% increase in student utilization of services for depressive symptoms from 1988 to 1992 when compared with the utilization rates from 1996 to 2001 (Voelker).

Significance, Morbidity, and Mortality 

The significance of depression cannot be overestimated. Depression can impair an individual's functioning to the extent of eight different chronic medical conditions, rendering depressed persons less able to perform as parents, employees, and/or students (Hays, Wells, Sherbourne, Rogers, & Spritzer, 1995). The depressed individual also perceives himself or herself as in worse condition than those with a physical chronic health diagnosis (Hays et al., 1995).

Among college students, depression has been associated with decreased GPA scores (Hysenbegasi, Hass, & Rowland, 2005), acute infectious illness (Adams, Wharton, Quilter, & Hirsch, 2008), increased levels of smoking (Cranford et al., 2009, Kenney & Holahan, 2008, Lee Ridner et al., 2005, Lenz, 2004), increased alcohol consumption (Miller et al., 2002, Weitzman, 2004), increased levels of anxiety (Rawson, Bloomer, & Kendall, 1994), increased self-injurious behaviors (Serras, Saules, Cranford, & Eisenberg, 2010), decreased academic productivity (Heiligenstein, Guenther, Hsu, & Herman, 1996), withdrawals from college (Meilman, Manley, Gaylor, & Turco, 1992), suicidal ideation (Arria et al., 2009), and suicide (Suicide Prevention Resource Center [SPRC], 2004).

Cost 

There is a lack of cost-related studies specifically about depression and the college population. However, studies have been performed to evaluate the costs of depression within the U.S. workforce. For instance, Stewart, Ricci, Chee, Hahn, and Morganstein (2003) compared productive work time of depressed individuals with nondepressed individuals (n = 1,127). They found that lost productive work time of depressed individuals, compared with that of nondepressed individuals, was 5.6 hours per week and 1.5 hours per week, respectively. Conclusions suggested that depressed employees may cost U.S. employers an estimated $44 billion annually, compared with only $13 billion for in nondepressed individuals (Stewart et al., 2003). Findings from an additional study estimated the total economic burden at $83.1 billion in 2000 for treating depression in the U.S. population (Greenberg et al., 2003).

The high incidence and prevalence rates among college and university students, as well as the overall morbidity, mortality, and costs of depression, help to identify college students as a vulnerable at-risk population. The National Institute of Mental Health recommends that interventions be designed to prevent the onset of clinical depression in at-risk groups (Hollon et al., 2002).

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Depression-prevention research 

Methods 

An electronic literature search was performed using the key words related to the aim of this review. Key words included depression, dysthymia, student, young adult, college, university, postsecondary, mental health, psychiatry, psychiatric nursing, cognitive–behavioral intervention/therapy, group therapy, and evidence-based practice. The literature search was not limited to specific years. Therefore, the earliest study included was published in 1987, whereas the most recent study was published in 2009.

The databases searched included the following: CINAHL, Medline, Pubmed, PsycInfo, Cochrane, and other internet search engines (Google and Google Scholar). Reference lists of key articles were also used and reviewed. No searching of unpublished data was performed.

Studies were included if a primary aim of the experimental intervention was to prevent or evaluate depressive symptoms in college students. Studies were excluded if depressive symptoms were measured as a secondary outcome variable (i.e., an intervention designed to reduce anxiety that measured depressive symptoms as a secondary outcome variable). The review was limited to studies published in English and conducted within the United States. Studies involving young adults (ages 18–24 years) were also included, but no studies were found that examined young adults that were not college students. All studies reviewed were single randomized controlled trials (RCTs). Literature reviews that exclusively evaluated depression-prevention strategies within the specific population of college students were not found in the literature.

However, four related literature reviews were discovered, but each review lacked evidence presented from the most recent studies available and/or reviewed only a limited number of studies (Christensen et al., 2010, Lee, 2005, Miller & Chung, 2009, Reavley & Jorm, 2010). Of these four reviews, some included adolescents within the study population (Christensen et al., 2010), trials from other countries (Christensen et al., 2010, Reavley & Jorm, 2010), studies with no experimental treatments performed, (Miller & Chung, 2009), and/or college students dealing with other psychiatric issues such as anxiety (Christensen et al., 2010) or alcohol abuse (Reavley & Jorm, 2010). The following literature review provides a focused comprehensive assessment of depression-prevention strategies that have been evaluated through RCTs within the U.S. college student population.

Leveling and Grading the Literature 

The quality of the evidence was evaluated using the Guyatt and Rennie Rating System (2002) for the Hierarchy of Evidence, which ranges from Level I (the highest quality of evidence and includes systematic reviews of RCTs) to Level VII (the lowest quality of evidence and includes opinions of authorities and experts; see Table 2; as cited in Melnyk & Fineout-Overholt, 2005). The 16 studies included in this review were all ranked at a Level II on the Guyatt and Rennie Rating System for the Hierarchy of Evidence, which symbolizes that the evidence provided originated from at least one RCT (as cited in Melnyk & Fineout-Overholt, 2005).

Table 2. Guyatt and Rennie Rating System for the Hierarchy of Evidence

Note. Adapted from Melnyk and Fineout-Overholt (2005). Copyright 2005 by Lippincott Williams & Wilkins. Melnyk and Finout-Overholt created this original version of this table through modification from the following sources: Guyatt and Rennie (2002). Users' guides to the medical literature. Copyright 2001 by the American Medical Association. Reproduced with permission of The McGraw-Hill Companies; and Harris, Hefland, Woolf, et al. (2001). Current methods of the U.S. Preventive Services Task Force: A review of the process. The American Journal of Preventative Medicine. Vol. 20 (Supplement 3). Copyright 2001, reproduced with permission by Elsevier.

To grade the research, a method that is used by the third United States Preventative Services Task Force (USPSTF/Task Force) was applied (Harris et al., 2001). The method used by the USPSTF/Task Force is supported by the Agency for HealthCare Research and Quality, as well as two evidence-based practice centers (Harris et al., 2001). Evidence is scored using the alphabetical scale A through D for evaluating both the quality of the evidence and the net benefit to patients or populations. This grading system categorizes the evidence using a grid. For example, studies that are determined to be in the “A” category include those with high-quality evidence and those that would provide a substantial amount of net benefits to the population (Harris et al., 2001). On the other hand, a study with fair-quality evidence, which would not hold any net benefits to the population, is graded as a level “D,” the lowest grade (Harris et al., 2001).

In this review, all studies except one were given a grade of B. The grade B suggests that there is fair evidence that the intervention may improve important health outcomes and assist in the implementation of new policies for depression treatment options in the college student population (Harris et al., 2001). This grade was given if there was statistical significance that the intervention reduced depressive symptoms in individuals. A grade of C was given if depressive symptoms in the participants only decreased significantly halfway through the intervention and not upon completion of the program or at the 2-month follow-up. In addition, the grade of C for fair evidence was based on the implication that although the intervention might have improved health outcomes, balance of benefits to harm was too close to justify a general recommendation to the population studied (Harris et al., 2001).

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Results 

The literature search resulted in 16 studies, all of which were RCTs (see Appendix A). The smallest sample size for the studies evaluated was 37 students (Hogg & Deffenbacher, 1988), whereas the largest sample size was 227 students (Seligman, Schulman, & Tryon, 2007).

Students 

The ages of students included in the reviewed studies ranged from 17 to 53 years. However, the mean age of the students in each study was more condensed, ranging from 18.9 to 22.2 years. To note, age characteristics were not revealed in two of the studies (Seligman et al., 2007, Seligman et al., 1999).

Interventions in some studies were also targeted toward a specific academic level of students. Fourteen of the studies looked only at undergraduate students, whereas the remaining two studies evaluated both undergraduate and graduate students (Hogg & Deffenbacher, 1988, Steinhardt & Dolbier, 2008). Two studies evaluated only undergraduates at the college freshmen level (Seligman et al., 1999, Seligman et al., 2007), and three studies only assessed female college students (Bearman et al., 2003, Johansson, 1991, Peden et al., 2000, Peden et al., 2001).

Other studies recruited students with specific population indicators. For example, some researchers selectively recruited women with body concerns (Bearman et al., 2003), those who were nursing students (Johansson, 1991), or those students who had been in relationships for longer than 4 months (Braithwaite & Fincham, 2007). However, most studies with selected interventions identified college students who were at-risk for depression using some type of standardized screening tool (Cukrowicz & Joiner, 2007, Cukrowicz et al., 2009, Forsyth, 2001, Geisner et al., 2006, Gortner et al., 2006, Hogg & Deffenbacher, 1988, Pace & Dixon, 1993, Peden et al., 2000, Peden et al., 2001, Philpot & Bamburg, 1996, Roth & Holmes, 1987, Seligman et al., 1999, Seligman et al., 2007). Only one study recruited volunteers with no inclusion or exclusion criteria (Steinhardt & Dolbier, 2008).

Types of Depression-Prevention Interventions 

Several different types of depression-prevention interventions were found in the RCTs that were reviewed. They included cognitive–behavioral therapy, interpersonal-process therapy, computer training, personal feedback through mailed intervention suggestions, and exercise and stress training. None of the studies evaluated the efficacy of depression medication management as a treatment for depression in the college student population.

Of the 16 trials, 10 evaluated some form of a cognitive–behavioral intervention (CBI; Bearman et al., 2003, Forsyth, 2001, Hogg & Deffenbacher, 1988, Johansson, 1991, Pace & Dixon, 1993, Peden et al., 2000, Peden et al., 2001, Philpot & Bamburg, 1996, Seligman et al., 1999, Seligman et al., 2007, Steinhardt & Dolbier, 2008). The remaining studies either evaluated some form of computer-based education/training (Braithwaite & Fincham, 2007, Cukrowicz & Joiner, 2007, Cukrowicz et al., 2009), personalized mailed-feedback intervention suggestions (Geisner et al., 2006), expressive writing (Gortner et al., 2006), or aerobic exercise and relaxation training (Roth & Holmes, 1987).

Intervention Format and Evaluation 

The depression-prevention interventions were either carried out in a group format (Bearman et al., 2003, Forsyth, 2001, Hogg & Deffenbacher, 1988, Johansson, 1991, Peden et al., 2000, Peden et al., 2001, Roth & Holmes, 1987, Steinhardt & Dolbier, 2008), individually (Braithwaite & Fincham, 2007, Cukrowicz & Joiner, 2007, Cukrowicz et al., 2009, Geisner et al., 2006, Gortner et al., 2006, Pace & Dixon, 1993, Philpot & Bamburg, 1996), or in a mixed format (Seligman et al., 1999, Seligman et al., 2007).

Of the 16 studies reviewed, there were several different evaluation points. The time frame for intervention evaluation ranged from immediately and only postintervention (Johansson, 1991, Philpot & Bamburg, 1996, Steinhardt & Dolbier, 2008) to a total of six follow-up points over the course of 3 years (Seligman et al., 1999).

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Research implications 

Gaps in the Literature 

Depression is the most prevalent mental health disorder on college campuses, and it is a growing concern for college students (ACHA-NCHA, 2009). Moreover, there are strong recommendations for implementing depression-prevention strategies with at-risk populations and to specifically design interventions to prevent the onset of clinical depression in these groups (Hollon et al., 2002). In a recent report, the Institute of Medicine (IOM) and the National Research Council (NRC) summoned political and health care officials to make prevention of mental, emotional, and behavioral disorders in young people a very high priority (NRC & IOM, 2009).

Regardless, prevalence and incidence rates within the college student population demonstrate that interventions are lacking (American College Health Association-National College Health Assessment [ACHA-NCHA], 2000, American College Health Association-National College Health Assessment [ACHA-NCHA], 2009), and this review indicates there are considerable gaps in the literature on the prevention of depression in college students. This review also revealed that although depression interventions for the college population have been implemented and evaluated, cohesive study on these interventions is lacking. For example, only two interventions were evaluated more than once within separate populations of college students (Cukrowicz & Joiner, 2007, Cukrowicz et al., 2009, Seligman et al., 1999, Seligman et al., 2007); thus, there is limited empirical support for the interventions included in this review.

Furthermore, although most interventions were based on cognitive–behavioral approaches, no standard intervention has been developed and tested across multiple college populations and campuses. More importantly, it is inconclusive whether group, individual, or a mixed format for CBIs is more effective in preventing depression in this population.

Implications for Future Research 

Findings of this review indicate there is a need to develop a standardized, effective depression-prevention intervention that can be implemented, measured, and evaluated across multiple college and university settings with diverse student populations. Standardizing an evidence-based prevention approach would assist in establishing a formal, understandable, nationwide prevention strategy to be used in the university health setting. Through this standardization, campus and other health officials could work to incorporate effective evidence-based depression-prevention programs into the campus setting and ultimately assist college students in preventing the onset of depression, or recurring episodes of depression, and its sequelae.

In addition, depression-prevention research should be standardized, evaluating depressive symptoms with a standard screening tool, such as the valid and reliable Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) or the Center for Epidemiological Studies-Depression scale (CES-D; Radloff, 1977). In this way, research could be more effectively compared and evaluated to determine the most effective and evidence-based prevention strategy among college students.

Future research should primarily focus on evaluating the efficacy between individual versus group CBIs. Research aims should evaluate not only the CBI format (group, individual, or combined) but also the mode of delivery of the intervention itself (Internet/computer-based, face-to-face, e-mail, mailed letters, aerobic exercise, etc.). Evaluating a standardized intervention between different college populations will assist in building the empirical evidence needed for depression-prevention interventions in the college population. From this standardized research, national depression-prevention guidelines for this population could be developed and implemented within the college/university setting.

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Recommendations 

Academic Setting Change Recommendations 

!Academic entities are encouraged to assist and/or accommodate future research efforts in developing standardized, effective evidence-based strategies for the prevention of depression in the college student population and to increase awareness on the implications of this research. Furthermore, academic institutions should increase their awareness of the university's overall mental health status through standardized and periodic depression screening in their student population. This initial screening should act as the gateway in proactive outreach to students with depressive symptoms. Embarking on greater proactive outreach would also require the institution to actively follow these at-risk students throughout their academic careers, offer evidence-based preventative and treatment modalities through campus mental health services, increase student perception of availability and access to campus mental health resources, and effectively dispel myths regarding the use of mental health resources on campus.

Nursing Practice Change Recommendations 

As evidenced by the lack of standardized interventions and outcomes of the experimental studies included in the current literature on this topic, a single recommendation or depression-prevention strategy/intervention cannot be identified at this time.

However, because of the severity of depression and its widespread effects in this at-risk population, there is a great need for effective depression-prevention programs to be implemented and to reach the population on campuses nationwide. A call for advanced practice psychiatric nurses (APPNs) with practice or research doctorates who can assist in implementing evidence-based depression-prevention interventions within this population is greatly needed.

The studies evaluated in this review offer the current available evidence of depression-prevention strategies that have been performed in the U.S. college student population from 1987 to 2011. Although further research has been encouraged to form specific guidelines for depression-prevention strategies within this population, APPNs may use the current evidence to begin to standardize and evaluate depression-prevention services within the college student population.

APPNs are also encouraged to collaborate with researchers and other psychiatric practitioners to promote the use of evidence-based depression-prevention strategies within this population. APPNs and other nurse researchers should also contribute by clarifying and directing the path where future research will take place and should seek to develop standardized preventative practice among academic institutions. In this way, nurse practitioners and nurse researchers can assist in closing the gap between current depression-preventative practices and evidence-based practice in the college student population.

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Conclusion 

College students have been identified as an at-risk group for the development of depressive symptoms and diagnosable depression. The National Institute of Mental Health recommends that interventions be developed and implemented in at-risk groups, such as college students (Hollon et al., 2002). In addition, the IOM and the NRC have called upon the nation's health care and political leaders to adopt mental health prevention efforts as a major health concern in the young adult population (NRC & IOM, 2009). This literature review details the processes and outcomes of 16 RCTs within this population and concludes that there is a lack of standardized interventions and effective outcomes within the current literature. Therefore, additional research is recommended to determine effective depression-prevention strategies for the college student population.

Academic entities are encouraged to assist and/or accommodate future research efforts in developing standardized, effective evidenced-based strategies for the prevention of depression in the college student population and to increase awareness on the implications of this research.

Moreover, the use of evidence-based prevention strategies in nursing practice is also recommended to improve the quality of life for this at-risk population. APPNs with practice or research doctorate preparation should direct current and future depression research in the college student population, as well as assist in the formulation of evidence-based treatment guidelines for this population.

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Acknowledgments 

The author would like to acknowledge Patricia B. Howard, PhD, RN; Suzanne S. Prevost, PhD, RN; Lynne A. Hall, DrPH, RN; and Whitney Kurtz-Ogilvie for their mentorship and editing assistance in writing this article.

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Appendix A. Depression-Prevention in the College Student Population: Research Studies 

ePREP = Prevention and Relationship Enhancement Program; CBASP = Cognitive Behavioral Analysis System of Psychotherapy; PANAS = Positive and Negative Affect Schedule; BAI = Beck Anxiety Inventory; PTSD = posttraumatic stress disorder; ISEL = Interpersonal Support Evaluation List; RSS = Rosenberg Self Esteem Scale; DDS = DSM-IV-Based Depression scale; IDD-L = Inventory to Diagnose Depression-Lifetime; MMPI-D = Minnesota Multiphasic Personality Inventory-Depression Scale; ATQ = Automatic Thoughts Questionnaire; SEI = Self-Esteem Inventory—Adult Form; STAI-S = State form of the State-Trait Anxiety Inventory; IPAT = Institute for Personality and Ability Testing; CCI = Crandell Cognitions Inventory; ASQ = Attribution Style Questionnaire

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