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Issues in Mental Health Nursing, 34:497–504, 2013

Copyright © 2013 Informa Healthcare USA, Inc.


ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2013.773473

Evaluation of a brief Cognitive Behavioral Group Therapy


for Psychological Distress among Female Icelandic
University Students

Johanna Bernhardsdottir, MS
School of Health Sciences, Faculty of Nursing, University of Iceland, Reykjavik, Iceland, and place
before Psychiatry, Landspitali—The National University Hospital of Iceland, Reykjavik, Iceland

Runar Vilhjalmsson, PhD


School of Health Sciences, Faculty of Nursing, University of Iceland, Reykjavik, Iceland

Jane Dimmitt Champion, PhD, DNP, FNP, AH-PMH-CNS, FAANP, FAAN


School of Nursing, The University of Texas at Austin, Austin, Texas, USA

than one third of students who scored in the upper 20% of dis-
A study of a brief cognitive behavioral group therapy inter- tress scores reported receiving professional help. Still, between
vention for psychologically distressed Icelandic female university 61 and 69% of distressed Icelandic female students reported
students was conducted using a pre–post test quasi-experimental that they needed professional help, indicating an unmet need for
design with intervention and control group conditions. Students
were randomly allocated to control and intervention group con-
mental health care (Bernhardsdottir & Vilhjalmsson, 2012).
ditions (n = 30). The intervention group received four sessions Psychological distress in general and symptoms of depres-
of cognitive behavioral group therapy, delivered by two advanced sion in particular, have been associated with lower academic
practice psychiatric nurses. Assessment of distress included self- achievement and detrimental health habits such as smoking and
reported depression and anxiety symptoms. Students in the inter- problem drinking among college students (Geisner, Mallett &
vention group experienced significantly lower levels of depression
and anxiety symptoms compared to the control group post-test pro-
Kilmer, 2012; Hysenbegasi, Hass, & Rowland, 2005; Kenney &
viding preliminary evidence concerning intervention effectiveness Holahan, 2008; Mahmoud, Staten, Hall, & Lennie, 2012; Weitz-
for Icelandic students. man, 2004). Furthermore, physical illness and acute infectious
illnesses have been associated with psychological distress in
Keywords: anxiety, cognitive behavioral therapy, depression, females, university students (Adams, Wharton, Quilter, & Hirsch, 2008;
students Rawson, Bloomer, & Kendall, 1994). The university years are a
time of transition and students are likely to experience increased
Psychological distress has been described as an unpleasant psychological distress during this time (Bewick, Koutsopoulou,
subjective state taking two major forms, depression and anxi- Miles, Slaa, & Barkham, 2010). It should also be noted that
ety, each represented by mood and malaise (Mirowsky & Ross, about three quarters of all mental health disorders have evolved
2003). Elevated psychological distress among university stu- among young people by their midtwenties, and as Kessler et al.
dents has been repeatedly reported, with women having higher (2007) note, most severe disorders are preceded by minor dis-
levels than men (Adlaf, Gliksman, Demers, & Newton-Taylor, orders. The high prevalence of elevated psychological distress,
2001; Nerdrum, Rustøen, & Rønnestad, 2006; Stallman, 2010). especially among university female students, indicates a need
This reflects general population findings, as symptoms of de- for interventions to decrease the distress, prevent adverse health
pression and anxiety are more common in women than men outcomes, and promote successful completion of academic stud-
(Seedat et al., 2009). A study of female Icelandic university ies and career preparation (Bewick et al., 2010; Vázquez, Otero,
students found that the prevalence rate for elevated depressive & Dı́az, 2012a).
and anxiety symptoms was 22.5% and 21.2%, respectively. Less
BACKGROUND
Address correspondence to Johanna Bernhardsdottir, Faculty of Cognitive behavioral therapy (CBT) is an evidence-based
Nursing, University of Iceland, Eirberg, Eiriksgata 34, 101 Reykjavik, therapy shown to be effective, for instance, for unipolar depres-
Iceland. E-mail: johannab@hi.is sion and general anxiety (Butler, Chapman, Forman, & Beck,

497
498 J. BERNHARDSDOTTIR ET AL.

2006). Studies have assessed the effectiveness of face-to-face RATIONALE FOR STUDY
CBT for psychological distress especially symptoms of depres- This study pilot tests the first Icelandic CBGT for psycholog-
sion among university students. However, only a few of these ical distress among female university students. This is a rather
studies have reported the effectiveness of brief cognitive be- homogenous group in regard to social factors like financial sta-
havioral group therapy (CBGT) for symptoms of depression in tus and roles. Bernhardsdottir and Vilhjalmsson (2012) found
a group of female students (Bearman, Stice, & Chase, 2003; that female students who experienced symptoms of psychologi-
Peden, Hall, Rayens, & Beebe, 2000; Peden, Rayens, Hall, & cal distress mostly reported mild to moderate levels. In addition,
Beebe, 2001). Cognitive behavioral therapy directed toward stu- they often feel they have limited time to seek professional mental
dents experiencing symptoms of depression often also addresses health care. Therefore, a more intensive intervention with fewer
problems related to anxiety, stress, self-esteem, or perfection- sessions than in previous intervention studies was developed in
ism. This therapy is commonly brief and provided in groups of response to these concerns. It was assumed that less time was
approximately 5–16 students, typically meeting in six to eight needed for the introduction phase in the beginning sessions and
consecutive weekly sessions that last for 1–2 hr (Koutra, Katsi- that students were facing similar problems related to age, gen-
adrami, & Diakogiannis, 2010; Kutlesa & Arthur, 2008; Peden der, and academic status and willing with the functional capacity
et al., 2000, 2001; Seligman, Schulman, & Tryon, 2007). Ac- to be active between sessions. Based on this understanding, a
cording to a meta-analysis by Feng et al. (2012), the average comprehensive educational manual with references was written
number of group sessions for depressed clients range from 8 to with inclusion of targeted homework assignments. This study
12, with 6–10 people in each group. It should be noted that face- describes the clinical short-term outcomes of a brief CBGT
to-face CBT among university students is most often directed at for psychologically distressed Icelandic female university
students with lower levels of depressive symptoms and related students.
distress, mainly for the purpose of prevention or early inter-
vention (Buchanan, 2012; Reavley & Jorm, 2010). Also, in so-
cioedemographic terms, university students may be more homo- PURPOSE OF THE STUDY
geneous than most patient groups. Therefore, an effective CBGT The purpose of this quasi-experimental study was to eval-
may require fewer sessions in the case of university students. uate the clinical outcomes of a brief CBGT for reduction of
Short-term recovery among Greek university students in- psychological distress assessed as symptoms of anxiety and de-
cluded a decrease in symptoms of anxiety and depression fol- pression among Icelandic female university students. The study
lowing completion of CBGT sessions (Koutra et al., 2010). used an intervention and control group condition including pre-
Brown and Schiraldi (2004) found a mental health skill course and postintervention assessments. The research question was:
including life-style skills, cognitive behavioral skills, and relax- Is there a significant difference in depressive and anxiety symp-
ation more effectively reduced subclinical symptoms of depres- toms between an intervention and control group of female uni-
sion and anxiety in college students compared to a conventional versity students following a brief cognitive behavioral group
stress management course. Deckro et al. (2002) evaluated the therapy?
short-term outcome of a combined cognitive behavioral ther-
apy with relaxation techniques among university students. They METHODS
found a reduction of distressing symptoms after six weeks of
intervention. Kutlesa and Arthur (2008) also found that de- Participants and Recruitment
pressive and anxiety symptoms decreased significantly among Participants were selected from a prevalence study among
university students, compared to a control group, after receiving female students of an Icelandic university that had been con-
eight weeks of group treatment which consisted of CBGT and ducted nine months prior to the current study. The students
interpersonal approach directed at perfectionism. were asked as part of the study whether or not they were will-
Longer term effects on symptoms of depression and enhance- ing to be contacted again if their score ranked in the top 20%
ment of mental health through brief CBGT among university of observed psychological distress scores assessed by the de-
students has been reported in several studies (Hamdan-Mansour, pression and anxiety subscales of the Symptom Checklist-90
Puskar, & Bandak, 2009; Peden et al., 2000, 2001; Seligman, (SCL-90) (Derogatis, Lipman, & Covi, 1973). This definition
Schulman, DeRubeis, & Hollon, 1999; Vázquez et al., 2012b). of elevated distress has been established in community-based
These findings indicate a reduction of psychological distress fol- studies (Comstock & Helsing, 1976; Vilhjalmsson, Kristjans-
lowing face- to-face brief CBGT or in combination with other dottir, & Sveinbjarnardottir, 1998).
distress-reducing interventions. Nevertheless, distress-reducing Inclusion criteria in the current study were female gender,
intervention studies are rarely reported among female students students registered at an Icelandic university, speaking Ice-
in university settings as part of health care despite high rates of landic, and scoring within the top 20% of distress scores. Ex-
psychological distress. The shortage of evidence-based studies clusion criteria included currently undergoing psychological or
to introduce interventions of this kind may constitute a barrier psychiatric treatment and being an international exchange stu-
when developing this service in countries such as Iceland. dent as they usually do not speak Icelandic. Findings from the
COGNITIVE BEHAVIORAL GROUP THERAPY 499

(n= 743) women were


assessed for eligibility

(n= 16)
declined
(n= 131) met participation
inclusion criteria,
(n= 9) e-
mails were
not working

Randomized (n= 106)

(n= 3) declined (n= 53) (n= 53) (n= 9) declined


participation allocated to allocated to participation
intervention control group
(n= 27) never group (n=2 e-mails
responded (n= 15) not working
(n=23) accepted
accepted participation (n= 27)
intervention never
responded

(n= 1) never (n=3) were


attended the (n= 20) responded (n= 12) responded busy or called
intervention to questionnaires to questionnaires in sick
pre intervention pre intervention
(n= 2) were
not eligible

(n= 1) (n=1) dropped


discontinued out without
after first (n= 19) (n= 11) explanations
session, analyzed analyzed post
without intervention
explanations

FIGURE 1 Flow of Participants Through the Study.

initial prevalence study showed that 131 of 743 women scored Figure 1. A total of 54 females, 27 in each group, never re-
within the top 20% of psychological distress scores on one or sponded to the offer to participate. Study recruitment is de-
both of the anxiety and depression SCL-90 subscales. Most of scribed in Figure 1. A resulting sample of 32 women responded
the women scored close to the respective cutoff points, indicat- to the questionnaires pretest. One woman in the intervention
ing mild to moderate distress (Bernhardsdottir & Vilhjalmsson, group discontinued the study after the first session without ex-
2012). They were invited to participate in the current study by us- planation and another woman in the control group did not an-
ing the e-mail addresses they had provided. Sixteen women de- swer the questionnaires posttest. Therefore, the sample for this
clined the offer as they had graduated, moved abroad, or were ex- analysis consisted of 30 women, 19 in the intervention and 11
pecting children. Nine e-mails did not work, leaving a sample of in the control group conditions (Figure 1). Randomization into
106 women. They were randomly assigned to either intervention intervention and control groups took place one week prior to
(n = 53) or control (n = 53) group conditions as shown in the beginning of the first cognitive behavioral session. Nineteen
500 J. BERNHARDSDOTTIR ET AL.

participants in the intervention group and 11 in the control group to the two SCL-90 subscales, the study also included Beck’s
completed the study (Figure 1). Depression (BDI-II) and Anxiety Inventories (BAI).

Beck’s Depression Inventory (BDI-II)


Procedure The Beck Depression Inventory II is a 21-item scale mea-
The National Bioethics Committee (VSNb2007100004/ suring symptoms of depression during the past two weeks. Re-
03-1) and the Rector of the respective university in Iceland sponse options range from 0 to 3 with 0 referring to no symptoms
reviewed and approved the study. All women identified as eli- and 3 to severe symptoms. The maximum total score is 63 (Beck
gible by the prevalence study received an invitation letter with et al., 1996). Cronbach’s alpha in this sample of Icelandic uni-
information about the intervention research, informing them that versity students was 0.82.
they would be randomly assigned to an intervention group or a
control group condition. The invitation also included informa- Beck’s Anxiety Inventory (BAI)
tion related to the objectives of the research, provision of the
The Beck Anxiety Inventory is a 21-item self-report instru-
brief CBGT, and administration of questionnaires.
ment to assess symptoms of anxiety for the past seven days.
One week prior to the beginning of the first CBGT session
Response options range from 0 to 3 with 0 referring to no symp-
and following randomization, participants received a second
toms and 3 to severe symptoms. The total maximum score is 63
introductory letter informing them of practical information re-
(Beck & Steer, 1993). Cronbach’s alpha of the Beck Anxiety
lated to time schedules and location. Those who were eligible
Inventory was 0.89.
and agreed to participate completed informed consent and sub-
sequently responded to questionnaires. The intervention group
responded to the questionnaires before the beginning of the first The Intervention
CBGT session and the no-therapy control group during the first The brief cognitive behavioral intervention used in this study
week of CBGT sessions. is based on Beck’s cognitive behavioral therapy (Beck, 1976;
The intervention was conducted over four weeks and ques- Beck, Rush, Shaw, & Emery, 1979). INSIGHT, a program de-
tionnaires were completed by intervention and control groups veloped to enhance women’s mental health through cognitions,
following completion of the intervention. Participants re- provided the basis for content included in the educational com-
sponded to the questionnaires at the Research Center at The ponent of the program (Gordon, Matwychuk, Sachs, & Canedy
School of Health Sciences at the respective university. Four 1988; Gordon & Sachs 2002; Gordon & Tobin, 2002). The first
self-report scales were administered by a research assistant author of the current study developed an intervention manual
and took approximately 20 min to answer. The scales were to standardize implementation and enable replication by differ-
as follows: depression and anxiety subscales of the SCL-90 ent therapists. The manual included comprehensive educational
(Derogatis et al., 1973), Beck Depression Inventory II (Beck, material and guidelines for the homework for each of the four
Steer, & Brown, 1996), and Beck Anxiety Inventory (Beck & sessions as active involvement of participants was expected.
Steer, 1993). Use of a manual by facilitators ensured intervention fidelity. All
participants and therapists worked with the same materials and
used guidelines to prepare sessions. The manual also served as
Instruments a reference for participant review.
The SCL-90 Depression and Anxiety Subscales Four consecutive weekly sessions were offered by two ad-
The SCL-90 depression scale is a 13-item self-report scale to vanced practice psychiatric nurses. One of the nurses was trained
assess depressive symptoms during the past seven days. Scores in cognitive behavioral therapy and the other is an assistant pro-
for individual items range from 0 to 4 with a maximum total fessor in psychiatric nursing. The intervention was carried out
score of 52 (Derogatis et al. 1973). Cronbach’s alpha in this sam- in three subgroups of five to eight women. Participants were al-
ple of Icelandic university women students is 0.87. The SCL-90 lowed to choose between three group session times. One group
anxiety scale is a 10-item scale to assess symptoms of anxiety met Tuesday nights, another on Wednesday afternoons, and the
during the past seven days. Scores for individual items range third group at lunchtime on Thursdays. All sessions were held
from 0 to 4 with a maximum total score of 40 (Derogatis et al. in a classroom at the School of Health Sciences at the respective
1973). Cronbach’s alpha in this sample of Icelandic university university that was decorated to provide a therapeutic environ-
women students is 0.86. A previous Icelandic general popula- ment. Each session included two hours of therapy with a re-
tion study using the SCL-90 depression and anxiety subscales freshment break. Students were offered light snacks during the
found an upper 20% threshold score of 7 for the depression breaks and books on mental health and cognitive behavioral ther-
scale and 5 for the anxiety scale (Vilhjalmsson, 2007). These apy were on display for review during the break. They were not
threshold scores constituted the cutoff points for the current otherwise compensated for their participation in the research.
study to indicate elevated depressive and anxiety symptoms, The intervention consisted of the following components: Ed-
and thus eligibility to enter the intervention study. In addition ucation, cognitive restructuring, activity scheduling, positive
COGNITIVE BEHAVIORAL GROUP THERAPY 501

affirmations, and relaxation. At the beginning of each session, on study leave. As previously indicated, one woman discontin-
a brief informative presentation was made and the group was ued the study after the first session and all the others attended
guided through a short relaxation exercise which lasted approx- all four sessions, except one participant who was ill and missed
imately 5 min. In every session, home assignments, such as the third CBGT session, but was still included in the analysis.
thought records, activity diaries, and positive affirmations, were
reviewed and discussed. In the first session, basics of cogni-
tive behavioral therapy were explained and put in context with Changes in Psychological Distress
psychological distress; both depressive and anxiety symptoms. Pre- and posttest findings for both groups as well as the com-
Participants practiced identifying thoughts, feelings, physical parison between groups were analyzed by repeated measures
reactions, and behavior in relation to distressing situations. The ANOVA and are presented in Table 1. The mean scores of the
concept of thought records was introduced and practiced with intervention and control groups differed both pre- and posttest
examples from the group. Thought records were given as a home despite utilization of randomization. The control group reported
assignment throughout the four weeks and were reviewed in ev- less psychological distress pretest compared to the intervention
ery session. The second session included a description of the group, although the difference was not statistically significant.
concepts of stress and mastery along with cognitive restructur- Posttest depression and anxiety scores among the intervention
ing and distraction techniques to deal with stress. Also, phys- group decreased significantly (p < .01) in comparison to the
ical techniques including relaxation and controlled breathing control group showing an interaction effect. The differential
were taught. Participants were asked to keep activity diaries to change in symptom scores between the groups pre- and posttest
help them reflect on how they spent their time, how much plea- was significant on all scales (p < .01) with the exception of
sure they took in different activities, and how well they mastered the Beck Anxiety Inventory. Anxiety, according to the SCL-90
them and identify possible stressors. Activity diaries were re- anxiety subscale and depression according to both the SCL-90
viewed in the third session and participants were encouraged to depression subscale and the Beck Depression Inventory-II in-
add activities to their schedules, where appropriate, to enhance creased over time within the control group in contrast to the
a sense of mastery and pleasure. The concept of self-esteem was intervention group. Anxiety developed differently by scales in
discussed along with helpful cognitive and behavioral ways to the control group, showing almost no change in the level of
enhance self-esteem and sense of mastery. The fourth and final symptoms according to the Beck Anxiety Inventory and an in-
session included a review of the program and summarization crease according to the SCL 90-anxiety subscale.
of educational topics from previous sessions. Participants’ ex-
periences from working with thought records, activity diaries,
relaxation training, and the practice of using positive affirma- DISCUSSION
tions were reviewed and discussed. This study indicates that a brief CBGT with four sessions, de-
livered by advanced practice psychiatric nurses, is effective in re-
ducing mild to moderate psychological distress among Icelandic
Statistical Analysis
female university students. These findings provide evidence to
Data were analyzed with SPSS software (version 18) using support previous findings by other studies (Deckro et al., 2002;
descriptive statistics, independent sample t-tests, and repeated Hamdan-Mansour et al., 2009; Peden et al., 2000), although our
measures ANOVA. Background data were analyzed by descrip- results indicate that fewer sessions suffice to achieve a signif-
tive statistics. Differences between the intervention and control icant reduction in symptoms of depression and anxiety among
group were assessed by independent sample t-test, and repeated female students. The interaction effect between groups showing
measures ANOVA was used to assess the effect of the interven- a decline of symptoms for the intervention group and a rise in the
tion over time. The level of significance was set at p < .05. control group may be related to the timing of the intervention, as
stress and strain of the academic year are most pronounced to-
RESULTS ward the end of semester. Through the intervention, participants
may have acquired new ways to deal with their psychological
Participants and Response distress, whereas control group participants did not.
Participants were between 22 and 45 years of age (mean Similarity of results across different scales measuring dis-
27.73). The sample represented participants from all schools tress supports the conclusions about the effectiveness of the
within the University. Forty-three percent (n = 12) were single intervention. The depression and anxiety subscales from the
and 57% (n = 16) were in a relationship or married/cohabiting. SCL-90 as well as the Beck Depression Inventory II identified
Twenty six point five percent (n = 8) were mothers and 73.5% changes in the respective scores for both groups. However, as
(n = 22) were childless. Seventy six point five percent (n = 23) the control group showed little change in anxiety according to
were undergraduates and 23.5% (n = 7) were graduate students. the BAI and more change by the SCL-90 anxiety subscale, de-
Eighty three point five percent (n = 25) were full-time students termining which scale is the better indicator of change should
and 13.5% (n = 4) were part-time students. One participant was be considered in further studies.
502 J. BERNHARDSDOTTIR ET AL.

TABLE 1
Results of Repeated Measures ANOVA for Depression and Anxiety
Baseline Postintervention Repeated measures
Variable M SD M SD Effect F p-value
Depression Derogatis
Intervention group 12.26 9.07 6.95 7.94 Treatment 0.003 0.959
Time 0.093 0.762
Treatment by time 9.646 0.004
Control group 7.27 5 11.64 11.4
Depression Beck
Intervention group 8.36 8.23 4.16 6.19 Treatment 2.045 0.164
Time 2.183 0.151
Treatment by time 22.666 0.000
Control group 5.82 3.43 13.82 10.13
Anxiety Derogatis
Intervention group 8.16 5.56 5.21 4.71 Treatment 0.223 0.008
Time 0.092 0.764
Treatment by time 10.996 0.003
Control group 4.73 3.8 7.18 3.06
Anxiety Beck
Intervention group 17.26 10.2 13.74 10.19 Treatment 1.986 0.171
Time 2.629 0.116
Treatment by time 2.629 0.116
Control group 10.73 7.79 10.72 7.64

The fact that many students never responded to the offer lems among the student population using standardized screening
of participation may have been influenced by improved mental scales such as the Beck and Derogatis anxiety and depression
health, graduation, change in universities, and relocation. This scales (Buchanan, 2012; Mahmoud et al., 2012). It is important
may also reflect known impediments to recruitment of individ- that nurses providing group CBT are trained especially in this
uals with subclinical symptoms of depression (Cuijpers, van therapy as was the case in this study. According to a literature
Straten, Warmerdam, & van Rooy, 2010). It has been shown review by Parrish and Peden (2009), clients express satisfac-
that relatively few university students seek help for their men- tion with care provided by advanced psychiatric practice nurses
tal health problems (Eisenberg, Hunt, Speer, & Zivin, 2011; and results show that their treatment is as effective as that of
Stallman, 2010), which may also be the case in the current other professionals. Advanced practice nurses need to be active
study. The attrition rate in the present study, after initiation of members of multiprofessional teams that develop, implement,
the intervention was low, despite no compensations, indicating and test evidence-based therapies to decrease psychological dis-
that the women felt the intervention was acceptable, met their tress among university students who experience elevated distress
mental health needs, and motivated them to invest their time symptoms (Mahmoud et al., 2012).
despite academic workload close to the end of semester.

Implications for Practice Limitations of the Study


Only about one third of distressed university students have The results of this study cannot be generalized to other stu-
been found to receive professional help related to mental health dent populations as the sample was recruited from a single
problems and rarely from nurses (Bernhardsottir & Vilhjalms- university in Iceland and excluded male and foreign exchange
son, 2012; Eisenberg, et al., 2011; Stallman, 2010). Nurses students. The number of students in the sample was small, dis-
practicing in any school setting where large groups of young tribution of participants in groups was uneven, and nonpartici-
people are accessible need to be aware of unmet health care pation may have been higher in the control group because they
needs among students, not the least females (Bernhardsdottir were not offered the intervention. The study should be replicated
& Vilhjalmsson, 2012; Vázquez, et al., 2012a). They are in an as an efficacy trial, including both genders and foreign students.
excellent position to screen and treat mental health problems Long-term follow-up of approximately one to three years is
and should initiate regular screening of mental health prob- also suggested to evaluate long-term effectiveness. The findings
COGNITIVE BEHAVIORAL GROUP THERAPY 503

of this study do not provide precise information about the most Bewick, B., Koutsopoulou, G., Miles, J., Slaa E., & Barkham, M. (2010).
beneficial components of the cognitive behavioral intervention. Changes in undergraduate students’ psychological well-being as they progress
Therefore, a qualitative study is suggested to acquire knowledge through university. Studies in Higher Education, 35(6), 633–645. doi:
10.1080/03075070903216643
about participants’ experiences and what components may con- Brown, S. L., & Schiraldi, G. R. (2004). Reducing subclinical symptoms of
tribute to beneficial outcomes. When implementing findings of anxiety and depression: A comparison of two college courses. American
this study, consideration should be given to development of men- Journal of Health Education, 35(3), 158–164.
tal health care services and health education for psychological Buchanan, J. L. (2012). Prevention of depression in the college student pop-
ulation: A review of the literature. Archives of Psychiatric Nursing, 26(1),
distress as well as involvement of nurses as care providers within
21–42. doi: 10.1016/j.apnu.2011.03.003
university-based settings. It is recommended that cognitive be- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The
havioral therapy be tested further through other modalities than empirical status of cognitive-behavioral therapy: A review of meta-analyses.
in our study, such as the Internet, computer-based programs, Clinical Psychology Review, 26(1), 17–31. doi: 10.1016/j.cpr.2005.07.003
and other technical communication channels (Buchanan, 2012; Comstock, G. W., & Helsing, K. J. (1976). Symptoms of depression in two
communities. Psychological Medicine, 6(4), 551–563.
Cukrowicz & Joiner, 2007).
Cukrowicz, K. C., & Joiner, T. E. (2007). Computer-based intervention for
anxious and depressive symptoms in a non-clinical population. Cognitive
Therapy and Research, 31(5), 677–693. doi: 10.1007/s10608-006-9094-x
CONCLUSION Cuijpers, P., van Straten, A., Warmerdam, L., & van Rooy, M. J. (2010). Recruit-
Results suggest that a brief cognitive behavioral group ther- ing participants for interventions to prevent the onset of depressive disorders:
apy led by advanced practice psychiatric nurses is feasible and Possible ways to increase participation rates. BioMedicalCentral Health Ser-
vices Research, 10, 181. doi:10.1186/1472-6963-10-181
effective for reducing psychological distress among female uni- Deckro, G. R., Ballinger, K. M., Hoyt, M., Wilcher, M., Dusek, J., Myers, P.,
versity students in Iceland. Results indicate that alleviation of et al. (2002). The evaluation of a mind/body intervention to reduce psycho-
distress is particularly effective in times of increased stress and logical distress and perceived stress in college students. Journal of American
strain during the academic year, especially, near the end of the College Health, 50(6), 281–287.
semester. The intervention is accessible for students, takes little Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: An outpatient
psychiatric rating scale—preliminary report. Psychopharmacology Bulletin,
time, and is structured to accommodate their daily schedules. 9(1), 13–28.
This overcomes barriers that have been reported to hinder stu- Eisenberg, D., Hunt, J., Speer, N., & Zivin, K. (2011). Mental health service uti-
dents from seeking help for mental health problems (Bernhards- lization among college students in the United States. The Journal of Nervous
dottir & Vilhjalmsson, 2012). and Mental Disease, 199(5), 301–308.
Feng, C. Y., Chu, H., Chen, C. H., Chang, Y. S., Chen, T. H., Chou, Y. H.,
Declaration of interest: The authors report no conflicts of et al. (2012). The effect of cognitive behavioral group therapy for depression:
A meta-analysis 2000–2010. Worldviews on Evidence-Based Nursing, 9(1),
interest. The authors alone are responsible for the content and 2–17. doi: 10.1111/j.1741-6787.2011.00229.x
writing of the paper. Geisner, I. M., Mallett, K., & Kilmer, J. R. (2012). An examination of depres-
sive symptoms and drinking patterns in first year college students. Issues
in Mental Health Nursing, 33(5), 280–287. doi: 10.3109/01612840.2011.
653036
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