The purpose of this study was to examine the effects on three interventions that could be used to improve mental health on U.S. university campuses. Students at universities are often plagued by anxiety, depression, or suicide. There is a shortage of counseling centers on campus. Students and universities can offset the cost by providing preventative, psychoeducational and skill-building programs that promote mental well-being and psychological thriving. The research literature has not yet produced a systematic evaluation and recommendation for preventative mental well-being and well-being programs that university students can use. A registered, randomized controlled trial involved 131 university students being either placed in a control group ( N = 47), or receiving training in one of three well-being programs that lasts for eight weeks. These were SKY Campus Happiness (“SKY”), Foundations of Emotional intelligence (“EI”), and Mindfulness-Based Stress Reduction (“MBSR”), N =34. SKY Campus Happiness had the highest impact on six outcomes, including positive affect, social connectivity, and stress reduction. EI had one benefit: mindfulness. No change was seen in the MBSR group. The delivery of SKY and EI to university students could be a cost-effective, efficient and effective way to address student mental health and to reduce financial stress.
Introduction
According to the World Health Organization, health is defined as “a state that is complete in terms of physical, mental, and social well-being” ( 1). Mental health can also be defined as the absence of mental illness (e.g. anxiety and depression) but also the presence psychological thriving (e.g. gratitude, social connection, mindfulness).
The last ten years have seen a decline in mental health among college students and university students in the United States ( 2). The highest risk of developing a mental illness in college-aged adults (age 18-25) is 3. Between 2017 and 2018, anxiety (58.0%), depression (48.0%), and stress (46.9% were the most frequently reported concerns by students who visited counseling centers in the United States. An American College Health Association survey, which included 88,178 college students from 140 campuses, found that 60% reported feeling overwhelmed by anxiety and 40% felt so depressed that they were unable to function ( 7).
Students with mental illness have lower grades and are more likely to struggle with learning ( 7,8). Substance abuse is also a common problem among university students in the United States ( 9), which can further impact academic performance ( 10) as well as exacerbate mental illness.
More than 90% of suicides in America are linked to mental illness or substance abuse ( 11, 12). While suicide is the 10th most common cause of death in America ( 13), it’s the second leading cause for death among college-aged students ( 14). In recent years, suicides among young adults between the ages of 15 and 24 have increased by a significant amount ( 13). In 2017, the highest number of suicides reported by this age group was 2. 13 and 15. Between 2000 and 2016, more than 10% of students said they had seriously considered suicide during the previous year (2, 5-7; 11, 13, 16, 16).
While social connection is a measure that psychological thriving is predictive of emotional well-being, mental illness can be associated with loneliness or isolation, which can further deteriorate mental health.
Insufficient preparation is required for campus counseling centers to handle increased demand. Campus counseling centers saw an average 30% increase in students seeking treatment from 2009 to 2014. This was compared to an average institutional enrollment increase of 6% ( 25). 94% of counseling center directors reported an increase in students with severe mental health issues ( 26), while 57% of the directors stated that they are unable to provide adequate resources for students (5).
Traditional mental illness treatment involves addressing symptoms once they are present. Students are usually diagnosed and given medication or counseling. This is because counseling has become more expensive. 29 Aside from the negative side effects of medications ( 4), medication can also disrupt cognitive functions (e.g. attention and memory) which are essential for college success ( 30). These types of interventions do not just treat mental illness symptoms but also provide the foundation for psychological resilience and thriving.
Students can be supported by campus counseling centers with a proactive and preventative approach to their mental health. This includes tools that are empirically proven to improve psychological resilience and thrive before they develop symptoms. Numerous studies have shown that skill-building interventions can improve the lives of college students and adolescents ( 31 – 33). Recent meta-analysis of universal mental healthcare prevention programs on university campuses revealed that skill-building with supervised practicum ( 34) was the most effective. These programs were significantly more effective in reducing anxiety, depression, stress and distress ( 34).
Unfortunately, campuses often fail to offer mental health prevention programs due to their primary focus on psychoeducation ( 34). The skill building components (including practice time and reflection as well as supervision) are not required for integration ( 34 ). The research literature has not produced a systematic evaluation and recommended skill-building protocol for psychological resilience that university administrators could implement ( 35). This gap was addressed by our study. We examined the effects of three skill-building prevention interventions with supervision that could improve student mental well-being.
SKY Campus Happiness was chosen because it has been proven to increase psychological resilience ( 36, 37), decrease stress levels ( 38), and reduce impulsive behaviour ( 39). SKY has been shown to increase emotion regulation (40), reduce stress (441-43), anxiety, depression (44-50) and reduce PTSD (51, 52).
Foundations in Emotional Intelligence was the second program that we chose. This program was adapted from a university course, as well as a pre-existing evidence based approach to emotional and social learning, RULER ( 53). RULER has been shown to be a promising tool for children of school age in both quasi-experimental as well as randomized controlled trials. RULER has shown promising results for school-aged children in quasi-experimental and randomized controlled studies. It has been shown that it can increase social and emotional competence (54), academic grades (54), empathy skills (55), cooperation (55), and social problem-solving abilities (56), as well as student-teacher relationships (57).
Koru Mindfulness was our third choice. Mindfulness-based interventions have been shown in university students to decrease psychological distress ( 58, 59), stress( 60 ), anxiety ( 61), and stress ( 60 ). It has been proven to decrease depression (62), anxiety (62) and stress symptoms (63).
Mental health can be viewed as a range from mental illness to psychological flourishing. We sought to measure the effects of interventions using measures that covered the entire spectrum (anxiety, depression, gratitude, and social connection). The focus of each workshop’s intervention curriculum would have an impact on mental health differently, we hypothesized. We believe that all three groups will benefit from measures of mental health, such as depression, anxiety, and stress, based on previous research. The interventions could also improve psychological thriving, according to our hypothesis. Based on past research, we also hypothesized that SKY could improve psychological resilience measures. EI, with its emphasis on emotion regulation and positive affect, was also suggested by us. We hypothesized that Koru Mindfulness would benefit mindfulness and self compassion due to its emphasis on mindfulness and self care.
An initial pilot study compared three well-being/skill-building interventions–SKY Campus Happiness (SKY), Foundations of Emotional Intelligence (EI), and Koru Mindfulness–to an inactive control group. The well-being interventions were favored by the majority of the 203 undergraduate participants. Self-reported well being was not affected. Low exposure to and practice of techniques and strategies during intervention delivery (10 hours over 5 weeks), and lack of at home practice (mode days of reported practice was zero) could explain the lack of intervention effects.
Based on the pilot, the pre-registered main research (Clinicaltrials.gov Registration number: NCT032295777) had the same randomized controlled design but with more intervention exposure (30 hours over 8 weeks) and additional at-home practice requirements. EI and SKY expanded the content to 8 weeks. Mindfulness-Based Stress Reduction was used instead of Koru Mindfulness because its curriculum is for an 8-week duration. We used the same self-reported measures of well-being as in our pilot.
Materials and Methods
Recruitment
Students from large four-year private universities learned about the study via departmental email lists. Participants in similar programs or those with significant mindfulness skills were not eligible. One hundred ninety-three students have committed to the semester-long study.
The study attracted 1,305 students. Figure1 explains how the final sample of participants was assembled. Participants who had participated in similar programs or interventions were not allowed to participate in this study. Students who were considered to be “experts” in mindfulness, or those who practiced mindful practices five times per week or more, were also excluded. Students who had participated in the pilot study last year were also excluded. These criteria led to 515 students being excluded from the study.
Figure 1.
FIGURE 1 Diagram summarizing the participant flow for recruitment and allocation.
The remaining 790 potential students were randomly divided into the four study groups SKY (MBSR), EI (and control). Each student who was interested in taking part in the study was given the schedule and the requirements after randomization. Prospective participants were then invited to sign up, agreeing to attend pre- and post-testing and to adhere to the dedication and attendance requirements. 193 of the 790 potential participants accepted the invitation.
The study saw fifty-eight students drop out because of schedule conflicts (N=11), inability or unwillingness to fulfill the time commitment (N= 9), dismissal for excessive absents (N=4), discontinuation of correspondence with researchers (N=11), physical and mental health reasons, N = 1, 1 (N=1), and unknown reasons (N= 21). The study was completed by one hundred thirty-five students. Three more participants were removed due to extreme outlier data for ten or greater outcome variables. One fourth participant was expelled for lying in all their practice logs.
The final sample consisted of 131 participants, with an average age 19.67 ( SD = 1.02). 56.5% were White, 30.5% Asian and 13.0% Black or African American. 6.1% two or three races, 3.8% American Indian/Alaska Native, 1.5% other and 0.8% declined information. Three-quarters of the participants were male (59.5%), 3.1% genderqueer/gender-non-conforming and 0.8% had “different identity”.
There were no significant differences in gender, personality, mental health diagnoses, current treatment or personality between the groups [measured using the Big Five Inventory ( 67)
Procedure
All participants signed the Time 1 (T1) questionnaires one week before the interventions. After providing written informed consent, Yale University Institutional Review Board approved the protocol. Three days later, all participants completed Time 2 (T2) questionnaires in-person. Students completed practice logs and practiced the techniques they had learned in class at least 3 times per week. Participants in the active group were paid $300 Participants in the control group were paid $80.
Interventions
The intervention (SKY, EI, and MBSR) provided equal instruction. Classes were taught twice per week over the course of a semester at university. There was a two-week break during spring break. One or more short retreats were included in the 30 h of intervention. Two absences were permitted. Facilitators with at least seven years’ teaching experience were certified to deliver interventions. Facilitators were not allowed to see data or research hypotheses.
SKY Campus Happiness – SKY
SKY is a university leadership and well-being program (campushappiness.org) that includes stress-management and tools for psychological resilience: yoga postures, breathing exercises, a breath-based meditation technique [Sudarshan Kriya Yoga; (68)]. SKY includes positive psychology skills such as gratitude, kindness, social connection, and acts of kindness. The curriculum also includes discussions and application of leadership skills as well as service learning.
Foundations of Emotional Intelligence (EI).
EI is an emotional intelligence program that teaches emotion regulation and emotions ( 54). EI was adapted from a university course on emotional intelligence and an evidence-based approach to social and emotional learning for school-aged children, RULER (www.rulerapproach.org). RULER stands for five skills of emotional intelligence, namely recognizing, understanding and labeling emotions, as well as expressing and regulating them.
Mindfulness-Based Stress Reduction
MBSR is a mindfulness meditation program [https://www.umassmed.edu/cfm/mindfulness-based-programs/, (69)] designed for “progressive acquisition of mindful awareness, of mindfulness” (66). The program includes instruction in three techniques: mindfulness meditation, body scanning (systematic awareness about different parts of your body from the toes to your head), and simple yoga postures. The class also includes discussion about meditation and its practical application in daily life.
Measures
The outcomes variables were divided into three categories: psychological thriving, mental health, and physical health. To ensure that change was captured accurately, we used many self-reported outcome measures. These self-report measures evaluated the impact of the programs on T1 and T2 in these categories. Participants also completed the Human Well-Being Scale and an emotion perception task. They are still in development and have not been validated. Participants also completed a measure that was not related to well being. This is not included in the report.
Mental Health
Burnout
The Single-Item Measure of Burnout ( 70 71), contains the item: “Overall based on your definition of burnout how would you rate it?” Participants can choose to answer one of the following questions: 1 = I enjoy what I do. I don’t feel any symptoms of burnout. I could also choose to answer 5 = I feel totally exhausted and wonder if it is possible to go on. I’m at the point that I need to make some changes or seek out help.
Stress
The Perceived Stress Scale 10-Item Inventory ( 72; Cronbach’s Alpha=0.85] measures how often participants feel stressed or have difficulty coping with life stress. It asks whether participants feel that they are unable to control important life events. “In the past month, how often did you feel that things were going your own way?” “.
Depression, Anxiety, and Distress
The Mood and Anxiety Symptom Questionnaire [MASQD30; ( 73] includes three subscales. They measure general distress symptoms (Cronbach’s Alpha=0.87) and anhedonic depression symptoms (Cronbach’s Alpha=0.80), and anxious arousal (Cronbach’s Alpha=0.90). Items were rated from 1 to 5 on a scale of 0 to 0 to 5 on a scale between very . Some examples of items are: “In the past two weeks, I felt irritable” and “felt optimistic.”
Mental Health
The question asked participants: “In general, would your health be …?”?” Items were rated from 1 to 5 on a scale of poor up to excellent. This self-assessment item was based on the Center for Disease Control (CDC) National Health Survey ( 12) and The RAND Corporation’s 36 Item Short Form Health Survey (SF-36; 74).
Psychological Thriving
Psychological well-being
The Ryff Scale of Psychological well-being has 18 items [RYFF] ( 75). Items can be described as statements about one’s self. Participants rate their agreement using a scale from 1 = strongly disagree up to 7 = strongly agreed. Some examples of items are “I like most of my personality” or “The demands of daily life often get me down.” This scale has six subscales that are each measured using three items. : Autonomy (Cronbach’s Alpha=0.70), Environment Mastery (Cronbach’s Alpha=0.61) Personal Growth (Cronbach’s Alpha=0.48) Positive Relations (Cronbach’s Alpha=0.67) Purpose in life (Cronbach’s Alpha=0.35) Self-acceptance and Acceptance (Cronbach’s Alpha=0.72).
Life satisfaction
The Satisfaction with Life Scale ( 76; Cronbach’s Algorithm=0.82] is a five item scale. Items are rated from 1 = disagree to 7 = agree. Some examples of items are “The conditions in my life are excellent” or “If I could change my life, almost nothing would be changed.”
Positive Affect
The Positive and Negative Effect Schedule ( 77; Cronbach’s Alpha=0.89) is a 20-item scale that includes two subscales, each with ten items. These are pleasant and unpleasant emotions. On a scale of 1 to 5, participants rate how much they felt certain emotions in the last week. You can choose from “Excited”, ‘Nervous’, ‘Ashamed’ and em>extremely /em>.
Negative Affect
The Negative and Positive Affect Schedules, see Positive Affect, above (Cronbach’s Alpha=0.87).
Gratitude
The Gratitude Questionnaire Six Item Form [GQ-6] ( 78; Cronbach’s Alpha=0.86] measures six items. Items are rated from 1 = disagree to 7= strongly agree. Some examples of items are “I have so many things in my life that I am thankful for” or “Long periods of time can pass before I feel grateful to someone or something.”
Self-Compassion
The Self-Compassion-Short Form [SCS-SF; (79); Cronbach’s Alpha=0.89] is a 12-item scale measuring the three components of self-compassion: self-kindness, common humanity, and mindfulness. The five-point scale allows participants to rate their behavior using the given format. It ranges from 1 = nearly never up to 5 = almost constantly. Some examples of items are “I try to understand and be patient with aspects of my personality that I don’t like” or “I’m critical and judgmental about myself and my inadequacies.”
Mindfulness
Five Facet Mindfulness Questionnaire ( 80; Cronbach’s Alpha=0.81] is a 15-item scale that allows participants to rate their agreement or disagreement with statements. It ranges from 1 = not true to 5= true very frequently or never , depending on how often they agree. Some examples of items are “I can find words to express my feelings” or “I do jobs and tasks automatically without being aware.”
Adaptive Coping
The 28-item Brief COPE scale measures tendencies to use adaptive and maladaptive strategies to cope [( 81; Cronbach’s Alpha=0.81] Items are rated from 1 to 4 on a scale of 1 to I haven’t been doing it at all to 4 I have been trying to figure out what to do.”
Maladaptive Coping
Adaptive Coping (Cronbach’s Alpha=0.75).
Optimism
The Life Orientation Test-Revised [LOTR; ( 82); Cronbach’s Alpha=0.852] measures optimism. The test includes 10 items that are rated on a 5-point scale: 1 = I disagree very 5 = I agree very. Some examples of items are “If something goes wrong, it will” or “In uncertain times I usually expect the worst.”
Self-Esteem
The Single Item Self-Esteem Score [SISE] ( 83) is a measure of self-esteem. It has been validated against Rosenberg’s Self-Esteem Scope. The scores range from 1-5 with low self-esteem being indicated by a score below 1.
Social Connectedness
To measure social connectivity, the Social Connectedness Scale Revised [SCS–R; 84] was used. Cronbach’s Alpha=0.94 was also used. Items were rated from 1 = disagree up to 6 = agree. Examples of items included “I can connect with others”, “I see myself as a loner”, “I feel like an outcast”, and “I feel like a stranger.”
Sleep and physical health
Two questions were asked of participants: “In general, would your health be …?”?” Items were rated from 1 to poor up to 5 to excellent. Participants also answered two questions: “Over the past 2 weeks, how often have you struggled to fall asleep, stay asleep or sleep too much?” Items were rated from 1 (day) up to 14 (days). These assessments were also based on the RAND and CDC questionnaires, which are listed under “Mental Health.”
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