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Mental disorders are responsible for a high level of disability burden in students attending university. However, many universities have limited resources available to support student mental health. Technology-based interventions may be highly relevant to university populations. Previous reviews have targeted substance use and eating disorders in tertiary students. However, the effectiveness of technology-based interventions for other mental disorders and related issues has not been reviewed.
To systematically review published randomized trials of technology-based interventions evaluated in a university setting for disorders other than substance use and eating disorders.
The PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials databases were searched using keywords, phrases, and MeSH terms. Retrieved abstracts (n=1618) were double screened and coded. Included studies met the following criteria: (1) the study was a randomized trial or a randomized controlled trial, (2) the sample was composed of students attending a tertiary institution, (3) the intervention was delivered by or accessed using a technological device or process, (4) the age range of the sample was between 18 and 25 years, and (5) the intervention was designed to improve, reduce, or change symptoms relating to a mental disorder.
A total of 27 studies met inclusion criteria for the present review. Most of the studies (24/27, 89%) employed interventions targeting anxiety symptoms or disorders or stress, although almost one-third (7/24, 29%) targeted both depression and anxiety. There were a total of 51 technology-based interventions employed across the 27 studies. Overall, approximately half (24/51, 47%) were associated with at least 1 significant positive outcome compared with the control at postintervention. However, 29% (15/51) failed to find a significant effect. Effect sizes were calculated for the 18 of 51 interventions that provided sufficient data. Median effect size was 0.54 (range –0.07 to 3.04) for 8 interventions targeting depression and anxiety symptoms and 0.84 (range –0.07 to 2.66) for 10 interventions targeting anxiety symptoms and disorders. Internet-based technology (typically involving cognitive behavioral therapy) was the most commonly employed medium, being employed in 16 of 27 studies and approximately half of the 51 technology-based interventions (25/51, 49%). Distal and universal preventive interventions were the most common type of intervention. Some methodological problems were evident in the studies, with randomization methods either inadequate or inadequately described, few studies specifying a primary outcome, and most of the studies failing to undertake or report appropriate intent-to-treat analyses.
The findings of this review indicate that although technological interventions targeting certain mental health and related problems offer promise for students in university settings, more high quality trials that fully report randomization methods, outcome data, and data analysis methods are needed.
University students are predominantly at an age when the incidence of mood and anxiety disorders is peaking—mental health problems are most likely to begin before 24 years of age [
Electronic media has the potential to play a significant role in developing university-based approaches to improving mental health. It is reported that young people seek help or information for emotional and mental health problems online [
Numerous studies and several reviews have evaluated Internet-based and non-Internet-based interventions for substance misuse and eating disorders in tertiary student populations [
General population reviews of Web-based depression and anxiety interventions have indicated that such interventions can be effective for treating common mental disorders, with moderate to large effect sizes [
The PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials databases were searched using keywords, phrases, and Medical Subject Headings (MeSH) terms in May 2012. The search strategy (see
1. The study investigated (1) an intervention for a mental health problem or disorder, or the promotion of positive mental health, or (2) the study measured a mental health–related outcome in relation to the intervention.
2. The intervention was either disseminated via or accessed using a technological device (eg, computer, smartphone, telephone) or process (eg, email, Internet, SMS/text-messaging, video).
3. The study was conducted in a university setting with students or young people.
4. The study was not a thesis or a conference proceeding.
5. The article was written in English.
Studies that were considered relevant by both raters were retained and those that were identified as relevant by only 1 rater were rescreened by both raters according to the preceding criteria. Following the second screen, abstracts that both raters considered relevant were retained. The remaining abstracts were discussed by the 2 raters and relevant abstracts were mutually agreed upon following discussion. A total of 125 abstracts were identified as relevant following the initial screening stage. An additional 40 papers were located through handsearching the reference lists of papers from the initial 125 identified abstracts and reviews located through the original 1618 abstracts. In addition, JC screened the reference lists on Beacon [
1. Study design: the study was a randomized controlled trial (RCT) or a randomized trial (ie, an equivalence trial).
2. Recruitment population: the sample was composed of students attending a tertiary institution, such as university, college, or a Technical and Further Education (TAFE) institution.
3. Intervention type: the intervention or some portion of the intervention (eg, reminder or follow-up contact) was either delivered by or accessed using a technological device or process (Internet, telephone, video). Studies that used technology only to conduct screening or measure outcomes (which are not considered part of the intervention) did not satisfy this criterion.
4. Age: the age range of the sample was between 18 and 25 years or the mean age of the sample was between 18 and 25 years. If sample age was not able to be sourced directly from the authors, studies that sampled undergraduates without specifying age were included.
5. Intervention focus: the intervention was designed to improve, reduce, or change symptoms relating to a mental disorder (as defined by the DSM-IV and ICD-10).
Studies that were considered relevant by both raters were retained and those that were identified as relevant by only 1 rater were rescreened by a third rater. A total of 108 papers were retained for coding by 2 coders (LF or AG and JC). Three of these papers [
A total of 28 papers were included. However, 2 papers [
Type of intervention (ie, intervention target group) was categorized using the framework described by Mrazek and Haggerty [
Amount of human contact was coded based on categories identified by Newman and colleagues [
Study quality was assessed using the risk of bias criteria proposed by the Cochrane Effective Practice and Organisation of Care Group [
A quantitative meta-analysis was not conducted because of the heterogeneous nature of the studies. Descriptive information regarding whether the study reported a significant time × group interaction was reported. This information was reported for the primary symptom outcome measure(s) as specified by the authors. In the event that a primary outcome was not specified or multiple measures of the same construct were examined (eg, multiple measures of depressive symptoms), only the first outcome that was described in the measures section of the paper was reported. Where possible, Hedge’s
Study identification flow diagram.
Most studies targeting depression and anxiety were conducted in the United States [
Ten studies employed universal interventions, and fewer studies focused on indicated (n=7), selective (n=7), and treatment (n=3) interventions.
Of the studies for depression and anxiety symptoms, 43% (3/7) examined selective interventions [
Of the 4 studies targeting anxiety symptoms, 3 were universal [
Of the 4 studies targeting examination anxiety, 2 were universal [
Of the 3 studies targeting specific phobias, 2 were indicated studies [
Of the 2 studies targeting stress, 1 was universal [
The study targeting computer-related anxiety was universal and delivered hypnosis or biofeedback [
For the 3 studies examining other issues, 1 used a universal intervention targeting hardiness and acculturation [
The 51 interventions examined in the present review employed a range of broad technology types including the Internet (n=18), audio (n=9), virtual reality (n=6), video (n=4), stand-alone computer programs (n=1), and/or a combination of these (Internet plus computer program, n=5; audio plus video, n=5; computer plus audio, n=1; Internet plus audio, n=1; Internet plus APS, n=1). There were no telephone-only interventions. The interventions were delivered using a range of specific devices, including computer (n=24), mobile phone (n=4), Moving Picture Experts Group Layer-3 (MP3) audio file (n=3), Digital Versatile Disc (DVD; n=3), compact disc (CD; n=2), virtual reality devices (n=6), audiotape player (n=4), video player (n=2), and combinations of these, including computer plus audio player (n=2) and computer plus APS (n=1). CBT interventions tended to be Internet-based and were commonly delivered using websites and in conjunction with therapist support in-person or via email. Email was the most common method of monitoring. Educational interventions tended to be delivered using stand-alone computer-based programs and videos. Interventions involving exposure, stress inoculation training, and relaxation tended to be delivered via audio (audiotape, CD, and MP3), combined audio and video (DVD), mobile phone, or virtual reality.
Intervention length ranged from 15 minutes to 10 weeks. For interventions of less than 1 week in duration, intervention length ranged from 15 to 60 minutes (mean 34.23, SD 13.82). For interventions that were 1 week or longer, the mean intervention length was 4.1 weeks (SD 3.04). Length of time to follow-up ranged from immediately postintervention to 12 months postintervention. Of the 51 technology-based interventions employed, 27 (52.9%) were delivered distally, 18 (35.3%) were delivered nondistally, and 6 (11.8%) contained distal and nondistal components. Of the 25 Internet-based interventions, 13 (52.0%) were completely distal, 6 (24.0%) contained a combined distal and nondistal component, and 6 (24.0%) interventions were not distal [
Over half of the interventions were self-administered (30/51, 59%), and approximately one-fifth were predominantly self-help (10/51, 20%). For interventions that were predominantly self-help, human contact was most commonly provided in the form of email monitoring or moderation of a discussion forum. Four interventions (8%) involved minimal contact and tended to include more intensive therapist involvement via email. Interventions classified as therapist administered (7/51, 14%) were often face-to-face interventions that served as comparison groups to a technology-based intervention, or were face-to-face interventions with a technology-based component as an adjunct (ie, Internet-based homework) [
By definition, the mean age of participants fell between 18 and 25 years. Most samples were composed solely of undergraduate university students. Two studies targeted specific groups of students: nursing students [
Four of the 7 depression and anxiety studies used the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) as their primary outcome measures [
Sample sizes across all studies ranged from 20 to 283 (median 60). Most studies were RCTs (n=26), and 1 study was a randomized trial [
Numbers (and percentages) of studies (with control groups) meeting quality rating criteria of the Cochrane Effective Practice and Organisation of Care (EPOC).
Criterion # | EPOC quality rating criteria | Studies, n (%) |
1 | Was the allocation sequence adequately generated? | 5 (19.2) |
2 | Was the allocation adequately concealed? | 1 (3.8) |
3 | Were baseline outcome measurements similar? | 17 (65.4) |
4 | Were baseline characteristics similar? | 11 (42.3) |
5 | Were incomplete outcome data adequately addressed? | 10 (38.5) |
6 | Was knowledge of the allocated interventions adequately prevented during the study? | 0 (0) |
7 | Was the study adequately protected against contamination? | 24 (92.3) |
8 | Was the study free from selective outcome reporting? | 21 (80.8) |
9 | Was the study free from other risks of bias? | 26 (100) |
As indicated in
Of the entire 27 studies, 8 studies undertook ITT analyses, and 13 did not. Six studies did not report this information. Of the 8 ITT studies, half (n=4) reported data from a full sample (no attrition), 2 used maximum likelihood estimation methodology, 1 used the last observation carried forward, and 1 used a mixed models analysis.
Among the 7 studies targeting depression and anxiety symptoms, there were 10 interventions that were compared to a control group (some studies had multiple intervention arms). Six interventions were CBT-based (delivered either online or using a stand-alone computer), 2 interventions involved relationship focused skills training, 1 intervention comprised physical activity and SCT, and 1 intervention involved online peer-support.
Postintervention, 3 of the CBT-based interventions were associated with a significant time × group interaction favoring the intervention group on both depression and anxiety symptom outcomes. The remaining CBT interventions (n=3) only found effects for anxiety symptoms postintervention, as did the online peer-support intervention. Only 1 of the relationship skills training interventions found a significant interaction at posttest for depression symptoms [
The physical activity and Web-based SCT intervention did not find a significant group × time interaction postintervention for either depression or anxiety [
Among the 4 studies targeting anxiety symptoms, 9 interventions were examined. Six interventions were relaxation-based: video plus an audio narrative (n=2), video alone (n=1), audio narrative alone (n=2), and virtual reality headset plus audio narrative (n=1). Two interventions were exposure-based: audiotape alone (n=1) and audiotape plus progressive muscle relaxation (n=1). One intervention was CBT-based.
The 2 exposure-based interventions were effective for reducing anxiety relative to a control condition [
Video alone, audio alone, and a virtual reality headset plus an audio narrative were not found to be effective for reducing anxiety symptoms [
Among the 4 studies targeting examination anxiety, 11 interventions were examined. Two interventions examined computer-assisted exposure plus audio relaxation, 8 interventions examined stress inoculation delivered by video and audio (n=3), video alone (n=2), and audio alone (n=3), and 1 intervention examined online CBT.
One study examining 4 stress inoculation interventions (video plus audio vs video only vs audio via MP3 only vs audio via CD only) found that all interventions were effective in reducing anxiety symptoms relative to a no-intervention control condition [
The remaining study examining stress inoculation interventions did not provide sufficient data to determine the effectiveness of the interventions relative to the control group [
Among the 3 studies targeting specific phobia, 5 interventions were examined. All interventions were exposure-based. Three were delivered using virtual reality and 2 were delivered using video.
Virtual reality exposure interventions for spider phobia [
Among the 2 studies examining stress, 4 interventions were examined. Interventions included online education (n=1) or online motivational feedback (n=1) [
None of the interventions were effective in reducing stress.
The study targeting social anxiety disorder examined online CBT [
Postintervention, online CBT was found to be effective for treating social anxiety disorder [
Online expressive writing was not found to be effective for symptoms of generalized anxiety disorder [
One study targeting psychological distress examined 2 interventions: online education and online education plus an online support group [
An online education intervention and a social support intervention each demonstrated within-group decline in psychological distress over time, but were not compared with a control group [
Online information was not found to be effective in the study targeting hardiness and acculturation [
For interventions targeting depression and anxiety symptoms with available data (n=8), effect sizes ranged from –0.07 to 3.04 (median 0.54; depression = 0.48, anxiety = 0.77). Across interventions targeting anxiety symptoms and disorders with available data (n=10), effect sizes ranged from 0.07 to 2.66 (median 0.84). Because of insufficient or unavailable data, effect sizes were unable to be calculated for 33 of the 51 interventions (64%) or 14 of the 27 studies (52%), which included all of the interventions targeting stress, computer anxiety, psychological distress, hardiness and acculturation, and Internet addiction.
Less than half of studies provided sufficient data to calculate effect sizes. For interventions that targeted depression and anxiety, effect sizes were as follows for the 1 universal (alpha = –0.74), 6 selective (alpha = 0.81), 1 indicated (alpha = 0.54), and 1 treatment (alpha = 0.18) interventions. For interventions targeting anxiety symptoms and disorders, none of the 16 universal interventions (5 trials) had had sufficient data to calculate effect size. Alpha levels were as follows for the 3 selective interventions (alpha = 0.67), 5 indicated interventions (alpha = 0.49), and 2 treatment interventions (alpha = 1.83).
Mann-Whitney
This systematic review identified 27 studies reporting RCTs of technology interventions targeting depression, anxiety, and related mental health issues, excluding substance misuse and eating disorders. Most of the studies (24/27, 89%) employed interventions focused on anxiety symptoms or disorders or stress, although 29% of these 24 studies (n=7) targeted both depression and anxiety. No study reported that they targeted depression alone in this population. Internet-based technology (typically involving CBT) was the most commonly employed medium, and it was used in 16 studies and almost half of the interventions. Distal and universal preventive interventions were the most common type of intervention. No study investigated the effectiveness of telephone interventions, and only 3 of 27 interventions (11%) targeted treatment. Audio and video were commonly used for exposure, stress inoculation, and relaxation training. More trials were undertaken in the United States than in any other country (13/27, 48%).
Overall, approximately half (n=24, 47%) of the 51 technology interventions were associated with at least 1 significant positive outcome compared with the control at postintervention, with 29% (n=15) failing to find a significant effect. Only 2 interventions (from 1 study) did not have a control group for comparison, and the remaining 10 interventions (from 3 studies) did not provide sufficient data on interaction effects to determine efficacy compared with the control. The studies finding a positive outcome compared with the control included 7 of the 10 technology-related interventions employed in the anxiety and depression studies, 2 of the 9 technology interventions in the anxiety studies, all 5 of the specific phobia interventions, none of the 4 stress interventions, and 4 of 5 interventions targeting other anxiety disorders. None of the 6 interventions targeting other conditions were demonstrated to be effective relative to controls, with 3 of these belonging to 1 study that did not provide sufficient data to determine efficacy compared with control [
Thus, the findings of the current review indicate that technological interventions targeting certain mental health and related problems offer promise for students in university settings. The data suggest that technology-based CBT may be particularly useful in targeting anxiety and, to a lesser extent, depressive symptoms in interventions targeting both depression and anxiety. A previous review on Internet-based interventions found comparable effect sizes for both depression (alpha = 0.42 to 0.65) and anxiety (alpha = 0.29 to 1.74) preventive and treatment interventions involving CBT [
It is important to acknowledge that the interventions included in the present review may not have been designed specifically for the university population; rather, the students may have simply been a convenient research sample. For studies clearly designed for university students in the tertiary setting (ie, exam anxiety [
However, the review also highlights that there are significant gaps in the current state of knowledge in this area. Very few studies have focused on the use of technology in the university setting for the treatment of mental disorders (n=3), and in very few cases did more than 1 study target the prevention or treatment of specific disorders. Most of the studies focused on anxiety symptoms or disorders. Moreover, some methodological problems were evident in the studies, with many studies failing to report sufficient information about randomization, or less frequently, suffering from inadequate randomization methods, few studies specifying a primary outcome, and most of the studies failing to undertake or report appropriate intent-to-treat analyses. It is also of note that none of the studies met criterion 6 of the EPOC quality scale. This criterion specifically refers to the blinding of outcome assessments (ie, “Score ‘low risk’ if the authors state explicitly that the primary outcome variables were assessed blindly, or the outcomes are objective, eg, length of hospital stay” [
None of the studies reported information about cost-effectiveness. However, 1 study targeting depression and anxiety provided broad information about costs of dissemination for the workshop leader (US $2000/10-15 participants), coaching emails, and face-to-face booster sessions (US $55/hour) [
Somewhat surprisingly, we failed to find an association between any of the characteristics of the studies or their methodological quality and whether they reported positive outcomes. In particular, it might have been predicted that there would be an association between length of intervention or number of intervention sessions and achieving a study outcome favoring the intervention group. The reason for this is unclear, but may reflect the heterogeneity of the studies across many variables and the small number of interventions for each condition, precluding investigation of the association for each condition separately.
There are some limitations to the present review that require consideration. Firstly, it is clear that some interventions were developed for university students (ie, the specific issues they face), and that others may have been simply tested in this population. Because of this, the included interventions may not have taken full advantage of the opportunities for technology-based interventions in a tertiary setting, which has important implications for the dissemination of these interventions within universities. However, some of the interventions were clearly university-specific with several of the anxiety interventions targeting student-focused problems, such as exam anxiety and stress in students, as well as adjustment and acculturation in international students. The present review searched 3 databases and it is possible that some relevant journals are not indexed by these databases. However, an attempt was made to address this by handsearching previous reviews, key papers, and the Beacon portal [
It is clear that further research is required in university settings to investigate the effectiveness of technological interventions for specific mental disorders in the tertiary student population, to compare the relative efficacy of and engagement with different types of technological intervention within a disorder and ultimately to evaluate the most appropriate means by which such interventions might routinely be implemented in university settings.
PubMed search terms/search history.
PRISMA checklist.
Full data from the review.
auto-photic stimulation
Beck Anxiety Inventory
Beck Depression Inventory
cognitive behavioral therapy
compact disc
Digital Versatile Disc
Effective Practice and Organisation of Care
intention-to-treat
Medical Subject Headings
National Health and Medical Research Council
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
social cognitive theory
State Trait Anxiety Inventory
Technical and Further Education
This project was resourced by the Young and Well CRC. The Young and Well CRC is established under the Australian Government’s Cooperative Research Centres Program.
KG is a co-developer of MoodGYM, which was evaluated as part of 2 [