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Counselling Centre, Students Union Building, Dalhousie University, Halifax, NS B3H 4R2, Canada
IWK Health Centre and Dalhousie University, Canada
c
Department of Psychology and Neuroscience, Dalhousie University, Canada
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 19 November 2012
Received in revised form
1 March 2013
Accepted 11 March 2013
Anxiety, depression and stress, often co-occurring, are the psychological problems for which university
students most often seek help. Moreover there are many distressed students who cannot, or choose not
to, access professional help. The present study evaluated the efcacy of an internet-based guided selfhelp program for moderate anxiety, depression and stress. The program was based on standard cognitive behavior therapy principles and included 5 core modules, some of which involved options for
focusing on anxiety and/or depression and/or stress. Trained student coaches provided encouragement
and advice about using the program via e-mail or brief weekly phone calls. Sixty-six distressed university
students were randomly assigned to either Immediate Access or a 6-week Delayed Access condition.
Sixty-one percent of Immediate Access participants completed all 5 core modules, and 80% of all participants completed the second assessment. On the Depression, Anxiety and Stress Scales-21, Immediate
Access participants reported signicantly greater reductions in depression (h2p . 07), anxiety (h2p . 08)
and stress (h2p . 12) in comparison to participants waiting to do the program, and these improvements
were maintained at a six month follow-up. The results suggest that the provision of individuallyadaptable, internet-based, self-help programs can reduce psychological distress in university students.
2013 Elsevier Ltd. All rights reserved.
Keywords:
Guided internet-based treatment
Self-help
Anxiety
Depression
Randomized controlled trial (RCT)
University students
345
346
Excluded (Decided to
seek personal counseling)
N= 3
Randomized (N=66)
Analyzed N=33
Excluded from analyses N= 0
Completed 1st assessment N= 33 (100%)
Completed 2nd assessment N= 24
(72.7%)
Completed 3rd assessment N= N/A
Completed 6 month follow-up N= 17
(51.5%)
Analyzed N=33
Excluded from analyses N= 0
Completed 1st assessment N= 33 (100%)
Completed 2nd assessment N= 29
(87.8%)
Completed 3rd assessment N= 14 (42.4%)
Completed 6 month follow-up N= 7
(21.2%)
347
Table 1
Description of program modules.
Core modules
Topics
Exercises
1. Introduction
2. Activity and mood
3. Motivation
Optional modules
6. Social relationships
7. Stress management
8. Sleep
10. Medication
348
Range 18e45) and 59 participants (89.3%) were females. Participants endorsed depression (Mean 19.97, SD 10.69), anxiety
(Mean 13.76, SD 7.97) and stress (Mean 21.82, SD 7.76)
scores in the moderate level according to normative data provided
by Lovibond and Lovibond (1995). Despite randomization, the
delayed-access group endorsed higher baseline stress scores
compared to the immediate-access group (t(64) 2.365,
p .021). No other differences in demographic variables emerged
between the two groups.
Thirteen participants (19.7%) learned about the study through
posters, 22 (33.3%) learned about the study via email, 21 (31.8%)
learned about the study from the Dalhousie Counselling website,
and 10 (15.2%) through other means (e.g. referral from student
services, advertisement in class). Baseline depression scores were
signicantly correlated with Anxiety (r .39, p .001) and Stress
(r .33, p .006) scores. Baseline anxiety scores were also
signicantly correlated with Stress scores (r .52, p < .001).
Completion rate
Twelve participants (18%) did not complete Assessment 2,
resulting in a completion rate of (80.3%). Nine of the noncompleters were in the Immediate Access Group and 4 were from
the Delayed Access Group. After completing Assessment 2, only 14
(42.4%) participants in the Delayed Access Group went on to
complete the online-based program as well as Assessment 3.
Twenty-four participants (36.4%) completed the 6-month followup assessment.
Intervention effect on depression, anxiety and stress symptoms
ITT analyses of the effect of intervention on participants in the
online self-help program compared with Delayed Access participants rendered a signicant main effect of time on depression
[F(1,64) 57.69, p < .001, h2p . 47], anxiety [F(1,64) 53.39,
p < .001,h2p . 46] and stress [F(1,64) 58.40, p < .001, h2p . 48]
scores. This result indicates that all participants endorsed lower
depression, anxiety, and stress scores in Assessment 2 compared to
Assessment 1 (See Table 3). Signicant group time interactions
were also found for depression [F(1,64) 4.93, p .03, h2p . 07],
anxiety [F(1,64) 5.65 p .02, h2p . 08]and stress [F(1,64) 8.74,
p .004, h2p . 12] scores. Planned post-hoc analyses, adjusted for
multiple comparisons, revealed that Immediate Access group had
signicantly lower depression (p .044), anxiety (p .021) and
stress (p < .001) scores at Assessment 2 (i.e. after the online selfhelp program) compared with the Delayed Access group. A significant main effect to Stress scores was also found [F(1,64) 16.59,
p < .001, h2p . 21], reecting the initial baseline differences between the Immediate Access and Delayed Access groups at
Assessment 1. Reliable Change Index (RCI) scores were calculated
for all participants to investigate clinical change in depression,
anxiety, and stress symptoms. In the intervention group, 22 participants (67%) demonstrated a reliable reduction (i.e. RCI > 1.96) in
depression symptoms, 26 (79%) in anxiety symptoms, and 17 (52%)
in stress symptoms. In the control group, 12 participants (36%)
demonstrated a reliable reduction in depression symptoms, 13
(39%) in anxiety symptoms, and 8 (24%) in stress symptoms.
24.12 (5.8)
5 (28)
3.75 (2.5)
22.97 (4.0)
2 (31)
2.79 (1.7)
20.06 (11.2)
19.88 (10.4)
13.58 (8.4)
13.93 (7.7)
19.64 (7.2)
24.00 (7.8)
6-Month follow-up
N (%)
7 (21.2)
10 (30.3)
9 (27.3)
7 (21.2)
N (%)
6 (18.2)
12 (36.4)
12 (36.4)
3 (9.1)
6-month follow-up data was available from 24 (36.4%) of participants. A 2 time points 3 outcomes (Depression, Anxiety, and
Stress) repeated measures ANOVA was conducted to examine
whether depression, anxiety and stress scores changed over a 6month period. There were no signicant main effects for
349
Table 3
Mean (SD) of immediate access group (N 33) and delayed access group (N 33) at Assessment 1 (i.e. baseline) and Assessment 2.
Assessment 1
Depression
Anxiety
Stress
Note:
p < .05,
Assessment 2
Mean (SD)
95% CI
Mean (SD)
95% CI
Mean (SD)
95% CI
Mean (SD)
95% CI
20.06 (11.16)
13.58 (8.36)
19.65 (7.18)
16.31e23.81
10.78e16.37
17.03e22.24
19.88 (10.37)
13.94 (7.69)
24.00c (7.79)
16.13e23.63
11.15e16.73
21.39e26.61
10.43a (4.49)
5.70a (4.49)
11.77b (6.05)
7.56e13.30
3.50e7.91
9.37e14.17
14.60 (9.51)
9.93 (7.77)
20.52 (7.63)
11.74e17.47
7.73e12.14
18.12e22.92
Depression
Anxiety
Stress
Post-intervention
Mean(SD)
6-Month assessment
Mean(SD)
8.17 (5.90)
5.08 (4.68)
11.17 (6.35)
7.56 (9.30)
6.17 (7.24)
11.92 (7.88)
350
351
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