Keywords

Introduction

The Mental Health of the University Student

Mental disorders have been increasing within the university. The prevalence of most emotional problems has increased in recent decades among college students. What before the 1990s was referred by them as the biggest problem (relationship problems) today has lost space to emotional and mental issues (Storrie et al., 2010), now they are being mainly affected by anxiety, stress, and depression (Beiter et al., 2015), in addition to other disorders such as eating disorders, psychosis, and obsessive-compulsive disorder (Storrie et al., 2010).

With important changes occurring in their lives and new demands of university life emerging, skills and competencies are required of the university student to handle these demands, which can be important stressors for the student (Ariño & Bardagi, 2018). Anxiety in academic situations may cause important consequences for student learning and well-being (Hjeltnes et al., 2015). Performance anxiety, for example, is described in DSM-5 as a subtype of social anxiety, and affects the individual’s academic and professional life (APA, 2014). According to Beiter et al. (2015), the main concerns affecting college student‘s mental health are academic performance, pressure to succeed, and plans for after graduation. In addition, academic experiences and the perception of self-efficacy are also important aspects in the correlation with students‘mental health (Ariño & Bardagi, 2018).

Even though they are experiencing emotional and mental difficulties most students do not seek help and one of the main reasons for this is the stigma associated with mental disorder. Thus, students have fear of being branded as weak, which could affect their careers in the future (Storrie et al., 2010). Ariño and Bardagi (2018) point out to the need to promote institutional actions aimed at empowering students to better manage their academic life, so that they are effective in their time management in a balanced way, not neglecting hours of sleep and leisure, in addition to being able to perform good study strategies. In addition, there is a great need to promote interventions that benefit the mental health of university students in order to prevent mental disorders such as anxiety disorders and excessive stress. Mindfulness may be a beneficial proposal in this sense.

Mindfulness

The term “mindfulness“is commonly understood as “full awareness” in medicine and psychology. Today, mindfulness practices used in health facilities are secular, although the concept of mindfulness was born in Buddhism and other contemplative traditions (Brown & Ryan, 2003; Demarzo & García-Campayo, 2015). Mindfulness is often described as a mental state characterized by intentionally bringing one’s attention to the present moment, observing what is there curiously, non-judgmentally, and with acceptance, without trying to change anything (Kabat-Zinn, 2004), and is taught through a variety of meditative practices (Baer, 2003). Meditation practice is used with the aim of developing skills to evoke the state of mindfulness, which is also not exclusive or limited to meditation. Once the skills to achieve it are learned, attention can be regulated to achieve this state in many situations (Bishop et al., 2004; Brown & Ryan, 2003; Demarzo & García-Campayo, 2015).

Bishop et al. (2004) propose that mindfulness is defined, in part, as a form of self-regulation of attention that involves sustained and alternating attention and inhibitory control, thus being considered a metacognitive skill. Mindfulness can also be considered as a process of relating to experience in a different way: openly. By adopting a relationship of openness and acceptance with experience, including unpleasant feelings and sensations, it can lead to a change in the psychological context in which they are experienced, leading to a possible greater tolerance to them, decreasing the need to react to them quickly. Shapiro et al. (2006) suggest that mindfulness involves three components: intention, attention, and attitude. These are blended aspects of a dynamic, cyclical, and unique process that happens simultaneously, from moment to moment. Whereas Baer et al. (2006) propose mindfulness as a 5-factor framework: observing, describing, acting with awareness, non-judging, and non-reacting.

Mindfulness-based interventions (MBIs) have in their structure some elements and influences elements. They are contemplative mindfulness practices, science, medicine, psychology, and education. In general, MBIs aim to enable participants to recognize conditioned and habitual modes of response and behavior and to make changes in their relationship with their thoughts, feelings, and body sensations, as well as with external circumstances. The change in this relationship is based on what is called decentering, in which the participant is trained to relate to thoughts or feelings as mental events, noticing how they come and go from the mind, and how each one has consequences in the next moments (Crane et al., 2016).

MBIs, in the format in which they are known today, applied to health, emerged in the United States of America, with the Mindfulness-Based Stress Reduction Program (MBSR), developed by Jon Kabat-Zinn in the 1970s, in Massachusetts, for chronically ill patients (Kabat-Zinn, 2004). From MBSR, several protocols for a variety of pathologies were born. MBIs have increasingly gained ground in healthcare as a complementary treatment for various disorders, such as depression and prevention of depressive relapse (Kuyken et al., 2016; Tickell et al., 2019; Van Aalderen et al., 2012), stress reduction (Kabat-Zinn, 2004), chronic pain, substance abuse (Goldberg et al., 2018), anxiety disorders (Ghahari et al., 2020; Hoge et al., 2013), and also for increasing quality of life (Godfrin & van Heeringen, 2010).

Some of the mechanisms of action of Mindfulness are already known, and the main ones are related to decentering, which occurs with the change of relationship with the experience, from getting in touch with it from a new point of view. It also reduces worry and rumination (Desrosiers et al., 2013).

Given the need to think about interventions that benefit the mental health of university students, and the benefits that MBIs have shown in the clinical field of mental health, we propose an integrative review on the effects of MBIs on the mental health of this population, especially regarding the stress and anxiety of these students.

The Present Study

This study is an integrative literature review that aimed to identify, analyze, and synthesize the studies on MBIs for anxiety and stress in college students. The integrative review allows the inclusion of several methods to synthesize knowledge and assess the clinical applicability of an intervention, in addition to pointing out gaps in the literature (Souza et al., 2010). It took place through the 6 phases of the development process described by (Mendes et al., 2008): 1a – identification of the topic, establishment of the hypothesis or research question; 2a – establishment of the inclusion and exclusion criteria of the studies, as well as of the sample, and literature search; 3a – definition of the data to be extracted and categorization of the studies; 4a – assessment of the studies included in the integrative review; 5a – interpretation of results; 6a – presentation of the review and synthesis of knowledge. The guiding question was: What are the effects of Mindfulness-based interventions on college students suffering from stress and/or anxiety?

In the period between March and April 2021, a bibliographic search was made through three main bases: PubMed/Medline, SciELO and LILACS, without restriction as to the year of publication of the articles. The descriptors used for the search were: MINDFULNESS, ANXIETY, STRESS, UNIVERSITY (or synonyms), and STUDENTS, with the Boolean operators AND or OR between them. In the LILACS search, the filter that excludes articles in common with MEDLINE was used.

For article eligibility, the inclusion criteria were: studies assessing mindfulness-based interventions for anxiety and/or stress in college students. Exclusion criteria were: case studies; studies in which stress or anxiety were not the primary outcomes; studies in which mindfulness interventions were not “multimodal”; reviews that were not specific to mindfulness interventions; studies on specific groups; studies in which populations were mixed, not being only college students; studies in which there was no mindfulness-based intervention; and studies in which the mindfulness intervention was not interactive.

After crossing the keywords, a total of 539 articles were obtained, 192 from PUBMED, 334 from LILACS, and 13 from SciELO. Duplicate articles were excluded, and the remaining articles were screened by reading the titles and abstracts. Then, the pre-selected studies underwent a second screening, through an evaluation of their methodology according to the inclusion and exclusion criteria, resulting in a final sample of 26 studies, as shown in the flowchart in Fig. 1.

Fig. 1
figure 1

Flowchart of the selection of articles

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To synthesize the data obtained in the studies, the proposal of Ursi (2005) was followed in the extraction of data.

What Are the Results of the Studies?

The studies selected for this integrative review were published between the years of 2008 and 2021. Most of them (55%) are randomized controlled trials, 15% are controlled and non-randomized clinical trials, 4% are meta-analysis, and 7% are systematic reviews. The percentage of study types is shown in Fig. 2. Regarding the experimental studies, 25% had only active control groups, 29% of them with active and passive control groups, 25% only with passive control groups, and 21% had no control group.

Fig. 2
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Types of study

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To facilitate the visualization of the results, Table 1 was built with a summary of the methodology, variables, and main results of each study.

Table 1 Main results of included studies
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What Do These Results Tell Us?

This study aimed to assess the effects of mindfulness-based interventions on the mental health of college students, especially regarding stress and anxiety levels. According to the initial hypothesis from this study, the results point to the benefits of the practice on the mental health of this population.

The number of studies in the field of mindfulness and mental health, and of mindfulness for college student health has grown and show benefits of the intervention in health, regardless of its duration (Chiodelli et al., 2020).

The results of most experimental studies assessed by this integrative review are similar to the results found by Dawson et al. (2019) in their systematic review and meta-analysis, with a significant decrease in stress and anxiety, as well as benefits found for other variables, such as improvement in depression, well-being, and mindfulness. In the studies that followed the sample for longer for further evaluation and showed that mindfulness interventions were related to a decrease in stress, having similar results to the comparison intervention or not, their results remained significant in the follow-ups, suggesting that the practice may benefit the management of stress in the long term (Falsafi, 2016; Long et al., 2021; Oman et al., 2010). Most studies that assessed perceived stress showed a decrease in this variable, including physiological changes as seen in the study of Voss et al. (2020).

With regard to academic anxiety, results point to positive effects on stress during exams and also a lasting effect of the intervention seen at follow-up (Galante et al., 2017, 2020). Furthermore, a significant decrease in exam anxiety was seen during the intervention and continued to decrease after the intervention (Dundas et al., 2016). These are promising results given the distress caused by academic and performance anxiety and its outcomes on students‘academic and professional lives (APA, 2014).

From the 26 studies included in this review, anxiety and stress variables were not benefited or worsened in only 3 of them (Bergen-Cico et al., 2013; Cuevas-Toro et al., 2017; Seppälä et al., 2020). In the study of Cuevas-Toro et al. (2017), there was an increase in state anxiety, however, data collection coincided with the exam period, and the study did not have a control group to assess whether students who did not receive the intervention would also increase their level of anxiety. In addition, the authors show that there was an increase in the level of life satisfaction, even with the worsening of anxiety in the period of tests, which suggests benefits of the intervention. On the other two studies, mindfulness interventions only did not have significant results when compared to another intervention, but there was no associated worsening to the intervention (Bergen-Cico et al., 2013; Seppälä et al., 2020). Bergen-Cico et al. (2013) suggest that to promote a significant effect on anxiety the mindfulness intervention should be longer. In the study by Demarzo et al. (2017) the longer intervention also showed significantly better results on anxiety when compared to the shorter one. This was also the case in the study by Sears and Kraus (2009) in which the longer intervention (with longer practices) and which mixed elements of mindfulness and compassion, also had better results for anxiety when compared the interventions brief ones. This is perhaps an important result to take into account when considering the clinical applicability of this type of intervention. Although in the study by Chiodelli et al. (2020) the results suggested that shorter interventions also benefit students‘mental health, perhaps for anxiety the interventions should be longer.

Although some studies justify the effectiveness of mindfulness interventions due to the mediation of increased mindfulness levels (Azevedo & Menezes, 2020; Shapiro et al., 2008), this mediation cannot be seen in all studies, for example in the study of Bergen-Cico et al. (2013). In addition, few studies have sought to explain the mechanisms of action of mindfulness-based intervention. We hypothesize that the improvement in anxiety and stress levels in college students found in this study are not only related to the increased level of mindfulness promoted by the intervention, but also to the decrease in rumination and worry, mechanisms of action indicated as mediators of the effects of MBIs on depression, anxiety, and stress (Desrosiers et al., 2013), variables that were not included in most studies.

Conclusion

This study found evidence pointing to an important benefit of the use of mindfulness-based interventions for university students‘mental health, especially regarding lower stress, increased well-being, lower test anxiety, and general anxiety. Mindfulness-based interventions can be important allies in the mental health care of students within the university. It is suggested that MBIs be introduced in the curricula at universities as a form of mental illness prevention and health promotion for the university population.

Limitations

It is important to highlight that the studies included in the integrative review have limitations, such as the methodology used, some did not have a control group, most did not perform follow-up, many did not mention the blinding of the evaluators, and the restricted number of participants. Studies with a better methodology are suggested, especially those that include active and passive control groups, double blinding, and medium and long-term follow-up.