Impact of Stress on Mental Well-being in Students

The provided content discusses various aspects of mental health and well-being in students, focusing on factors such as depression, anxiety, stress, burnout, and fatigue. The studies explore the prevalence and correlates of psychological distress among university students, examining associations with substance use, lifestyle risk factors, and student support services. Additionally, the articles investigate the effectiveness of interventions, such as computer-based biofeedback programs, in reducing anxiety and promoting wellness.

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Running head: BIOFEEDBACK INTERVENTION
Biological Bases of Behaviour PSY 351
NAME
Number
Biofeedback Intervention for Anxiety, Stress and Depression among Students
2528 words

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Abstract
The nursing graduate students are seen to have high prevalence of the problems associated with
mental health. The severity of the mental health problems have increased in the university
campus and therefore alternative interventions are required around the limited resources for the
treatment of mental health. This paper will help in investigating the benefits of biofeedback
training for helping in reduction of symptoms associated with anxiety, stress and depression. 60
sample graduate students were chosen and assigned to a control or biofeedback intervention
group. The results were helpful in indicating that the biofeedback intervention was seen to be
highly effective in reducing the stress, depression and anxiety level over 1 month period whereas
the control group were seen to increase the symptoms over the same timeframe. There is a
requirement of more psychologically healthy graduate students as the better the nursing
professionals in this public health nursing arena, the better they will go forth towards serving the
society after completion of studies.
1. Background
Higher amount of efforts have been seen among the graduate students in order to manage
anxiety, stress and depression with increasing mental health problems among the graduate
students. The graduate students should not be academically and professionally competent but
also strive towards having a psychological and mental health. Only very few research studies on
the topic of mental health and interventions present among the graduate students have been
performed on nursing students. Significantly high level of distress was found in graduates and
undergraduate students of two very large Australian University compared to the general public
(Stallman, H. M., 2010). In another study by Lee, Y. C., Chien, K. L., & Chen, H. H. (2007),
high fatigue rate was found in Taiwanese graduate students leading to similar psychological
distress. Similarly, a study depicted high prevalence of anxiety, stress and depressive symptoms
among the Thai University students (Ratanasiripong, P., & Rodriguez, A., 2011).
As the graduates and students of public health nursing programs, it is important for these
students to learn interventions and strategies which will be beneficial for managing their lives
and coping with the life stressors. High rate of moderate psychological distress has been seen in
Australian tertiary students compared to the non-students and evidence have been provided by
the national survey (Cvetkovski et al. 2012). Specific stressors are seen to be involved in the
roles as well as demands of those who study nursing which increases the distress among these
students while progressing towards their course. Various studies have investigated these similar
mental health issues in medical and nursing students. A study by Rella et. al (2009), noticed that
by completion of their course, 20% out of the 431 Australian undergraduates nursing students
experienced increased stress level along with serious maladaptive stress and fatigue. A
systematic literature review by Pulido Martos et. al (2012), identified two primary sources of
high stress level among the nursing students which were clinical factors (mistakes with patients,
fear for unknown situations, handling the equipment etc.) and academic factors ( increased
workload and issues with studying).

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The main stressors during the three years of nursing program among the Australian nursing
students was identified to the finances and difficulties with studies (Lo 2002). In Australia the
mental health of nursing and medical students along with the doctors is seen to be an ongoing
concern. (Elliot et al. 2010; Schlicht et al. 1990).
Psychiatric morbidity was measured in one study for the mental illnesses seen in the Australian
students where it was seen that a significant increase in scores from beginning towards the
finishing of their internship. Additionally, final measures scores were seen to increase past the
cutoff in the case of the potential psychiatric morbidity (Willcock et al. 2004). This finding are
supported by international literature where a number of factors were seen as significant stressors
and included the academic pressure, volume of workload, bullying from staff, teachers, residents
or interns, stressed out or burned out supervisors. (Wear, 2002); and exposure to human suffering
(Supe 1998). The negative outcomes resulting from the mental health problems in nursing
students are seen to be absenteeism, discontinuation of university studies, higher failure rates,
reduced productivity (Andrews and Wilding 2004; Arria et al. 2013).
One of the important method towards reduction of these negative outcomes can be performed
through early intervention for the mental health problems in medical and nursing students. But
this stigma might become a barrier in the help-seeking technique. A similar survey was
performed for the Australian and New Zealand medical students where 55 percent of the students
agreed to the stigma with being a medical student and bearing a psychological distress whereas
72 percent of these students agreed towards being a medical students having being diagnosed
from the mental illness (Elliot and Tan 2010). 20 percent of the Australian medical students in a
2011 study agreed towards concealing their emotional and mental problems (Walter et al. 2013).
One of the effective method towards helping the student with their mental illness is found to be
the biofeedback intervention (Henriques, G., Keffer, S., Abrahamson, C., & Horst, S. J., 2011).
No such research has been performed on biofeedback study related to the depression in the
university students although a high co-occurrence rate has been found along with depression and
anxiety. Biofeedback can be explained as a process of mind-body requiring self-regulation which
helps in improving health and performance. The individuals are seen to be highly aware of their
physiological unction through the biofeedback equipment where they can learn towards
modifying their thoughts, feelings and behaviour for making positive changes to these
physiological function.
Various studies have seen that biofeedback training is highly beneficial for reducing the anxiety,
stress, depression and related health condition. (Yucha C., Montgomery D, 2008). Various
biofeedback training include electromyography (EMG), electrocardiogram (ECG),
electrodermograph (EDG), and electroencephalograph (EEG) and heart rate variability (HRV). I
have used HRV for this study. This biofeedback helps the individual to gain awareness for the
involuntary HRV, attaining reduction in stress, depression and anxiety.
2. Methods
Participants
This experimental study was conducted with 60 graduate students in the nursing course from
Murdoch University in Australia. 60 participants were required for this study on the basis of a
priori power analysis by G∗Power. The parameters used were and 0.8 power, 0.05 alpha and

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0.75 moderate effect size, for the t-test, the required sample size per group was found to be 29
respondents.
The participants have their graduate degree and were enrolled in the graduate program in their
own faculty of public health nursing. The age of the participants was seen to be present in the
age bracket of 21 to 50 (M = 34.05 and SD = 7.61). Only three percent of the participants were
seen to be male and ninety-seven percent of the participants were females. The GPA or Grade
Point Average (GPA) of these students were seen to be between 3 and 4 (M = 3.66 and SD =
0.25). Out of these 60 participants, 44 percent belonged to the first year of their program, 23
percent were present in second year, 16 and 11 percent respectively in their third and fourth
years and lastly 7 percent were in their fifth year.
Procedures
The participants were recruited and their informed consent was obtained after which their pre-
intervention survey packet along with the Center for Epidemiological Study-Depression Scale,
State Anxiety Scale, Perceived Stress Scale, and brief questionnaire was presented to them.
These participants were then assigned to the biofeedback intervention or the control group. In
this study stratified randomization was used and were assigned their group randomly.
The potential biases were accounted and addressed and their omission was considered
thoroughly. The participants belonging to the final group were held as representative and these
students were reminded to answer honestly and were reminded of their voluntary participation
and no incentive was provided to these students.
No training was given to participants of the control group and one training session was given to
the biofeedback intervention group by the researchers. They were further given a portable
biofeedback device for a month and were asked to use it three times a day. This session helped
them to learn this equipment in managing their depression, anxiety and stress and to be aware of
the HRV baseline. The participants were told to control their breath and to feel positive vibes and
emotions. This equipment helped the participants to receive auditory and visual feedback on
feeling positive emotions and their breathing. When the participants were capable of sustaining
their heart-rhythm pattern relating to the positive emotions, the training was seen to be complete.
The post intervention survey packet was completed at the end of the study which also included
State Anxiety Scale, Center for Epidemiological Study-Depression Scale and Perceived Stress
Scale. On completion of the study, the pre-intervention and post-intervention survey packet were
printed out and these participants were asked to fill them. Three participants emailed their survey
pack as they could not come because of their fieldwork.
Instruments
The level of stress of these participants in the last month was measured using the Perceived
Stress Scale. High score (0 = never, 4 = very often), in this scale depicts the high level of
perceived stress and had 10 items on the list. The Cronbach's alpha of the Perceived Stress Scale
was found to be 0.81 for pre-intervention and similar for the post-intervention. State-Trait
Anxiety Inventory’s State Anxiety scale was used for measuring the level of anxiety. There were
20 items and higher score were indicator of high level of anxiety (0 = not at all, 3 = very much
so). The Cronbach's alpha of the State Anxiety Scale was found to be 0.94 and 0.93 for pre-
intervention and post-intervention. Further, Center for Epidemiological Study-Depression Scale

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was used for measuring the depression level. There were 20 items and higher score were
indicator of high level of depression (0 = none, 3 = all or most of them). The Cronbach's alpha of
the Center for Epidemiological Study-Depression Scale indicated a reading of 0.89 and 0.87 for
pre-intervention and post-intervention.
3. Results
Analysis
No considerable difference was found in the basic characteristics of control groups and
biofeedback from the t-tests, Fisher’s exact tests and chi-square test.
Figure 1: Characteristics of control and biofeedback group
The pretest results of all the Scare reading were also compared using independent sample t-tests
between the sample t-tests and from the results it was evident that there was no considerable
difference between the two.

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Stress
The biofeedback group experienced decrease in their stress level on the Perceived Stress Scale
over the study but the control group depicted an increase in the stress level. The mean score of
the perceived stress in post-intervention (M = 12.66 and SD = 3.69) was found to be lower than
the mean score of the pre-intervention stress (M = 14.34 and SD = 4.82). But in case of the
control group, the case was opposite with a higher perceived stress in post-intervention score (M
= 12.60 and SD = 5.44) as compared to the pre-intervention mean score of perceived stress (M =
12.53 and SD = 3.87). A significant decrease was encountered in the paired sample t-test in case
of the biofeedback group in the stress score Cohen's d = 0.01, t(28) = 2.26, p < 0.05.
Figure 2: Mean Score of Perceived Stress Scale
Anxiety
A considerable decrease was seen in the score from the State Anxiety Scale over the course of
the study on the other hand, the control group depicted an increase. The mean score of perceived
anxiety score in the post-intervention (M = 14.41 and SD = 7.22) was lower than the perceived
anxiety score of the pre-intervention (M = 19.93 and SD = 9.15). But in case of the control
group, the case was opposite with a higher state anxiety score of post-intervention score (M =
19.17 and SD = 9.29) as compared to the state anxiety score of pre-intervention (M = 17.07, SD
= 7.55). A significant decrease was encountered in the paired sample t-test in case of the

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biofeedback group in the state anxiety score Cohen's d = 0.67, t (28) = 3.47, p < 0.01. However,
the increased in the control group’s state anxiety score was not seen to be highly significant.
Figure 3: Mean Score for State Anxiety Scale
Depression
A considerable decrease was seen in the score from the Center for Epidemiological Study-
Depression Scale over the course of the study on the other hand, the control group depicted an
increase. The mean score of the depression score of post-intervention (M = 9.90 and SD = 11.40)
was lower than the mean score of the depression score of pre-intervention (M = 12.07, SD =
8.59). But in case of the control group, the case was opposite with a higher state depression score
of post-intervention score (M = 11.40 and SD = 7.54) as compared to the state depression score
of pre-intervention (M = 9.90 and SD = 7.13). A significant decrease was encountered in the
paired sample t-test in case of the biofeedback group in the depression score Cohen's d = 0.21, t
(28) = 2.90, p < 0.01. However, the increased in the control group’s state depression score was
not seen to be highly significant.

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Figure 4: Mean Scores for CES- Depression Scale
4. Discussions
It can be demonstrated from the study that the biofeedback training is an effective form of
intervention that benefits the students in reducing their anxiety, stress and depression level in just
four weeks. On the other hand, students enrolled in the control groups were seen to have
increment in the level of stress, anxiety and depression. The study and its results helped in
confirming that the biofeedback studies on the reduction of anxiety, depression and stress among
the participants. The students of nursing are seen to face various challenges due to their academic
coursework and related stress in academic and professional life. The case of unmanageable stress
is seen to lead to severe anxiety, violent behaviour, depression leading to suicide, incapacitation
etc. The symptoms of anxiety, stress and depression has to be managed so as not to impact their
health, academic performance and relationships. While looking at the biofeedback and control
group and their post-intervention differences one can indicate that the biofeedback intervention
has a more considerable impact on the anxiety level. But the difference were not significant
between the two groups in depression and stress during the course of the study.
Some of the limitations of these study were that although the participants were randomized into
their respective groups but they all belonged to the same university campus. Furthermore, the
number of male participants were seen to be only 3 percent and more male participants have to
be recruited for future studies for increasing generalizability. For studying the longer-term

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impact of the biofeedback intervention on the mental health a longitudinal study with a follow-up
on the participants is required.

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