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  1. Which aspects of the article did you find most interesting?
  2. In what ways does this study expand your thinking (e.g., what did you learn, application, information, etc.) about wellness methods and strategies?
  3. What is one question you have in regards to this article?
  4. How will you use this information in the nursing or health science fields? 
  5. How will you use this information for your personal wellness? 
  6. Referring back to Ch2: Emotional and Spiritual Well-being, Ch3: Caring for Your Mind, and Ch4: Stress Management
    1. Ch2. What lessons/methods/tools from positive psychologyspiritual health, and sleep and health do you currently use and why (e.g. how do they benefit you)? Or which lessons/methods/tools that you would like to apply/try to your life and why?
    2. Ch3. What self-care strategies do you currently use and how do they benefit you? Or which self-care strategies do you want to apply/try and why?
    3. Ch4. What interventions mentioned under “Managing Stress” do you currently use and why? Or which interventions would you like to apply/try and why?

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Lancet Public Health. 2018 Feb; 3(2): e72–e81.
Published online 2017 Dec 19.
doi: 10.1016/S2468-2667(17)30231-1: 10.1016/S2468-2667(17)30231-1

PMCID: PMC5813792
EMSID: EMS75520

PMID: 29422189

A mindfulness-based intervention to increase resilience to stress in
university students (the Mindful Student Study): a pragmatic
randomised controlled trial
Julieta Galante, PhD, Géraldine Dufour, MA, Maris Vainre, MA, Adam P Wagner, PhD, Jan Stochl,
PhD, Alice Benton, MSc, Neal Lathia, PhD, Emma Howarth, PhD, and Peter B Jones, Prof, PhD

Department of Psychiatry, University of Cambridge, Cambridge, UK
University Counselling Service, University of Cambridge, Cambridge, UK
Educational and Student Policy, Academic Division, University of Cambridge, Cambridge, UK
National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care East of

England, Cambridge, UK
British Association for Counselling and Psychotherapy: Universities and Colleges Division, Leicestershire, UK
Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
Department of Computer Science, University College London, London, UK

Julieta Galante: [email protected]
Correspondence to: Dr Julieta Galante, Department of Psychiatry, University of Cambridge, Douglas House,

Cambridge CB2 8AH, UKCorrespondence to: Dr Julieta Galante, Department of PsychiatryUniversity of
CambridgeDouglas HouseCambridgeCB2 8AHUK [email protected]

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0
license

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Summary

Background

The rising number of young people going to university has led to concerns about an increasing demand for
student mental health services. We aimed to assess whether provision of mindfulness courses to university
students would improve their resilience to stress.

Methods

We did this pragmatic randomised controlled trial at the University of Cambridge, UK. Students aged 18
years or older with no severe mental illness or crisis (self-assessed) were randomly assigned (1:1), via
remote survey software using computer-generated random numbers, to receive either an 8 week
mindfulness course adapted for university students (Mindfulness Skills for Students [MSS]) plus mental
health support as usual, or mental health support as usual alone. Participants and the study management
team were aware of group allocation, but allocation was concealed from the researchers, outcome
assessors, and study statistician. The primary outcome was self-reported psychological distress during the

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examination period, as measured with the Clinical Outcomes in Routine Evaluation Outcome Measure
(CORE–OM), with higher scores indicating more distress. The primary analysis was by intention to treat.
This trial is registered with the Australia and New Zealand Clinical Trials Registry, number
ACTRN12615001160527.

Findings

Between Sept 28, 2015, and Jan 15, 2016, we randomly assigned 616 students to the MSS group (n=309)
or the support as usual group (n=307). 453 (74%) participants completed the CORE–OM during the
examination period and 182 (59%) MSS participants completed at least half of the course. MSS reduced
distress scores during the examination period compared with support as usual, with mean CORE–OM
scores of 0·87 (SD 0·50) in 237 MSS participants versus 1·11 (0·57) in 216 support as usual participants
(adjusted mean difference -0·14, 95% CI -0·22 to -0·06; p=0·001), showing a moderate effect size (ß
-0·44, 95% CI -0·60 to -0·29; p<0·0001). 123 (57%) of 214 participants in the support as usual group
had distress scores above an accepted clinical threshold compared with 88 (37%) of 235 participants in the
MSS group. On average, six students (95% CI four to ten) needed to be offered the MSS course to prevent
one from experiencing clinical levels of distress. No participants had adverse reactions related to self-
harm, suicidality, or harm to others.

Interpretation

Our findings show that provision of mindfulness training could be an effective component of a wider
student mental health strategy. Further comparative effectiveness research with inclusion of controls for
non-specific effects is needed to define a range of additional, effective interventions to increase resilience
to stress in university students.

Funding

University of Cambridge and National Institute for Health Research Collaboration for Leadership in
Applied Health Research and Care East of England.

Introduction
Supporting young people’s health and wellbeing is an investment that results in considerable economic
benefit. Participation in higher education is growing among young people, including students from
increasingly diverse backgrounds; more than a third of each generation now attends university in
England. Prevalence of mental illness in first-year undergraduates is lower than in the general population,
but becomes higher during the second year. The number of students accessing university counselling in
some services in the UK grew by 50% from 2010 to 2015, surpassing the growth in the number of
university entrants in the same period. Reasons for this increase are unclear, with little consensus about
whether students are experiencing more mental disorders, are less resilient than in the past, whether there
is less stigma in accessing support, and how all these factors affect academic attainment.
Nevertheless, the journey through university provides a golden, yet underused, opportunity for prevention
of mental illness in young people.

Mindfulness is a means of training the regulation of attention for the purpose of mental health promotion,
and has become popular in universities. Uptake of the approach might partly be explained by the
perception of mindfulness training as a skill rather than a mental health intervention. Evidence has
shown the efficacy of mindfulness training in improvement of symptoms of common mental disorders,
such as anxiety and depression. However, little robust evidence exists for the effectiveness in prevention
of common mental disorders in university students, and no studies have actively monitored adverse effects.
Previous trials focused mostly on health-care students, but most were underpowered and had no

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prospective protocol or clear primary outcome. Furthermore, there are concerns about multiple testing,
researcher allegiance bias with teachers acting as researchers, inadequate analysis and treatment of missing
data, and unrealistically short follow-up times. One good-quality study randomly assigned 288
health-care students to receive mindfulness training or be placed on a waiting list and found moderate
post-intervention effects on psychological distress and wellbeing. A systematic review and meta-analysis
assessed findings from nine randomised and non-randomised trials and showed that mindfulness reduced
anxiety among university students.

Research in context

Evidence before this study

On March 20, 2017, we searched CENTRAL, CINAHL, Embase, MEDLINE, and PsycINFO, with the
terms “mindfulness” and “meditation”, combined with “university”, “college”, “school”, “higher
education”, “postgraduate”, “undergraduate”, “student”, or “trainee”, with no date or language
restrictions. Our search identified comprehensive systematic reviews and meta-analyses showing
evidence for the efficacy of mindfulness meditation programmes in improvement of symptoms of
common mental disorders, such as depression or anxiety. Systematic reviews of mindfulness training
for university students show preliminary evidence for its effectiveness. However, the evidence is
inconsistent and mostly from non-randomised evaluations or evaluations involving only health-care
students. Previous randomised controlled trials of mindfulness support for university students have
been generally underpowered, enrolled too few students, and had no prospective protocol, no primary
outcome, multiple testing problems, researcher allegiance bias, inadequate analysis or treatment of
missing data, lack of follow-up, or other methodological and reporting issues. The largest and best
quality pre-existing trial randomly assigned 288 health-care students to mindfulness-based stress
reduction or a wait-list control group. The findings showed moderate post-intervention effects on
psychological distress and wellbeing.

Added value of this study

We present a randomised controlled trial of provision of an 8 week Mindfulness Skills for Students
(MSS) course in the year leading up to the main annual examination period. Compared with
participants assigned to receive mental health support as usual, MSS participants were a third less
likely to experience psychological distress at a clinically relevant level during the examination period.
Of the 30 students in each MSS course, an average of five students will be prevented from
experiencing clinical levels of distress during examinations—evidence of an effective preventive
intervention. The absence of a control for non-specific effects precludes us from attributing our
findings entirely to the specific components of mindfulness training, but evidence of such effects is
available in the published literature. This trial, co-produced with students and university officers, is an
example of participatory research informing student welfare policy.

Implications of all the available evidence

Evidence indicates that preventive mindfulness courses are acceptable to students and universities, and
are feasible and effective components of a wider student mental health strategy. Comparative
effectiveness research is needed into preventive mental health interventions for students.

In view of the increasing demands on student mental health services, the popularity of mindfulness, and its
promise as a preventive intervention, we did the Mindful Student Study to assess whether provision of
mindfulness courses to university students would improve their resilience to stress. Our primary

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hypothesis was that provision of mindfulness courses would reduce students’ psychological distress during
the examination period, when stress peaks, compared with support as usual. A reduction in distress while
under a universal stressor (examinations) was deemed an indicator of resilience to stress.

Methods

Study design and participants

We did this pragmatic randomised controlled trial at the University of Cambridge, UK. Eligibility criteria
were self-assessed by students, and replicated those used routinely by the University of Cambridge
Counselling Service. We included current undergraduate or postgraduate students (aged =18 years) at the
University of Cambridge, and students who believed they could attend at least seven of the eight sessions
of the mindfulness course. We excluded students who were currently experiencing severe periods of
anxiety or depression; a severe mental illness, such as hypomania or psychotic episodes; recent
bereavement or major loss; or any other serious mental or physical health problem that would affect their
ability to engage with the course.

Participants were recruited in two waves before randomisation. The first wave promoted the study and
enrolled interested students in the term starting in October, 2015 (cohort one). The second wave promoted
the study again and enrolled interested students in the term starting in January, 2016 (cohort two; figure 1).

The study protocol was submitted to the Australian New Zealand Clinical Trials Registry on Aug 31,
2015, before the study began, and accepted on Oct 30, 2015. The Cambridge Psychology Research Ethics
Committee approved the trial on Aug 25, 2015 (number PRE.2015.060). We set up an independent data
monitoring and ethics committee, and co-produced the trial with students and university officers to
increase the validity of the results. All participants provided written informed consent.

Randomisation and masking

The study management team enrolled participants and sent them personal links to an online baseline
questionnaire. After completion of the questionnaire, participants were randomly assigned (1:1), via
remote survey software (Qualtrics) using computer-generated random numbers (simple randomisation), to
receive either mindfulness training with the Mindfulness Skills for Students (MSS) course plus mental
health support as usual, or mental health support as usual alone.

Each participant was informed of their allocation automatically after completion of the baseline
questionnaire. Concurrently, members of the study management team were also informed automatically of
participants’ allocation; thus, the allocation process was concealed from the researchers. Due to the nature
of the intervention, participants were aware of group allocation for the duration of the study. Data
collection was remote and automatic using the web-based Qualtrics software to ensure masking of
outcome assessors. The primary analysis was done by a statistician masked to group assignment.

Procedures

The MSS intervention consisted of a secular, face-to-face, group-based skills training programme based on
the course book “Mindfulness: a practical guide to finding peace in a frantic world”, and adapted for
university students (appendix p 2). Adaptations were focused on permeating every session with elements
of flexibility, self-discovery, self-compassion, and empowerment, aimed at generating a natural transfer of
skills developed in meditation to study, decision making, and relationships. The course aimed to optimise
wellbeing and resilience for all students, and was not specifically developed for those with distress in a
clinical range.

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Seven MSS courses ran in parallel during university terms, with up to 30 students in each course, all
delivered by an experienced and certified mindfulness teacher. The eight, weekly sessions lasted 75–90
min. Sessions included mindfulness meditation exercises, periods of reflection and inquiry, and interactive
exercises. Students were encouraged to also practise at home. The recommended home practise time varied
throughout the course, starting at 8 min and increasing to about 15–25 min per day. Home practise
included meditations from the course book’s audio files and other mindfulness practices, such as a mindful
walk, mindful eating, and habit breakers. Before and after each class, students received a generic email
from the mindfulness teacher with relevant materials.

Students were required to choose a usual session time and day to attend each week, but when this was not
possible, students could attend an alternative session within the same week (so-called session hopping).
Students were contacted by email when they missed a session to check whether the absence was related to
a negative experience with mindfulness. Students were also given the opportunity to talk with the teacher
in confidence outside course times if they had any problems, or needed clarification. This routine practice
ran for two terms before and then during the trial.

Support as usual consisted of access to comprehensive centralised support at the University of Cambridge
Counselling Service in addition to support available from the university and its colleges, and from health
services external to the University, including the National Health Service (NHS). Participants assigned to
receive support as usual were guaranteed a space in the mindfulness courses in the following year, and
were requested to inform the team if they decided to learn mindfulness elsewhere during the follow-up
period.

MSS courses were free to students. £11 was available to each participant as a token of appreciation for
questionnaire completion.

Outcomes

The primary outcome was psychological distress, measured with the Clinical Outcomes in Routine
Evaluation Outcome Measure (CORE–OM), during the main annual examination period, as defined by the
Student Registry. This period spans May 16, 2016, to June 10, 2016—the most stressful weeks for most
students. Participants in cohort one started the course in October, 2015, and those in cohort two in January,
2016. CORE–OM is a 34 item scale that has been widely used in UK university students. Higher scores
indicate more distress. The total mean score (range 0–4) is obtained by dividing the total score by the
number of completed items (as long as no more than three items have been missed).

Prespecified secondary outcomes were CORE–OM score immediately after the MSS courses (post
intervention); scores on the 14 item Warwick–Edinburgh Mental Wellbeing Scale post-intervention and
during the examination period (total score is calculated by adding the response values of all items [range
14–70, higher scores indicate greater wellbeing]); examination results graded according to the British
undergraduate degree classification system (examination ranking was unavailable); numbers of requests
for special examination arrangements for any cause, and due to mental health problems; inability to sit
examinations; questions assessing the perceived effect of problems on academic performance (“To what
extent are you considering leaving your course?”, “To what extent do you have problems affecting your
study?”, and “To what extent do you have problems affecting your overall experience at
University/College?”); daily questions assessing problem-focused and emotion-focused coping with
academic workload for 2 weeks during the examination period (appendix p 5); physical activity
patterns (diurnal and sleep; smartphone accelerometer data were automatically sampled every 15 min for 2
weeks during the examination period [appendix p 6]); and a measure of altruism, based on offering high-
street shopping vouchers to participants upon questionnaire completion (equivalent to £3 for post-

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intervention and £5 for examination period questionnaires), with a choice to donate them to a named
charity. Prespecified secondary outcomes at 1 year follow-up are yet to be analysed and will be reported
elsewhere. We additionally collected information about process measures (eg, MSS attendance).

During the study, we actively and systematically monitored for adverse events, using three different
routes for identification, as detailed in the study protocol. Emergence of symptoms was recorded on a
form sent to the independent data monitoring and ethics committee, who determined whether they could be
related to the intervention. Participants with adverse events were offered support.

Statistical analysis

Data collection began 2 weeks before the start of the examination period—about 6 months after
randomisation for participants in cohort one, and 3 months after randomisation for those in cohort two (
figure 1). To detect a change in CORE–OM score of SD 0·3 at a p value of less than 0·05 with 90% power,
550 students were estimated to be needed, allowing for 20% loss to follow-up. Any clustering effect
within each course delivery was expected to be negligible: although this is a group intervention, the work
is highly personal, all the courses were taught by the same teacher, each mindfulness course included
students from different colleges and academic courses, and the session-hopping option introduced some
variability. However, we did intraclass correlation analyses of outcome and attendance data to measure the
extent of clustering.

The primary analysis was by intention to treat. Regression modelling of imputed data included baseline
scores, sex, age, and timing of receipt of intervention relative to exams as covariates. Multiple
imputation addressed missing data (appendix pp 3, 4). We did post-hoc two-sample t tests, and
prespecified per-protocol (minimum dose assumed to be 50% attendance of sessions) and subgroup
analyses (interaction tests) of the primary outcome. A post-hoc exploratory subgroup analysis was added
to test the influence of being in cohort one versus cohort two. Normative UK data were compared with
baseline values (prespecified) and primary outcome data (post hoc). We considered standardised effect
sizes as small (Cohen’s d 0·2), moderate (0·5), or large (0·8).

Regression modelling of the imputed datasets was used for the secondary outcomes of post-intervention
CORE–OM and Warwick–Edinburgh Mental Wellbeing Scale scores; no data were imputed for the other,
more exploratory, outcomes. A total daily coping score was plotted by intervention group, together with
locally weighted scatterplot smoothing with 95% CIs (appendix p 5). Physical activity scores, derived
from accelerometer data (appendix p 6), were calculated from the magnitude of the acceleration vector.
Aggregated physical activity scores were categorised according to time of day to assess diurnal and
nocturnal movement, and plotted with locally weighted scatterplot smoothing and confidence intervals.
Odds ratios were calculated for binary outcomes and ? and Fisher’s exact tests for ordinal outcomes
(including examination grades because no student had more than one). We used logistic regression to
assess baseline predictors of whether the primary outcome was completed. Analyses were done at a two-
sided a level of 0·05, using R (version 3.3.2).

This trial is registered with the Australian and New Zealand Clinical Trials Registry, number
ACTRN12615001160527.

Role of the funding source

The funders of the study had no role in study design, data collection, data analysis, data interpretation, or
writing of the report. The corresponding author had full access to all of the data in the study and had final
responsibility for the decision to submit for publication.

Results

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Between Sept 28, 2015, and Jan 1, 2015, we randomly assigned 616 students to the MSS group (n=309) or
the support as usual group (n=307; figure 2). Five (2%) people, all in the support as usual group, withdrew
from the study; three of four in their final year said this was because they could not undertake the MSS
course the following year. 182 (59%) participants attended four or more MSS sessions (figure 2). 39 (13%)
participants provided reasons for abandoning their mindfulness course; schedule conflicts (n=16) and
being too busy (n=12) were the most frequent reasons. 15 (5%) participants cancelled without attending
any sessions (appendix p 6). 26 (8%) participants in the support as usual group practised more than 10 h of
any type of meditation or did an 8 week mindfulness course after randomisation; data for meditation
practice were unavailable for 114 (37%) participants (no response).

Baseline characteristics were similar between groups (table 1). Higher wellbeing at baseline and final-year
status reduced the likelihood of completing the primary outcome measure (appendix p 11). The intraclass
correlation coefficient for the main outcome was 0, and for the other outcomes ranged from 0 to 0·016;
therefore, outcomes are reported without correction for clustering effect.

453 (74%) participants completed the CORE–OM during the examination period (table 2). MSS reduced
distress during the examination period compared with support as usual: participants’ distress scores were
on average 0·25 CORE–OM total mean score points lower in the MSS group than in the support as usual
group after adjustment for our a-priori set of covariates (table 2, table 3, appendix p 14). In standardised
terms, this difference is an average of 0·44 SDs (95% CI 0·60–0·29; p<0·0001)—a moderate effect size
(appendix p 14). Sensitivity and per-protocol analyses gave similar results (p<0·0001 in all cases;
appendix p 8).

To explore the practical effect of this primary finding, we dichotomised observed CORE–OM scores
during the examination period according to those above or below one total mean score point (appendix p
28), a threshold that discriminates between UK NHS clinical samples and general population samples.
MSS participants were a third less likely than support as usual participants to be in this clinical range of
distress (risk ratio 0·65, 95% CI 0·53–0·80; p<0·0001). On average, about six students (95% CI four to
ten) needed to be offered the MSS course to prevent one from being distressed at a clinical level during the
examination period.

The effect of the mindfulness intervention in participants who had examinations or assessments during the
examination period (n=267) was on average 0·19 CORE–OM score points greater than the effect in those
with no known assessments during this period (p=0·043; appendix p 8). The effect of the mindfulness
intervention in men was on average 0·18 CORE–OM score points less than the effect in women, but did
not differ significantly between sexes (p=0·061; appendix p 8).

In analysis of secondary outcomes, mindfulness training reduced distress immediately after the course
compared with support as usual (table 3). Distress among participants in the support as usual group
increased over the academic year, whereas for MSS participants, a decrease in CORE–OM scores after the
course was maintained during the examination period (figure 3, appendix p 27).

MSS improved wellbeing during the examination period and after the course compared with support as
usual (table 3). Warwick–Edinburgh Mental Wellbeing Scale scores among support as usual participants
decreased over the academic year, whereas for MSS participants, wellbeing increased after the course and
was maintained during the examination period, although less so than CORE–OM scores (figure 3).

In the intention-to-treat population, students assigned to receive MSS were slightly more likely to get the
highest (first-class) or lowest (third-class) grades than were those assigned to receive support as usual (no
differences in the few fails; appendix p 15). Results for grade attainment were no longer statistically
significant in a post-hoc sensitivity analysis in the per-protocol sample (ie, participants who completed at
least four mindfulness course sessions), but between-group differences were numerically similar to those
in the intention-to-treat analysis (appendix p 15). Participants with third-class grades (n=7, all in the MSS

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813792/table/tbl3/