Evaluating the Impact of Cognitive Behavioral Therapy on Stress Severity Transitions among University Students: A Multi-Group Analysis

Evaluating the Impact of Cognitive Behavioral Therapy on Stress Severity Transitions among University Students: A Multi-Group Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Evaluating the Impact of Cognitive Behavioral Therapy on Stress Severity Transitions among University Students: A Multi-Group Analysis Bhawna Gurnani¹, Shubhagata Awasthi² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7856331/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: University students often encounter considerable stress arising from academic demands, social expectations, and personal responsibilities. Cognitive Behavioral Therapy (CBT) is widely recognized as an effective psychological intervention for alleviating emotional distress; however, limited attention has been given to its comparative effects across students from different academic disciplines. The present study aimed to examine changes in stress severity before and after a CBT-based intervention among university students enrolled in medical, para-medical, and non-medical programs. Methods: The study involved 600 participants representing the three academic streams. The Stress subscale of the Depression Anxiety Stress Scales (DASS-21) was administered both prior to and following the intervention. Data analyses comprised internal consistency estimation, descriptive statistics, paired-samples t -tests, and categorical transition evaluations using McNemar and McNemar–Bowker tests. Results: The Stress subscale demonstrated high internal reliability (α = .95–.96). No significant differences were observed in mean stress scores across time points or academic groups (all p > .25, d < 0.10). Distributional analysis revealed stable stress severity patterns (χ² = 8.57, p = .57), with nearly half of the respondents classified within the Normal range. Medical students exhibited a marginally higher normalization rate (60%) compared with para-medical (52.5%) and non-medical (49.5%) students. Conclusion: While CBT did not produce statistically significant group-level reductions in stress, individual-level improvements were evident among participants initially presenting with elevated stress levels. These findings emphasize the enduring nature of stress among university students and underscore the necessity for sustained, discipline-specific mental-health interventions. Health sciences/Health care Biological sciences/Psychology Social science/Psychology Cognitive Behavioral Therapy stress university students DASS-21 academic disciplines Introduction Stress is a common concern among university students, emerging from demanding coursework, social adjustment, and uncertainty about future careers. In India, several studies report that a large proportion of students experience moderate to severe levels of stress, often accompanied by anxiety and sleep disturbances (Kaur et al., 2024 ; Reddy et al., 2018 ). Although some stress may enhance motivation, persistent exposure can impair concentration, mental health, and academic performance. Discipline-related variations in stress are also well documented. Students in medical and para-medical programs face intense workloads, examinations, and emotionally taxing clinical experiences compared with peers in non-medical fields (Ibrahim et al., 2013 ). Given these pressures, universities increasingly integrate psychological interventions into their wellness programs. Cognitive Behavioral Therapy (CBT) is a structured, goal-oriented intervention that helps individuals identify and replace maladaptive thought patterns (Beck, 2011 ). Numerous studies demonstrate its effectiveness in reducing anxiety, depression, and stress among students (Irie et al., 2019 ; Murad, 2021 ). However, most previous research has focused solely on changes in mean scores, neglecting the possibility that students may transition across clinically meaningful severity categories (e.g., from Severe to Moderate). Additionally, comparisons of CBT outcomes across academic disciplines remain limited. The present study addresses these gaps by analyzing both continuous and categorical shifts in stress severity before and after CBT among students from three academic streams. By using the DASS-21 Stress subscale, this research aims to provide a nuanced understanding of CBT’s role in modifying stress profiles. Objectives To evaluate the internal consistency of the DASS-21 Stress subscale. To compare mean stress scores before and after CBT across academic groups. To assess pre–post transitions in stress severity categories using McNemar and McNemar–Bowker tests. To compare stress severity distributions across medical, para-medical, and non-medical students. Hypotheses H₁: Mean stress scores will significantly decrease following CBT. H₂: The proportion of students in higher stress severity categories will significantly reduce post-intervention. H₃: Stress reduction patterns will differ significantly across academic groups. H₄: The DASS-21 Stress subscale will show high internal consistency (α ≥ .80). Method Participants A total of 600 university students participated, with equal representation from medical (n = 200), para-medical (n = 200), and non-medical (n = 200) streams. Participants ranged in age from 18 to 30 years (M = 20.2, SD = 1.8). Inclusion criteria required full-time enrolment, fluency in English, and availability for both assessments. Students receiving psychotherapy or psychiatric medication were excluded. All participants provided informed consent and were assured of confidentiality. Instrument Depression Anxiety Stress Scales–21 (DASS-21; Lovibond & Lovibond, 1995 ) The DASS-21 is a 21-item self-report measure assessing depression, anxiety, and stress. Only the seven stress items were used. Items are rated from 0 (“Did not apply to me at all”) to 3 (“Applied to me very much or most of the time”). Scores were doubled to align with DASS-42 norms. Stress severity was classified as Normal (0–14), Mild (15–18), Moderate (19–25), Severe (26–33), and Extremely Severe (34+). Internal consistency was excellent (α = .946 pre-test; α = .961 post-test). Procedure The study employed a pre–post quasi-experimental design. Phase 1 : Participants completed the DASS-21 Stress subscale during classroom sessions. Phase 2 : An eight-week, group-based CBT intervention was delivered, emphasizing cognitive restructuring, behavioral activation, problem-solving, and relaxation training. Each session lasted approximately 60 minutes. Phase 3 : The same measure was re-administered post-intervention. Participant data were matched using anonymous codes. Ethical approval was granted by the university’s Institutional Review Board Data Analysis Analyses were conducted in Jamovi (Version 2.5). Reliability was assessed via Cronbach’s α. Descriptive statistics summarized pre post stress scores. Paired-samples t -tests evaluated mean differences within groups. Effect sizes (Cohen’s d ) were calculated. Severity transitions were analyzed through McNemar and McNemar–Bowker tests. Chi-square tests compared stress distributions across academic groups. Boxplots, stacked bar charts, and a Sankey diagram visualized transitions. Significance was set at p < .05. Results Reliability The Stress subscale showed high internal consistency (α = .946 pre-intervention; α = .961 post-intervention). Descriptive Statistics Across all participants, stress scores ranged from 0–42. Non-medical students reported the highest stress both pre (M = 16.1, SD = 12.4) and post (M = 16.4, SD = 12.2). Medical students averaged 14.5 (SD = 11.8) pre and 14.8 (SD = 12.3) post, and para-medical students averaged 14.4 (SD = 12.4) pre and 15.2 (SD = 12.6) post (see Table 1 ) Table 1 Descriptive Statistics for Stress Scores by Group (N = 600) Group Pre-CBT M (SD) Post-CBT M (SD) Median (Pre/Post) Range Medical 14.5 (11.8) 14.8 (12.3) 14 / 12 0–42 Non-medical 16.1 (12.4) 16.4 (12.2) 14 / 16 0–42 Para-medical 14.4 (12.4) 15.2 (12.6) 12 / 14 0–42 Note. Stress measured using the DASS-21 Stress subscale. Higher scores indicate greater perceived stress. Paired Comparisons Paired-samples t -tests revealed no significant differences between pre- and post-CBT stress means in any group (see Table 2 ): Table 2 Paired-Samples t -Tests Comparing Pre- and Post-CBT Stress Scores Group t (199) p Mean Difference Cohen’s d Interpretation Medical −0.49 .626 −0.31 0.03 No change Non-medical −0.42 .673 −0.29 0.03 No change Para-medical −1.14 .254 −0.82 0.08 No change Note. p values are two-tailed. Medical: t (199) = − 0.49, p = .63, d = 0.03 Non-medical: t (199) = − 0.42, p = .67, d = 0.03 Para-medical: t (199) = − 1.14, p = .25, d = 0.08 Severity Distributions Before CBT, 54% of students were classified as Normal, 14.5% as Moderate, and 22.9% as Severe or Extremely Severe. After CBT, the overall proportions remained nearly identical (Normal = 54%, Moderate = 11.8%, Severe/Extremely Severe = 25.3%), χ²(10, N = 600) = 8.57, p = .573. Post-intervention differences across academic streams were non-significant, χ²(8, N = 600) = 11.3, p = .187. (see Table 3 ) Table 3 Distribution of Stress Severity Categories (Pre- and Post-CBT, N = 600) Severity Level Pre (%) Post (%) Normal 54.0 54.0 Mild 8.7 8.8 Moderate 14.5 11.8 Severe 12.7 14.5 Extremely Severe 10.2 10.8 Note. Based on DASS-21 categorical thresholds (Lovibond & Lovibond, 1995 ). Severity Transitions Transition analyses indicated that around 48–53% of students in the Moderate and Severe categories improved, while 34–35% worsened. Nearly half of those in the Extremely Severe category remained unchanged. It confirmed minor within-individual shifts but no large group-level change (see Table 4 ). Table 4 Transitions in Stress Severity Categories (Pre vs. Post-CBT) Pre-Category Improved (%) Unchanged (%) Worsened (%) Normal — 77.8 22.2 Mild 48.1 17.3 34.6 Moderate 52.8 12.6 34.4 Severe 41.0 25.0 26.3 Extremely Severe 19.0 45.9 35.1 Note. Based on McNemar–Bowker analysis, χ²(10, N = 600) = 8.57, p = .573. Discussion The study investigated the effect of CBT on stress severity among students from three academic disciplines. Contrary to expectations, stress means did not significantly decrease following the intervention, suggesting limited short-term effects of brief group-based CBT. This finding echoes prior studies indicating that shorter CBT formats may be insufficient in high-pressure academic contexts (Irie et al., 2019 ; Reddy et al., 2018 ). Despite non-significant mean differences, individual transitions revealed that many students initially categorized as Moderate or Severe improved by one level, suggesting partial benefits. However, persistent high stress among roughly one-quarter of participants indicates the need for more intensive or sustained support. Group comparisons showed similar outcomes across streams, with medical students demonstrating slightly greater normalization. Differences may reflect familiarity with health concepts or structured academic environments. Implications These findings underscore that brief CBT programs may be more effective as preventive or awareness-raising interventions than as full therapeutic solutions. Universities should consider extended or repeated CBT modules, screening for high-stress individuals, and integrating mental-health components within curricula. Limitations and Future Directions The study’s quasi-experimental design and lack of control group limit causal interpretations. Reliance on self-report measures may introduce bias. Future research should employ randomized controlled trials, include follow-ups, and test hybrid approaches combining CBT with mindfulness or peer-support elements. Conclusion While mean stress levels remained statistically stable, individual improvements highlight CBT’s potential for early-stage stress management. Sustained, discipline-specific interventions may enhance long-term effectiveness and overall student well-being. Declarations Author Contributions Statement: B.G. conceived and designed the study, collected and analyzed data, and drafted the main manuscript text. S.A. supervised the research, contributed to study design and intervention framework, provided critical revisions, and approved the final version. Both authors reviewed and approved the final manuscript. Funding: This research received no external funding. Conflicts of Interest: The authors declare no conflicts of interest. Ethical Approval: Approved by the Institutional Ethics Committee, Amity University, Gwalior. Informed Consent: Obtained from all participants. Data Availability: Available from the corresponding author upon reasonable request. Acknowledgment and Ethical Approval The authors thank all participating students and faculty for their cooperation. The Institutional Review Board approved the study of the participating university. Participants provided informed consent, and no conflicts of interest were declared. References Beck, J. S. Cognitive behavior therapy: Basics and beyond 2nd edn (Guilford Press, 2011). Donadkar, R. K., Sharma, N. & Bansal, R. Effectiveness of cognitive behavioral therapy on stress and anxiety among undergraduate students. Indian J. Psychol. Sci. 9 (1), 58–65 (2019). Gull, I., Ahmed, S. & Jabeen, F. Academic stress, coping strategies, and psychological well-being among university students in India. Journal Educ. Health Promotion (in press). Ibrahim, A. K., Kelly, S. J., Adams, C. E. & Glazebrook, C. A systematic review of studies of depression prevalence in university students. J. Psychiatr. Res. 47 (3), 391–400. https://doi.org/10.1016/j.jpsychires.2012.11.015 (2013). Irie, T., Yokomitsu, K. & Sakano, Y. The effect of a cognitive behavioral therapy-based stress management program on anxiety, depression, and quality of life in university students. Psychol. Health Med. 24 (7), 841–852. https://doi.org/10.1080/13548506.2019.1574352 (2019). Kaur, G. & Sandhu, D. S. Managing academic stress through cognitive behavioral interventions among Indian college students. Int. J. Indian Psychol. 10 (1), 100–113. https://doi.org/10.25215/1001.010 (2022). Kaur, M., Singh, R. & Dhillon, G. Psychological distress and coping mechanisms among university students: A cross-sectional analysis. Asian J. Educ. Social Stud. 48 (2), 55–63 (2024). Lovibond, S. H. & Lovibond, P. F. Manual for the Depression Anxiety Stress Scales 2nd edn (Psychology Foundation of Australia, 1995). Murad, F. Cognitive behavioral interventions for academic stress: A randomized trial among university students. J. Behav. Cogn. Therapy . 31 (4), 232–240. https://doi.org/10.1016/j.jbct.2021.06.005 (2021). Reddy, K. J., Menon, K. R. & Thattil, A. Academic stress and its sources among university students. Biomedical Pharmacol. J. 11 (1), 531–537. https://doi.org/10.13005/bpj/1404 (2018). Additional Declarations No competing interests reported. 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is a common concern among university students, emerging from demanding coursework, social adjustment, and uncertainty about future careers. In India, several studies report that a large proportion of students experience moderate to severe levels of stress, often accompanied by anxiety and sleep disturbances (Kaur et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Reddy et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Although some stress may enhance motivation, persistent exposure can impair concentration, mental health, and academic performance.\u003c/p\u003e\u003cp\u003eDiscipline-related variations in stress are also well documented. Students in medical and para-medical programs face intense workloads, examinations, and emotionally taxing clinical experiences compared with peers in non-medical fields (Ibrahim et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Given these pressures, universities increasingly integrate psychological interventions into their wellness programs.\u003c/p\u003e\u003cp\u003eCognitive Behavioral Therapy (CBT) is a structured, goal-oriented intervention that helps individuals identify and replace maladaptive thought patterns (Beck, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Numerous studies demonstrate its effectiveness in reducing anxiety, depression, and stress among students (Irie et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Murad, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, most previous research has focused solely on changes in mean scores, neglecting the possibility that students may transition across clinically meaningful severity categories (e.g., from Severe to Moderate). Additionally, comparisons of CBT outcomes across academic disciplines remain limited.\u003c/p\u003e\u003cp\u003eThe present study addresses these gaps by analyzing both continuous and categorical shifts in stress severity before and after CBT among students from three academic streams. By using the DASS-21 Stress subscale, this research aims to provide a nuanced understanding of CBT\u0026rsquo;s role in modifying stress profiles.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo evaluate the internal consistency of the DASS-21 Stress subscale.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo compare mean stress scores before and after CBT across academic groups.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo assess pre\u0026ndash;post transitions in stress severity categories using McNemar and McNemar\u0026ndash;Bowker tests.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo compare stress severity distributions across medical, para-medical, and non-medical students.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eHypotheses\u003c/h3\u003e\n\u003cp\u003eH₁: Mean stress scores will significantly decrease following CBT.\u003c/p\u003e\u003cp\u003eH₂: The proportion of students in higher stress severity categories will significantly reduce post-intervention.\u003c/p\u003e\u003cp\u003eH₃: Stress reduction patterns will differ significantly across academic groups.\u003c/p\u003e\u003cp\u003eH₄: The DASS-21 Stress subscale will show high internal consistency (α ≥ .80).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Method","content":"\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eA total of 600 university students participated, with equal representation from medical (n = 200), para-medical (n = 200), and non-medical (n = 200) streams. Participants ranged in age from 18 to 30 years (M = 20.2, SD = 1.8). Inclusion criteria required full-time enrolment, fluency in English, and availability for both assessments. Students receiving psychotherapy or psychiatric medication were excluded. All participants provided informed consent and were assured of confidentiality.\u003c/p\u003e\n\u003ch3\u003eInstrument\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eDepression Anxiety Stress Scales\u0026ndash;21 (DASS-21; Lovibond \u0026amp; Lovibond, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1995\u003c/span\u003e)\u003c/h2\u003e\u003cp\u003eThe DASS-21 is a 21-item self-report measure assessing depression, anxiety, and stress. Only the seven stress items were used. Items are rated from 0 (\u0026ldquo;Did not apply to me at all\u0026rdquo;) to 3 (\u0026ldquo;Applied to me very much or most of the time\u0026rdquo;). Scores were doubled to align with DASS-42 norms. Stress severity was classified as Normal (0\u0026ndash;14), Mild (15\u0026ndash;18), Moderate (19\u0026ndash;25), Severe (26\u0026ndash;33), and Extremely Severe (34+). Internal consistency was excellent (α\u0026thinsp;=\u0026thinsp;.946 pre-test; α\u0026thinsp;=\u0026thinsp;.961 post-test).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eThe study employed a pre\u0026ndash;post quasi-experimental design.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePhase 1\u003c/b\u003e: Participants completed the DASS-21 Stress subscale during classroom sessions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePhase 2\u003c/b\u003e: An eight-week, group-based CBT intervention was delivered, emphasizing cognitive restructuring, behavioral activation, problem-solving, and relaxation training. Each session lasted approximately 60 minutes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePhase 3\u003c/b\u003e: The same measure was re-administered post-intervention. Participant data were matched using anonymous codes.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003ewas granted by the university\u0026rsquo;s Institutional Review Board\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eAnalyses were conducted in Jamovi (Version 2.5).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eReliability was assessed via Cronbach\u0026rsquo;s α.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDescriptive statistics summarized pre post stress scores.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePaired-samples \u003cem\u003et\u003c/em\u003e-tests evaluated mean differences within groups.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEffect sizes (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e) were calculated.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSeverity transitions were analyzed through McNemar and McNemar\u0026ndash;Bowker tests.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eChi-square tests compared stress distributions across academic groups.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBoxplots, stacked bar charts, and a Sankey diagram visualized transitions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSignificance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eReliability\u003c/h2\u003e\u003cp\u003eThe Stress subscale showed high internal consistency (α\u0026thinsp;=\u0026thinsp;.946 pre-intervention; α\u0026thinsp;=\u0026thinsp;.961 post-intervention).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive Statistics\u003c/h2\u003e\u003cp\u003eAcross all participants, stress scores ranged from 0\u0026ndash;42. Non-medical students reported the highest stress both pre (M\u0026thinsp;=\u0026thinsp;16.1, SD\u0026thinsp;=\u0026thinsp;12.4) and post (M\u0026thinsp;=\u0026thinsp;16.4, SD\u0026thinsp;=\u0026thinsp;12.2). Medical students averaged 14.5 (SD\u0026thinsp;=\u0026thinsp;11.8) pre and 14.8 (SD\u0026thinsp;=\u0026thinsp;12.3) post, and para-medical students averaged 14.4 (SD\u0026thinsp;=\u0026thinsp;12.4) pre and 15.2 (SD\u0026thinsp;=\u0026thinsp;12.6) post (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive Statistics for Stress Scores by Group (N\u0026thinsp;=\u0026thinsp;600)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-CBT M (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost-CBT M (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian (Pre/Post)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.5 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.8 (12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 / 12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-medical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.1 (12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.4 (12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 / 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePara-medical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.4 (12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.2 (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 / 14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote.\u003c/b\u003e Stress measured using the DASS-21 Stress subscale. Higher scores indicate greater perceived stress.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePaired Comparisons\u003c/h2\u003e\u003cp\u003ePaired-samples \u003cem\u003et\u003c/em\u003e-tests revealed no significant differences between pre- and post-CBT stress means in any group (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePaired-Samples\u003c/b\u003e \u003cem\u003et\u003c/em\u003e\u003cb\u003e-Tests Comparing Pre- and Post-CBT Stress Scores\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e(199)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInterpretation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.626\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-medical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePara-medical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.254\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eNote.\u003c/b\u003e \u003cem\u003ep\u003c/em\u003e values are two-tailed.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMedical: \u003cem\u003et\u003c/em\u003e(199)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.63, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNon-medical: \u003cem\u003et\u003c/em\u003e(199)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.42, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.67, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePara-medical: \u003cem\u003et\u003c/em\u003e(199)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.25, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSeverity Distributions\u003c/h2\u003e\u003cp\u003eBefore CBT, 54% of students were classified as Normal, 14.5% as Moderate, and 22.9% as Severe or Extremely Severe. After CBT, the overall proportions remained nearly identical (Normal\u0026thinsp;=\u0026thinsp;54%, Moderate\u0026thinsp;=\u0026thinsp;11.8%, Severe/Extremely Severe\u0026thinsp;=\u0026thinsp;25.3%), χ\u0026sup2;(10, N\u0026thinsp;=\u0026thinsp;600)\u0026thinsp;=\u0026thinsp;8.57, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.573. Post-intervention differences across academic streams were non-significant, χ\u0026sup2;(8, N\u0026thinsp;=\u0026thinsp;600)\u0026thinsp;=\u0026thinsp;11.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.187. (see Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Stress Severity Categories (Pre- and Post-CBT, N\u0026thinsp;=\u0026thinsp;600)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeverity Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtremely Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote.\u003c/b\u003e Based on DASS-21 categorical thresholds (Lovibond \u0026amp; Lovibond, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1995\u003c/span\u003e).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSeverity Transitions\u003c/h2\u003e\u003cp\u003eTransition analyses indicated that around 48\u0026ndash;53% of students in the Moderate and Severe categories improved, while 34\u0026ndash;35% worsened. Nearly half of those in the Extremely Severe category remained unchanged. It confirmed minor within-individual shifts but no large group-level change (see Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTransitions in Stress Severity Categories (Pre vs. Post-CBT)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePre-Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImproved (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnchanged (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWorsened (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtremely Severe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e45.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eNote.\u003c/b\u003e Based on McNemar\u0026ndash;Bowker analysis, χ\u0026sup2;(10, N\u0026thinsp;=\u0026thinsp;600)\u0026thinsp;=\u0026thinsp;8.57, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.573.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study investigated the effect of CBT on stress severity among students from three academic disciplines. Contrary to expectations, stress means did not significantly decrease following the intervention, suggesting limited short-term effects of brief group-based CBT. This finding echoes prior studies indicating that shorter CBT formats may be insufficient in high-pressure academic contexts (Irie et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Reddy et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite non-significant mean differences, individual transitions revealed that many students initially categorized as Moderate or Severe improved by one level, suggesting partial benefits. However, persistent high stress among roughly one-quarter of participants indicates the need for more intensive or sustained support.\u003c/p\u003e\u003cp\u003eGroup comparisons showed similar outcomes across streams, with medical students demonstrating slightly greater normalization. Differences may reflect familiarity with health concepts or structured academic environments.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eImplications\u003c/h2\u003e\u003cp\u003eThese findings underscore that brief CBT programs may be more effective as preventive or awareness-raising interventions than as full therapeutic solutions. Universities should consider extended or repeated CBT modules, screening for high-stress individuals, and integrating mental-health components within curricula.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e\u003cp\u003eThe study\u0026rsquo;s quasi-experimental design and lack of control group limit causal interpretations. Reliance on self-report measures may introduce bias. Future research should employ randomized controlled trials, include follow-ups, and test hybrid approaches combining CBT with mindfulness or peer-support elements.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile mean stress levels remained statistically stable, individual improvements highlight CBT\u0026rsquo;s potential for early-stage stress management. Sustained, discipline-specific interventions may enhance long-term effectiveness and overall student well-being.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.G. conceived and designed the study, collected and analyzed data, and drafted the main manuscript text.\u003c/p\u003e\n\u003cp\u003eS.A. supervised the research, contributed to study design and intervention framework, provided critical revisions, and approved the final version.\u003c/p\u003e\n\u003cp\u003eBoth authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding: This research received no external funding.\u003c/p\u003e\n\u003cp\u003eConflicts of Interest: The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eEthical Approval: Approved by the Institutional Ethics Committee, Amity University, Gwalior.\u003c/p\u003e\n\u003cp\u003eInformed Consent: Obtained from all participants.\u003c/p\u003e\n\u003cp\u003eData Availability: Available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment and Ethical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participating students and faculty for their cooperation. The Institutional Review Board approved the study of the participating university. Participants provided informed consent, and no conflicts of interest were declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBeck, J. S. \u003cem\u003eCognitive behavior therapy: Basics and beyond\u003c/em\u003e 2nd edn (Guilford Press, 2011).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDonadkar, R. K., Sharma, N. \u0026amp; Bansal, R. Effectiveness of cognitive behavioral therapy on stress and anxiety among undergraduate students. \u003cem\u003eIndian J. Psychol. Sci.\u003c/em\u003e \u003cb\u003e9\u003c/b\u003e (1), 58\u0026ndash;65 (2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGull, I., Ahmed, S. \u0026amp; Jabeen, F. Academic stress, coping strategies, and psychological well-being among university students in India. \u003cem\u003eJournal Educ. Health Promotion\u003c/em\u003e (in press).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbrahim, A. K., Kelly, S. J., Adams, C. E. \u0026amp; Glazebrook, C. A systematic review of studies of depression prevalence in university students. \u003cem\u003eJ. Psychiatr. Res.\u003c/em\u003e \u003cb\u003e47\u003c/b\u003e (3), 391\u0026ndash;400. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpsychires.2012.11.015\u003c/span\u003e\u003cspan address=\"10.1016/j.jpsychires.2012.11.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2013).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIrie, T., Yokomitsu, K. \u0026amp; Sakano, Y. The effect of a cognitive behavioral therapy-based stress management program on anxiety, depression, and quality of life in university students. \u003cem\u003ePsychol. Health Med.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e (7), 841\u0026ndash;852. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13548506.2019.1574352\u003c/span\u003e\u003cspan address=\"10.1080/13548506.2019.1574352\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur, G. \u0026amp; Sandhu, D. S. Managing academic stress through cognitive behavioral interventions among Indian college students. \u003cem\u003eInt. J. Indian Psychol.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e (1), 100\u0026ndash;113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.25215/1001.010\u003c/span\u003e\u003cspan address=\"10.25215/1001.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaur, M., Singh, R. \u0026amp; Dhillon, G. Psychological distress and coping mechanisms among university students: A cross-sectional analysis. \u003cem\u003eAsian J. Educ. Social Stud.\u003c/em\u003e \u003cb\u003e48\u003c/b\u003e (2), 55\u0026ndash;63 (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLovibond, S. H. \u0026amp; Lovibond, P. F. \u003cem\u003eManual for the Depression Anxiety Stress Scales\u003c/em\u003e 2nd edn (Psychology Foundation of Australia, 1995).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurad, F. Cognitive behavioral interventions for academic stress: A randomized trial among university students. \u003cem\u003eJ. Behav. Cogn. Therapy\u003c/em\u003e. \u003cb\u003e31\u003c/b\u003e (4), 232\u0026ndash;240. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jbct.2021.06.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jbct.2021.06.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReddy, K. J., Menon, K. R. \u0026amp; Thattil, A. Academic stress and its sources among university students. \u003cem\u003eBiomedical Pharmacol. J.\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e (1), 531\u0026ndash;537. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.13005/bpj/1404\u003c/span\u003e\u003cspan address=\"10.13005/bpj/1404\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2018).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cognitive Behavioral Therapy, stress, university students, DASS-21, academic disciplines","lastPublishedDoi":"10.21203/rs.3.rs-7856331/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7856331/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003cbr\u003e\n \u003c/strong\u003eUniversity students often encounter considerable stress arising from academic demands, social expectations, and personal responsibilities. Cognitive Behavioral Therapy (CBT) is widely recognized as an effective psychological intervention for alleviating emotional distress; however, limited attention has been given to its comparative effects across students from different academic disciplines. The present study aimed to examine changes in stress severity before and after a CBT-based intervention among university students enrolled in medical, para-medical, and non-medical programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nThe study involved 600 participants representing the three academic streams. The Stress subscale of the Depression Anxiety Stress Scales (DASS-21) was administered both prior to and following the intervention. Data analyses comprised internal consistency estimation, descriptive statistics, paired-samples \u003cem\u003et\u003c/em\u003e-tests, and categorical transition evaluations using McNemar and McNemar–Bowker tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe Stress subscale demonstrated high internal reliability (α = .95–.96). No significant differences were observed in mean stress scores across time points or academic groups (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .25, \u003cem\u003ed\u003c/em\u003e \u0026lt; 0.10). Distributional analysis revealed stable stress severity patterns (χ² = 8.57, \u003cem\u003ep\u003c/em\u003e = .57), with nearly half of the respondents classified within the Normal range. Medical students exhibited a marginally higher normalization rate (60%) compared with para-medical (52.5%) and non-medical (49.5%) students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nWhile CBT did not produce statistically significant group-level reductions in stress, individual-level improvements were evident among participants initially presenting with elevated stress levels. These findings emphasize the enduring nature of stress among university students and underscore the necessity for sustained, discipline-specific mental-health interventions.\u003c/p\u003e","manuscriptTitle":"Evaluating the Impact of Cognitive Behavioral Therapy on Stress Severity Transitions among University Students: A Multi-Group Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 04:07:13","doi":"10.21203/rs.3.rs-7856331/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc3c9c98-df7d-47b0-9282-4739034a0361","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56386918,"name":"Health sciences/Health care"},{"id":56386919,"name":"Biological sciences/Psychology"},{"id":56386920,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2025-11-12T18:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 04:07:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7856331","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7856331","identity":"rs-7856331","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}