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Preventing Depression in High-Risk College Women: A

Report of an 18-month Follow-up
Ann R. Peden ARNP-CS, DSN , Mary Kay Rayens PhD , Lynne A. Hall DrPH & Lora H. Beebe PhD
Published online: 24 Mar 2010.

To cite this article: Ann R. Peden ARNP-CS, DSN , Mary Kay Rayens PhD , Lynne A. Hall DrPH & Lora H. Beebe PhD (2001)
Preventing Depression in High-Risk College Women: A Report of an 18-month Follow-up, Journal of American College Health,
49:6, 299-306, DOI: 10.1080/07448480109596316

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 JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 49, NO. 6
Preventing Depression in High-Risk
College Women: A Report
of an 18-month Follow-up
Ann R. Peden, ARNP-CS, DSN; Mary Kay Rayens, PhD;
Lynne A. Hall, DrPH; and Lora H. Beebe, PhD
Downloaded by [University of North Texas] at 05:23 11 November 2014
Abstract. The authors tested the long-term effectivenessof a cog-
nitive-behavioral group intervention in reducing depressive symp-
toms, decreasing negative thinking, and enhancing self-esteem in
92 college women aged 18 to 24 years who ere at risk for clinical
depression. The women were randomly assigned to either an
experimental or a no-treatment control group. The experimental
group participated in a 6-week cognitive-behavioral intervention
that targeted identification and reduction of negative thinking,
using such techniques as thought stopping and affirmations. Data
on depressive symptoms, self-esteem, and negative thinking were
collected before the intervention and at intervals of I , 6, and 18
months postintervention. The women in the intervention group
experienced a greater decrease in depressive symptoms and nega-
tive thinking and a greater increase in self-esteem than those in the
control group. The beneficial effects continued over an 18-month
follow-up period. These findings support the importance of
thought stopping and affirmationsas prevention interventions with
at-risk college women.
Key Words: college women, depression, negative thinking, self-
esteem
W e designed this study to test the long-term effec-
tiveness of a cognitive-behavioral group inter-
vention in reducing depressive symptoms,. -
decreasing negative thinking, and enhancing self-esteem in
Ann R. Peden is an associate professor; College of Nursing at
the University of Kentucky, Laington, where Mary Kay Rayens is
a research assistant professor; College of Nursing and Department
of Preventive Medicine and Environmental Health und School of
Public Health, College of Medicine, and associate director; biosta-
tistics consulting unit, Chandler Medical Center: and Lynne A.
Hall is professor and assistant deanfor research and doctoral stud-
ies, College of Nursinx and professor; Department of Behavioral
Science and School of Public Health, College of Medicine. b r a H.
Beebe is an assistant pmfessor; College qf Nursing, Univer.sity of
Florida, Gainesville.
299
college women at risk for clinical depression. Depression in
college women affects academic performance, school satis-
faction, and social relationships.! It may result in cognitive,
social, and functional impairment.2 Left untreated, depres-
sion may result in suicide, although even treated patients
sometimes choose to end their lives.
Stress and depression are increasing among college stu-
dents3 Sax4 surveyed college freshmen and found that
9.7% experienced frequent depression; only 48% of the
women, compared with 59.3% of the men, were confident
in their emotional health. Reed et a15 found that 58% of
their sample of African American college women had a
high rate of depressive symptoms, with 12% to 18% expe-
riencing severe symptoms. Beeber6 and Peden et a17-R
reported mild-to-severe depressive symptoms in more than
one third of the college women in their samples. In the
1995 National College Health Risk Behavior S ~ r v e y , ~
10.3% of the students reported serious thoughts of suicide,
6.7% had made plans for suicide, and 1.5% said they had
attempted suicide. The findings in these studies suggest the
need for prevention interventions to reduce risks for depres-
sion among college students.
In women, low and negative thinking”.”
have been identified as predictors for the later development
of depression. Negative thinking, a common, debilitating
symptom of d e p r e ~ s i o n , dominates
’~ the individual’s per-
ceptions and maintains depressed moods. Low self-
esteem is a risk factor for developing depression, whereas
high self-esteem protects women from d e p r e ~ s i 0 n . lIn~
young college women, a lack of social support, low self-
esteem, and negative life events have been shown to be
associated with depressive symptom^.^^'* These findings
suggest the important role that negative thinking and low
self-esteem may play in the development of depressive
symptoms in college students.
 PEDEN ET AL
Many investigators have documented the effectiveness of
cognitive-behavioral interventions in various populations.
In his seminal work, developed cognitive-behav-
ioral strategies to identify negative thoughts and replace
them with more accurate, helpful views, and Gordon and
Ledrayzl tested a cognitive-behavioral group intervention
with mildly depressed women and found that the interven-
tion was effective in reducing depressive symptoms. May-
nard2’ compared the use of Gordon’s2’ structured cognitive
group intervention with a support-group-only approach and
found that the intervention was more effective than the sup-
port group only. Peterson and HalsteadZ4tested a cognitive-
behavioral group intervention that focused on skills to
reduce depressive symptoms; 84% of their participants
reported a decrease in depressive symptoms. In a pilot test
of a group intervention designed to reduce negative think-
ing and enhance positive thinking in clinically depressed
women, Peden” found that negative thinking and depres-
sive symptoms declined in the intervention group.
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Cognitive-behavioral interventions that target negative
thinking and depressive symptoms are effective in prevent-
ing the onset of clinical depression in adolescent^.^^^^^
Clarke et 29 used a focused intervention for high school
students at risk for unipolar depression; at 12-month follow-
up, findings from the intervention group revealed the sig-
nificant advantages of the intervention. Peden et alx tested
the cognitive-behavioral intervention used in the present
study and found that it decreased depressive symptoms and
negative thinking and increased self-esteem at 1-month and
6-month postintervention follow-ups in 18-to-24-year-old
college women. Undergraduate students who practiced pos-
itive self-statements three times a day for 2 weeks reported
an increase in self-esteem and a decrease in depressive
symptoms.”) This article reports on a follow-up of these
women 18 months after the intervention.8
A moderate level of depressive symptoms has been
linked to later development of major d e p r e s ~ i o n . ~ Reduc-
~.”
ing subdiagnostic levels of depressive symptoms may
reduce the risk of developing clinical depression in the
future.2h Munoz et al’? recommended randomized con-
trolled trials in euthymic and at-risk samples to determine
whether depression can be prevented by teaching people to
manage their own moods, and Hoilon et all2 suggested
adapting cognitive therapy for use with euthymic popula-
tions to prevent depression in people at risk for depression.
Although cognitive-behavioral interventions have been
quite successful in treating depression, few studies have
focused on reducing negative thinking through group inter-
vention as a means of preventing clinical depression. In our
present study, we tested the long-term effectiveness of a
cognitive-behavioral group intervention that specifically
focused on reducing negative thinking and increasing posi-
tive self-talk and affirmations.x Our hypotheses were that
(a) compared with women in a no-treatment control group,
women who received the intervention would demonstrate a
greater increase in self-esteem and a greater decrease in
negative thinking and depressive symptoms; and (b) these
300
beneficial effects would be maintained 18 months after the
intervention.
METHOD
Design and Sample
We conducted a randomized, controlled prevention trial
to test the long-term effectiveness of an intervention
designed to reduce negative thinking, decrease depressive
symptoms, and increase self-esteem among 18-to-24-year
old college women who were at risk for clinical depression.
To test our hypotheses, we used a repeated-measures
design. In addition to collecting baseline data on the out-
come variables, we also collected data I , 2, and 18 months
postintervention. The inclusion criteria were (a) no prior
treatment for psychiatric illness and no previous psychiatric
care; (b) never on antidepressants; (c) never diagnosed with
clinical depression; (d) not suicidal, indicated by Beck
Depression Inventory rating on question 9; (e) single or
never married; (f)no dependent children; and (g) a full-time
student.
We studied a volunteer sample of 246 women from the
student population of the University of Kentucky, a public
institution serving 22,192 students in a metropolitan a r e a x
They were recruited through an announcement in the stu-
dent newspaper, fliers posted in women’s dormitories and
restrooms across campus, and fliers sent to the presidents
of sororities. Of the 461 women who responded, 100 did
not meet the inclusion criteria and 115 declined to partici-
pate.
For the remaining 246 women, we collected baseline data
on negative thinking, self-esteem, and depressive symp-
toms, as well as sociodemographic characteristics.’ We
administered the Beck Depression Inventory (BDI)33 and
the Center for Epidemiologic Studies-Depression Scale
(CES-D)34to identify those with high levels of depressive
symptoms. The BDI and CES-D are not measures of clini-
cal depression; however, they do assess subdiagnostic levels
of depressive symptom^.^^,^^ A score of 9 or above on the
BDI or a score of 16 or above on the CES-D indicate a mild-
to-moderate level of depressive symptoms (ie, at risk for
development of clinical depression). Of the 246 women
who completed the baseline data collection, 92 had elevat-
ed BDI a n d o r CES-D scores and agreed to participate in
the intervention phase of the study. As they were enrolled,
the women with high scores on the BDI or CES-D were ran-
domly assigned to control or experimental groups in blocks
of 16 (8 each, control and experimental), resulting in five
blocks with 16 women and one block with 12.
Baseline sociodemographic data on the participants are
described in a previously published article.’ The mean age
of the 92 in the intervention portion was 19.3 years (SD=
1.4), 45% were employed, 26% were sorority members,
46% were satisfied with their living arrangements, and the
women’s median monthly income was $200. Eight percent
of the participants reported major health problems, such as
migraine headaches, epilepsy, asthma, and allergies. Forty-
JOURNAL OF AMERICAN COLLEGE HEALTH

nine percent of the women used prescription medication-
primarily for birth control, allergies, and acne.
Depressive Symptoms
The BDI” is a 21-item tool designed to assess affective,
behavioral, cognitive, motivational, and vegetative aspects
of depression. Each item consists of 4 statements, scored
from no symproms (0) to severe distress (3). The partici-
pants rated each item in terms of how they had felt in the
past week. We summed item ratings to get a cumulative
score. The higher the score, the greater the depressive
symptoms. Beck recommended a cutoff score of 9 or above
as indicative of at least mild depressive symptoms.3sM The
BDI has been used extensively and has excellent psycho-
metric proper tie^.^^.^^ Cronbach’s alphas ranged from .88 to consistency in implementing the intervention, we developed
.92 across the four data collection points in this study.
The CES-D34 measures “the presence of dysphoria and
somatic complaints that are often accompanied by associat-
ed features of depression, but do not necessarily meet the
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criteria for the clinical syndrome of depressi~n.’’~~@‘~~~) A
20-item scale, it contains items relating to depressed mood
and psychophysiologic indicators of depression. Respon-
dents indicate how often they experienced each symptom
during the past week, using a scale from rarely or none of
the time (0) to most or all ofthe time (3). The ratings of the sions. Cognitive distortions (eg, mind reading, generali-
4 positive items are reversed and added to those of the other zation, all-or-nothing thinking, etc) were introduced to the
16 items, forming a summary score ranging from 0 to 60. A
score of 16 or above indicates a high level of depressive
symptom^.'^ Both the reliability and validity of the CES-D
have been supported in a number of studies. Cronbach’s
alphas in this study ranged from .82 to .93.
NegativeThinking
We used the 45-item Crandell Cognitions Inventory
(CCI)3xto measure negative thinking. The CCI was devel-
oped with depressed and nondepressed psychiatric patients.
The respondents rate each negative self-statement for fre-
quency of occurrence, ranging from almost never (1) to
altnosr always (5). Higher scores indicate greater frequency
of negative thinking. Crandell and ChambledO reported a
Cronbach’s alpha of .95 in a volunteer sample of depressed,
psychiatric, and normal persons. Cronbach’s alphas in our
sample ranged from .95 to .97.
Self-esteem
To measure self-worthkelf-acceptance, we used the 10-
item Rosenberg Self-esteem Scale (RSE).4’ The women
rated each item on a scale ranging from stronglv disagree (1) at 6-month
to strongly agree (4). The higher the score, the higher the
self-esteem. This measure has been used extensively in pre-
vious research and has excellent psychometric properties. In
this sample, Cronbach’s alphas ranged from .90 to .91.
The Intervention
The 6-week cognitive-behavioral group intervention
emphasized reducing negative thinking in depressed
women and was implemented using a standardized proto-
VOL 49, MAY 2001
DEPRESSION IN COLLEGE WOMEN
col. It evolved from a series of studies in which women
recovering from depression identified negative thinking as
the depressive symptom most difficult to o ~ e r c o m e . ’The
~.~~
women in the earlier studies described strategies they used
to manage negative thinking. Thought stopping and positive
self-talk were the key approaches they used to reduce nega-
tive thinking. The Depression WorkboopP’provided infor-
mation on thought stopping, affirmations, and distorted
thinking styles. We adapted affirmations and direct actions
from the Insight23program.
Group sessions allow contact with peers with similar
problems, reduce isolation, promote change, and are cost-
effective.2’ Because of these advantages, we offered the
intervention in six 1 -hour small-group sessions. To ensure
a script for each session and gave each participant a folder
containing handouts on the weekly topics and homework
assignments. Table 1 provides a more complete description
of the intervention.
The first session focused on understanding the effect that
thinking has on mood. Each woman received an outline of
the 6-week group intervention. We also gave the partici-
pants weekly homework assignments that included practic-
ing the skills and techniques they learned in the group ses-
participants and discussed each week.
At the second session, the participants were taught to use
the STOP technique,a were introduced to affirmations, and
made their first tape recording, using the STOP technique
and affirmations. During the third session, we introduced a
relaxation technique incorporating affirmations, and at the
fourth session, participants wrote and recorded their own
affirmations.
Identifying triggers to depressive symptoms and strate-
gies to combat them was the focus of the fifth session. The
final session was a review of previous content. We encour-
aged group members to continue using the skills they had
developed over the 6-week intervention.
Procedure
The study received approval from the university’s institu-
tional review board and the women gave their informed con-
sent to participate. We used self-report data on depressive
symptoms, negative thinking, and self-esteem collected
from the control and experimental groups at baseline (ie,
before the intervention), 1 month after the intervention, and
and I 8-month follow-ups. Participants were paid
$10 for each interview and group session they attended.
Data Analysis
For each outcome variable (BDI, CES-D, CCI, and RSE),
we considered a separate repeated measures ANCOVA,
using the baseline value as a covariate. We used Fisher’s
least significant difference procedure to make post hoc
comparisons. For the dichotomous versions of the BDI and
the CES-D, we used the Cochran-Mantel-Haenszel chi-
301
 PEDEN ET AL

TABLE 1
A 6-Week Group Intervention for Reducing Negative Thinking

Focus Content Homework

Week 1 Overview of group Read thought distortions handout

Getting acquainted
Understanding the effect thinking has
on mood
Week 2
Using a cognitive-behavioraltechnique
to manage negative thinking
(‘STOP’)
Week 3
Using relaxation and affirmations
Week 4
Creating your own affirmations
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Group rules
What you think affects how you feel:
An overview
Discussion of thought distortions
Affirmations
Teach and practice STOP technique
Use affirmation with STOP technique
Discuss thought distortions
Select new affirmations; write and record
Practice relaxation exercise using
affirmations
Discuss how to write own affirmations
Write and record own affirmations. Write
Begin to identify how your thinking
affects your feelings and behavior
Listen to STOP tape twice a day, use
STOP without tape throughout day
Work with one affirmation
Continue using STOP
Do relaxation exercise each day
Listen to taped affirmations twice a day
Look at written affirmations as needed
Use STOP as needed
Listen to tape affirmations twice a day

affirmations on cards, post-its Do relaxation exercise

Discuss thought distortions
Week 5 Identifying behaviors that foster Use STOP as needed
Changing behavior depression Listen to taped affirmations twice a day
Strategies to fight depression Do relaxation exercise
Week 6 Review various approaches to manage
Review of all techniques, wrap-up negative thoughts
Decide which are most helpful

square test45-46to determine whether the percentage of
women with elevated scores (BDI 2 9; CES-D 2 16) dif-
fered by group membership, controlling for the factor of
time. To limit Type 1 error, we set the alpha level for all
hypothesis testing at .O 1. Some attrition occurred over the
course of the study; therefore only 42 of the women-21
(46%) women in both the experimental and control groups
- c o m p l e t e d all three postintervention surveys. However,
the analysis strategies we selected for hypothesis testing
allowed us to use data from all 92 women.
RESULTS
At the outset of the study, the control ( n = 46) and exper-
imental ( n = 46) groups did not differ on employment sta-
tus, age, income, sorority membership, satisfaction with liv-
ing arrangements and school or number of self-reported
major health problems. In addition, we found no differences
between the groups at baseline on either measure of depres-
sion, negative thinking, or self-esteem. Those women who
were lost to follow-up ( n = 50) did not differ from those
who completed all four points of data collection (n = 42) on
group assignment (ie, intervention vs control), or baseline
scores on depressive symptoms (CES-D and BDI), negative
thinking (CCI), and self-esteem (SE).
BDI
The main effect of group was significant, whereas the
main effect of time and the Group x Time interaction effects
were not significant. Over the 18-month follow-up period,
the experimental group participants had fewer depressive
symptoms across all time points than the control group did,
F ( 1 , 73) = 1 0 . 4 ; <
~ .002 (see Figure 1).
The mean BDI score of the experimental group, adjusted
for baseline BDI scores, was 7.1, compared with 1 1.5 for
the control group over all postintervention time points. The
percentages of women reporting at least mild depressive
symptoms (BDI 2 9) at each of the four time points are
shown in Figure 2. Although the groups were similar at
baseline, we found significant group differences postinter-
vention (Cochran-Mantel-Haenszel x2, = 13.9, p I.001).
The experimental group demonstrated a more striking
decline in the prevalence of high BDI scores across time
than the control group did.
Center for Epidemiologic Studies-
Depression Scale
As was true with the BDI, only the main effect of group
was significant. When we controlled for baseline CES-D
scores, the experimental group had lower depressive symp-
tom scores than the control group across the 18-month fol-
low-up, F( 1, 73) = 7.4, p I.008 (see Figure 3). Even after
adjusting for CES-D scores at baseline, we found the mean
CES-D score of the experimental group was 1 1.6 compared
with 16.5 for the control group across all postintervention
time points. See Figure 4 for the percentages of women in
each group reporting a high level of depressive symptoms
(CES-D 2 16) over the course of the study.
Although the groups were similar at baseline, the per-

302 JOURNAL OF AMERICAN COLLEGE HEALTH

 DEPRESSION IN COLLEGE WOMEN

FIGURE 1
Mean Postintervention Scores on the Beck Depression Inventory (BDI) of Experimental
and Control Groups in a Study of College Women at Risk for Depression

Baseline 1 month 6 months 18 months

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Experimental (n = 46) Control ( n = 46)

FIGURE 2
Prevalence of Beck Depression Scores 2 9 at Each Postintervention Point in a
Study of College Women at Risk for Depression

50
40
30
20
10

Baseline I month 6 months 18 months

Experimental (n = 46) Control (n = 46)

centage of women with high depressive symptoms differed
between the two groups over time (Cochran-Mantel-Haen-
szelx12 = 26.4, p I .001). In a comparison with the experi-
mental group, we found a greater proportion of the women
in the control group had a high level of depressive symp-
toms across all postintervention follow-ups. At baseline,
89% of the experimental participants had high CES-D
scores, compared with 96% of the controls. The difference
between experimental and control groups became more
VOL 49, MAY 2001
striking at the I-month follow-up (25% vs 58%). Even at
18-months postintervention, the percentage of women in
the experimental group with high depressive symptoms was
approximately half that of the control group (15% vs 29%).
Crandall Cognitions Inventory
The main effects of group and time were significant, but
the interaction between group and time was not. Adjusting
for baseline CCI scores, the mean score for the experimen-
303
 PEDEN ET AL

FIGURE 3
Mean CES-D Scores of Experimental and Control Groups Over 18 Months in a
Study of College Women at Risk for Depression

3 0 4

25

20

15

10

0
Baseline 1 month 6 months 18 months
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Experimental ( n = 46) Control ( n = 46)

Note. CES-D = Center for Epidemiologic Studies-Depression.

FIGURE 4
Prevalence of CES-D Symptoms 1 16 of Experimental and Control Groups at Each
Time Point in a Study of College Women at Risk for Depression

100
90
80
70
60
50
40
30
20
10
0
Baseline 1 month 6 months 18 months

Experimental (n = 46) Control ( n = 46)

tal group over the 18-month follow-up period of 61.9 was
significantly lower than the adjusted mean score of 72.5 for
the control group, F( 1, 72) = 6.2, p 2.01. For experimental
and control groups combined, we also found a significant
decline over time, controlling for baseline level of negative
thinking, F(2,9) = 4.7, p 5 .O I . The post hoc analysis of this
significant main effect revealed that the mean adjusted CCI
score for all women, both experimental and control groups
combined, declined significantly from the 1-month to the
18-month follow-up, t(98) = 3. I , p 5 .003. The 1 -month, 6-
month, and 18-month adjusted mean CCI scores were 7 1.7,
68.6, and 6 1.2, respectively. However, only the women’s 1-
month and 18-month mean scores differed significantly.
Rosenberg Self-esteem Scale
The main effect of group was significant for self-esteem.
The experimental group had a significantly higher self-
esteem score ( M = 30.4) than the control group ( M = 27.1 )

304 JOURNAL OF AMERICAN COLLEGE HEALTH


across time, after controlling for baseline self-esteem,
F( 1, 73) = 6.5, p < .01. The main effect of time and the
Group x Time interaction were not significant.
COMMENT
No matter which measure of depressive symptoms we
used, the results were the same: Depressive symptoms
remained lower in the experimental group than in the con-
trol group from the 1-month through the 18-month follow-
up. The intervention decreased the prevalence of a high
level of depressive symptoms, and this effect persisted 18
months after the intervention. For the symptom of negative
thinking, the intervention was beneficial, as shown by the
significantly lower negative-thinking scores of the experi-
mental group over the 18-month follow-up period. In addi-
tion, negative thinking declined significantly for both con-
trol and experimental women from 1 to 18 months. The
intervention also had a positive effect on self-esteem.
In this study, we followed the recommendations of
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Munoz et a132and Hollon et all2 to use prevention interven-
tions that teach at-risk individuals to manage their own
moods. College women are one group at risk for depression.
Cognitive-behavioral interventions such as thought stop-
ping and affirmations focus on managing mood. Our find-
ings provide support for the effectiveness of these strategies
in managing mood and preventing depression. In this study,
the combination of techniques we used was effective in
reducing depressive symptoms and negative thinking and in
improving self-esteem. Periodic booster sessions may be
needed to maintain the beneficial effects of the intervention.
The study adds to the limited body of literature on college
women’s mental health. A growing number of studies iden-
tify depression in this group as a significant problem.’.I8
Cost-effective, easy-to-implement interventions, such as the
ones we used in this study, can be offered in university
health settings and college counseling centers; they are
essential for improving the mental health of young women.
Although no special training is required to implement the
intervention, leaders need to be comfortable in facilitating
psychoeducational groups and familiar with the symptoms
and behaviors of depressed women. This intervention,
offered over a 6-week period, was shorter than most cogni-
tive-behavioral group interventions; however, it was effec-
tive, and its effectiveness was maintained over the 18-month
postintervention follow-up. College students have busy
schedules and many work full or part time. They may be
able to commit to a 6-week group but not to a lengthy inter-
vention. Interventions designed to fit their busy schedules
may be more appealing, and shorter group interventions are
also more cost effective.
Limitations of the study include attrition and the potential
of the Hawthorne effect. Only 46% of the participants com-
pleted all three post-intervention surveys. However, given
the transient nature of college students’ lives, this level of
attrition was not surprising. All women in the study also
seemed to experience beneficial effects from their participa-
tion. In addition, we focused on a small sample from a sin-
VOL 49, MAY 2001
DEPRESSION IN COLLEGE WOMEN
gle university campus. Replication of the study by investiga-
tors on other campuses, using the same intervention protocol
with different samples of college women, is warranted
Both control and experimental groups showed a decline
in depressive symptoms and negative thinking, and their
self-esteem improved. The decrease in isolation and
increased sense of belonging experienced by all research
participants may be attributed to the Hawthorne effect. Both
social isolation and low sense of belonging are common
experiences of depressed women.47 The interest in the
young women’s lives and the positive attention all partici-
pants received also may have been beneficial. The depres-
sive symptom measures do not assess clinical depression,
but they do identify subdiagnostic levels that may lead to
later development of depression in at-risk individuals.26
Depression is a costly public health problem that may go
undetected in college women. To combat this problem, col-
lege health surveys must include more questions about
depressive symptoms for early identification of those at
risk. Prevention efforts. along with early detection and treat-
ment, may improve the mental health, academic perfor-
mance, and social well-being of college students. Interven-
tions that focus on the reduction of negative thinking and
the enhancement of self-esteem may be one key to the pre-
vention of clinical depression in college women.
ACKNOWLEDGMENTS
This research was funded by Grant #R15 NR04203 awarded to
Drs Peden, Hall, and Rayens from the National Institute of Nurs-
ing Research, National Institutes of Health. The authors wish to
express their appreciation to Carol Donnelly for editorial assis-
tance and to Libby Moss for preparing the manuscript.
NOTE
For further information, please address communications to Dr
Ann R. Peden, College of Nursing, University of Kentucky, Lex-
ington, KY 40536-0232 (e-mail: arpedeOl @pop.uky.edu).
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