Metacognitive Bibliotherapy for Anxiety, Depression, and Metacognitions in University Students

Background and Rationale Medical and health sciences students represent a high-risk subgroup for anxiety and depressive symptoms due to intense academic demands and clinical responsibilities. Current literature indicates that the Cognitive Attentional Syndrome (CAS) - a transdiagnostic mechanism encompassing perseverative worry, rumination, threat monitoring, and maladaptive coping strategies - plays a central mediating role in the transition from academic stress to clinical psychopathology. Low-intensity, structured self-help bibliotherapy offers an accessible, cost-effective, and scalable intervention that may support self-regulation capacity in at-risk student populations.

Objective This randomized controlled trial aims to evaluate the therapeutic efficacy of structured bibliotherapy on anxiety, depression, and metacognitive beliefs in university students studying medicine and health sciences.

Study Design

A three-arm randomized controlled trial will be conducted with 110 participants. Sample size was determined through G\*Power analysis (α = 0.05, power = 80%), with at least 30 participants per group and an allowance for dropout. Participants will be allocated to one of three groups using computer-based block randomization:

Group 1: Receives the self-help book "The Art of Letting Go - How to Stop Rumination" as a structured, low-intensity bibliotherapy material Group 2: Receives the self-help book "Anchored: How to Befriend Your Nervous System Using Polyvagal Theory" as a structured, low-intensity bibliotherapy material Waiting List Control Group: Receives no intervention during the study period; after the 8-week data collection is complete, participants may obtain both self-help books free of charge.

Participants and Setting The study population consists of students enrolled in health sciences programs at Istanbul Nişantaşı University. Participants will be recruited through voluntary convenience sampling.

Inclusion Criteria: Active enrollment in the specified faculties; voluntary informed consent.

Exclusion Criteria: Currently receiving active psychiatric treatment (psychotherapy or pharmacotherapy); change in psychopharmacological medication within the past 6 months; prior reading of the study books; presence of acute psychotic symptoms or suicidal risk.

Intervention Participants in the experimental groups receive the assigned book free of charge and are asked to read it at their own pace over an 8-week guided bibliotherapy period.

Outcome Measures

Data will be collected via online self-report questionnaires at three time points: baseline (Week 0), mid-intervention (Week 4), and post-intervention (Week 8). The following validated instruments will be used:

Cognitive Attentional Syndrome Scale (CAS-1): to assess perseverative thinking and threat monitoring

Metacognitions Questionnaire-30 (MCQ-30): to evaluate metacognitive beliefs

Depression Anxiety Stress Scales-21 (DASS-21): to measure the severity of depression, anxiety, and stress symptoms

Statistical Analysis Data will be analyzed using repeated measures ANOVA to examine between-group differences and within-group changes over time. Intent-to-treat principles will be applied to address missing data.

Ethical Considerations The study was approved by the Istanbul Nişantaşı University Health Sciences Ethics Committee (Approval No: 2026.04.10, dated 14.04.2026). All participants will provide digital informed consent and may withdraw at any time without consequence. Participant data will be anonymized and stored securely. Participants showing high-risk indicators will be referred to appropriate psychological support services.

• Change in Cognitive Attentional Syndrome (CAS-1) [Срок оценки: Baseline (Week 0), mid-intervention (Week 4), and post-intervention (Week 8)]