Issues in Mental Health Nursing, 35:480–488, 2014 copyright© 2013 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.879628
Effectiveness of Resilience Training versus Cognitive Therapy on Reduction of Depression in Female Iranian College Students Somayeh Zamirinejad and Seyed Kaveh Hojjat Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Islamic Republic of Iran Issues Ment Health Nurs Downloaded from informahealthcare.com by Drexel University on 10/03/14 For personal use only.
Mahmoud Golzari and Ahmad Borjali Allameh Tabatabayi University, Tehran, Islamic Republic of Iran
Arash Akaberi Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Islamic Republic of Iran
Depression is the most common mental illness among women. Its prevalence in women is two to three times that of men. The purpose of the present study was to evaluate the effectiveness of resilience training on the reduction of depression in female college students. This semi-empirical study was carried out with two experimental groups and one control group. The research sample was women with symptoms of depression who were 18–22 years of age and living in a college dormitory. One experimental group was given eight 90-minute resilience training sessions, while the other received eight 90-minute cognitive therapy sessions. The control group didn’t receive any interventions. The three groups under study were evaluated using the Beck II depression inventory before and after the interventions and two months after the treatment had ended. The three groups didn’t have significant differences in age, marital status, or depression scores on the pretest. The resilience training group and cognitive therapy group showed a significant decrease in the average depression score from pretest to posttest and from pretest to follow-up. The main effect of groups, stage, and interaction between groups and stage also were significant (all were p < 0.001). There was no significant difference between effectiveness of resilience training and cognitive therapy on depression but there was a significant difference between these two treatment groups and the control group. The effectiveness of resilience training was just as good as the effectiveness of cognitive therapy. The effects of resilience training on depression remained stable from the posttest to the follow-up, like that of cognitive therapy.
Address correspondence to Arash Akaberi, Addiction and Behavioral Sciences Research Center, Faculty of Medicine, North Khorasan University of Medical Sciences, South Shriati Avenue, Bojnurd, North Khorasan Province, Iran, E-mail: [email protected]; [email protected]
Mood disorders are very prevalent. The latest studies show that among mental disorders, major depressive disorder has the highest lifetime prevalence of about 17%. The annual occurrence rate of depression is 1.59% (1.89% women, 1.1% men) (Sadock & Sadock, 2007). Depression is the fourth cause of disability in the United States and is projected to become the second cause by the year 2020 (Varcarolis, Elizabeth, Carson & Shoemaker, 2006). A depressed mood, apathy, and disinterest are the main symptoms of depression. The patient may express feelings of sadness, despair, sorrow, and worthlessness. About two-thirds of all depressed patients think about suicide and almost 10–15% attempt suicide. The main complaints (almost 97%) of all patients with depression include energy reduction, disturbances in school and work achievement, and a decreased motivation for accepting new plans. About 80% of patients complain about sleep disorders and many face a decrease in appetite and weight. Some, however, may find an increase in appetite, weight, and sleep (Sadock & Sadock, 2007). Depression has a large effect on physical movement, pain perception, and general health in individuals (Ford, 2004). Some behaviorists believe that life events play the main or number one role in the outbreak of depression, while others believe it to have a limited role (Sadock & Sadock, 2007). Observations have shown that stressful life events often take place before the first period of the depression rather than its later periods. Stress leading to the first period of the depression causes lasting changes in the brain’s biological condition, putting the individual at an increased risk for developing future periods of depression even in the absence of outside stress (Sadock & Sadock, 2007). Due to several factors, including
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EFFECTIVENESS OF RESILIENCE TRAINING ON DEPRESSION.
distance from family, living in a strange city, unsuitable environment, a lack of adequate hygiene and facilities, living with people from different cultures, and high costs of living without a source of income, living in a dorm can be a stressful life event that can lead to depressive disorders in students (Votta & Manion, 2003). In addition to causing severe physical problems and intensifying some symptoms, such as pain and side effects of treatments, depression decreases an individual’s abilities and adaptabilities. It also takes away the ability to make decisions and to take care of oneself, resulting in lack of independence. All of these factors lead to dependency, inability, and lack of confidence, which naturally have a negative effect on all life aspects of the individual and those around him, bringing about much damage to the individual and to the society as a whole (Bollinger, 2003). According to the cognitive theory proposed by Aaron T. Beck, depression is a result of specific cognitive distortions that exist in individuals who are more prone to depression. These distortions, called depressogenic schemata, are cognitive patterns that make the individual perceive internal and external data in a distorted way, under the effect of a previous experience. Cognitive therapy emphasizes uncovering cognitive distortions, which Beck believes to exist in depressive disorders. These distortions include selective attention to the negative aspects of events and the assumption that everything will end in a tragic way due to the individual’s unrealistic inferences. Cognitive therapy aims to relieve and reduce depression cycles through helping the patient identify and test negative thoughts; prevent relapse; find more flexible ways of thinking; and practice new cognitive and behavioral reactions (Sadock & Sadock, 2007). The goal of cognitive therapy is not to completely eliminate or manage these negative emotions. Rather, it aims at using the patient’s own ability for providing realistic and precise evaluation of situations they face. Cognitive techniques do not ask the patient to think positively. Rather they want the patient to think realistically (Hofmann, Asmundson, & Beck, 2013). The treatment process begins by teaching the client the cognitive model and the role of thoughts in forming emotions and behavior. Emphasis is put on the conceptualization of the patient’s problems, teaching him the cognitive model, and providing grounds for solving the patient’s problems. The next steps in the treatment process are for the therapist to help the client identify realistic goals for treatment and start to work on cognitive errors, automatic thoughts, and schemata, while the therapist models behavioral change. The therapist ultimately helps the client become his or her own therapist and prevent his or her own relapse (Hofmann, Asmundson, & Beck, 2013). In 1989, Dobson published a meta-analysis of the efficacy of Beck’s cognitive therapy for depression. He identified 28 studies that used a common outcome measure of depression and compared cognitive therapy with other psychotherapeutic modalities. The average effectiveness of cognitive therapy was very high. Clients treated with cognitive therapy felt better than 98% of the individuals in the control group. These results showed that cognitive
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therapy brings about more changes compared to no treatment, pharmacotherapy, behavior therapy, and other psychotherapies (Prochaska & Norcross, 2009). Although studies show that the use of antidepressants have an effect on the process of positive and negative emotions (Harmer et al., 2010; Rawlings, Norbury, Cowen, & Harmer, 2010), recent studies report that a change in positive emotions rather than negative emotions may be more effective in the improvement of depression. First, improvement of depression is linked to an increased ability in reward experience in everyday life, rather than the reduction of sensitivity to psychological distress (Wichers et al., 2009). Second, a high capacity for experiencing positive emotions in everyday life is related to a lower risk of developing depression and also higher resilience against the development of emotional symptoms (Geschwind et al., 2010; Wichers et al., 2007; Wichers et al., 2010). Psychological resilience is the ability to bounce back to a previous state of normal functioning after experiencing negative emotions (Tugade & Fredrickson, 2004). Recent studies show that positive, not negative, emotions are predictive of resilience (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009). In addition, faster changes in positive feelings as compared to negative feelings are the best prediction for treatment (Geschwind, Nicolson, Peeters, Barge-Schaapveld, van Os, & Wichers, 2011). Researchers believe that resilience is a kind of self-recovery with positive emotional and cognitive outcomes, which in turn has an important role in achieving greater adaptability and life satisfaction (Luthar, Cicchetti, & Becker, 2000; Rutter, 1999). Resilience is applied to individuals who are exposed to the risk of depression but do not develop the disorder. We may be able to conclude that facing a risk factor is a prerequisite for getting damaged, but it is not enough. Resilience factors help the individual use existing capacities for achieving growth and success in life in difficult situations despite the presence of risk factors. It helps the person see challenges and tests as an opportunity for strengthening him- or herself and helps him or her pass any trials faced (Zarrinkelk, 2010). Researchers believe that resilience, as a basic sense of self-control, enables individuals to draw on and access a list of coping strategies. This, in turn, has an important role in allowing individuals to confront stressful life events and acts as a shield-like source of resistance (Lazarus, 2001; Silliman, 1997). Findings of a survey carried out by Pour sardar et al. (2012) verified the primary role of resilience in adaptability outcomes. These findings indicate the importance of the primacy of emotional change over attitude change. It can be said that an individual’s change of emotions may be followed by a change of attitude about life and one’s surroundings (Pour sardar, Abbas pour, Abdizarrin, & Sangari, 2012). In a recent study, Steinhardt & Dolbier (2008) examined the effectiveness of a resilience intervention designed to enhance resilience, individual coping strategies, and protective factors while reducing symptomatology related to increased academic stress. This study was carried out on 57 students were divided into experimental and control groups. Analysis of the data revealed significantly higher
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resilience scores, effective coping strategies, and scores on protective factor measures, and lower scores on symptomatology in the experimental group compared to the control group. The researchers concluded that using a resilience program curriculum can prove beneficial for students’ stress management and academic success (Grunert, 2008). We discussed the high prevalence of depression in society, especially among women, and the effects and costs of this common chronic illness on the individual’s social, academic, and work performance (which may ultimately become a burden on society). The mechanisms that make resilience help individuals better cope with stressful events, and subsequently minimize the risk of individuals developing psychological distress, can lead to faster recovery from difficult circumstances. Therefore, we tested the effect of a resilience skills enhancement program for females who had symptoms of depression. In order to evaluate the effectiveness of resilience training on the reduction of depression symptoms, cognitive therapy was chosen as a base for comparison. What we know about this issue is that cognitive therapy is an effective and recognized treatment for depression, and is the treatment of choice in most cases. Its effectiveness has been verified by numerous studies. But so far, the efficacy of resiliency training for the treatment of depression has not been addressed, and we do not know whether it can be effective in the treatment of depression. Therefore, this research was designed and carried out with the purpose of studying the effectiveness of resilience training on the reduction of depression in female college students. METHOD This study was carried out with three groups: a resilience training group, a cognitive therapy group, and a control group. The assessment of depression levels was carried out in three stages: pretest, posttest, and follow-up. The study’s population was girls living in the dormitories at North Khorasan University of Medical Sciences in the year 2012. The University students living in dormitories were invited to become familiar with the study using a call for participation in the project. First, the objectives of the study were completely explained to each individual who expressed interest. Those who showed continued interest in participating in the study were asked to fill out the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), in order to identify those with some degree of depression. Potential participants also were asked for a contact number or e-mail address so that they could be reached if they met the inclusion criteria for participation in the group therapy study. Inclusion and Exclusion Criteria Criteria for inclusion in this study were: being a female student, living in the dormitory, providing consent for inclusion in the study, having a depression score of 19 or higher
on the BDI-II (Beck, Steer, & Brown, 1996), and not receiving any other psychotherapy during the group therapy sessions (in order to prevent interference and influences of outside factors on research results). Exclusion criteria for this study were: being discontented with continuing to be in the study, being absent from more than two group therapy sessions, or having severe depression (based on a psychiatrist’s diagnosis using the DSM-IV diagnostic interview) in which case psychotherapy alone would not be effective in its treatment. In this case, a combination of psychotherapy and pharmacotherapy is the suggested treatment (Sadock & Sadock, 2007). In studies where interventions are made through group therapy, if individuals in the group know each other and talk about the interventions at times other than group therapy sessions, it is possible that they will develop a sense of competition for better performance and for displaying a better image of themselves. In addition, they might talk about interventions and retell learnt techniques for one another. In such cases, it is said that the effect of one intervention has been contaminated by the effect of another intervention (Corey & Corey, 2006). In order to prevent both the contamination effect of the groups and a sense of competition between sample individuals, each group was selected from a different dormitory; the resilience training group was selected from dorm A; the cognitive therapy group from dorm B; those not chosen for the training groups were placed in the control group. The two dorms were exactly identical in terms of the students’ majors, semesters, and accommodations, and were both under the university’s coverage. Twelve individuals were assigned to each experimental group (resiliency group and cognitive group) and 14 individuals were non-randomly assigned to the control group. Individuals who were absent from more than two group therapy sessions were not included in the statistical analysis. Because these interventions took place at the dorm and students made up the sample four individuals from the resiliency group and three individuals from the cognitive group left the group sessions, reportedly because of university exams or to visit their families (Figure 1). In this research, depression is considered a symptom and the individual is assessed according to his score on the BDIII. Like the original version of this questionnaire, the BDI- II is composed of 21 items. For each item, the participant has to choose one of the four choices which correspond to the intensity of felt depressive symptoms. Each item is scored on a scale value of 0–3, and the whole inventory has a scope of 0–63. The BDI-II does not include four items from the original version and has additional items, instead. Also, the items “change in sleeping patterns” and “change in appetite” have been revised so that they are more sensitive to the severity of depression, because sleep and appetite symptoms may show different changes among various depressed individuals; individuals may experience either a decrease or increase in sleep and appetite and the addition of these items gives the possibility of better screening of
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Number of female students living in dormitory (n = 300) Assessed for eligibility (n = 170)
Enrollment
Assigned to Resilience Training Group (n = 12) Received Experimental Manipulation (n = 8) Did not receive Experimental Manipulation (n = 4) because of university exams and to visit the family
Assigned to Cognitive Therapy Group (n = 12) Received Experimental Manipulation (n = 9) Did not receive Experimental Manipulation (n = 3) because of university exams and to visit the family
Assigned to comparison group (n = 14); The comparison group did not receive any manipulation
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Follow-up
Analyzed (n = 9) Excluded from analysis (n = 0)
Analyzed (n = 14)
Analysis
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Assignment
Excluded (total n = 131) because of BDI score < 19 Did not meet inclusion criteria (n = 1) because of chronic depression based on psychiatrist’s diagnosis using the DSMIV diagnostic interview
Analyzed (n = 8) Excluded from analysis (n = 0)
Excluded from analysis (n = 0)
FIGURE 1 Participants through Each Stage of the Study.
individuals. The 21 items in this inventory can be classified into three categories: emotional, cognitive, and physical symptoms. This questionnaire can be used with a population aged 13 and over (Beck et al., 1996). Results of studies carried out by Beck, Steer, and Brown show that this test has high consistency (Sharifi et al., 2004). The alpha coefficient obtained using the BDI-II was 0.92 for regular patients and 0.93 for students (Dobson & Mohammadkhani, 2007). Validity was obtained based on the convergent validity calculation method. For this purpose, the correlation coefficient of the scores obtained on the BDI-II and the Brief Symptom Inventory (BSI, with 6 items) depression scale was calculated (r = 0/873) (Dobson & Mohammadkhani, 2007). Members of the experimental groups were given psychotherapeutic interventions while members of the control group received no intervention. Both the resilience training group and the cognitive therapy group were given eight 90-minute sessions, which were held three times weekly. Group therapy is a form of psychotherapy in which carefully selected individuals with emotional problems take part in a group under the guidance of a trained therapist and help each other in modifying their
character. The group leader uses a variety of tactics and theoretical concepts and guides the group members’ interactions in a direction that leads to modification and improvement (Sadock & Sadock, 2007).
Resilience Training Resilience training was instructed based on self-awareness, self-esteem enchantment, goal setting, communication, and self-efficacy (Zarrinkelk, 2010). Self-awareness requires an understanding of components such as physical traits, feelings, thoughts, beliefs, values, goals, inner dialogue, and one’s strengths and weaknesses. To fulfill this purpose, participants were trained to identify these components in themselves and were given the task of describing themselves as they are and as they would like to be. In order to promote self-esteem, an individual must first know what things give him or her a good feeling, and plan in a way to actualize those events in life. To achieve this goal, individuals were taught to turn negative self-talk into positive self-talk, make positive assessments (in order to see the positive aspects
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of performed activities), perform enjoyable activities, and set and reach achievable goals (which helps promote self-esteem). Individuals also were trained on strategies for setting goals (such as listing them on paper); having a purpose in various aspects of life; having more than one way of reaching a goal; prioritizing goals; and breaking big goals into small ones. They also were taught the characteristics of a good goal: being objective, having an end point, and being such that those around them notice a change in them for reaching that goal. They were instructed on how to communicate effectively, through the introduction of the elements of a successful relationship, such as trust, sympathy, acceptance, and active listening, and also were taught about obstacles to communication and rules for dispute settling. Self-efficacy promotion was achieved by individual work on self-efficacy sources. According to Bandura (1977), selfefficacy sources are performance accomplishments, vicarious experiences, verbal persuasion, and emotional arousal. Cognitive Training Cognitive Training (CT) was carried out based on Guidelines and Resources for Practice in Cognitive Therapy in Groups (Free, 1999). In the CT group, the ABC (A: Activating Event—the actual event and the client’s immediate interpretations of the event; B: Beliefs—about the event [this evaluation can be rational or irrational]; C: Consequences—how you feel and what you do or other thoughts) model was taught so that participants understand that physiologic, cognitive, and behavioral processes in human beings are interrelated, and to find out how different beliefs about one activating event determines the emotions they experience. The main aspects of cognitive theory about depression also were taught, namely the following four thought patterns: 1. Negative automatic thoughts are the thoughts people repeat in similar situations. 2. Negative core beliefs, or schemas, are more general than negative automatic thoughts and reflect the overall attitude of a person toward life. 3. Negative automatic thoughts and negative core beliefs create negative content, or a negative cognitive triangle about oneself, the world, and the future. 4. Negative automatic thoughts, core beliefs, and content lead to logic errors that cause a person’s reasoning process to conclude negatively about events he or she experiences. Individuals in the CT group also were trained on the nature of schemas, the relationship between schemas and automatic thoughts, and identifying schemas through the vertical arrow technique. By asking questions such as “What was the meaning of that event for me?” or “Why should it be that disturbing or painful?” participants can follow their stream of thoughts to reach their core beliefs. To ensure reaching one’s core belief, the stream of questions about one’s thoughts must be followed until the final state is expressed as an absolute statement such
as, “I am worthless.” Participants were trained to identify ten types of negative schemas and to classify their beliefs into these categories. Participants were supposed to make a list of their negative beliefs and draw a cognitive map about how they relate to each other. In the vertical arrow technique, some beliefs are shallow and depend on the situation while others are on lower levels, which are more general and more definite, known as core beliefs or schemas. So, participants had to provide two lists: situation-related beliefs and core beliefs. Then, in order to organize these beliefs participants created a cognitive map. Automatic thoughts, which are on the surface, are related to other automatic thoughts and deeper beliefs. The closer the automatic thought is to the core belief, the more likely it is to activate that core belief and cause an intense emotion. Another way to organize beliefs is to rate them as subjective units of disturbance on a 100-degree scale, with 100 being the most disturbing belief and zero being the least disturbing one. Also participants were helped to understand that beliefs aren’t immutable. Just as dominant cultural beliefs have changed over time, one’s own beliefs can also change; it only takes time. Samples of scientific and legal processes were provided to show participants how they could detect facts based on evidence. Individuals had to learn that they could evaluate their beliefs through certain criteria, and that beliefs can differ in efficacy. Knowing the consistency and compatibility of one’s beliefs with others does not make those beliefs true. Once this part of the training was complete, participants had to evaluate their lists of beliefs. The next step in the training was to teach the logical analysis method, which is the most powerful method for challenging beliefs. This method is similar to the scientific method in which one has to clarify the problem, define the terms and rules, collect evidence, and then make a conclusion. Finally, participants had to provide some counter beliefs for their negative beliefs. Counter beliefs must be direct and opposite to negative beliefs, use logic, and be liable statements that are brief, assertive, with intense emotion, and powerful.
Statistical Analyses In this study Chi-squared tests were used to compare qualitative variables in the three groups, and the means from the three groups were compared using the one way analysis of variance and Bonferroni post hoc test. In order to evaluate the effect of interventions in the resilience therapy group with the cognitive therapy and the control groups, repeated measures analysis of variance was used. In the RMANOVA, the stages’ effects and interaction between stages and groups was evaluated using the sphericity assumed test, given the results of Mauchly’s sphericity test. Comparison of the groups’ effectiveness was calculated using the interaction between group and stage. Results pertaining to
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TABLE 1 Comparison of Baseline Characteristics of Individuals Under Study, Separated into Three Groups of Resilience Training, Cognitive Therapy, and Control Group
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Group Resilience Training
Cognitive Therapy
Control
p-value
Age Mean ± SD
21.50 ± 1.20
20.78 ± 1.30
20.23 ± 1.167
0.085
Marital status Single n (%) Married n (%) Depression score on pretest Mean ± SD
7 (87.5%) 1 (12.5%) 24.63 ± 4.41
9 (100%) 0 (0%) 24.89 ± 4.83
10 (76.9%) 3 (23.1%) 26.08 ± 5.72
0.343
the group’s main effect and time also were reported. The effect size and partial eta square was reported for each effect and each parameter estimate. The eta square statistic describes the proportion of total variability attributable to a factor. All the description and analysis of the data was done using SPSS 20 software. A significance level of 0.05 was chosen for this study. RESULTS Baseline Demographic Data At pretest, there was no significant difference in the mean age of the participants (p = 0.085), marital status (p = 0.343), or in the average depression score (p = 0.0785) of the three groups under study (Table 1). Analytical Results The average depression score in the resilience training group and cognitive group showed a dramatic and significant reduction from the pretest to the posttest and at follow-up (Table 2). In the resilience training group, a reduction of the mean depression score was seen from the pretest to the posttest (13.00 ± 3.55) and from the pretest to the follow-up (14.38 ± 4.37). This reduction in the cognitive group was 11.78 ± 3.11 from the pretest to the posttest and 13.78 ± 7.14from the pretest to the follow-up.
0.785
The groups’ main effect on the depression score was significant (F(2.27) = 14.9, p < 0.001). With the effect size being eta-squared = 0.525 (Table 3). The stages’ main effect (the three stages of pretest, posttest, and follow-up) on the depression score was significant (FSphericity Assumed (2.54) = 62.2, p < 0.001) and the effect size was eta-squared = 0.697. Interaction effect among groups and stages was significant (FSphericity Assumed (4.54) = 5.96, p < 0.001) with an effect size of eta-squared = 0.306 (Table 4). Comparisons of adjusted means using the Bonferroni test reflected a significant reduction of mean depression scores from the pretest to posttest (mean difference = –8.95, p < 0.001). It also showed a significant reduction of mean depression scores from the pretest to the follow-up (mean difference = –11.62, p < 0.001). In addition the mean depression score from the posttest to the follow-up also was reduced (mean difference = –2.74, p = 0.078) although this reduction was statistically insignificant. Overall the difference between the three groups’ means was statistically significant with a notable effect size of p < 0.001and eta-squared = 0.697. The Bonferroni post-hoc test displayed no significant difference between the resilience group and the cognitive group (mean difference = 0.87, p = 1) but there was a significant difference between the resilience group and the control group (mean difference = 7.58, p = 0.002). A significant difference
TABLE 2 Depression Score Means and Standard Deviation in Resilience Training, Cognitive Therapy, and Control Groups in the Pretest, Posttest, and Follow-Up Stages Group Stage Pretest Posttest Follow-up
Resilience Training Mean ± SD
Cognitive Therapy Mean ± SD
Control Mean ± SD
24.63 ± 4.41 11.63 ± 3.16 10.25 ± 3.54
24.89 ± 4.83 13.11 ± 6.81 11.11 ± 3.82
26.08 ± 5.72 24.00 ± 4.93 19.15 ± 5.01
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TABLE 3 The Main Effect of Group with Repeated Measures Analysis of Variance
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Intercept Group Error
Sum of Squares
df
Mean Square
F
p-value
Partial Eta Squared
28934.91 1128.76 1021.73
1 2 27
28934.91 564.38 37.84
764.63 14.91
< 0.001 < 0.001
0.966 0.525
was seen between the cognitive group and the control group (mean difference = 6.7, p = 0.001). Upon comparing the effectiveness of the resiliency group with that of the control group, it was concluded that the interaction between the group and stages was significant (FSphericity Assumed (2, 38) = 10.053, p < 0.001) with an effect size of eta-square = 0.346. Also, after comparing the effectiveness of the two groups of resiliency and cognitive therapy, it was concluded that the interaction between the group and stages was not statistically significant (FSphericity Assumed (2, 30) = 0.108, p = 0.898) with an effect size of eta-square = 0.007. The three groups’ means were compared in the posttest stage, and a significant difference was seen (F(2.27) = 18.4, p < 0.001). The Bonferroni post-hoc test used for two-by-two comparison of groups showed that the mean depression score of the resilience group was significantly lower than that of the control group (mean difference = 12.37, p < 0.001) and likewise the mean depression score of the cognitive group was significantly lower than that of the control group (mean difference = 10.89, p < 0.001). However, the resilience group and cognitive groups’ main depression scores did not have a significant difference (mean difference = 1.49, p = 1). DISCUSSION This research showed that in the population under study, the effectiveness of the resiliency group therapy was just as good as the effectiveness of the cognitive group therapy. No significant difference was seen between the resilience training group and the cognitive training group. The effectiveness of the resilience training was significantly higher than the control group. The effects of resiliency group therapy on depression remained stable from the posttest to the follow-up, like that of cognitive group therapy.
Results from this research show that cognitive therapy measures were effective in the treatment of depressive disorders. Research by Scott and colleagues (Scott, Palmer, Paykel, Teasdale, & Hayhurst, 2003) has shown that cognitive therapy is a beneficial and proven treatment for depression. Depression relapse is one of the difficulties of treating this illness, and studies show that cognitive therapy has a more durable effect in the treatment of depression. In this study, we witnessed a moderate reduction in the cognitive therapy group’s mean depression score, which reflects the durable effects of this treatment on the reduction of depression scores. In a six year follow-up of patients with depression who had received cognitive therapy treatment, Jonghe et al. (2004) concluded that cognitive therapy measures effectively reduce the risk of depression relapse (Paykel, 2007). In the study by Scott et al., 158 patients with depression were treated with cognitive therapy measures; patients’ illness relapse rates were significantly reduced (47%) compared to the control group (Scott et al., 2003). After comparing cognitive therapy and pharmacotherapy, Ravindran et al. (1999) also reported that cognitive therapy methods are more effective for patients with depression. Strunk and colleagues (Strunk, Cooper, Ryan, DeRubeis, & Hollon, 2012) also noticed that patients treated with cognitive therapy responded to treatment better than patients who were treated solely with pharmacotherapy. Results from all cited research are in line with the outcomes of the present study, which confirms that cognitive therapy is the treatment of choice for depression and is a good basis of comparison for evaluating the effectiveness of other treatment methods on depression. Therefore in this research, cognitive therapy was chosen as a criterion for studying the effectiveness of resilience. In the resilience training group, the mean depression score from the pretest to the posttest (–13.0 ± 3.55) shows a greater decrease than in the cognitive group (–11.78 ± 3.11). The extent of decrease in the two groups’ means was considerable
TABLE 4 The Main Effect of Time and Interaction Effect between Groups and Time with Repeated Measures Analysis of Variance
Stage Interaction Effect between Group and Stage Error
Sum of Squares
df
Mean Square
F
p-value
Partial Eta Squared
2150.01 411.71
2 4
1075.00 102.93
62.23 5.96
< 0.001 < 0.001
.697 .306
932.80
54
17.27
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EFFECTIVENESS OF RESILIENCE TRAINING ON DEPRESSION.
and significant. However, the decrease between the two groups was not significant. When we look at depression score means in the follow-up and compare them with the pretest and posttest means, we can see a similarity between the resilience training and cognitive therapy groups. This is such that depression score means from the posttest to the follow-up also show a rate of reduction (a 1.38 unit decrease in the resilience group and a 2.0 unit decrease in the cognitive group). This illustrates the durability and effectiveness of both resilience and cognitive interventions. Since the cognitive method has been shown to be the treatment of choice for depression, the achieved results confirm the effectiveness of resilience as another treatment for depression and the durability of the treatment effects for resilience training. Resilience training in this study focused on a number of objectives: Instructing and promoting fundamental communication, attachment, goal-setting, and foresight skills; improving emotional problems; and increasing motivation, self-esteem, and self-worth. Performing interventions for improving students’ emotional problems seems completely necessary given the existence of negative emotional symptoms in the Iranian student population (Mohammadi & Amiri, 2010; Mohammadi, Fata, &Yazdandoost, 2009). It appears that paying attention to protective factors against mental health problems is one of the most effective approaches in this field. In this study, participants were taught communication and attachment skills. This instruction may be one of the reasons for the reduction of depression in resilience training. We know that emotions such as sadness, depression, jealousy, and loneliness are signs that indicate a life without high quality, satisfying intimate relationships; satisfying the need for affiliation promotes vitality and well-being and lessens loneliness and depression (Reeve, 2004). Participants also were taught goal-setting and foresight techniques. Individuals who have a goal generally function better than those without a goal. Therefore, individuals who set a goal for themselves, or those who accept goals others set for them, perform better than those without a goal. Difficult specific goals enhance performance by energizing effort and persistence and directing one’s attention and strategy to achieving the task (Reeve, 2004). Since depressed people have poor social, academic, and work performance, this decline in performance can be improved indirectly through teaching purposefulness. Sense of efficacy is the ability to properly utilize individual facilities under various difficult situations. Perceived self-efficacy is the generative ability whereby the individual devises new ways of turning personal capabilities into productive performance. Self-efficacy skills were taught in this study and after self-efficacy beliefs are formed, they affect the person’s quality of performance in various ways (Bandura, 1997). In general, the more an individual expects to be able to carry out a task properly, the more likely he or she is to exert effort and persistence in the face of difficulties. Another resilience therapy approach used in this study was teaching self-esteem and self-worth skills, for the best way to increase motivation in others is to raise their self-esteem. The most important benefit of having high self-esteem is its protective role against depres-
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sion and anxiety (Orth, Robins, & Widaman, 2012). Anxiety and depression are usually seen together. Thus, the effect of this training on the resilience therapy group can be one of the causes of depression reduction. In addition to the above mentioned theoretical framework, resilience has positive effects on reducing depression and brings about deep positive personality effects. Resilience affects a person’s feelings and emotions, and is followed by a positive attitude change, leading to life satisfaction (Luthar, Cicchetti & Becker, 2000; Rutter, 1999). Some researchers believe that resilience is a type of selfhealing with positive emotional and cognitive outcomes that, in addition to higher life satisfaction, plays an important role in adaptability (Lazarus, 2001; Silliman, 1997; Waller, 2001). In many studies, increased mental health levels are shown to be the outcome of resilience (Hamarat, Thompson, Zabrucky, & Matheny, 2001; Inzlicht, Aronson, Good, & McKay, 2006; Lazarus, 2001; Silliman, 1997; Tugade & Fredrickson, 2004; Waller, 2001). Research shows that resilient individuals maintain adaptability and mental health in unpleasant situations and while experiencing negative emotions (Wolff, 1995). The foremost effect of increasing a person’s ability in resilience is the reduction of emotional and mental problems. Researchers believe that resilience, as a basic sense of self-control, enables individuals to draw on and access a list of coping strategies. This, in turn, has an important role in allowing individuals to confront stressful life events and acts as a shield-like source of resistance (Lazarus, 2001; Silliman, 1997) against negative feelings. Strengths and Weaknesses of the Study In order to prevent contamination of the interventions’ effects, this study was not randomized, which can be considered a limitation of this study. Another limitation was that the research was only carried out on female students in medical science majors. Therefore, in order to generalize the findings to the student population as a whole, similar studies must be carried out in other universities, with students of both genders, studying in various fields. The research’s strengths include the novelty of the research topic. Only the protective factors of resilience and cognition of individuals were taken into account. A focus on other protective factors (especially cultural and sub-cultural factors) is recommended for future research. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This research grant (Grant number 91p495) was acquired from the North Khorasan University of Medical Sciences on July 17, 2012 from the University Research Council and was approved by the University Ethics Committee on October 26, 2012. REFERENCES Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman.
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Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory –II. San Antonio, TX: Harcourt Brace. Cohn, M. A., Fredrickson, B. L., Brown, S. L., Mikels, J. A., & Conway, A. M. (2009). Happiness unpacked: Positive emotions increase life satisfaction by building resilience. Emotion, 9(3), 361–368. Corey, M. S., & Corey, G. (2006). Groups: Process and practice (7th ed.). Stamford, CT: Cengage Learning. Dobson, K., & Mohammadkhani, P. (2007). Psychometric features of Beck Depression-II questionnaire in a large sample with major depression. Journal of Rehabilitation, 8(2), 80–86. Ford, G. D. (2004). Prospective association of anxiety, depressive and addictive disorders with high utilization of primary, specialty and emergency medical cares. Social Science and Medicine, 58, 2145–2148. Free, M. L. (1999). Cognitive therapy in groups: Guidelines and resources for practice. New York, John Wiley. Geschwind, N., Nicolson, N. A., Peeters, F., Barge-Schaapveld, D., van Os, J., & Wichers, M. (2011). Early improvement in positive rather than negative emotion predicts remission from depression after pharmacotherapy. European Neuropsychopharmacology, 21, 241–247. Geschwind, N., Peeters, F., Jacobs, N., Delespaul, P., Derom, C., Thiery, E., van Os, J., & Wichers, M. (2010). Meeting risk with resilience: High daily life reward experience preserves mental health. Acta Psychiatrica Scandinavica, 122, 129–138. Grunert, S. L. (2008). The relationship between adult attachment style and resilience factors of hope and positive affect. Capella University, School of Psychology, ProQuest pub. Hamarat, E. R., Thompson, D. A., Zabrucky, K. M., & Matheny, K. B. (2001). Perceived stress and coping resource: Availability as predictors of life satisfaction in young, middle-aged, and older adults. Journal of Experimental Aging Research, 27, 181–196. Harmer, C. J., de Bodinat, C., Dawson, G. R., Dourish, C. T., Waldenmaier, L., Adams, S., Cowen, P. J., & Goodwin, G. M. (2010). Agomelatine facilitates positive versus negative affective processing in healthy volunteer models. Journal of Psychopharmacology, 25(9), 1159–1167. Hofmann, S. G., Asmundson, G. J., & Beck, A. T. (2013). The science of cognitive therapy. Behavior Therapy, 44(2), 199–212. Inzlicht, M., Aronson, J., Good, C., & McKay, L. (2006). A particular resiliency to threatening environments. Journal of Experimental Social Psychology, 42, 323–336. Jonghe, F., Hendriksen, M., Aalst, G., Kool, S., Van, R., Eijnen, E. et al. (2004). Psychotherapy alone and combined with pharmacotherapy in the treatment of depression. British Journal of Psychiatry, 189, 37–45. Lazarus, A. (2001). Ordinary magic: Resilience processes in development. Journal of American Psychology, 56, 227–238. Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562. Mohammadi, A., & Amiri, M. (2010). Behavioral activation for depression scale: Psychometric properties and confirmatory factor analysis for Persian version. Iranian Journal of Psychiatry and Clinical Psychology, 16(1), 65–73. Mohammadi, A., Fata, L., & Yazdandoost, R. (2009). Predictors of obsessivecompulsive symptoms in students. Iranian Journal of Psychiatry and Clinical Psychology, 15(3), 274–282. National Center on Addiction and Substance Abuse (CASA). (2003). Depression, Substance Abuse and College Student Engagement: A Review of the Literature. National Center on Addiction and Substance Abuse at Columbia University. Orth, U., Robins, R. W., & Widaman, K. F. (2012). Life-span development of self-esteem and its effects on important life outcomes. Journal of Personality and Social Psychology, 102(6), 1271. Paykel, E. S. (2007). Cognitive therapy in relapse prevention in depression. International Journal of Neuropsychopharmacology, 10(1), 131–136. Pour sardar, F., Abbas pour, Z., Abdizarrin, S., & Sangari, A. (2012). The effect of resiliency on mental health and life satisfaction: A psychological pattern
of well-being. Journal of Lorestan University of Medical Sciences, 14(1), 81–89. Prochaska, J. O., & Norcross, J. C. (2009). Systems of psychotherapy: A transtheoretical analysis. Pacific Grove, CA: Brooks Cole. Ravindran, A., Anisman, H., Merali, Z., Charbonneau, Y., Telner, J., Robert, J. et al. (1999). Treatment of primary dysthymia with group cognitive therapy and pharmacotherapy. Clinical symptoms and functional impairments. American Journal of Psychiatry, 156, 1608–1617. Rawlings, N., Norbury, R., Cowen, P., & Harmer, C. (2010). A single dose of mirtazapine modulates neural responses to emotional faces in healthy people. Psychopharmacology, 212(4), 625–634. Reeve, J. M. (2004).Understanding motivation and emotion. New York, NY: John Wiley & Sons. Rutter, M. (1999). Resilience concepts and findings: Implications for family therapy. Journal of Family Therapy, 21, 119–144. Sadock, B. J., & Sadock, V. A. (2007). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Baltimore, MD: Lippincott. Scott, J., Palmer, S., Paykel, E., Teasdale, J., & Hayhurst, H. (2003). Use of cognitive therapy for relapse prevention in chronic depression. British Journal of Psychiatry, 182, 221–227. Sharifi, V., Asadi, S. M., Mohammadi, M., Amini, H., Kavyani, H., Semnani, Y., Shabani, A., Shahrivar, Z., Davari Ashtyani, R., Hakim Shoushtari, M., Sedigh, A., & Jalali Roudsari, M. (2004). Reliability and applicability of the Persian version of the Structured Clinical Interview for DSM-IV (SCID). Journal of News in Cognitive Sciences, 6(1, 2), 8–22. Silliman, B. (1997). Vulnerable but invincible: High risk children from birth to adulthood. Journal Acta Paediatrica Supplement, 422, 103–105. Steinhardt, M., & Dolbier, C. (2008). Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. Journal of American College Health, 56(4), 445–453. Strunk, D. R., Cooper, A. A., Ryan, E. T., DeRubeis, R. J., & Hollon, S. D. (2012). The process of change in cognitive therapy for depression when combined with antidepressant medication: Predictors of early intersession symptom gains. Journal of Consulting and Clinical Psychology, 80(5), 730–738. Tugade, M. M., & Fredrickson, B. L. (2004). Resilient individuals use positive emotions to bounce back from negative emotional experiences. Journal of Personality and Social Psychology, 86, 320–333. Varcarolis, E., Elizabeth, M., Carson, U., & Shoemaker, U. (Eds.). (2006). Foundations of psychiatric mental health nursing: A clinical approach (5th ed.). Philadelphia, PA: Saunders Elsevier. Votta, E., & Manion, I. G. (2003). Depression in college students: Personality and coping factors. Journal of the American Academy of Child and Adolescent Psychiatry, 24, 775–785. Waller, M. A. (2001). Resilience in ecosystemic context: Evolution of the child. American Journal of Orthopsychiatry, 71, 290–297. Wichers, M. C., Barge-Schaapveld, D. Q. C. M., Nicolson, N. A., Peeters, F., de Vries, M., Mengelers, R., & van Os, J. (2009). Reduced stress sensitivity or increased reward experience: The psychological mechanism of response to antidepressant medication. Neuropsychopharmacology, 34, 923–931. Wichers, M. C., Myin-Germeys, I., Jacobs, N., Peeters, F., Kenis, G., Derom, C., Vlietinck, R., Delespaul, P., & van Os, J. (2007). Genetic risk of depression and stress-induced negative affect in daily life. British Journal of Psychiatry, 191, 218–223. Wichers, M. C., Peeters, F., Geschwind, N., Jacobs, N., Simons, C. J. P., Derom, C., Thiery, E., Delespaul, P. H., & van Os, J. (2010). Unveiling patterns of affective responses in daily life may improve outcome prediction in depression: A momentary assessment study. Journal of Affective Disorders, 124, 191–195. Wolff, S. (1995). The concept of resilience. Australian and New Zealand Journal of Psychiatry, 29, 565–574. Zarrinkelk, H. (2010). The effectiveness of training aspects of resiliency on reducing addiction acceptance and changing attitudes toward drug use among high school students in Tehran. Master’s thesis, Allame Tabatabayi University.
Effectiveness of Resilience Training versus Cognitive Therapy on Reduction of Depression in Female Iranian College Students Somayeh Zamirinejad and Seyed Kaveh Hojjat Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Islamic Republic of Iran Issues Ment Health Nurs Downloaded from informahealthcare.com by Drexel University on 10/03/14 For personal use only.
Mahmoud Golzari and Ahmad Borjali Allameh Tabatabayi University, Tehran, Islamic Republic of Iran
Arash Akaberi Addiction and Behavioral Sciences Research Center, North Khorasan University of Medical Sciences, Bojnurd, Islamic Republic of Iran
Depression is the most common mental illness among women. Its prevalence in women is two to three times that of men. The purpose of the present study was to evaluate the effectiveness of resilience training on the reduction of depression in female college students. This semi-empirical study was carried out with two experimental groups and one control group. The research sample was women with symptoms of depression who were 18–22 years of age and living in a college dormitory. One experimental group was given eight 90-minute resilience training sessions, while the other received eight 90-minute cognitive therapy sessions. The control group didn’t receive any interventions. The three groups under study were evaluated using the Beck II depression inventory before and after the interventions and two months after the treatment had ended. The three groups didn’t have significant differences in age, marital status, or depression scores on the pretest. The resilience training group and cognitive therapy group showed a significant decrease in the average depression score from pretest to posttest and from pretest to follow-up. The main effect of groups, stage, and interaction between groups and stage also were significant (all were p < 0.001). There was no significant difference between effectiveness of resilience training and cognitive therapy on depression but there was a significant difference between these two treatment groups and the control group. The effectiveness of resilience training was just as good as the effectiveness of cognitive therapy. The effects of resilience training on depression remained stable from the posttest to the follow-up, like that of cognitive therapy.
Address correspondence to Arash Akaberi, Addiction and Behavioral Sciences Research Center, Faculty of Medicine, North Khorasan University of Medical Sciences, South Shriati Avenue, Bojnurd, North Khorasan Province, Iran, E-mail: [email protected]; [email protected]
Mood disorders are very prevalent. The latest studies show that among mental disorders, major depressive disorder has the highest lifetime prevalence of about 17%. The annual occurrence rate of depression is 1.59% (1.89% women, 1.1% men) (Sadock & Sadock, 2007). Depression is the fourth cause of disability in the United States and is projected to become the second cause by the year 2020 (Varcarolis, Elizabeth, Carson & Shoemaker, 2006). A depressed mood, apathy, and disinterest are the main symptoms of depression. The patient may express feelings of sadness, despair, sorrow, and worthlessness. About two-thirds of all depressed patients think about suicide and almost 10–15% attempt suicide. The main complaints (almost 97%) of all patients with depression include energy reduction, disturbances in school and work achievement, and a decreased motivation for accepting new plans. About 80% of patients complain about sleep disorders and many face a decrease in appetite and weight. Some, however, may find an increase in appetite, weight, and sleep (Sadock & Sadock, 2007). Depression has a large effect on physical movement, pain perception, and general health in individuals (Ford, 2004). Some behaviorists believe that life events play the main or number one role in the outbreak of depression, while others believe it to have a limited role (Sadock & Sadock, 2007). Observations have shown that stressful life events often take place before the first period of the depression rather than its later periods. Stress leading to the first period of the depression causes lasting changes in the brain’s biological condition, putting the individual at an increased risk for developing future periods of depression even in the absence of outside stress (Sadock & Sadock, 2007). Due to several factors, including
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distance from family, living in a strange city, unsuitable environment, a lack of adequate hygiene and facilities, living with people from different cultures, and high costs of living without a source of income, living in a dorm can be a stressful life event that can lead to depressive disorders in students (Votta & Manion, 2003). In addition to causing severe physical problems and intensifying some symptoms, such as pain and side effects of treatments, depression decreases an individual’s abilities and adaptabilities. It also takes away the ability to make decisions and to take care of oneself, resulting in lack of independence. All of these factors lead to dependency, inability, and lack of confidence, which naturally have a negative effect on all life aspects of the individual and those around him, bringing about much damage to the individual and to the society as a whole (Bollinger, 2003). According to the cognitive theory proposed by Aaron T. Beck, depression is a result of specific cognitive distortions that exist in individuals who are more prone to depression. These distortions, called depressogenic schemata, are cognitive patterns that make the individual perceive internal and external data in a distorted way, under the effect of a previous experience. Cognitive therapy emphasizes uncovering cognitive distortions, which Beck believes to exist in depressive disorders. These distortions include selective attention to the negative aspects of events and the assumption that everything will end in a tragic way due to the individual’s unrealistic inferences. Cognitive therapy aims to relieve and reduce depression cycles through helping the patient identify and test negative thoughts; prevent relapse; find more flexible ways of thinking; and practice new cognitive and behavioral reactions (Sadock & Sadock, 2007). The goal of cognitive therapy is not to completely eliminate or manage these negative emotions. Rather, it aims at using the patient’s own ability for providing realistic and precise evaluation of situations they face. Cognitive techniques do not ask the patient to think positively. Rather they want the patient to think realistically (Hofmann, Asmundson, & Beck, 2013). The treatment process begins by teaching the client the cognitive model and the role of thoughts in forming emotions and behavior. Emphasis is put on the conceptualization of the patient’s problems, teaching him the cognitive model, and providing grounds for solving the patient’s problems. The next steps in the treatment process are for the therapist to help the client identify realistic goals for treatment and start to work on cognitive errors, automatic thoughts, and schemata, while the therapist models behavioral change. The therapist ultimately helps the client become his or her own therapist and prevent his or her own relapse (Hofmann, Asmundson, & Beck, 2013). In 1989, Dobson published a meta-analysis of the efficacy of Beck’s cognitive therapy for depression. He identified 28 studies that used a common outcome measure of depression and compared cognitive therapy with other psychotherapeutic modalities. The average effectiveness of cognitive therapy was very high. Clients treated with cognitive therapy felt better than 98% of the individuals in the control group. These results showed that cognitive
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therapy brings about more changes compared to no treatment, pharmacotherapy, behavior therapy, and other psychotherapies (Prochaska & Norcross, 2009). Although studies show that the use of antidepressants have an effect on the process of positive and negative emotions (Harmer et al., 2010; Rawlings, Norbury, Cowen, & Harmer, 2010), recent studies report that a change in positive emotions rather than negative emotions may be more effective in the improvement of depression. First, improvement of depression is linked to an increased ability in reward experience in everyday life, rather than the reduction of sensitivity to psychological distress (Wichers et al., 2009). Second, a high capacity for experiencing positive emotions in everyday life is related to a lower risk of developing depression and also higher resilience against the development of emotional symptoms (Geschwind et al., 2010; Wichers et al., 2007; Wichers et al., 2010). Psychological resilience is the ability to bounce back to a previous state of normal functioning after experiencing negative emotions (Tugade & Fredrickson, 2004). Recent studies show that positive, not negative, emotions are predictive of resilience (Cohn, Fredrickson, Brown, Mikels, & Conway, 2009). In addition, faster changes in positive feelings as compared to negative feelings are the best prediction for treatment (Geschwind, Nicolson, Peeters, Barge-Schaapveld, van Os, & Wichers, 2011). Researchers believe that resilience is a kind of self-recovery with positive emotional and cognitive outcomes, which in turn has an important role in achieving greater adaptability and life satisfaction (Luthar, Cicchetti, & Becker, 2000; Rutter, 1999). Resilience is applied to individuals who are exposed to the risk of depression but do not develop the disorder. We may be able to conclude that facing a risk factor is a prerequisite for getting damaged, but it is not enough. Resilience factors help the individual use existing capacities for achieving growth and success in life in difficult situations despite the presence of risk factors. It helps the person see challenges and tests as an opportunity for strengthening him- or herself and helps him or her pass any trials faced (Zarrinkelk, 2010). Researchers believe that resilience, as a basic sense of self-control, enables individuals to draw on and access a list of coping strategies. This, in turn, has an important role in allowing individuals to confront stressful life events and acts as a shield-like source of resistance (Lazarus, 2001; Silliman, 1997). Findings of a survey carried out by Pour sardar et al. (2012) verified the primary role of resilience in adaptability outcomes. These findings indicate the importance of the primacy of emotional change over attitude change. It can be said that an individual’s change of emotions may be followed by a change of attitude about life and one’s surroundings (Pour sardar, Abbas pour, Abdizarrin, & Sangari, 2012). In a recent study, Steinhardt & Dolbier (2008) examined the effectiveness of a resilience intervention designed to enhance resilience, individual coping strategies, and protective factors while reducing symptomatology related to increased academic stress. This study was carried out on 57 students were divided into experimental and control groups. Analysis of the data revealed significantly higher
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resilience scores, effective coping strategies, and scores on protective factor measures, and lower scores on symptomatology in the experimental group compared to the control group. The researchers concluded that using a resilience program curriculum can prove beneficial for students’ stress management and academic success (Grunert, 2008). We discussed the high prevalence of depression in society, especially among women, and the effects and costs of this common chronic illness on the individual’s social, academic, and work performance (which may ultimately become a burden on society). The mechanisms that make resilience help individuals better cope with stressful events, and subsequently minimize the risk of individuals developing psychological distress, can lead to faster recovery from difficult circumstances. Therefore, we tested the effect of a resilience skills enhancement program for females who had symptoms of depression. In order to evaluate the effectiveness of resilience training on the reduction of depression symptoms, cognitive therapy was chosen as a base for comparison. What we know about this issue is that cognitive therapy is an effective and recognized treatment for depression, and is the treatment of choice in most cases. Its effectiveness has been verified by numerous studies. But so far, the efficacy of resiliency training for the treatment of depression has not been addressed, and we do not know whether it can be effective in the treatment of depression. Therefore, this research was designed and carried out with the purpose of studying the effectiveness of resilience training on the reduction of depression in female college students. METHOD This study was carried out with three groups: a resilience training group, a cognitive therapy group, and a control group. The assessment of depression levels was carried out in three stages: pretest, posttest, and follow-up. The study’s population was girls living in the dormitories at North Khorasan University of Medical Sciences in the year 2012. The University students living in dormitories were invited to become familiar with the study using a call for participation in the project. First, the objectives of the study were completely explained to each individual who expressed interest. Those who showed continued interest in participating in the study were asked to fill out the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996), in order to identify those with some degree of depression. Potential participants also were asked for a contact number or e-mail address so that they could be reached if they met the inclusion criteria for participation in the group therapy study. Inclusion and Exclusion Criteria Criteria for inclusion in this study were: being a female student, living in the dormitory, providing consent for inclusion in the study, having a depression score of 19 or higher
on the BDI-II (Beck, Steer, & Brown, 1996), and not receiving any other psychotherapy during the group therapy sessions (in order to prevent interference and influences of outside factors on research results). Exclusion criteria for this study were: being discontented with continuing to be in the study, being absent from more than two group therapy sessions, or having severe depression (based on a psychiatrist’s diagnosis using the DSM-IV diagnostic interview) in which case psychotherapy alone would not be effective in its treatment. In this case, a combination of psychotherapy and pharmacotherapy is the suggested treatment (Sadock & Sadock, 2007). In studies where interventions are made through group therapy, if individuals in the group know each other and talk about the interventions at times other than group therapy sessions, it is possible that they will develop a sense of competition for better performance and for displaying a better image of themselves. In addition, they might talk about interventions and retell learnt techniques for one another. In such cases, it is said that the effect of one intervention has been contaminated by the effect of another intervention (Corey & Corey, 2006). In order to prevent both the contamination effect of the groups and a sense of competition between sample individuals, each group was selected from a different dormitory; the resilience training group was selected from dorm A; the cognitive therapy group from dorm B; those not chosen for the training groups were placed in the control group. The two dorms were exactly identical in terms of the students’ majors, semesters, and accommodations, and were both under the university’s coverage. Twelve individuals were assigned to each experimental group (resiliency group and cognitive group) and 14 individuals were non-randomly assigned to the control group. Individuals who were absent from more than two group therapy sessions were not included in the statistical analysis. Because these interventions took place at the dorm and students made up the sample four individuals from the resiliency group and three individuals from the cognitive group left the group sessions, reportedly because of university exams or to visit their families (Figure 1). In this research, depression is considered a symptom and the individual is assessed according to his score on the BDIII. Like the original version of this questionnaire, the BDI- II is composed of 21 items. For each item, the participant has to choose one of the four choices which correspond to the intensity of felt depressive symptoms. Each item is scored on a scale value of 0–3, and the whole inventory has a scope of 0–63. The BDI-II does not include four items from the original version and has additional items, instead. Also, the items “change in sleeping patterns” and “change in appetite” have been revised so that they are more sensitive to the severity of depression, because sleep and appetite symptoms may show different changes among various depressed individuals; individuals may experience either a decrease or increase in sleep and appetite and the addition of these items gives the possibility of better screening of
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Number of female students living in dormitory (n = 300) Assessed for eligibility (n = 170)
Enrollment
Assigned to Resilience Training Group (n = 12) Received Experimental Manipulation (n = 8) Did not receive Experimental Manipulation (n = 4) because of university exams and to visit the family
Assigned to Cognitive Therapy Group (n = 12) Received Experimental Manipulation (n = 9) Did not receive Experimental Manipulation (n = 3) because of university exams and to visit the family
Assigned to comparison group (n = 14); The comparison group did not receive any manipulation
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Lost to follow-up (n = 0) Discontinued participation (n = 0)
Follow-up
Analyzed (n = 9) Excluded from analysis (n = 0)
Analyzed (n = 14)
Analysis
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Excluded (total n = 131) because of BDI score < 19 Did not meet inclusion criteria (n = 1) because of chronic depression based on psychiatrist’s diagnosis using the DSMIV diagnostic interview
Analyzed (n = 8) Excluded from analysis (n = 0)
Excluded from analysis (n = 0)
FIGURE 1 Participants through Each Stage of the Study.
individuals. The 21 items in this inventory can be classified into three categories: emotional, cognitive, and physical symptoms. This questionnaire can be used with a population aged 13 and over (Beck et al., 1996). Results of studies carried out by Beck, Steer, and Brown show that this test has high consistency (Sharifi et al., 2004). The alpha coefficient obtained using the BDI-II was 0.92 for regular patients and 0.93 for students (Dobson & Mohammadkhani, 2007). Validity was obtained based on the convergent validity calculation method. For this purpose, the correlation coefficient of the scores obtained on the BDI-II and the Brief Symptom Inventory (BSI, with 6 items) depression scale was calculated (r = 0/873) (Dobson & Mohammadkhani, 2007). Members of the experimental groups were given psychotherapeutic interventions while members of the control group received no intervention. Both the resilience training group and the cognitive therapy group were given eight 90-minute sessions, which were held three times weekly. Group therapy is a form of psychotherapy in which carefully selected individuals with emotional problems take part in a group under the guidance of a trained therapist and help each other in modifying their
character. The group leader uses a variety of tactics and theoretical concepts and guides the group members’ interactions in a direction that leads to modification and improvement (Sadock & Sadock, 2007).
Resilience Training Resilience training was instructed based on self-awareness, self-esteem enchantment, goal setting, communication, and self-efficacy (Zarrinkelk, 2010). Self-awareness requires an understanding of components such as physical traits, feelings, thoughts, beliefs, values, goals, inner dialogue, and one’s strengths and weaknesses. To fulfill this purpose, participants were trained to identify these components in themselves and were given the task of describing themselves as they are and as they would like to be. In order to promote self-esteem, an individual must first know what things give him or her a good feeling, and plan in a way to actualize those events in life. To achieve this goal, individuals were taught to turn negative self-talk into positive self-talk, make positive assessments (in order to see the positive aspects
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of performed activities), perform enjoyable activities, and set and reach achievable goals (which helps promote self-esteem). Individuals also were trained on strategies for setting goals (such as listing them on paper); having a purpose in various aspects of life; having more than one way of reaching a goal; prioritizing goals; and breaking big goals into small ones. They also were taught the characteristics of a good goal: being objective, having an end point, and being such that those around them notice a change in them for reaching that goal. They were instructed on how to communicate effectively, through the introduction of the elements of a successful relationship, such as trust, sympathy, acceptance, and active listening, and also were taught about obstacles to communication and rules for dispute settling. Self-efficacy promotion was achieved by individual work on self-efficacy sources. According to Bandura (1977), selfefficacy sources are performance accomplishments, vicarious experiences, verbal persuasion, and emotional arousal. Cognitive Training Cognitive Training (CT) was carried out based on Guidelines and Resources for Practice in Cognitive Therapy in Groups (Free, 1999). In the CT group, the ABC (A: Activating Event—the actual event and the client’s immediate interpretations of the event; B: Beliefs—about the event [this evaluation can be rational or irrational]; C: Consequences—how you feel and what you do or other thoughts) model was taught so that participants understand that physiologic, cognitive, and behavioral processes in human beings are interrelated, and to find out how different beliefs about one activating event determines the emotions they experience. The main aspects of cognitive theory about depression also were taught, namely the following four thought patterns: 1. Negative automatic thoughts are the thoughts people repeat in similar situations. 2. Negative core beliefs, or schemas, are more general than negative automatic thoughts and reflect the overall attitude of a person toward life. 3. Negative automatic thoughts and negative core beliefs create negative content, or a negative cognitive triangle about oneself, the world, and the future. 4. Negative automatic thoughts, core beliefs, and content lead to logic errors that cause a person’s reasoning process to conclude negatively about events he or she experiences. Individuals in the CT group also were trained on the nature of schemas, the relationship between schemas and automatic thoughts, and identifying schemas through the vertical arrow technique. By asking questions such as “What was the meaning of that event for me?” or “Why should it be that disturbing or painful?” participants can follow their stream of thoughts to reach their core beliefs. To ensure reaching one’s core belief, the stream of questions about one’s thoughts must be followed until the final state is expressed as an absolute statement such
as, “I am worthless.” Participants were trained to identify ten types of negative schemas and to classify their beliefs into these categories. Participants were supposed to make a list of their negative beliefs and draw a cognitive map about how they relate to each other. In the vertical arrow technique, some beliefs are shallow and depend on the situation while others are on lower levels, which are more general and more definite, known as core beliefs or schemas. So, participants had to provide two lists: situation-related beliefs and core beliefs. Then, in order to organize these beliefs participants created a cognitive map. Automatic thoughts, which are on the surface, are related to other automatic thoughts and deeper beliefs. The closer the automatic thought is to the core belief, the more likely it is to activate that core belief and cause an intense emotion. Another way to organize beliefs is to rate them as subjective units of disturbance on a 100-degree scale, with 100 being the most disturbing belief and zero being the least disturbing one. Also participants were helped to understand that beliefs aren’t immutable. Just as dominant cultural beliefs have changed over time, one’s own beliefs can also change; it only takes time. Samples of scientific and legal processes were provided to show participants how they could detect facts based on evidence. Individuals had to learn that they could evaluate their beliefs through certain criteria, and that beliefs can differ in efficacy. Knowing the consistency and compatibility of one’s beliefs with others does not make those beliefs true. Once this part of the training was complete, participants had to evaluate their lists of beliefs. The next step in the training was to teach the logical analysis method, which is the most powerful method for challenging beliefs. This method is similar to the scientific method in which one has to clarify the problem, define the terms and rules, collect evidence, and then make a conclusion. Finally, participants had to provide some counter beliefs for their negative beliefs. Counter beliefs must be direct and opposite to negative beliefs, use logic, and be liable statements that are brief, assertive, with intense emotion, and powerful.
Statistical Analyses In this study Chi-squared tests were used to compare qualitative variables in the three groups, and the means from the three groups were compared using the one way analysis of variance and Bonferroni post hoc test. In order to evaluate the effect of interventions in the resilience therapy group with the cognitive therapy and the control groups, repeated measures analysis of variance was used. In the RMANOVA, the stages’ effects and interaction between stages and groups was evaluated using the sphericity assumed test, given the results of Mauchly’s sphericity test. Comparison of the groups’ effectiveness was calculated using the interaction between group and stage. Results pertaining to
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EFFECTIVENESS OF RESILIENCE TRAINING ON DEPRESSION.
TABLE 1 Comparison of Baseline Characteristics of Individuals Under Study, Separated into Three Groups of Resilience Training, Cognitive Therapy, and Control Group
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Group Resilience Training
Cognitive Therapy
Control
p-value
Age Mean ± SD
21.50 ± 1.20
20.78 ± 1.30
20.23 ± 1.167
0.085
Marital status Single n (%) Married n (%) Depression score on pretest Mean ± SD
7 (87.5%) 1 (12.5%) 24.63 ± 4.41
9 (100%) 0 (0%) 24.89 ± 4.83
10 (76.9%) 3 (23.1%) 26.08 ± 5.72
0.343
the group’s main effect and time also were reported. The effect size and partial eta square was reported for each effect and each parameter estimate. The eta square statistic describes the proportion of total variability attributable to a factor. All the description and analysis of the data was done using SPSS 20 software. A significance level of 0.05 was chosen for this study. RESULTS Baseline Demographic Data At pretest, there was no significant difference in the mean age of the participants (p = 0.085), marital status (p = 0.343), or in the average depression score (p = 0.0785) of the three groups under study (Table 1). Analytical Results The average depression score in the resilience training group and cognitive group showed a dramatic and significant reduction from the pretest to the posttest and at follow-up (Table 2). In the resilience training group, a reduction of the mean depression score was seen from the pretest to the posttest (13.00 ± 3.55) and from the pretest to the follow-up (14.38 ± 4.37). This reduction in the cognitive group was 11.78 ± 3.11 from the pretest to the posttest and 13.78 ± 7.14from the pretest to the follow-up.
0.785
The groups’ main effect on the depression score was significant (F(2.27) = 14.9, p < 0.001). With the effect size being eta-squared = 0.525 (Table 3). The stages’ main effect (the three stages of pretest, posttest, and follow-up) on the depression score was significant (FSphericity Assumed (2.54) = 62.2, p < 0.001) and the effect size was eta-squared = 0.697. Interaction effect among groups and stages was significant (FSphericity Assumed (4.54) = 5.96, p < 0.001) with an effect size of eta-squared = 0.306 (Table 4). Comparisons of adjusted means using the Bonferroni test reflected a significant reduction of mean depression scores from the pretest to posttest (mean difference = –8.95, p < 0.001). It also showed a significant reduction of mean depression scores from the pretest to the follow-up (mean difference = –11.62, p < 0.001). In addition the mean depression score from the posttest to the follow-up also was reduced (mean difference = –2.74, p = 0.078) although this reduction was statistically insignificant. Overall the difference between the three groups’ means was statistically significant with a notable effect size of p < 0.001and eta-squared = 0.697. The Bonferroni post-hoc test displayed no significant difference between the resilience group and the cognitive group (mean difference = 0.87, p = 1) but there was a significant difference between the resilience group and the control group (mean difference = 7.58, p = 0.002). A significant difference
TABLE 2 Depression Score Means and Standard Deviation in Resilience Training, Cognitive Therapy, and Control Groups in the Pretest, Posttest, and Follow-Up Stages Group Stage Pretest Posttest Follow-up
Resilience Training Mean ± SD
Cognitive Therapy Mean ± SD
Control Mean ± SD
24.63 ± 4.41 11.63 ± 3.16 10.25 ± 3.54
24.89 ± 4.83 13.11 ± 6.81 11.11 ± 3.82
26.08 ± 5.72 24.00 ± 4.93 19.15 ± 5.01
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TABLE 3 The Main Effect of Group with Repeated Measures Analysis of Variance
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Intercept Group Error
Sum of Squares
df
Mean Square
F
p-value
Partial Eta Squared
28934.91 1128.76 1021.73
1 2 27
28934.91 564.38 37.84
764.63 14.91
< 0.001 < 0.001
0.966 0.525
was seen between the cognitive group and the control group (mean difference = 6.7, p = 0.001). Upon comparing the effectiveness of the resiliency group with that of the control group, it was concluded that the interaction between the group and stages was significant (FSphericity Assumed (2, 38) = 10.053, p < 0.001) with an effect size of eta-square = 0.346. Also, after comparing the effectiveness of the two groups of resiliency and cognitive therapy, it was concluded that the interaction between the group and stages was not statistically significant (FSphericity Assumed (2, 30) = 0.108, p = 0.898) with an effect size of eta-square = 0.007. The three groups’ means were compared in the posttest stage, and a significant difference was seen (F(2.27) = 18.4, p < 0.001). The Bonferroni post-hoc test used for two-by-two comparison of groups showed that the mean depression score of the resilience group was significantly lower than that of the control group (mean difference = 12.37, p < 0.001) and likewise the mean depression score of the cognitive group was significantly lower than that of the control group (mean difference = 10.89, p < 0.001). However, the resilience group and cognitive groups’ main depression scores did not have a significant difference (mean difference = 1.49, p = 1). DISCUSSION This research showed that in the population under study, the effectiveness of the resiliency group therapy was just as good as the effectiveness of the cognitive group therapy. No significant difference was seen between the resilience training group and the cognitive training group. The effectiveness of the resilience training was significantly higher than the control group. The effects of resiliency group therapy on depression remained stable from the posttest to the follow-up, like that of cognitive group therapy.
Results from this research show that cognitive therapy measures were effective in the treatment of depressive disorders. Research by Scott and colleagues (Scott, Palmer, Paykel, Teasdale, & Hayhurst, 2003) has shown that cognitive therapy is a beneficial and proven treatment for depression. Depression relapse is one of the difficulties of treating this illness, and studies show that cognitive therapy has a more durable effect in the treatment of depression. In this study, we witnessed a moderate reduction in the cognitive therapy group’s mean depression score, which reflects the durable effects of this treatment on the reduction of depression scores. In a six year follow-up of patients with depression who had received cognitive therapy treatment, Jonghe et al. (2004) concluded that cognitive therapy measures effectively reduce the risk of depression relapse (Paykel, 2007). In the study by Scott et al., 158 patients with depression were treated with cognitive therapy measures; patients’ illness relapse rates were significantly reduced (47%) compared to the control group (Scott et al., 2003). After comparing cognitive therapy and pharmacotherapy, Ravindran et al. (1999) also reported that cognitive therapy methods are more effective for patients with depression. Strunk and colleagues (Strunk, Cooper, Ryan, DeRubeis, & Hollon, 2012) also noticed that patients treated with cognitive therapy responded to treatment better than patients who were treated solely with pharmacotherapy. Results from all cited research are in line with the outcomes of the present study, which confirms that cognitive therapy is the treatment of choice for depression and is a good basis of comparison for evaluating the effectiveness of other treatment methods on depression. Therefore in this research, cognitive therapy was chosen as a criterion for studying the effectiveness of resilience. In the resilience training group, the mean depression score from the pretest to the posttest (–13.0 ± 3.55) shows a greater decrease than in the cognitive group (–11.78 ± 3.11). The extent of decrease in the two groups’ means was considerable
TABLE 4 The Main Effect of Time and Interaction Effect between Groups and Time with Repeated Measures Analysis of Variance
Stage Interaction Effect between Group and Stage Error
Sum of Squares
df
Mean Square
F
p-value
Partial Eta Squared
2150.01 411.71
2 4
1075.00 102.93
62.23 5.96
< 0.001 < 0.001
.697 .306
932.80
54
17.27
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EFFECTIVENESS OF RESILIENCE TRAINING ON DEPRESSION.
and significant. However, the decrease between the two groups was not significant. When we look at depression score means in the follow-up and compare them with the pretest and posttest means, we can see a similarity between the resilience training and cognitive therapy groups. This is such that depression score means from the posttest to the follow-up also show a rate of reduction (a 1.38 unit decrease in the resilience group and a 2.0 unit decrease in the cognitive group). This illustrates the durability and effectiveness of both resilience and cognitive interventions. Since the cognitive method has been shown to be the treatment of choice for depression, the achieved results confirm the effectiveness of resilience as another treatment for depression and the durability of the treatment effects for resilience training. Resilience training in this study focused on a number of objectives: Instructing and promoting fundamental communication, attachment, goal-setting, and foresight skills; improving emotional problems; and increasing motivation, self-esteem, and self-worth. Performing interventions for improving students’ emotional problems seems completely necessary given the existence of negative emotional symptoms in the Iranian student population (Mohammadi & Amiri, 2010; Mohammadi, Fata, &Yazdandoost, 2009). It appears that paying attention to protective factors against mental health problems is one of the most effective approaches in this field. In this study, participants were taught communication and attachment skills. This instruction may be one of the reasons for the reduction of depression in resilience training. We know that emotions such as sadness, depression, jealousy, and loneliness are signs that indicate a life without high quality, satisfying intimate relationships; satisfying the need for affiliation promotes vitality and well-being and lessens loneliness and depression (Reeve, 2004). Participants also were taught goal-setting and foresight techniques. Individuals who have a goal generally function better than those without a goal. Therefore, individuals who set a goal for themselves, or those who accept goals others set for them, perform better than those without a goal. Difficult specific goals enhance performance by energizing effort and persistence and directing one’s attention and strategy to achieving the task (Reeve, 2004). Since depressed people have poor social, academic, and work performance, this decline in performance can be improved indirectly through teaching purposefulness. Sense of efficacy is the ability to properly utilize individual facilities under various difficult situations. Perceived self-efficacy is the generative ability whereby the individual devises new ways of turning personal capabilities into productive performance. Self-efficacy skills were taught in this study and after self-efficacy beliefs are formed, they affect the person’s quality of performance in various ways (Bandura, 1997). In general, the more an individual expects to be able to carry out a task properly, the more likely he or she is to exert effort and persistence in the face of difficulties. Another resilience therapy approach used in this study was teaching self-esteem and self-worth skills, for the best way to increase motivation in others is to raise their self-esteem. The most important benefit of having high self-esteem is its protective role against depres-
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sion and anxiety (Orth, Robins, & Widaman, 2012). Anxiety and depression are usually seen together. Thus, the effect of this training on the resilience therapy group can be one of the causes of depression reduction. In addition to the above mentioned theoretical framework, resilience has positive effects on reducing depression and brings about deep positive personality effects. Resilience affects a person’s feelings and emotions, and is followed by a positive attitude change, leading to life satisfaction (Luthar, Cicchetti & Becker, 2000; Rutter, 1999). Some researchers believe that resilience is a type of selfhealing with positive emotional and cognitive outcomes that, in addition to higher life satisfaction, plays an important role in adaptability (Lazarus, 2001; Silliman, 1997; Waller, 2001). In many studies, increased mental health levels are shown to be the outcome of resilience (Hamarat, Thompson, Zabrucky, & Matheny, 2001; Inzlicht, Aronson, Good, & McKay, 2006; Lazarus, 2001; Silliman, 1997; Tugade & Fredrickson, 2004; Waller, 2001). Research shows that resilient individuals maintain adaptability and mental health in unpleasant situations and while experiencing negative emotions (Wolff, 1995). The foremost effect of increasing a person’s ability in resilience is the reduction of emotional and mental problems. Researchers believe that resilience, as a basic sense of self-control, enables individuals to draw on and access a list of coping strategies. This, in turn, has an important role in allowing individuals to confront stressful life events and acts as a shield-like source of resistance (Lazarus, 2001; Silliman, 1997) against negative feelings. Strengths and Weaknesses of the Study In order to prevent contamination of the interventions’ effects, this study was not randomized, which can be considered a limitation of this study. Another limitation was that the research was only carried out on female students in medical science majors. Therefore, in order to generalize the findings to the student population as a whole, similar studies must be carried out in other universities, with students of both genders, studying in various fields. The research’s strengths include the novelty of the research topic. Only the protective factors of resilience and cognition of individuals were taken into account. A focus on other protective factors (especially cultural and sub-cultural factors) is recommended for future research. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This research grant (Grant number 91p495) was acquired from the North Khorasan University of Medical Sciences on July 17, 2012 from the University Research Council and was approved by the University Ethics Committee on October 26, 2012. REFERENCES Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman.
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