Document Type : Research Article

Authors

Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran

Abstract

Background: Research has shown that the incidence of psychological well-being problems among students is on an increasing trend. According to the Pennsylvania State University Center for Public Health Psychology, the number of students seeking mental health help rose by 50% between 2015 and 2016. The present study was conducted to compare the effectiveness of group acceptance and commitment therapy (ACT) matrix with group Behavioral Activation Therapy on quality of life and Alexithymia in depress mood females.
Methods: In a quasi-experimental pre-test-post-test design with a control group, 45 students with mood depressive disorder were selected following initial clinical evaluation and research conditions. They were randomly divided into three groups of Behavioral Activation Therapy (n=15), ACT matrix (n=15), and control (n=15). The experimental group received six sessions of weekly treatment based on acceptance and commitment employing matrix method with group Behavioral Activation Therapy. All the participants completed the Hamilton Depression Scale, the World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), and the Alexithymia Scale (AAS-26), in three stages: pre-test, post-test, and one-month follow-up. The obtained data were analyzed using SPSS V. 23
Results: The results revealed that weekly treatment based on acceptance and commitment employing matrix method with group Behavioral Activation treatment positively affected the quality of life F=6.324; P=0.004), and reduced Alexithymia-associated symptoms (F=1.780; P=0.181). The results were maintained in the one-month follow-up phase.
Conclusion: Group psychotherapy based on acceptance and commitment through matrix method with group Behavioral Activation Therapy had a significant effect on increasing the quality of life and reducing the symptoms associated with Alexithymia in depressed females.

Keywords

1. Auerbach RP, Mortier P, Bruffaerts R, Alonso J, Benjet C, Cuijpers P, et al. WHO World Mental Health Surveys International College Student Project: Prevalence and distribution of mental disorders. J Abnorm Psychol. 2018;127(7):623. doi: 10.1037/abn0000362.PubMed PMID: 30211576; PubMed Central PMCID: PMC6193834. ## 2. January J, Madhombiro M, Chipamaunga S, Ray S, Chingono A, Abas M. Prevalence of depression and anxiety among undergraduate university students in low-and middle-income countries: a systematic review protocol. Syst Rev. 2018;7(1):57. doi: 10.1186/s13643-018-0723-8. PubMed PMID: 29636088; PubMed Central PMCID: PMC5894225. ## 3. Mayer FB, Santos IS, Silveira PS, Lopes MH, de Souza AR, Campos EP, de Abreu BA, Hoffman II I, Magalhães CR, Lima MC, Almeida R. Factors associated to depression and anxiety in medical students: a multicenter study. BMC Medical Education. 2016;16(1):282. doi: 10.1186/s12909-016-0791-1. PubMed PMID: 27784316; PubMed Central PMCID: PMC5080800. ## 4. Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, et al. Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA psychiatry. 2016;73(2):150-8. doi: 10.1001/jamapsychiatry.2015.2688. PubMed PMID: 26719969; PubMed Central PMCID: PMC5333921. ## 5. Ryff CD. Beyond Ponce de Leon and life satisfaction: New directions in quest of successful ageing. International journal of behavioral development. 1989;12(1):35-55.doi: 10.1177/016502548901200102. ## 6. Burns RA. The utility of between-nation subjective wellbeing comparisons amongst nations within the European Social Survey. Journal of Happiness Studies. 2019;20(3):683-705.doi: 10.1007/s10902-018-9964-4. ## 7. Fonseca X, Lukosch S, Brazier F. Social cohesion revisited: a new definition and how to characterize it. Innovation: The European Journal of Social Science Research. 2019;32(2):231-53.doi: 10.1080/13511610.2018.1497480. ## 8. Mc Gee SL, Höltge J, Maercker A, Thoma MV. Sense of coherence and stress-related resilience: Investigating the mediating and moderating mechanisms in the development of resilience following stress or adversity. Front Psychiatry. 2018;9:378. doi: 10.3389/fpsyt.2018.00378. PubMed PMID: 30186189; PubMed Central PMCID: PMC6110848. ## 9. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976-. doi: 10.1001/jamanetworkopen.2020.3976. PubMed PMID: 32202646; PubMed Central PMCID: PMC7090843. ## 10. Gigantesco A, Fagnani C, Toccaceli V, Stazi MA, Lucidi F, Violani C, et al. The relationship between satisfaction with life and depression symptoms by gender. Front Psychiatry. 2019;10:419. doi: 10.3389/fpsyt.2019.00419. PubMed PMID: 31258495; PubMed Central PMCID: PMC6588028. ## 11. Mohammadzadeh J, Mami S, Omidi K. Mean Scores of Depression, Anxiety and Stress in Iranian University Students Based on DASS-21: A Systematic Review and Meta-analysis. International Journal of Epidemiologic Research. 2019;6(1):42-8. doi:10.15171/ijer.2019.08. ## 12. Hemming L, Haddock G, Shaw J, Pratt D. Alexithymia and its associations with depression, suicidality, and aggression: an overview of the literature. Front Psychiatry. 2019;10:203. doi: 10.3389/fpsyt.2019.00203. PubMed PMID: 31031655; PubMed Central PMCID: PMC6470633. ## 13. Panasiti MS, Ponsi G, Violani C. Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis. Frontiers in Psychology. 2020;11:836. doi: 10.3389/fpsyg.2020.00836. PubMed PMID: 32508706; PubMed Central PMCID: PMC7248221. ## 14. Zakhour M, Haddad C, Salameh P, Akel M, Fares K, Sacre H, et al. Impact of the interaction between alexithymia and the adult attachment styles in participants with alcohol use disorder. Alcohol. 2020;83:1-8. doi: 10.1016/j.alcohol.2019.08.007. PubMed PMID: 31476366. ## 15. Alzahrani SH, Coumaravelou S, Mahmoud I, Beshawri J, Algethami M. Prevalence of alexithymia and associated factors among medical students at King Abdulaziz University: a cross-sectional study. Ann Saudi Med. 2020;40(1):55-62. doi: 10.5144/0256-4947.2020.55. PubMed PMID: 32026718; PubMed Central PMCID: PMC7012024. ## 16. Pinna F, Manchia M, Paribello P, Carpiniello B. The impact of alexithymia on treatment response in psychiatric disorders: a systematic review. Front Psychiatry. 2020;11:311. doi:10.3389/fpsyt.2020.00311. PubMed PMID: 32372987; PubMed Central PMCID: PMC7177022. ## 17. Serafini G, De Berardis D, Valchera A, Canepa G, Geoffroy PA, Pompili M, et al. Alexithymia as a possible specifier of adverse outcomes: Clinical correlates in euthymic unipolar individuals. J Affect Disord . 2020;263:428-36. doi: 10.1016/j.jad.2019.10.046. PubMed PMID: 31969274. ## 18. Obeid S, Akel M, Haddad C, Fares K, Sacre H, Salameh P, et al. Factors associated with alcohol use disorder: the role of depression, anxiety, stress, alexithymia and work fatigue-a population study in Lebanon. BMC public health. 2020;20(1):1-1. doi: 10.1186/s12889-020-8345-1. PubMed PMID: 32070314; PubMed Central PMCID: PMC7029557. ## 19. De Berardis D, Fornaro M, Valchera A, Rapini G, Di Natale S, De Lauretis I, et al. Alexithymia, resilience, somatic sensations and their relationships with suicide ideation in drug naïve patients with first‐episode major depression: An exploratory study in the “real world” everyday clinical practice. Early intervention in psychiatry.2020;14(3) 336-342.doi: 10.1111/eip.12863. ## 20. Chen G, He J, Zhang B, Fan X. Revisiting the relationship between body dissatisfaction and eating disorder symptoms in Chinese adolescents: the mediating roles of regulatory emotional self-efficacy and depression symptoms. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity. 2020 20:1-9. doi: 10.1007/s40519-020-00848-0. PubMed PMID: 31960348. ## 21. Testoni I, Bonelli B, Biancalani G, Zuliani L, Nava FA. Psychodrama in attenuated custody prison-based treatment of substance dependence: The promotion of changes in wellbeing, spontaneity, perceived self-efficacy, and alexithymia. The Arts in Psychotherapy. 2020;68.101650.doi: 10.1016/j.aip.2020.101650. ## 22. Taylor GJ, Bagby RM, Parker JD. What’s in the name ‘alexithymia’? A commentary on “Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy.” Neurosci Biobehav Rev . 2016;68:1006-20. doi: 10.1016/j.neubiorev.2016.05.025. PubMed PMID: 27235080. ## 23. Motamedi H, Samavi A, Fallahchai R. Investigating and Comparing the Effectiveness of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy on Emotional Self-efficacy of Family Headed Women. Iranian Evolutionary and Educational Psychology Journal. 2019;1(2):123-34.doi: 10.29252/IEEPJ.1.2.123. ## 24. Mirsharifa SM, Mirzaian B, Dousti Y. The Efficacy of Acceptance and Commitment Therapy (ACT) Matrix on Anxiety and Quality Of Life of Patients with Irritable Bowel Syndrome. International Journal of Medical Investigation. 2019;8(1):19-30. ## 25. Pirani Z, Abbasi M, Kalvani M, Nourbakhsh M. Effectiveness of Acceptance and Commitment Therapy on Sexual Self-Esteem, Emotional Skillfulness and Marital Adjustment in Veterans’ Wives. Iranian Journal of War and Public Health.;9(1):25-32. ## 26. Darvish Baseri L, DashtBozorgi Z. Effectiveness of group therapy based on acceptance and commitment on cognitive emotion regulation and alexithymia of patients with type 2 diabetes. Iranian Journal of Psychiatric Nursing. 2017;5(1):7-14.doi: 10.21859/ijpn-05012. ## 27. Rostami R, Dasht Bozorgi Z. Effectiveness of Acceptance and Commitment Therapy on Resiliency and Alexithymia of Somatic Symptoms. Practice in Clinical Psychology. 2019;7(2):87-94.doi: 10.32598/jpcp.7.2.87. ## 28. AghaYousefi A, Javanmard G, Mohammadi R. Brain Behavioral Inhibition and Activation Systems (BIS/BAS) and Hemispheric Dominance in People with and without Alexithymia. Scientific Journal of Clinical Psychology & Personality. 2018;16(1):141-9.doi: 10.22070/cpap.2020.2843. ## 29. Khaledinia A, Makvandi B, Asgari P, Pasha R. Comparative Effect of Behavioral Activation Treatment for Depression and Acceptance and Commitment Therapy Matrix on the Depression of College Students. Avicenna J Neuro Psycho Physiology. 2018; 5 (2) :63-72.doi: 10.32598/ajnpp.5.2.63. ## 30. Samur D, Tops M, Schlinkert C, Quirin M, Cuijpers P, Koole SL. Four decades of research on alexithymia: moving toward clinical applications. Front Psychol. 2013;4:861. doi: 10.3389/fpsyg.2013.00861. PubMed PMID: 24312069; PubMed Central PMCID: PMC3832802. ## 31. Panayiotou G, Leonidou C, Constantinou E, Hart J, Rinehart KL, Sy JT, et al. Do alexithymic individuals avoid their feelings? Experiential avoidance mediates the association between alexithymia, psychosomatic, and depressive symptoms in a community and a clinical sample. Comprehensive psychiatry. 2015;56:206-16. doi: 10.1016/j.comppsych.2014.09.006. PubMed PMID: 25263517. ## 32. Waller KG, Shaw RW. Endometriosis, pelvic pain, and psychological functioning. Fertil Steril. 1995;63(4):796–800. doi: 10.1016/s0015-0282(16)57484-6. PubMed PMID: 7890065. ## 33. Polk KL, Schoendorff B, Webster M, Olaz FO. The essential guide to the ACT Matrix: A step-by-step approach to using the ACT Matrix model in clinical practice. New Harbinger Publications; 2016. ## 34. Lejuez CW, Hopko DR, Hopko SD. A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification. 2001;25(2):255-86. doi: 10.1177/0145445501252005. PubMed PMID: 11317637. ## 35. First MB, Spitzer RL, Gibbon M, Williams JB. User’s guide for the Structured clinical interview for DSM-IV axis I disorders SCID-I: clinician version. American Psychiatric Pub; 1997. ## 36. Sharifi V, Asadi SM, Mohammadi MR, Amini H, Kaviani H, Semnani Y, et al. Reliability and feasibility of the Persian version of the structured diagnostic interview for DSM-IV (SCID). Advances in cognitive science. 2004;6(1):10-22. ## 37. Nejat SA, Montazeri A, Holakouie Naieni K, Mohammad KA, Majdzadeh SR. The World Health Organization quality of Life (WHOQOL-BREF) questionnaire: Translation and validation study of the Iranian version. Journal of school of public health and institute of public health research. 2006;4(4):1-2. ## 38. Makvandi B, Haydarei AR, Shehni Yailagh M, Najarian B, Askery P. Construction and validation of a scale for the measurement of alexithymia in university student. Journal of American Science. 2011;7(12):325 29. ## 39. Bai Z, Luo S, Zhang L, Wu S, Chi I. Acceptance and commitment therapy (ACT) to reduce depression: a systematic review and meta-analysis. Journal of Affective Disorders. 2020;260:728-37. doi: 10.1016/j.jad.2019.09.040. PubMed PMID: 31563072. ## 40. Li J, Long L, Liu Y, He W, Li M. Effects of a mindfulness-based intervention on fertility quality of life and pregnancy rates among women subjected to first in vitro fertilization treatment. Behaviour research and therapy. 2016; 77:96-104. doi: 10.1016/j.brat.2015.12.010. PubMed PMID: 26742022. ## 41. Fernández EN, Mairal JB. Behavioral activation versus cognitive restructuring to reduce automatic negative thoughts in anxiety generating situations. Psicothema. 2017;29(2):172-7. doi: 10.7334/psicothema2016.325. PubMed PMID: 28438238. ## 42. Broderick PC. Mindfulness and coping with dysphoric mood: Contrasts with rumination and distraction. Cognitive Therapy and Research. 2005;29(5):501-10.doi: 10.1007/s10608-005-3888-0. 43. Eisanezhad Boshehri S, Dasht Bozorgi Z. Effectiveness of Behavioral Activation Treatment in Reduction of Anxiety and Depression of Premenopausal Women. The Neuroscience Journal of Shefaye Khatam. 2018;6(1):19-26. ## 44. Shareh H. Effectiveness of behavioral activation group therapy on attributional styles, depression, and quality of life in women with breast cancer. Journal of fundamentals of mental health. 2016;18(4):179-88. ## 45. Fernández-Rodríguez C, Villoria-Fernández E, Fernández-García P, González-Fernández S, Pérez-Álvarez M. Effects of behavioral activation on the quality of life and emotional state of lung cancer and breast cancer patients during chemotherapy treatment. Behavior modification. 2019;43(2):151-80. doi: 10.1177/0145445517746915. PubMed PMID: 29276837. ## 46. Lejuez CW, Hopko DR, Acierno R, Daughters SB, Pagoto SL. Ten-year revision of the brief behavioral activation treatment for depression: revised treatment manual. Behav Modif . 2011;35(2):111-61. doi: 10.1177/0145445510390929. PubMed PMID: 21324944. ## 47. Alijanzadeh Tonkaboni M, Bagheri M. Comparative examine of effectiveness of training behavioral activation and education based on acceptance and commitment on increasing psychological well-being among high school boy students of Grade nine in Kerman. Shenakht Journal of Psychology and Psychiatry. 2019; 6 (1): 75-86 .doi: 10.29252/shenakht.6.1.75. ## 48. King LA, Emmons RA. Conflict over emotional expression: Psychological and physical correlates. Journal of personality and social psychology. 1990;58(5):864. doi: 10.1037//0022-3514.58.5.864. PubMed PMID: 2348373. ## 49. Dimidjian S, Barrera Jr M, Martell C, Muñoz RF, Lewinsohn PM. The origins and current status of behavioral activation treatments for depression. Annual review of clinical psychology. 2011; 7:1-38. doi: 10.1146/annurev-clinpsy-032210-104535. PubMed PMID: 21275642. ## 50. McNeely C, Bose K. Adolescent social and emotional development: A developmental science perspective on adolescent human rights. Human rights and adolescence. 2014;102-24. ## 51. Venta A, Hart J, Sharp C. The relation between experiential avoidance, alexithymia and emotion regulation in inpatient adolescents. Clinical child psychology and psychiatry. 2013;18(3):398-410. doi: 10.1177/1359104512455815. PubMed PMID: 22990482. ## 52. Hayes SC, Levin ME, Plumb-Vilardaga J, Villatte JL, Pistorello J. Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior therapy. 2013;44(2):180-98. doi: 10.1016/j.beth.2009.08.002. PubMed PMID: 23611068; PubMed Central PMCID: PMC3635495. ##