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Volume 25, Issue 3 (Autumn 2023)
Advances in Cognitive Sciences 2023, 25(3): 1-17 |
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Ethics code: IR.UT.IRICSS.REC.1400.015
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Saadati H, Moradi A, Shalbafan M, Mirabolfathi V. The effect of acceptance and commitment therapy on autobiographical memory, episodic future thinking, and depression in major depressive disorder. Advances in Cognitive Sciences 2023; 25 (3) :1-17
URL: http://icssjournal.ir/article-1-1523-en.html
URL: http://icssjournal.ir/article-1-1523-en.html
1- PhD Candidate of Cognitive Psychology, Cognitive Psychology Department, Institute for Cognitive Science Studies, Tehran, Iran
2- Professor of Clinical Psychology, Department of Clinical Psychology, Kharazmi University, Tehran, Iran / Professor of Clinical Psychology, Department of Cognitive Psychology, Institute for Cognitive Science Studies, Tehran, Iran
3- Associate Professor of Psychiatry, Mental Health Research Center, Psychosocial Health Research Institute (PHRI), Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran/ Associate Professor of Psychiatry, Brain and Cognition Clinic, Institute for Cognitive Sciences Studies, Tehran, Iran
4- PhD in Cognitive Psychology, Cognitive Psychology Department, Institute for Cognitive Science Studies, Tehran, Iran
2- Professor of Clinical Psychology, Department of Clinical Psychology, Kharazmi University, Tehran, Iran / Professor of Clinical Psychology, Department of Cognitive Psychology, Institute for Cognitive Science Studies, Tehran, Iran
3- Associate Professor of Psychiatry, Mental Health Research Center, Psychosocial Health Research Institute (PHRI), Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran/ Associate Professor of Psychiatry, Brain and Cognition Clinic, Institute for Cognitive Sciences Studies, Tehran, Iran
4- PhD in Cognitive Psychology, Cognitive Psychology Department, Institute for Cognitive Science Studies, Tehran, Iran
Abstract: (2785 Views)
Introduction: Depression is the most common mood disorder, the most critical symptoms of which are loss of interest and low mood, and women suffer from this disorder more than men. Many studies have shown multiple cognitive deficits in people with depression, such as overgeneralization and weakness of episodic future thinking. Autobiographical memories are complex structures of knowledge created during the process of recollection. These memories involve two types of knowledge. The first is experiential or episodic knowledge, the understanding of which is likely linked to objectives active during memory creation and reconstruction. The second is conceptual knowledge (e.g., scripts), which serves to provide context for the recalled episodic knowledge during the construction of the memory. Episodic future thinking involves mentally simulating possible future events, a crucial tool for adapting to our surroundings. Third-generation therapies focus on the thinking process, unlike traditional treatment methods that target symptoms and analyze behavior. These innovative approaches prioritize enhancing cognitive abilities as part of the intervention. An effective and proven intervention in the treatment of emotional disorders is Acceptance and Commitment Therapy (ACT).
On the other hand, in the conditions of the outbreak of the COVID-19 pandemic and to minimize leaving the house, it is essential to use online methods. In addition, due to the multidimensionally of major depressive disorder and the presence of several cognitive defects, such as weakness in autobiographical memory and episodic future thinking, it is important to investigate the effect of treatments on the improvement of those defects. Therefore, the present study aimed to investigate the effectiveness of ACT in specifying autobiographical memory, episodic future thinking, and depression in patients with major depressive disorder using an online method.
Methods: The current research is a randomized quasi-experimental design of pre-test, post-test, and follow-up with a three-month interval, carried out on two experimental and control groups. The statistical population included depressed patients who were referred to the Tehran Institute of Psychiatry, Iran. All participants were diagnosed with major depression by a psychiatrist. Besides, they signed a written consent form after meeting the entry criteria and introducing the study. Based on this, 30 participants were selected as available and randomly replaced in two groups, experimental (15 people) and control (15 people). The inclusion criteria were suffering from major depressive disorder, the age range of 18 to 60 years, familiarity with the use of WhatsApp, and literacy at the level of reading and writing. The exclusion criteria were having a physical illness, neurological disorders, suffering from mental disorders other than major depressive disorder, participating in active therapeutic intervention (even depression), and participating in other research. A structured clinical interview and tests of autobiographical memory, episodic future thinking, and DASS-21 were taken from all participants. For the experimental group, treatment based on ACT was conducted in eight online sessions through the WhatsApp program, and the control group did not receive any training. After the completion of the sessions of the experimental group and three months after that, the tests were conducted again for both groups.
Results: Data analysis in the current research was accomplished based on the scores obtained from different time stages, including pre-test, post-test, and 3-month follow-up. Based on this, the mean scores of autobiographical memory and episodic future thinking and depression in these time stages in two groups of experimental and control were statistically analyzed using the method of mixed ANOVA. The Shapiro-Wilk test was used to check the statistical tests' assumptions for the data distribution's normality for the data distribution's normality. Levene's test was used for the homogeneity of the variances, and Mauchly's sphericity test was used to check the compound symmetry. Correspondingly, partial Eta square (η2P) was presented to check the effect size, and the Pairwise comparison method was used to check the difference between the averages of time steps. Statistical methods in this study were done using SPSS version 26. An independent t-test was used to compare the average age of the experimental and control groups, and the results of this test showed an insignificant difference (P=0.13, t=1.58) between the ages of the experimental group (mean=39.73, standard deviation=10.55) and the control group (mean=33.73, standard deviation=10.22). The results of mixed ANOVA for autobiographical memory showed that significant values had been observed over time (η2P=0.47, P<0.0001, F(1, 28)=25.25). Furthermore, the interaction effect of time and group (P<0.0001, F(1, 28)=17.32) was significant and showed that considering the time factor, a significant difference was found between the experimental and control groups, and the effect size was large. In addition, pairwise comparisons for the time factor (difference between the pre-test, post-test, and follow-up stages) showed that there was a significant difference between the average autobiographical memory in the pre-test stage and the two stages of the post-test (P=0.002) and follow-up (P<0.0001). However, the two post-test and follow-up stages did not have a significant difference (P=0.299). The results of mixed ANOVA for episodic future thinking showed that significant values had been observed over time (η2P=0.50, P<0.0001, F(1, 28)=27.53). Similarly, the interaction effect of time and group (P<0.0001, F(1, 28)=17.91) was significant and showed that considering the time factor, there was a significant difference between the experimental and control groups, and the effect size was large. Moreover, pairwise comparisons for the time factor showed a significant difference between the averages of different assessment times in the pre-test stage with two post-test stages (P<0.0001) and follow-up (P<0.0001). Nevertheless, the two post-test and follow-up stages did not have significant differences (P=0.227). The results of mixed ANOVA for depression showed that significant values had been observed over time (η2P=0.13, P=0.047, F(1, 28)=4.32). Besides, the interaction effect of time and group (P=0.003, F(1, 28)=10.66) was significant and showed that considering the time factor, a significant difference was found between the experimental and control groups, and the effect size was moderate. Moreover, pairwise comparisons showed a significant difference between the pre-test stage and the two post-test stages (P=0.009), and follow-up (P=0.047). Nonetheless, the two post-test and follow-up stages did not have significant differences (P=0.844).
Conclusion: The current research concluded that ACT effectively improves cognitive impairments like the overgeneralization of autobiographical memory and episodic future thinking while reducing symptoms of major depression. This research suggests that ACT can ameliorate overgeneralization, a deficit often observed in autobiographical memory. Essentially, ACT uses a strategy called cognitive defusion, which aids individuals struggling with depression in distancing themselves from negative thoughts and experiences. It also encourages them to commit to life-affirming behaviors aligning with their values. Furthermore, pay attention to the details of the events with mindfulness strategies, which makes the autobiographical memory more specific. The results of the present study also showed that treatment based on ACT with the strategy of strengthening the ability to accept and rely on individual values in life can help depressed people think positively and optimistically about the future. Likewise, with a committed action strategy, this change will reduce negative outlook and thinking towards future events and disappointment. Finally, the treatment based on ACT helps to reduce the symptoms of depression by creating psychological flexibility, which exerts this effect through six groups of therapeutic techniques. Among the limitations of this study, we should point out the problem of coordinating meetings, which was challenging to create a regular and continuous schedule due to the problem of depression and the low psychomotor energy level of the participants. Similarly, the present study was limited to the population of patients at the Tehran Institute of Psychiatry, Iran, so using a larger statistical population is suggested to achieve better results. It is also suggested to carry out more extended follow-up periods (one year) to determine the stability of the treatment and examine its relationship with the recurrence rate of depression symptoms.
Ethical Considerations
Compliance with ethical guidelines
The purpose and details of the study were explained to all participants, and written consent was obtained. In order to protect privacy, the names of the participants in the study process were recorded with a code, and they could freely withdraw from the study process at any time. This study has been registered with the Ethics Code IR.UT.IRICSS.REC.1400.015.
Authors' contributions
Hossein Saadati did the study, presentation of the initial plan, implementation of the research, collection, and analysis of information and data, and initial writing of the article. Alireza Moradi guided the implementation of the study, edited the article, and was the corresponding author. Mohammadreza Shalbafan and Vida Mirabolfathi were responsible for expert and research advice, supervision, and active participation in the research stages. All authors reviewed the study results and participated in editing and preparing the final version of the article.
Funding
This research has not received financial support from any organization or institution.
Acknowledgments
In the end, the authors are very grateful for the assistance and cooperation of the Tehran Institute of Psychiatry and their respected staff, and they also express gratitude to all the participants in the research who helped us.
Conflicts of interest
The authors declared no conflict of interest.
On the other hand, in the conditions of the outbreak of the COVID-19 pandemic and to minimize leaving the house, it is essential to use online methods. In addition, due to the multidimensionally of major depressive disorder and the presence of several cognitive defects, such as weakness in autobiographical memory and episodic future thinking, it is important to investigate the effect of treatments on the improvement of those defects. Therefore, the present study aimed to investigate the effectiveness of ACT in specifying autobiographical memory, episodic future thinking, and depression in patients with major depressive disorder using an online method.
Methods: The current research is a randomized quasi-experimental design of pre-test, post-test, and follow-up with a three-month interval, carried out on two experimental and control groups. The statistical population included depressed patients who were referred to the Tehran Institute of Psychiatry, Iran. All participants were diagnosed with major depression by a psychiatrist. Besides, they signed a written consent form after meeting the entry criteria and introducing the study. Based on this, 30 participants were selected as available and randomly replaced in two groups, experimental (15 people) and control (15 people). The inclusion criteria were suffering from major depressive disorder, the age range of 18 to 60 years, familiarity with the use of WhatsApp, and literacy at the level of reading and writing. The exclusion criteria were having a physical illness, neurological disorders, suffering from mental disorders other than major depressive disorder, participating in active therapeutic intervention (even depression), and participating in other research. A structured clinical interview and tests of autobiographical memory, episodic future thinking, and DASS-21 were taken from all participants. For the experimental group, treatment based on ACT was conducted in eight online sessions through the WhatsApp program, and the control group did not receive any training. After the completion of the sessions of the experimental group and three months after that, the tests were conducted again for both groups.
Results: Data analysis in the current research was accomplished based on the scores obtained from different time stages, including pre-test, post-test, and 3-month follow-up. Based on this, the mean scores of autobiographical memory and episodic future thinking and depression in these time stages in two groups of experimental and control were statistically analyzed using the method of mixed ANOVA. The Shapiro-Wilk test was used to check the statistical tests' assumptions for the data distribution's normality for the data distribution's normality. Levene's test was used for the homogeneity of the variances, and Mauchly's sphericity test was used to check the compound symmetry. Correspondingly, partial Eta square (η2P) was presented to check the effect size, and the Pairwise comparison method was used to check the difference between the averages of time steps. Statistical methods in this study were done using SPSS version 26. An independent t-test was used to compare the average age of the experimental and control groups, and the results of this test showed an insignificant difference (P=0.13, t=1.58) between the ages of the experimental group (mean=39.73, standard deviation=10.55) and the control group (mean=33.73, standard deviation=10.22). The results of mixed ANOVA for autobiographical memory showed that significant values had been observed over time (η2P=0.47, P<0.0001, F(1, 28)=25.25). Furthermore, the interaction effect of time and group (P<0.0001, F(1, 28)=17.32) was significant and showed that considering the time factor, a significant difference was found between the experimental and control groups, and the effect size was large. In addition, pairwise comparisons for the time factor (difference between the pre-test, post-test, and follow-up stages) showed that there was a significant difference between the average autobiographical memory in the pre-test stage and the two stages of the post-test (P=0.002) and follow-up (P<0.0001). However, the two post-test and follow-up stages did not have a significant difference (P=0.299). The results of mixed ANOVA for episodic future thinking showed that significant values had been observed over time (η2P=0.50, P<0.0001, F(1, 28)=27.53). Similarly, the interaction effect of time and group (P<0.0001, F(1, 28)=17.91) was significant and showed that considering the time factor, there was a significant difference between the experimental and control groups, and the effect size was large. Moreover, pairwise comparisons for the time factor showed a significant difference between the averages of different assessment times in the pre-test stage with two post-test stages (P<0.0001) and follow-up (P<0.0001). Nevertheless, the two post-test and follow-up stages did not have significant differences (P=0.227). The results of mixed ANOVA for depression showed that significant values had been observed over time (η2P=0.13, P=0.047, F(1, 28)=4.32). Besides, the interaction effect of time and group (P=0.003, F(1, 28)=10.66) was significant and showed that considering the time factor, a significant difference was found between the experimental and control groups, and the effect size was moderate. Moreover, pairwise comparisons showed a significant difference between the pre-test stage and the two post-test stages (P=0.009), and follow-up (P=0.047). Nonetheless, the two post-test and follow-up stages did not have significant differences (P=0.844).
Conclusion: The current research concluded that ACT effectively improves cognitive impairments like the overgeneralization of autobiographical memory and episodic future thinking while reducing symptoms of major depression. This research suggests that ACT can ameliorate overgeneralization, a deficit often observed in autobiographical memory. Essentially, ACT uses a strategy called cognitive defusion, which aids individuals struggling with depression in distancing themselves from negative thoughts and experiences. It also encourages them to commit to life-affirming behaviors aligning with their values. Furthermore, pay attention to the details of the events with mindfulness strategies, which makes the autobiographical memory more specific. The results of the present study also showed that treatment based on ACT with the strategy of strengthening the ability to accept and rely on individual values in life can help depressed people think positively and optimistically about the future. Likewise, with a committed action strategy, this change will reduce negative outlook and thinking towards future events and disappointment. Finally, the treatment based on ACT helps to reduce the symptoms of depression by creating psychological flexibility, which exerts this effect through six groups of therapeutic techniques. Among the limitations of this study, we should point out the problem of coordinating meetings, which was challenging to create a regular and continuous schedule due to the problem of depression and the low psychomotor energy level of the participants. Similarly, the present study was limited to the population of patients at the Tehran Institute of Psychiatry, Iran, so using a larger statistical population is suggested to achieve better results. It is also suggested to carry out more extended follow-up periods (one year) to determine the stability of the treatment and examine its relationship with the recurrence rate of depression symptoms.
Ethical Considerations
Compliance with ethical guidelines
The purpose and details of the study were explained to all participants, and written consent was obtained. In order to protect privacy, the names of the participants in the study process were recorded with a code, and they could freely withdraw from the study process at any time. This study has been registered with the Ethics Code IR.UT.IRICSS.REC.1400.015.
Authors' contributions
Hossein Saadati did the study, presentation of the initial plan, implementation of the research, collection, and analysis of information and data, and initial writing of the article. Alireza Moradi guided the implementation of the study, edited the article, and was the corresponding author. Mohammadreza Shalbafan and Vida Mirabolfathi were responsible for expert and research advice, supervision, and active participation in the research stages. All authors reviewed the study results and participated in editing and preparing the final version of the article.
Funding
This research has not received financial support from any organization or institution.
Acknowledgments
In the end, the authors are very grateful for the assistance and cooperation of the Tehran Institute of Psychiatry and their respected staff, and they also express gratitude to all the participants in the research who helped us.
Conflicts of interest
The authors declared no conflict of interest.
Keywords: Major depressive disorder, Autobiographical memory, Episodic future thinking, Acceptance and commitment therapy
Type of Study: Research |
Received: 2023/02/1 | Accepted: 2023/06/19 | Published: 2023/12/13
Received: 2023/02/1 | Accepted: 2023/06/19 | Published: 2023/12/13
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