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Volume 24, Issue 3 (Autumn 2022)
Advances in Cognitive Sciences 2022, 24(3): 148-163 |
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Ethics code: IR.UI.REC.1396.048
Clinical trials code: IR.UI.REC.1396.048
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Azimi A, Yazdkhasti F, Maracy M, Ebrahimi A. Comparison of the effectiveness of culture-based psychotherapy and cognitive-behavioral therapy on depression and suicidal ideation for the role of brain-derived neurotrophic moderators in adolescent girls. Advances in Cognitive Sciences 2022; 24 (3) :148-163
URL: http://icssjournal.ir/article-1-1363-en.html
URL: http://icssjournal.ir/article-1-1363-en.html
1- PhD Student, Department of Psychology, University of Isfahan, Isfahan, Iran
2- Associate Professor, Department of Psychology, University of Isfahan, Isfahan, Iran
3- Professor, Department of Biostatistics and Epidemiology, Isfahan University of Medical Sciences, Isfahan, Iran
4- Associate Professor, Department of Health Psychology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2- Associate Professor, Department of Psychology, University of Isfahan, Isfahan, Iran
3- Professor, Department of Biostatistics and Epidemiology, Isfahan University of Medical Sciences, Isfahan, Iran
4- Associate Professor, Department of Health Psychology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract: (930 Views)
Introduction
Suicidal thoughts in adolescence can have irreparable consequences due to poor control over life, feelings of social loneliness, problems with parents and friends, and weakness in problem-solving and emotion management (1). Although Iran ranks 58th in the world with a suicide rate of 6 people per 100,000 people, it is necessary to address this psychological-social variable (2). In the field of etiology of suicide, although suffering from mental disorders (3), including depression, has been reported in 40-60% of people (4), recent studies emphasize the effect of biological factors, including neurotrophins (5). Among the neurotrophins, BDNF has attracted more study attention. BDNF maintains normal neurogenesis, synaptic function, neuroplasticity, and neuronal survival (6). So far, different and sometimes contradictory results have been proposed regarding the relationship between BDNF and depression (7, 8), and some believe that BDNF levels decrease significantly in suicidal patients (9). Culture and cultural context are also vital factor influencing suicide (11). In Iran, several qualitative studies have been conducted to identify the causes of suicidal behavior and thoughts (2, 12, 13). Azimi et al. showed that the causes of suicidal thoughts in teenage girls are: 1- Negative attitude toward the father (due to hard family life, lack of warmth between family members, and deprivation of freedom) 2- Perception of hopelessness (individual and social) 3- Unsafe school (unfavorable role of the teacher, school staff and education system) 4- Lack of religious excellence (lack of correct knowledge about God, defective attachment to God, external orientation towards religion) 5- Individual lack of maturity (problem in skills life, cognitive and emotion regulation) (13).
Among the psychological treatments, CBT has received the most research for treating depression and suicide among adolescents. However, its effectiveness seems to be influenced by the cultural and religious backgrounds of the clients (22). Similarly, at least half of the patients who undergo CB still experience psychosocial symptoms after the termination of treatment (15). Kennedy (2019) believes that the reason for the emergence and persistence of disease symptoms in people should be sought in biological components (16). In the current research, in line with the need to pay attention to biological and cultural factors in psychotherapy, a treatment protocol based on the psychological-cultural model has been designed and examined and compared with CBT treatment on depression and suicidal thoughts and BDNF. Besides, the modulating role of BDNF on the effectiveness of treatments on psychological variables was investigated.
Methods
This is a quasi-experimental research (pre-test. post-test, and control group). The study population consisted of 15-year-old female students in Isfahan who were selected by multi-stage cluster sampling of 45 people and randomly assigned to three groups cognitive-behavioral therapy, culture-based psychotherapy, and control group (without intervention). The CBT was implemented according to the valid protocols provided (27, 28). To design psychotherapy based on culture, according to the components of the cultural-psychological model (13), the interventions whose effectiveness was confirmed were selected. The techniques were arranged in the form of an integrated and coherent treatment package and presented to six experts. The agreement coefficient about the content of the treatment sessions was between 0.96 to 0.98 was obtained. Both intervention groups included 12 sessions of adolescent education and three sessions of parent education. Research variables were assessed through Beck Depression Inventory (1996), the Multi-attitude Suicide Tendency Scale (Orbach et al., 1981), and blood samples Data were analyzed using SPSS-24 software, multivariate analysis of covariance (MANCOVA).
Results
First, the statistical assumptions were checked through the Shapiro-Wilk test, and the results showed that the variables had a normal distribution. Lune's test also showed that the variances of the three groups were homogeneous. The assumption of homogeneity of the slope of the regression lines was also maintained. The results of the univariate covariance analysis test showed that after controlling the pre-test scores of the subjects, a difference was found between the mean post-test scores of the research groups in depression variables (F=6.230, P<0.05, η=0.247) and thoughts suicide (F=4.183, P<0.05, η=0.180) a significant difference was observed. However, no significant difference was found between the groups in BDNF (F=0.229, P<0.05, η=0.012). The statistical power indicated the relative adequacy of the sample size. Pairwise comparisons in the LSD test showed that both treatment groups decreased the scores of the participants in both depression and suicidal thoughts variables compared to the control group (P<0.05). However, in both mentioned variables, no significant difference was observed between culture-based psychotherapy and CBT. Furthermore, in this study, the modulating effect of BDNF was investigated. The assumptions of covariance analysis were valid. The assumption of sphericity was also checked and confirmed by using Mauchly's test of Sphericity W statistic (P<0.05). The results of covariance analysis with repeated measures indicated that BDNF could not moderate the effects of treatment on suicidal thoughts in any intervention groups (P<0.05).
Conclusion
The effectiveness of both treatment groups in reducing depression and suicidal thoughts was confirmed, and no difference was observed between the two groups in terms of effectiveness. Emphasis on self-knowledge, recognition of thoughts and feelings, cognitive errors, problem-solving, lifestyle, and communication skills leads to the effectiveness of both treatments on the level of depression of people. Indeed, four axes of depression have been considered in both treatments, including cognitive, emotional, behavioral, and physiological changes (through lifestyle).
In the field of suicidal thoughts, in culture-based psychotherapy (according to the research of Azimi et al.), in addition to individual maturity and cognitive skills, the cultural context, including the socio-economic characteristics of the family, religious characteristics, identity background (with an emphasis on gender identity) as a girl and existing conditions (such as facilities and characteristics of schools and the possibility of employment in the future) were widely considered. Although the role-playing method is one of the CBT techniques, in culture-based psychotherapy, this technique was used in a more evolved derived from psychodrama therapy in most therapy sessions, and interpersonal relationships and regulation of emotions and behavioral skills. It was investigated practically and more deeply. Also, in culture-based psychotherapy, in addition to cognitive treatments, ultra-modern treatment techniques were used. Besides, based on the three axes of mind awareness and acceptance of emotions and thoughts, the need to persevere in reaching the goal (committed action) and cultivating a compassionate mind was emphasized. For example, one of the factors predicting vulnerability to suicide is the ability to resist negative emotions and coping strategies; this ability under the title of accepting and tolerating distress was one of the techniques in culture-based psychotherapy (derived from the DBT approach). Furthermore, considering that suicide is an injury arising from the conflict between the situations (socio-economic conditions). It desires that the techniques used in culture-based psychotherapy can lead to acceptance of the situation and realistic goal setting, reducing the lead to suicidal thoughts. Techniques used in culture-based psychotherapy, such as self-knowledge, distress tolerance, problem-solving, considering family relationships, purposefulness, self-efficacy, and cognitive flexibility, not only the totality of the individual's psyche but also family relationships and problem-solving methods according to environmental and cultural conditions, were considered.
In the present study, the significant effect of both interventions on BDNF was not confirmed, and the moderating effect of BDNF on psychological variables was not significant. The present results are inconsistent with some studies based on the moderating role of BDNF on the effectiveness of treatment (18, 19, 21) and consistent with some studies that show no effect of BDNF on the results of therapeutic interventions (29, 30). Response to pharmacological treatment occurs more quickly (33), whereas the response to psychotherapy may take months (32) and depends on factors such as the therapeutic relationship (35). BDNF levels tend to be stable over time (36); therefore, it is necessary to investigate the treatment results on this biological variable for a longer time. Seemingly, the contradictory findings in different studies are due to the influence of other variables (including biological and clinical variables) that have not yet been identified and taken into account. Future studies regarding the interaction of biological variables, psychological components, and treatments may provide additional insights.
Ethical Considerations
Compliance with ethical guidelines
In compliance with ethical guidelines, the Ethics Committee of the University of Isfahan (IR.UI.REC.1396.048) has granted requisite ethical approvals. Written informed consent was obtained from the adolescent. They were informed about the confidentiality of the information and their voluntariness in participation in the study.
Authors' contributions
Akram Azimi participated in the research design, data collection, analysis, revision, and article writing. Fariba Yazdakhasi participated in the research article’s design, analysis, and writing. Mohammadreza Maracy and Amraleh Ebrahimi participated in the data analysis and revision of the article. All authors read and approved the final version.
Funding
No financial support has been received for this research.
Acknowledgments
The author appreciated Isfahan Education Organization, school principals, and students who cooperated with the researchers in this research. The researchers are also grateful to Sharife Joshanpoosh and Zahra Akhtarian, who collaborated with the researchers in the research’s statistical analysis and implementation stages of the.
Conflicts of interest
The authors declare no conflicts of interest.
Suicidal thoughts in adolescence can have irreparable consequences due to poor control over life, feelings of social loneliness, problems with parents and friends, and weakness in problem-solving and emotion management (1). Although Iran ranks 58th in the world with a suicide rate of 6 people per 100,000 people, it is necessary to address this psychological-social variable (2). In the field of etiology of suicide, although suffering from mental disorders (3), including depression, has been reported in 40-60% of people (4), recent studies emphasize the effect of biological factors, including neurotrophins (5). Among the neurotrophins, BDNF has attracted more study attention. BDNF maintains normal neurogenesis, synaptic function, neuroplasticity, and neuronal survival (6). So far, different and sometimes contradictory results have been proposed regarding the relationship between BDNF and depression (7, 8), and some believe that BDNF levels decrease significantly in suicidal patients (9). Culture and cultural context are also vital factor influencing suicide (11). In Iran, several qualitative studies have been conducted to identify the causes of suicidal behavior and thoughts (2, 12, 13). Azimi et al. showed that the causes of suicidal thoughts in teenage girls are: 1- Negative attitude toward the father (due to hard family life, lack of warmth between family members, and deprivation of freedom) 2- Perception of hopelessness (individual and social) 3- Unsafe school (unfavorable role of the teacher, school staff and education system) 4- Lack of religious excellence (lack of correct knowledge about God, defective attachment to God, external orientation towards religion) 5- Individual lack of maturity (problem in skills life, cognitive and emotion regulation) (13).
Among the psychological treatments, CBT has received the most research for treating depression and suicide among adolescents. However, its effectiveness seems to be influenced by the cultural and religious backgrounds of the clients (22). Similarly, at least half of the patients who undergo CB still experience psychosocial symptoms after the termination of treatment (15). Kennedy (2019) believes that the reason for the emergence and persistence of disease symptoms in people should be sought in biological components (16). In the current research, in line with the need to pay attention to biological and cultural factors in psychotherapy, a treatment protocol based on the psychological-cultural model has been designed and examined and compared with CBT treatment on depression and suicidal thoughts and BDNF. Besides, the modulating role of BDNF on the effectiveness of treatments on psychological variables was investigated.
Methods
This is a quasi-experimental research (pre-test. post-test, and control group). The study population consisted of 15-year-old female students in Isfahan who were selected by multi-stage cluster sampling of 45 people and randomly assigned to three groups cognitive-behavioral therapy, culture-based psychotherapy, and control group (without intervention). The CBT was implemented according to the valid protocols provided (27, 28). To design psychotherapy based on culture, according to the components of the cultural-psychological model (13), the interventions whose effectiveness was confirmed were selected. The techniques were arranged in the form of an integrated and coherent treatment package and presented to six experts. The agreement coefficient about the content of the treatment sessions was between 0.96 to 0.98 was obtained. Both intervention groups included 12 sessions of adolescent education and three sessions of parent education. Research variables were assessed through Beck Depression Inventory (1996), the Multi-attitude Suicide Tendency Scale (Orbach et al., 1981), and blood samples Data were analyzed using SPSS-24 software, multivariate analysis of covariance (MANCOVA).
Results
First, the statistical assumptions were checked through the Shapiro-Wilk test, and the results showed that the variables had a normal distribution. Lune's test also showed that the variances of the three groups were homogeneous. The assumption of homogeneity of the slope of the regression lines was also maintained. The results of the univariate covariance analysis test showed that after controlling the pre-test scores of the subjects, a difference was found between the mean post-test scores of the research groups in depression variables (F=6.230, P<0.05, η=0.247) and thoughts suicide (F=4.183, P<0.05, η=0.180) a significant difference was observed. However, no significant difference was found between the groups in BDNF (F=0.229, P<0.05, η=0.012). The statistical power indicated the relative adequacy of the sample size. Pairwise comparisons in the LSD test showed that both treatment groups decreased the scores of the participants in both depression and suicidal thoughts variables compared to the control group (P<0.05). However, in both mentioned variables, no significant difference was observed between culture-based psychotherapy and CBT. Furthermore, in this study, the modulating effect of BDNF was investigated. The assumptions of covariance analysis were valid. The assumption of sphericity was also checked and confirmed by using Mauchly's test of Sphericity W statistic (P<0.05). The results of covariance analysis with repeated measures indicated that BDNF could not moderate the effects of treatment on suicidal thoughts in any intervention groups (P<0.05).
Conclusion
The effectiveness of both treatment groups in reducing depression and suicidal thoughts was confirmed, and no difference was observed between the two groups in terms of effectiveness. Emphasis on self-knowledge, recognition of thoughts and feelings, cognitive errors, problem-solving, lifestyle, and communication skills leads to the effectiveness of both treatments on the level of depression of people. Indeed, four axes of depression have been considered in both treatments, including cognitive, emotional, behavioral, and physiological changes (through lifestyle).
In the field of suicidal thoughts, in culture-based psychotherapy (according to the research of Azimi et al.), in addition to individual maturity and cognitive skills, the cultural context, including the socio-economic characteristics of the family, religious characteristics, identity background (with an emphasis on gender identity) as a girl and existing conditions (such as facilities and characteristics of schools and the possibility of employment in the future) were widely considered. Although the role-playing method is one of the CBT techniques, in culture-based psychotherapy, this technique was used in a more evolved derived from psychodrama therapy in most therapy sessions, and interpersonal relationships and regulation of emotions and behavioral skills. It was investigated practically and more deeply. Also, in culture-based psychotherapy, in addition to cognitive treatments, ultra-modern treatment techniques were used. Besides, based on the three axes of mind awareness and acceptance of emotions and thoughts, the need to persevere in reaching the goal (committed action) and cultivating a compassionate mind was emphasized. For example, one of the factors predicting vulnerability to suicide is the ability to resist negative emotions and coping strategies; this ability under the title of accepting and tolerating distress was one of the techniques in culture-based psychotherapy (derived from the DBT approach). Furthermore, considering that suicide is an injury arising from the conflict between the situations (socio-economic conditions). It desires that the techniques used in culture-based psychotherapy can lead to acceptance of the situation and realistic goal setting, reducing the lead to suicidal thoughts. Techniques used in culture-based psychotherapy, such as self-knowledge, distress tolerance, problem-solving, considering family relationships, purposefulness, self-efficacy, and cognitive flexibility, not only the totality of the individual's psyche but also family relationships and problem-solving methods according to environmental and cultural conditions, were considered.
In the present study, the significant effect of both interventions on BDNF was not confirmed, and the moderating effect of BDNF on psychological variables was not significant. The present results are inconsistent with some studies based on the moderating role of BDNF on the effectiveness of treatment (18, 19, 21) and consistent with some studies that show no effect of BDNF on the results of therapeutic interventions (29, 30). Response to pharmacological treatment occurs more quickly (33), whereas the response to psychotherapy may take months (32) and depends on factors such as the therapeutic relationship (35). BDNF levels tend to be stable over time (36); therefore, it is necessary to investigate the treatment results on this biological variable for a longer time. Seemingly, the contradictory findings in different studies are due to the influence of other variables (including biological and clinical variables) that have not yet been identified and taken into account. Future studies regarding the interaction of biological variables, psychological components, and treatments may provide additional insights.
Ethical Considerations
Compliance with ethical guidelines
In compliance with ethical guidelines, the Ethics Committee of the University of Isfahan (IR.UI.REC.1396.048) has granted requisite ethical approvals. Written informed consent was obtained from the adolescent. They were informed about the confidentiality of the information and their voluntariness in participation in the study.
Authors' contributions
Akram Azimi participated in the research design, data collection, analysis, revision, and article writing. Fariba Yazdakhasi participated in the research article’s design, analysis, and writing. Mohammadreza Maracy and Amraleh Ebrahimi participated in the data analysis and revision of the article. All authors read and approved the final version.
Funding
No financial support has been received for this research.
Acknowledgments
The author appreciated Isfahan Education Organization, school principals, and students who cooperated with the researchers in this research. The researchers are also grateful to Sharife Joshanpoosh and Zahra Akhtarian, who collaborated with the researchers in the research’s statistical analysis and implementation stages of the.
Conflicts of interest
The authors declare no conflicts of interest.
Keywords: Culture-based psychotherapy, Cognitive-behavioral therapy, Brain-derived neurotrophic factor, Depression, Suicidal ideation
Type of Study: Research |
Received: 2021/11/22 | Accepted: 2022/07/19 | Published: 2022/11/15
Received: 2021/11/22 | Accepted: 2022/07/19 | Published: 2022/11/15
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