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The Effectiveness of ACT Treatment
in Reducing the Symptoms of Depression in Patients
with Epilepsy
Mina
Mojtabayi
Safiyeh Behzadi
Faezeh Alipour
Clinical Psychology, Department of Psychology,
Faculty of Psychology and Social Sciences, Islamic
Azad University, Roodehen Branch, Iran
Correspondence:
Faezeh Alipour
Clinical Psychology, Department of Psychology,
Faculty of Psychology and Social Sciences,
Islamic Azad University,
Roodehen Branch,
Iran
Email: faezehalipour6767@gmail.com
Received: April 2019; Accepted: May 2019; Published:
June 1, 2019. Citation: Mina Mojtabayi, Safiyeh
Behzadi, Faezeh Alipour. The Effectiveness of
ACT Treatment in Reducing the Symptoms of Depression
in Patients with Epilepsy. World Family Medicine.
2019; 17(6): 26-36. DOI: 10.5742MEWFM.2019.9365
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Abstract
The
aim of this research was to determine
the effect of Acceptance and Commitment
Therapy (ACT) on reducing depression symptoms
in people with epilepsy. This research
was semi-experimental and it contained
a pre-test-post-test and a control group
at convenience which was based on the
results of Beck Depression Inventory (BDI)
. To investigate the research, 30 patients
with epilepsy and depression symptoms
were selected from among the people having
epilepsy and referring to the Epilepsy
Association in Tehran (2013). They were
randomly divided into two groups of experimental
(15 persons) and control (15 persons).
Acceptance and Commitment Therapy was
done in 8 sessions of 60-90 minutes in
the experimental group and the control
group did not receive any interventions.
Pre-test and post-test scores were analyzed
by one-way covariance (ANCOVA) for both
groups. The results of this research showed
that the difference between the experimental
and control groups in the depression variable
was significant with the confidence interval
of F = 87.433. Moreover, the anxiety scores
of the experimental group were significantly
decreased (P = 0.000) compared to the
control group. This suggests that Acceptance
and Commitment Therapy (ACT) is effective
in reducing the symptoms of depression
in people with epilepsy.
Key words:
Epilepsy, Depression Symptoms, Anxiety,
Acceptance and Commitment Therapy
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Epilepsy is not a mental disorder. People of
all ages can be affected by epilepsy, it is
a brain chronic disorder (Khalil, et al. 2018).
It is a neurological disorder that has not yet
been cured (Crotzer, translated by Soltani translation,
2009). Therefore, epilepsy is a brain disorder
that occurs with frequent seizures caused by
electrical disorders in the brain’s neurons;
a physiological disorder of the cerebral cortex.
In this kind of disorder, the electrical drainage
is abnormal and simultaneously the brain cells
are temporarily and transiently created. Epilepsy
is the most common chronic neurological disease
in the world and affects around 45 million people
worldwide (Bahrpeyma, 2009). The causes of epilepsy
include: problems with the completion of the
prenatal brain, lack of oxygen at or after birth,
severe brain injury, unusual brain shape, tumour,
subsequent effects of brain infection such as
meningitis or brain tumors and genetic factors
(Crotzer, 2004). Epilepsy is associated with
a range of biological aspects and psychopathology,
among which depression disorder is the most
common psychiatric disorder (Zahiruddin and
Qureyshi, 2006).
Mood disorders encompass a large group of psychiatric
disorders (Vidya, et al., 2015). Among the most
prevalent psychiatric turmoils and problems
of human life, is depression (Osman & Bahri,
2019). Depression is known as a single disorder
(excitement and temper), though, there are practically
four sets of signs and symptoms (Rita et al.,
2007). Depression disorder as temper disorder
is one of the most common psychiatric diseases.
Depression is a mental disorder that commonly
presents with depressed mood, decreased energy,
emotions of guilt or low self-confidence, loss
of interest or pleasure, poor concentration,
and disturbed sleep or appetite (AL-Asiri &
Alotaibi, 2018). Its prevalence is about 15%
for whole life. For women, there may be up to
25%. The incidence of depression among the patients
of general practitioners is about 10% and among
the hospitalized patients it amounts to 15%
(Saduk and Saduk, 2007, quoted by Razaei, 2005).
Anxiety is another disorder which is an unpleasant
emotion that we all have experienced to some
extent in form of words such as worry, anxiety,
tension and fear (Sanei & Nabavi Chasmi,
2018).
Acceptance and commitment therapy (ACT) therapy
creates therapeutic changes through "creation
and development of mental admission and increasing
the practice of values" in patients. The
obvious advantage of this psychotherapy is to
give the individual a kind of opportunity to
learn new and specific skills, such as increased
psychological admission and contact with the
present, and this also makes it difficult for
the individual not only to avoid it, but to
face it flexibly (Mohammadi, et al., 2018).
Acceptance and Commitment Therapy (ACT) is a
behavioral therapy that uses mindfulness, acceptance,
and cognitive dissociation to enhance psychological
flexibility (Herbert, Forman, 2011, quoted by
Izadi and Abedi, 2013). In acceptance and commitment
therapy, the psychological flexibility is to
increase the ability of clients to communicate
with their experiences in the present; so they
act based on what is possible at that moment
for them, and in a manner that their action
is consistent with their chosen values (Hayes
et al., 2010, quoted by Izadi, Abedi, 2013).
The goal of intervention of acceptance and commitment
therapy is to change the processes that contribute
to the psychopathology of these disorders. In
fact, this kind of treatment empowers the individuals
to change the hard thoughts and feelings and
the ways to cope with problems through the specific
techniques. ACT is a contextual approach that
challenges the clients to accept their thoughts
and feelings and commit themselves to the necessary
changes. The core of the change in ACT is the
change in internal and external verbal behavior.
ACT believes that engaging with emotions will
make them feel worse (Brykan, 2006).
In 2013, Narimani et al. conducted research
comparing the effectiveness of Acceptance and
Commitment Education (ACT) with training excitement
regulation in the adaptation of students with
math disorders. The results showed the effectiveness
of Acceptance and Commitment Training (ACT)
with emotional regulations in improving social,
emotional and educational adaptations of students
with maths disorders. Gharayi Ardakani et al.
(2012) conducted research on the effectiveness
of the Acceptance and Commitment approach in
reducing pain intensity in women with chronic
headache disorder. The results of this research
indicated that ACT was effective in reducing
pain experience in women with chronic headaches.
In the research of Salehzadeh et al. (2011),
on the effect of cognitive-behavioral therapy
on the ineffective attitudes in patients with
epilepsy, the effectiveness of this treatment
was confirmed. Research was conducted by Salehzadeh
et al. (2010), on the effect of cognitive-behavioral
group therapy on depression in patients with
epilepsy resistant to drugs. The findings of
their study confirmed the efficacy of this type
of treatment. Other research by Hashemi (2010)
on the effectiveness of cognitive-behavioral
intervention in reducing the level of depression,
anxiety and stress in patients with epilepsy
the effectiveness of the above components was
shown. Najafi et al. (2010) conducted a study
investigating the pattern of personality characteristics
and psychopathology of patients with complex
and grand mal epilepsy and comparing it with
the control group. They concluded that the psychological
interventions in the treatment of this disease
were necessary and useful.
Pereira and De Valent, (2013), studied the
severity of symptoms of depression and performance
dysfunction in children and adolescents with
epilepsy. The results indicated that children
with epilepsy at the early stages of their disease
faced a general, moderate to severe performance
disorder, and this situation also occurred in
adolescents which could lead to depression.
Gaudiano et al. (2013) treated 14 people with
depression and concluded that not only was this
therapy useful for the treatment of people with
major depression but it also increased their
psychosocial performance. Moto (2012) conducted
research for measuring the effectiveness of
acceptance and commitment therapy for the treatment
of people with chronic depression in an individual
58 years old; in a follow-up period of 5 months,
he concluded that this therapy for the treatment
of chronic depression was recommendable.
Because acceptance and commitment therapy is
a part of the third wave treatments of behavioral
therapy, and given that new therapies cover
the weaknesses of previous treatments, this
therapy can reduce the symptoms of depression
in people with epilepsy. Since acceptance and
commitment therapy is almost unknown in our
country, its introduction would be very helpful.
Therefore, considering the success of acceptance
and commitment therapy in recent years, the
effectiveness of ACT in reducing the symptoms
of depression in patients with epilepsy has
been addressed in the present study.
This research was semi-experimental with pre
test, post test design and using a control group.
The statistical population of this research
included all people having Epilepsy with the
symptoms of depression who had referred to Iranian
Epilepsy Society in 2013. Sampling method in
this research was convenience with the randomization
of the control and experimental groups. The
sample size was estimated to be 15 individuals,
based on a Cohen table with the effect size
of 0.5 and test power of 0.75 for each group.
The treatment protocol has been presented in
the table below.
In this research, the BDI-II Beck Depression
Inventory (BDI-II), a self-report questionnaire
of 21 items, was used. It was applied for measuring
the severity of depression and determining the
symptoms of depression in the population of
psychiatric patients and to determine depression
in the normal population. The scores of this
questionnaire were based on four options (0-3)
for the absence of a specific symptom to the
highest degree of its existence in the range
of 0 to 3. The psychometric studies performed
on this questionnaire indicated that it enjoyed
a good validity. Beck, Stear and Brown (2000)
reported the internal consistency of the instrument
as 73% to 92% with an average of 86%, and the
alpha coefficient for the patient group was
86% and for the non-patient was 81%. The alpha
coefficient of this questionnaire was 0.92 for
ambulatory patients and 0.93 for students. In
a meta-analysis that was performed on 9 psychiatric
samples, this questionnaire showed more internal
consistency than the first version of the questionnaire.
The test-retest reliability coefficient in a
subgroup of outpatients was 0.93 for a week
(Beck, Stear and Brown, 1996, quoted by Zemestani
Bamchi, 2008). Fati (2003) performed this questionnaire
on an Iranian sample of 94 people, and reported
an alpha coefficient of 0.91, a coefficient
of correlation of 0.89 and a retest coefficient
of one-week interval of 0.94. Ghasemzadeh et
al. (2005) examined the psychometric properties
of the Persian version of the Beck depression
inventory on 125 Iranian students from among
Tehran University of Medical Sciences and Allameh
Tabataba’i University. They reported the
alpha coefficient of 0.87 and the coefficient
of re-test of 0.74 (Quoted by Issazadegan in
2006). In addition, Bakhshai (2002) reported
the correlation between Beck questionnaire and
Hamilton depression scale to be 0.93.
Table of Treatment protocol
Data collection was done using the questionnaire
for a group in the Treatment Center for the
Iranian Epilepsy Association. Beck Depression
Inventory was performed on patients with depression
symptoms. After that, 30 people who received
the required score in the test were selected
and randomly assigned to the control and experimental
groups. The identified subjects , had a high
degree of depression symptoms and they were
randomly assigned to experimental (15 subjects)
and control (15 subjects) groups. After the
pretest, the experimental group received the
acceptance and commitment therapy for 8 sessions
and each session for 60-90 minutes. At the end
of the sessions, a post-test was performed on
them. The control group was under no intervention
and only the pre-test and post-test were performed
on the experimental group. In observing the
ethical requirements of the research, these
individuals benefited from a free session in
communication skills. The inclusion criteria
for participating in the research included:
individuals with Epilepsy referring to Iranian
Epilepsy Association, receiving the score 20
and above in the BDI-II test, lack of history
of drug use and psychotropic drug use, lack
of psychological treatment history, lack of
use of psychiatric drugs, lack of history of
psychiatric disorders, and their acceptance
to participate in the research project. However,
the exclusion criteria included: reluctance
to continue working with the researcher, not
attending and delaying 3 treatment sessions.
Descriptive indicators such as frequency, standard
deviations of variance, etc. were used to describe
the data. One-way covariance (ANCOVA) was used
for the statistical analysis.
According
to
Table
1,
there
were
15
people
in
each
of
the
control
and
experimental
groups;
the
same
number
of
participants
were
also
involved
in
the
post-test
without
downsizing.
Click
here
for
Table
1:
Frequency
distribution
of
participants
in
the
experimental
and
control
groups
In
this
study,
16
participants
were
male
(53.3%)
and
14
were
female
(46.7%).
Table
2
shows
the
frequency
of
gender
by
the
experiment
and
control
groups.
Among
the
participants
in
the
experimental
group,
there
were
8
women
(26.67%)
and
7
men
(23.33%),
and
the
control
group
consisted
of
6
women
(20%)
and
9
men
(30%).
Click
here
for
Table
2:
Frequency
of
Gender
of
Participants
in
Experimental
and
Control
Groups
Table
3
shows
the
descriptive
indicators
of
the
age
of
all
participants
in
this
study.
According
to
the
information
given
in
this
table,
the
age
of
the
participants
ranged
between
20
and
35,
with
an
average
age
of
28
years.
The
amount
of
kurtosis
of
the
age
between
+1
and
-1
indicates
the
normal
distribution
of
the
age
of
the
participants.
Click
here
for
Table
3:
Descriptive
indicators
related
to
age
of
participants
Table
4
shows
the
descriptive
indicators
of
the
age
of
the
participants
in
the
experimental
and
control
groups
separately.
Accordingly,
the
age
of
the
participants
in
the
experimental
group
was
between
20
and
35,
with
an
average
age
of
27.8
years.
The
age
of
the
control
group
ranged
between
the
ages
of
21
and
35,
with
an
average
of
27.93
years.
The
kurtosis
of
the
individuals’
age
between
+1
and
-1
indicates
the
normal
distribution
of
the
age
of
the
participants
in
the
two
groups.
Click
here
for
Table
4:
Descriptive
indices
of
age
of
participants
in
experimental
and
control
groups
Diagrams
1
and
2
show
the
frequency
distribution
of
the
participants
in
the
experimental
and
control
groups.
The
curve
of
the
diagrams
also
indicates
the
normal
distribution
of
the
frequency
of
the
age
of
the
individuals.
Diagram
1:
Frequency
Distribution
of
the
age
of
the
participants
in
the
experimental
group
Diagram
2:
Frequency
Distribution
of
the
age
of
control
group
participants
Table
5
shows
the
descriptive
indices
of
central
tendency
and
the
dispersion
of
depression
scores
in
the
pretest
and
posttest
groups.
According
to
the
data,
the
mean
scores
of
depression
in
the
pre-test
of
the
two
groups
did
not
differ
significantly.
In
the
post-test,
the
depression
scores
of
the
experimental
group
decreased
significantly.
This
can
indicate
the
effect
of
the
acceptance
and
commitment
therapy
on
the
depression
scores
in
people
with
epilepsy.
Negative
values
of
the
kurtosis
of
depression
scores
in
all
conditions
implied
a
lack
of
distribution
of
people’s
scores
around
the
mean
that
led
to
the
expansion
and
lowering
of
the
height
of
the
normal
distribution
diagram.
Click
here
for
Table
5:
Descriptive
indices
of
depression
scores
of
control
and
experimental
groups
in
pre-test
and
post-test
Rectangular
diagrams
3
to
6
show
the
distribution
of
depression
scores
in
the
pre-test
and
post-test
of
the
experimental
and
control
groups.
Based
on
the
curve
of
the
diagrams,
the
normal
distribution
of
depression
scores
can
be
evaluated
in
different
situations.
Diagram
3:
Distribution
of
depression
scores
of
subjects
of
the
experimental
group
in
the
pre-test
Diagram
4:
Distribution
of
depression
scores
in
the
control
group
in
the
pretest
Diagram
5:
Distribution
of
depression
scores
in
the
experimental
group
in
the
post-test
Diagram
6:
Distribution
of
depression
scores
in
the
control
group
in
the
post-test
Table
6
shows
the
results
of
statistical
analysis
of
interactions
between
the
groups
and
pre-test.
As
shown
in
this
table,
given
that
the
significance
level
of
the
interaction
was
greater
than
0.05,
it
can
be
safely
stated
that
the
assumption
of
the
homogeneity
of
the
regression
slopes
has
not
been
violated.
Table
6:
Statistical
Results
of
Interaction
between
the
Groups
and
the
Pre-Test
Table
7
shows
the
results
of
the
main
test
of
covariance
analysis,
the
test
of
the
effects
between
the
subjects.
After
adjusting
the
pre-test
scores,
there
was
a
significant
effect
of
the
factor
between
the
subjects
of
group
(p=0.000
F1,27=87.433).
The
adjusted
means
of
depression
suggested
that
the
experimental
group
that
was
being
treated
with
acceptance
and
commitment
therapy
was
significantly
less
depressed
compared
to
the
control
group.
Also,
the
eta
square
(0.764)
indicates
that
there
was
a
strong
correlation
between
the
independent
variable
(therapeutic
intervention)
and
the
dependent
variable
(depression
of
individuals).
In
other
words,
about
76.4%
of
depression
variance
was
explained
by
the
therapeutic
intervention.
Also,
this
table
shows
that
there
was
a
significant
relationship
between
pre-test
and
post-test
scores
(p
=
0.001,
ETA
=
0.707);
in
other
words,
the
pre-test
has
played
a
role
in
explaining
post-test
scores
of
about
70.7%.
Click
here
for
Table
7:
Results
of
the
tests
of
the
effects
between
the
subjects
(dependent
variable:
depression)
Table
8
shows
the
adjusted
means
of
depression
scores
in
post-test
(dependent
variable)
for
control
and
experimental
groups.
Table
8:
Adjusted
means
of
post-test
depression
for
control
and
experimental
groups
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