The Effect of Psychosocial Group Based on Positive Psychology on Hopefulness in Patients with Major Depressive Disorder : A Clinical Trial

Introduction & Objective: Major depression is one of the most common psychiatric illnesses and, according to the World Health Organization, by 2020, the second most common disease in the world. Since one of the important goals of treating depression is the use of measures that can, in the short term, create favorable conditions, make people change from negative emotional state to positive state of affairs. Based on theoretical knowledge, positive psychology has this feature. The aim of this study was to determine the effect of positive group psychotherapy on the hope of patients with major depressive disorder. Materials and Methods: The present study was an experimental study in which the population of this study was composed of patients with major depressive disorder in Yasuj, Shahid Rajaee Nursing and Psychiatric Hospital. Among the patients with the criteria for entering the study, 32 first cases were randomly assigned to the experimental group and the other 32 as the control group. After completing the Snyder Hearing Inventory in the pretest, four sessions and weekly sessions a 90-minute psychotherapy group was established for positive psychology. Immediately after completing the post-test training sessions and two weeks afterwards, the follow up was assessed. Data were analyzed by SPSS software version 21 through independent t-test and Mann-Whitney test, Chi-square test, Fisher exact test, and ANOVA with repeated measurements at 95% confidence level. Results: At the beginning of the study, there was no significant difference between the experimental and control groups in terms of demographic characteristics. The hopefulness of the research units at the beginning of the study was 33.31 ± 5.31 in the experimental group and 30.72 ± 5.96 in the control group. Independent T-test did not show any significant difference between the two groups (P > 0.07). The hopefulness of the research units in the experimental group was 40.44 ± 5.9 in the first post test and 41.59 ± 5.48 in the second post test was significantly increased (P <0.001), while the hopefulness Control units of the control group in the first and second posttest have a decreasing trend toward the pretest. Conclusion: According to the findings of this study, it seems that psychosocial group based on positive psychology is effective on the hope of patients with major depressive disorder.


INTRODUCTION
One of the most common psychiatric illnesses is major depression, which today is widespread in the world and, according to the World Health Organization, by 2020, the world's second-largest disease (1)(2)(3).In the World Health Organization's review of 17 the country reported that in 2011, an average of 20 people, 1 person experienced a depression (4).The prevalence of major depressive disorder in the United States is estimated to be around 7%, aged between 18 and 30 years old and over 60 years of age, while women are 1.5 to 3 times more likely than men to develop this disorder (5).
According to the national study of diseases and injuries in Iran, mental illness and behavioral disorders after intentional and unintentional events are the largest health problem in Iran in terms of the index of years of adjusted life of disability (6).According to research carried out in Iran, depression is the third health problem in the country, and its prevalence has been reported from 6% to 73% in various studies and in various time periods (7).
Major depression is one of the most common psychiatric disorders based on the American Psychiatric Association's benchmarks in the fifth diagnostic and statistical diagnostic guide for mental disorders, with clinical manifestations of at least one symptom of mood, loss of pleasure, and at least five of the following symptoms There is a change in the size of the plantation and at least five percent of the body's normal weight, change in sleep, fatigue or lack of strength, feelings of guilt and worthlessness, problems of thinking, concentration and decision-making, repetitive thoughts of death and suicide, which for two weeks this Symptoms should be present and should change the level of previous performance of the person (5).
Another clinical manifestation that is noticeable in depressed patients is the lack of hope in their lives.Studies confirm the role of frustration as a key factor between depression and the emergence and susceptibility of mental health (8).
Research also showed that there is a positive relationship between self-esteem and optimism, and there is a negative relationship between depression and hope (9).Mental health, which in addition to curbing negative emotions improves people's relationships and performance, is associated with high hopes.Hope is not only a factor in mental health but also as a relief to physical problems and helps to heal the physical illness.Also, people who are hoping to achieve their goals are more comfortable (10).Considering the preconditions, it should be acknowledged that in order to reduce the symptoms of major depressive disorder, and as a result of a positive effect on improving the quality of life of such people, disappointment modification is essential in addition to medication and other selective therapies for major depression, and nursing interventions Inspired by theories and psychology schools, they can be helpful in this direction.One of these interventions derived from psychology is group psychotherapy based on positive psychology.
Positive psychology is one of the areas of psychology that has attracted many scholars and psychologists in the last century.The reason for this general interest is that clinical psychology has traditionally focused on mental disabilities and disabilities, while the goal of positive psychology is to focus on human strengths and positive emotions in order to complete deficiency-based approaches (11,12).
Since positive psychology states that real life can be emphasized by identifying individual abilities and identifying them to people (13); therefore, by inducing positive attitudes in life, one can reduce the symptoms of depression in patients (9).Since group psychotherapy can provide an opportunity for individual encounters, a secure base for exploring new cognitive, behavioral and emotional options, and a space for mutual understanding (14).By combining positive psychology and group psychotherapy, a new approach to the recovery of depressed patients can be taken.
According to the above, based on theoretical knowledge bases, using easy and affordable solutions along with medication with a happy and promising life can help prevent and treat many mental illnesses, including depression; Therefore, this study has been designed and evaluated to determine the effect of group psychotherapy based on positive psychology on the hope of patients with major depressive disorder.

MATERIALS AND METHODS
The present study is an experimental study.In this study, among the research community which included all patients referred to the Yazd University of Medical Sciences in Yazd, Iran, with the diagnosis of major depression in 1394, the eligible individuals were randomly selected to enter the study by gradual random sampling based on The following formula was estimated based on similar studies (8), which included 10% probable loss, 32 individuals in each group and a total of 64 individuals as sample size of the study.
(µ  − µ  )  Entry requirements included: the willingness of the patients to participate in the study, patients with major psychiatric disorder and DSM-V diagnosed with major depression, 2-3 weeks after hospitalization, over 15 years of age, reading and based on Depression Inventory, Depression Scale has a score of 20-28, with a Hope score of less than 50 according to Snyder's Hope Questionnaire.Exit criteria included: lack of willingness to cooperate with each other, lack of completeness of questionnaires, disabling illness, death or transfer from the psychiatric and psychiatric hospital of Martyr Rajaee Yasuj to another hospital.
The process of the study was started after the approval of the Ethics Committee of Yasuj University of Medical Sciences (YUMS.REC1394.75).After the presentation of the letter of introduction from the university's research deputy and obtaining permission from the authorities of Shahid Rajaee Hospital in Yasuj, samples were collected.Ethical standards such as: informed consent, confidentiality of information, and freedom of departure were emphasized.In this study, Beck Depression Inventory and Schneider's Hope Questionnaire were used.The Beck Depression Inventory, developed in 1961, has 21 self-monitoring items to measure the severity of depression in people over the age of 13, each item containing 4 statements ranging from 0 to 3 and after summing the total score of items based on the total score is judged by the individual's depression status.The higher scores showed the severity of depression; in this way, a score of 0-13, normal to least depression, a score of 19-14 indicates mild depression, a score of 28 -20 indicates moderate depression and a score of 29 and more Depression Extreme (15).The Hope Questionnaire, prepared by Schneider et al. (1991) for measuring hope and its components or subscales including incentives and paths (16), has 12 questions and aims to assess the level of life expectancy in individuals.The method of scoring this questionnaire designed for people aged 15 years and older, based on the Likert spectrum, has eight consensus, strongly agree, agree, slightly agree, slightly opposed, opposed, strongly opposed, and totally opposed, respectively, scores 8, 7, 6, 5, 4, 3, 2, 1.In order to obtain the total score of the questionnaire, the total points of each question are counted together.Higher privileges indicate a greater life expectancy in the respondent, and vice versa, with a cut point of 43.Validity and reliability of these two questionnaires have been approved inside and outside of Iran (17,18).The demographic information questionnaire was also extracted from similar studies and questionnaires and available books, and then by five members of the faculty, the qualitative and qualitative content was confirmed and formalized.
After completing the data gathering tools in the pre-test, the subjects of the experimental group were divided into groups of 8 to 10, based on the basis of the dynamics of the Yalom group, and for each of these groups, based on the protocol adopted From the positive treatment protocol, Seligman (2006) (19), Asgharipoor (2012) (20), Seligman (2004) (21), during the 4 weeks, 8 sessions of 90 minutes of positive psychotherapy by the researcher were as follows in the room The conference was held at the Shahid Rajaee Hospital in Yasuj.During the first session of psychotherapy, the relationship between the researcher and people was discussed, and in relation to the goals of psychotherapy and the content Meetings and discuss questions were resolved.Initiation of a session accompanied by muscle relaxation to reduce the anxiety of depressed patients from being in the group.During this meeting, individuals were also familiar with their duties and were given an assignment at the end of the session.The second to seventh sessions of group psychotherapy were focused on topics related to positive psychology, including positive affirmation, emotions and positive emotions, good pleasure against bad memories, empathy, pleasure of hope and optimism, pleasure and gratitude; In this way, at the beginning of each session, a summary of the previous sessions is presented and after the implementation of the group's psychotherapy based on the subjects of the foreword, at the end of the meeting, in addition to answering the ambiguities and questions, the summary of the content of the session is expressed and for the next meeting assignment It was given to them; It is worth noting that in each session for resting people for ten minutes to relieve fatigue Based on the principles of group therapy, in the seventh session, in addition to the usual tasks of each session, the approach to the final session was again reminded.
At the eighth session, all the content was reviewed again and discussed how to get happiness from the Seligman view, and at the end of the meeting, they were asked to complete the hopefuls as a follow-up test.It is worth noting that in order to measure the survival rate of the effects of independent psychotherapy based on positive psychology on the hope of research units in the experimental group, two weeks after the end of the sessions, the questionnaires were completed by the research units as follow up.(IRCT2015101824582N1) The data were analyzed by SPSS software version 21 and analyzed by descriptive statistics and inferential statistics tests according to the status of the study variables from normal distribution in the Kolmogorov-Smirnov test, taking into account the 95% confidence level.
The findings of the study showed that in the test group, the mean and standard deviation of the total score of hope before intervention, the end of the eighth and tenth week were 33.31 ± 5.31, 40.44 ± 5.9 and 41.59 ± 5.48, 41 has been.
While the mean and standard deviation of the overall hope score in the control group at three different measuring times were 30.72 ± 5.96, 25.47 ± 3.78, 25.59 ± 4.02, respectively.The repeated ANOVA test showed a statistically significant difference in the mean total score of hope between the two groups of test and control (p <0.05).The findings showed that there was no significant difference between the two groups in the test and control group (p = 0.07) in the mean score of total hope (p = 0.07).However, at the end of the eighth and tenth week of group psychotherapy sessions based on positive psychology on hope patients This significant difference was reported for major depressive disorder (P = 0.001, P = 0.001, respectively) (Figure 1).Other findings of the study also indicate that the average adjusted hope was in the order of ascending, corresponding to the interventions and then to the control group.In other words, after the research interventions, there was the highest level of hope in the patients with essential depressive disorder (57) and the least hope was in the patients with major depressive disorder in the control group (32).It is worth noting that in order to examine the significance of these differences, the moderated mean of hope and control among the groups was compared using the Bonferoni test.The results indicate that after completing the research interventions (first and second post-tests), the level of hopefulness of the group was significantly increased statistically (p <0/0001) in comparison with the control group's hopefulness.This indicates the effectiveness of group psychosocial therapy based on positive psychology on the increase in hope in patients with major depressive disorder and on this basis, the research hypothesis that "group psychotherapy based on positive psychology in increasing the hope of patients with major depressive disorder Is effective "was approved.
(Table 2) Also, the findings of the study on intra-group comparisons between two of the two mean differences in the total score of hope in the test group in the two post-intervention period compared to the pre-intervention showed that the difference between the mean total score of hope and the pre-interventional point of view was statistically significant They have been reported (p <0.05).However, no statistically significant difference was observed in the control group (p> 0.05).(Table 3)

DISCUSSION
The findings of this study showed that among the groups in terms of demographic variables including age, number of children, gender, marital status, educational status, occupation, place of residence, family history of mental illness,   history of hospitalization, History of psychotherapy and duration of illness, there was no significant difference between the two groups.Also, there was no significant difference between the mean depression scores, hopefulness of patients in both groups.Therefore, it should be acknowledged that the study groups mentioned at the beginning of the study were completely identical and that the changes in the dependent variables in the first and second posttest were due to the effect of the independent variable of the study, and with respect to the similarity of the two groups, Judging from the results and considering any kind of change in the results to the effect of intervention, the implementation of psychotherapy.
Although the results of published studies have reported a positive psychosocial benefit of positive psychological therapy on depressive symptoms, they differ in terms of type and duration of intervention, and the tool for collecting data related to its effects.Lee (2015) examined his quasi-experimental study (with control and non-random) and combination (quantitative and quantitative) with the aim of influencing positive group psychology on the self-confidence and anger of adolescents in churches of Korean immigrants.Both groups completed questionnaires (STAXI) and (Self-Esteem Inventories) before intervention.The of this study showed the positive psychological effect in increasing adolescent self-esteem (P <0.05).However, it did not affect the reduction of anger and anger.Also, qualitative research showed improvement in interpersonal relationships and acquisition of communication skills in adolescents (22).As discussed above, this study, with a different tool from the present study, examines this approach to adolescents, which ultimately indicates its positive impact on adolescent self-esteem.
Scherank et al. ( 2014) investigated a positive correlational model of positive psychology with the effect on improving the mental health of psychosis patients in a study that was conducted using mental health scale, Rosenberg Self-Esteem Scale, Short Scale of Depression-Happiness, Scale Hope, Rogers Empowerment Scale, Short Scale of Psychiatric Symptoms, and Sense of Consciousness Scale.Finally, in patients, the increase in the rate of hope score, feeling good, symptoms of recovery and meaning of life was self-evident (23).Seligman et al. (2006) study the effects of positive psychological interventions on the improvement of depression symptoms.The results of the study showed an improvement in depressive symptoms in the test group compared to the control group (19).Also, positive psychotherapy can be a good alternative to other treatments in people with major depressive disorder (24) because of its short duration and simple and understandable exercises compared to other psychotherapy approaches.
In the present study, group psychotherapy with a positive psychological approach, along with routine and primary therapies for patients with major depressive disorder, has been used to make positive changes in people with this disease.Scientific evidence suggests that psychotherapy, along with drug therapy, can be more effective if it is consistent with the patient's follow-up (25).
Slad (2010) emphasizes in his research the use of positive psychological approach alongside medical-related services and training for employees (26).This indicates the importance of this approach not only in the humanities but also in medical sciences, which can be used to highlight the importance of this study and its hypotheses.
In addition to the extensive explanation given above, we must acknowledge that the results of this study are based on the findings of Seligma et al. (19), Sin et al. (27), Sergeant and Mongrain (28), Sadeghi (29) 30), (31) is also consistent and it can be inferred that group psychotherapy based on positive psychology does not deny negative emotions, such as depression, but tries to bring people to positive living, unknown abilities and hand Nurse to encourage and push (32).
Although the findings of the present study indicate the impact of group psychiatric intervention based on positive psychology and affect the level of hope of research units, this study also encountered some constraints that should be considered in generalizing the results.The low level of education access to research units in this study was one of the factors that contributed to this study.Because of the lack of exposure to sample deficiencies, one of the criteria for entering the sample was considered to be literacy, and therefore some patients had difficulty completing the related assignments in each session, as well as This study was conducted in Yasuj city and because of the dominant native dialect, Lori, not familiar with this dialect and the lack of a fellow familiar with this dialect, along with the researcher, only allowed people who were able to speak Persian in their study.In addition to the limitations of the study, the time required to complete the sample size was also recommended.
Also, this study was considered as a student's thesis with a time limit, and some of the cases, such as the study of the mediational and long-term effects of this treatment, were not feasible in patients, which are suggested to be considered in future studies.

CONCLUSION
Based on the findings of this study, group psychotherapy based on positive psychology on patients' hope has been able to significantly improve the hope of patients with major depressive disorder.Considering the positive results of positive psychology, doing these activities combined with other approaches and therapies such as psychotherapy is one of the measures that can be useful in controlling depression and improving its symptoms.
Considering the precautions and considering that depression is one of the most common diseases in the present age, it is important to address it due to its negative effects on individual, social, and economical performance of the person and other complications.The reason for the use of modern approaches combined with other treatments is very effective in the recovery and treatment of these patients.Accordingly, according to the results of this study, as well as the roles of nurses in the community and their close relationship with patients, this approach can be used in treating and increasing the patients' positive emotional excitements and thereby increasing the hope of patients with impaired provided major depression.

Figure 1 :
Figure 1: The mean total score of patients' hope in the two groups of intervention and control Depending on the time of intervention Electron J Gen Med 2018;15(3):em49 http://www.ejgm.co.uk 7 / 8

Table 1 :
Comparison of demographic variables in patients in both intervention and control groups Comparison of sociodemographic characteristics based on gender

Table 2 :
Comparison of moderate and standard deviation of hope in patients intervention and control groups

Table 3 :
Comparison of two and two differences in the mean score of hope in the two groups of intervention and control in terms of evaluation times