INFLUENCE OF PSYCHOTHERAPY AND GENDER ON DEPRESSION

ABSTRACT
This study centered on influence of psychotherapy and gender on depression. 60 participants were used in the study (30 males and 30 females). 15 of the males and 15 of the females were administered only positive self-talk and 15 participants of the female, and 15 of the males were administered exercise and positive self-talk. 30 participant of the male and 30 participant of the female were administered only exercise. The participants where drawn from student of Nnamdi Azikiwe University, Awka. Beck Depression Inventory and self rating depression scale of Williams (1965) which was later re-validated by Obiorah (1995) were used in the study. 3-way ANOVA were also used in the study to test three hypotheses. The first hypothesis stated that there will be a significant difference on the effect of exercise in combination with positive self-talk on depression than exercise alone.
The second hypothesis stated that there will be a significant difference between males and females on the influence of psychotherapy on depression.
The third hypothesis states that there will be a significant difference on those administered high exercise than those administered low exercise on reducing of depression. The researcher concludes that there is no significant difference on the effect of exercise in combination with positive self talk on depression than exercise alone. The researcher also concludes that those administered high exercise will have a significant increase in reducing depression than those administered low exercise. The implication and recommendation where made for further study.

CHAPTER ONE

1.0                                           INTRODUCTION
This study will be centered on influenced of psychotherapy and gender on depression. But the type of psychotherapy that was used in this study was positive self-talk and exercise. Self-talk can be defined as what people say to themselves with particular emphasis on the words used to express thoughts and beliefs about oneself and the world to oneself. Positive self-talk are those words people say to themselves for encouragement.
Exercise can be defined as an activity or a task that trains the body or the mind. We have two types of exercise namely Isotomic and Isometric exercise. Isotomic exercise involves moving a muscles through long distance against low resistance as in running. While Isometric exercise involves moving a muscles through a short distance against a high resistance as in body budding, wrestling, boxing and press up etc.

We also have Aerobic exercise. Aerobic exercise are those exercise that help to increase cardiovascular fitness by improving the body’s use of oxygen and allowing the heart to work less strenuously. Aerobic exercise include running, cycling, swimming and dancing.

Depression is a mood disorder that is characterized by emotional, physiological/behavioural and cognitive symptoms.

Emotional Symptoms


1.                  Sadness

2.                  Depressed mood

3.                  Anhedonia (lost of interest or pleasure in usual activity)

4.                  Irritability (particularly in children and adolescents)

Physiological and behavioural symptoms

1.                  Sleep disturbances (hypersomnia or insomnia)

2.                  Appetite disturbances

3.                  psychomotor retardation or agitation)

4.                  Catatonia (unsual behaviours ranging from complete lack of movement to excited agitation)

5.                  fatigue and loss of energy

Cognitive Symptoms

1.                  Poor concentration and attention

2.                  Indecisiveness

3.                  Sense of worthlessness or guilt

4.                  Poor self-esteem

5.                  Hopelessness

6.                  Suicidal thoughts

7.                  Delusion and hallucinations with depressing themes.

For some time now, it has been common knowledge that exercise is good for one’s physical health. It has only been in recent years, however, that it has become commonplace to read in magazines and health newsletters that exercise can also be of value in promoting sound mental health. Although this optimistic appraisal has attracted a great deal of attention, the scientific community has been much more cautious in offering such a blanket endorsement. Consider the tentative conclusions from the Surgeon General’s report on Physical Activity and Health (PCPEFS Research Digest, 1996) that “physical activity appears to relieve symptoms of depression and anxiety and improve mood” and that “regular physical activity may reduce the risk of developing depression, although further research is needed on this topic”.

The use of carefully chosen words, such as “appears to” and “may” illustrate the caution that people in the scientific community have when it comes to claiming mental health benefits derived from exercise. Part of the problem in interpreting the scientific literature is that there are over 100 scientific studies dealing with exercise and depression or exercise and anxiety and not all of these studies show statistically significant benefits with exercise training. The paucity of clinical trial studies and the fact that a “mixed bag” of significant and non-significant findings exists makes it difficult for Scientifics to give a strong endorsement for the positive influence of exercise on mental health. There is no doubt that the mental health area variables associated with sound mental health. However, until these clinical trial studies materialize, there is still much that can be done to strengthen statements made about exercise and mental health.

What evidence would prompt some Scientifics to “stick their neck out” in favour of more definitive statements? One reason for greater optimism is the recent appearance of quantitative reviews (i.e. meta-analyses) of the literature on a number of summaries of results across studies. By including all published and unpublished studies and combining their results, statistical power is increased. Another advantage of using this type of review process is that a clearly defined sequence of steps is followed and included in the final report so that anyone can replicate the studies. Two additional advantages that meta-analysis has over other types of reviews include:

(a)                The use of a quantification technique that gives an objective estimate of the magnitude of the exercise treatment effect; and

(b)               Its ability to examine potential moderating variables to determine if they influence exercise – mental health relationships. Given these advantages, this paper will focus primarily on results derived from large-scale meta-analysis reviews.

ANXIETY REDUCTION FOLLOWING EXERCISE
It is estimated that in the United States approximately 7.3% of the adult population has an anxiety disorder that necessitates some form of treatment (Regier 1988). In addition, stress-related emotions, such as anxiety, are common among healthy individuals (Cohen, Tyrell, & Smith, 1991). The current interest in prevention has heightened interest in exercise as an alternative or adjunct to traditional interventions such as psychotherapy or drug therapies.

Anxiety is associated with the emergence of a negative form of cognitive appraisal typified by worry, self-doubt, and apprehension. According to Lazarus and Cohen (1977), it usually arises in the face of demands that tax or exceed the resources of the system of … demands to which there are no readily available or automatic adaptive responses” (p. 109). Anxiety is a cognitive phenomenon and is usually measured by questionnaire instruments. These questionnaires are sometimes accompanied by physiological measures that are associated with heightened arousal/anxiety (e.g. heart rate, blood pressure, skin conductance, muscle tension). A common distinction in this literature is between state and trait questionnaire measures of anxiety. Trait anxiety is the general predisposition to respond across many situations with high levels of anxiety. State anxiety, on the other hand, is much more specific and refers to the person’s anxiety at a particular moment. Although “trait” and “state” aspects of anxiety are conceptually distinct, the available operational measures show a considerable amount of overlap among these subcomponents of anxiety (Smith, 1989).

For meta-analytic reviews of this topic, the inclusion has been criterion which has been included in the review. Studies with experiment-imposed psychosocial stressors during the post exercise period have not been included since this would confound the effects of exercise with the effects of stressor (e.g., Stoop color-word test, active physical performance). The meta-analysis by Schlicht (1994), however, included some stress-reactivity studies and therefore was not interpretable.

Landers and Petruzzello (1994) examined the results of 27 narrative reviews that had been conducted between 1960 and 1991 and found that in 81% of them the authors had concluded that physical activity/fitness was related to anxiety reduction and depression following exercise and there was little or no conflicting data presented in these reviews. For the other 19%, the authors had concluded that most of the findings were supportive of exercise being related to a reduction in anxiety, but there were some divergent results. None of these narrative reviews concluded that there was no relationship.

There have been six meta-analyses examining the relationship between exercise and anxiety reduction (Calfas & Taylor, 1994; Kugler, Seelback, & Kruskemper, 1994; Landers & Petruzzello, 1994; Long & van Stavel, 1995; McDonald & Hodgdon, 1991; Petruzzellor, Landers, Hatfield, Kubitz, & Salazar, 1991). These meta-analyses ranged from 159 studies (Landers & Petruzzello, 1994; Petruzzello et al., 1991) to five studies (Calfas & Taylor, 1994) reviewed. All six of these effects ranged from “small” to “moderate” in size and were consistent for trait, state, and psychophysiological measures of anxiety. The vast majority of the narrative reviews and all of the meta-analytic reviews support the conclusion that across studies published between 1960 and 1995 there is a small to moderate relationship showing that both acute and chronic employed (i.e., state, trait or psychophysiological), the intensity or the duration of the exercise, the type of exercise paradigm (i.e. acute or chronic), and the scientific quality of the studies. Another meta-analysis (Kelley & Tran, 1995) of 35 clinical trial studies involving 1,076 subjects has confirmed the psychophysiological findings in showing small (-4/03), but statistically significant, post exercise reductions for both systolic and diastolic blood pressure among normal normotensive adults.

In addition to these general effects, some of these meta-analyses (Landers & Petruzzello, 1994; Petruzzello et al., 1991) that examined more studies and therefore had more findings to consider were able to identify several variables that moderated the relationship between exercise and anxiety reduction. Compared to the overall conclusion noted above, this is based on database. More research, therefore, is warranted to examine further the conclusions derived are based on a much smaller variables. The meta-analyses show that the larger effects of exercise on anxiety reduction are shown here:

a.                   The exercise is “aerobic” (e.g., running, swimming, cycling) as opposed to nonaerobic (e.g. handball, strength-flexibility training),
b.                  The length of the aerobic training program is at least 10 weeks and preferably greater than 15 weeks, and


c.                   Subjects have initially lower levels of fitness or higher levels of anxiety. The “higher levels of anxiety” includes coronary (Kugler 1994) and panic disorder patients (Meyer, Broocks,

Hillmer – Vogel, Bandelow, & Ruther, 1997).

In addition, there is limited evidence which suggests that the anxiety reduction is not an artifact “due more to the cessation of a potentially threatening activity than to the exercise itself” (Petruzzello, 1995, p. 109), and the time course for postexercise anxiety reduction is somewhere between four to six hours before anxiety returns to pre-exercise levels (Landers & Petruzello, 1994). It also appears that although exercise differs from no treatment control groups, it is usually not shown to differ from other known anxiety-reducing treatments (e.g., relaxation training). The finding that exercise can produce an anxiety reduction similar in magnitude to other commonly employed anxiety treatments is noteworthy since exercise can be considered at least as good as these techniques, but in addition, it has many other physical benefits.

EXERCISE AND DEPRESSION
Depression is a prevalent problem in today’s society. Clinical depression affects 2-5% of Americans each year (Kessler et al., 1994) and it is estimated that patients suffering from clinical depression make up 6-8% of general medical practices (Katon & Schulberg, 1992). Depression is also costly to the health care system in that depressed individuals annually spend 1.5 times more on health care than nondepressed individuals, and those being treated with antidepressants spend three times more on outpatient pharmacy costs than those not on drug therapy (Simon, VonKorff, & Barlow, 1995). These costs have led to increased governmental pressure to reduce health care costs in America. If available and effective, alternative low-cost therapies that do not have negative side effects need to be incorporated into treatment plants. Exercise has been proposed as an alternative or adjunct to more traditional approaches for treating depression (Hales & Travis, 1987; Martinsen, 1987.

The research on exercise and depression has a long history of investigators (Franz & Hamilton, 1905; Vaux, 1926) suggesting a relationship between exercise and decreased depression. Since the early 1900s, there have been over 100 studies examining this relationship, and many narrative reviews on this topic have also been conducted. During the 1990s there have been at least five meta-analytic reviews (Craft, 1997; Calfas & taylor, 1994; Kugler et al., 1994; McDonald & Hodgdon, as many as 80 (North et al., 1990). Across these five meta-analytic reviews, the results consistently show that both acute and chronic exercise are related to a significant reduction in depression. These effects are generally “moderate” in magnitude (i.e. depressed, or mentally ill. The findings indicate that the antidepressant effect of exercise begins as nondepressed, clinically exercise and persists beyond the end of the exercise program (Craft, 1997; North et al., 1990). These effects are also consistent across age, gender, exercise group size, and type of depression inventory.

Exercise was shown to produce larger antidepressant effects when:

a.                   The exercise training program was longer than nine weeks and involved more sessions (Craft, 1997; North et a;., 1990);

b.                  Exercise was of longer duration, higher intensity, and performed a greater number of days per week (Craft, 1997); and

c.                   Subjects were classified as medical rehabilitation patients (North et al., 1991) and, number on questionnaire instruments, were classified as moderately/severely depressed compared to mildy/moderately depressed (Craft, 1997). The latter effect is limited since only one study used individuals who were classified as severely depressed and only two studies used individuals who were classified as moderately to severely depressed. Although limited at this time, this finding calls into question the conclusions of several narrative reviews (Gleser & Mendelberg, 1990; Martinsen, 1987), which indicate that exercise has antidepressant effects only for those who are initially mild to moderately depressed.

The meta-analyses are inconsistent when comparing exercise to the more traditional treatment for depression, such as psychotherapy and behavioural interventions (e.g., relaxation, meditation), and this may be related to the types of subjects employed. In examining all types of subjects, North et al. (1990) found that exercise decreased depression more than relaxation training or engaging in enjoyable activities, but did not produce effects that were different from psychotherapy. Craft (1997), using only clinically depressed subjects, found that exercise produced the same effects as psychotherapy, behavioral interventions, and social contact. Exercise used in combination with individual psychotherapy or exercise together with drug therapy produced the larges effects; however, these effects were not significantly different from the effect produced by exercise alone (Craft, 1997).

That exercise is very effective as more traditional therapist is encouraging, especially considering the time and cost involved with treatments like psychotherapy. Exercise may be a positive adjunct for the treatment of depression since obesity can also cured through exercise which behavioral interventions do not. Thus, since exercise is cost effective, has positive health benefits, and is effective in alleviating depression, it is a viable adjunct or alternative to many of the more traditional therapies future research also needs to examine the possibility of systematically lowering antidepressant medication dosages while concurrently supplementing treatment with exercise.


OTHER VARIABLES ASSOCIATED WITH MENTAL HEALTH Positive mood: The Surgeon General’s Report also mentions the possibility of exercise improving mood. Unfortunately the area of increased positive mood as a result of acute and chronic exercise has only recently been investigated and therefore there are no meta-analytic reviews in this area. Many investigators are currently examining this subject and many of the preliminary results have been encouraging. It remains to be seen if the additive effects of these studies will result in conclusions that are as encouraging as the relationship between exercise and the alleviation of negative mood states like anxiety and depression.

Self-esteem: Related to the area of positive mood states in the area of physical activity and self-esteem. Although narrative reviews exist in the area of physical activity and enhancement of self-esteem, there are currently four meta-analytic reviews on this topic (Calfas &     Taylor, 1994; Gruber 1986; McDonald & Hodgdon, 1991; Spence, Poon, & Dyck, 1997). The number of studies in these meta-analyses ranged from 10 studies (Calfas & Taylor, 1994) to 51 studies (Spence et al., 1997). All four of the reviews found that physical activity/exercise brought about small, but statistically significant, increases in physical self-concept or self-esteem. These effects generalized across gender and age groups. In comparing self-esteem scores in children, Gruber (986) found that aerobic fitness produce much larger effects on self-esteem scores than other types of physical education class activities (e.g., learning sports skills or perceptual-motor skills). Gruber 91986) also found that the effect of physical activity was larger for handicapped compared to non-handicapped children.

Restful sleep: Another area associated with positive mental health is the relationship between exercise and restful sleep. Two meta-analyses have been conducted on this topic (Kubitz, landers, Petruzzello, & Han, 1996; O’Connor & Youngstedt, (1995). The studies reviewed have primarily examined sleep duration and total sleep time as well as measures derived from electroencephalographic (EEG) activity while subjects are in various stages of sleep. Operationally, sleep researchers have predicted that sleep duration, total sleep time, and the amount of high amplitude, slow wave EEG activity would be higher in physically fit individuals than those who are unfit ( chronic effect) and higher on nights following exercise (i.e. acute effect). This prediction is based on the “compensator’ position, which posits that ‘fatiguing daytime activity (e.g. exercise) would probably result in a compensatory increase in the need for and depth of nighttime sleep, thereby facilitating recuperative, restorative and/or energy conservation processes” (Kubtiz et al., p. 278).

The sleep meta-analyses by O’Connor and Youngstedt (1995) and Kubitz et al. (1996) show support for this prediction. Both reviews show that exercise significantly increases total sleep time and aerobic exercise decreases rapid eye movement (REM) sleep. REM sleep is a paradoxical form in that it is a deep sleep, but it is not as restful as slow wave sleep (i.e, stages 3 and 4 sleep). Kubtiz et al. (1996) found that acute and chronic exercise was related to an increase in slow wave sleep and total sleep time, but was also related to a decrease in sleep onset latency and REM sleep. These findings support the compensatory position in that trained subjects and those engaging in an acute bout of exercise went to sleep more quickly, slept longer, and had a more restful sleep than untrained subjects or subjects who did not exercise. There were moderating variables influencing these results. Exercise had the biggest impact on sleep when:

a.                   The individuals were female, low fit, or older,

b.                  The exercise was longer in duration; and

c.                   The exercise was completed earlier in the day (Kubitz et al., 1996).

To determine “where” and “how” positive self-talk fits into the scheme of intrapersonal communication, and communication as a whole, some definitions must be derived. The reality of emotional choice - - that intrapersonal communication (IAPC), imaging, and visualization (Weaver and Cottrell, 1987). Positive self-talk is part of IAPC, but the part cannot be equal to the whole.

Having concluded that positive self-talk and IAPC are separate but related, what is IAPC? Shedletsky (1989) places it into the traditional model of communication, but all elements of “sender” “receiver”, and “transmitter” are carried out within individual people. Pearson and Nelson 9185) expand that definition as follows:


Intrapersonal communication is not restricted to “talking to ourselves”; it also includes such activities as internal problem solving, resolution of internal conflict, planning for the future, emotional catharsis, evaluation of ourselves and others.

Fletcher (1989) adds the physiological dimension to IAPC. Fletcher defines, “Intrapersonal communication … is the process interior to the individual by which reality evolves and is man tined.” It is a process which involves other parts of the body including the nervous system, organs, muscles, hormones, and neurotransmitters. IAPC, as well as the internal thoughts and language associated with it, serve as another “control” system in the body, on much the same level as the body’s other system. This is the beginning of the mind-body, or psychophysiological, connection.

Medical professionals are beginning to take note of mind-body interrelationships in their treatment of patient. The basis of this is the recognition of the functions of inner speech. These functions are to:

v                  Coordinate other connective sensory and motor functions within the brain

v                  To integrate and link the individual to the social order

v                  To regulate human behaviour through spoken language

v                  To provide for human mentation as reflected in mental processes and activities (Korba, 1989).

Positive self-talk is a health behaviour that has potentially far-reaching effects. Although it will most likely be used by those who have a high internal locus of control and place a high value on health, it can also help relatively healthy people in health “maintenance” programs. Self-talk is categorized as being positive or negative. As its label implies, positive self-talk has good implications for people’s mental and physical well-being. However, the negative is not all bad. The key to using self-talk is to strive for an appropriate balance (which is a tenet of holistic medicine itself) between the two.

The use of positive self-talk has been linked to the reduction of stress, in turn, can effect other positive health changes. Positive self-talk, like thoughts, is not neutral because it triggers behavior in either a positive or negative direction. Both thoughts and positive self-talk are based on beliefs – which ‘can exist with or without evidence that they are accurate” (Grainger, 1989) --- which are formed early in life. Beliefs shaped our positive self-talk, which in turn affects our self-esteem.

However, negative thinking as the “thinking of choice,” may not be so bad, because it heightens people’s sensitivity to the situation they are facing. They are likely to think more clearly. Grainger says, “Negative thinking, then, is the most productive, the most useful, and the healthiest thinking to adopt “when risk is high”.

Instead of categorizing negative self-talk as “negative,” it might be better to call it “logical and accurate” self-talk. Braiker (1989) emphasizes the “responsible” use of self-talk. She warms against confusing positive inner dialogue with positive thinking, happy affirmations, or self-delusions. Logical, accurate self-talk recognizes personal short-comings, but also modifies them to help people define a plan of correction.

DEVELOPING A POSITIVE MENTAL ATTITUDE
A positive mental attitude as a basis for self-talk does not require self-dilution. The development of optimistic thought patterns requires essentially three things; recognizing self-talk for what it is, dealing with negative messages, and harnessing the positive for the greater good of individual person. By using inner speech, people can influence their health states, but the benefits potentially react beyond that. To make self-talk positive, people must change what goes into their subconscious. All this hinges on recognition of inner messages.

Levine (1991) expands on the idea of noticing through patterns. Regardless of the thought type (positive or negative), she suggests people reflect upon the antecedents to and the feelings about the particular thought. When people determine which thoughts improve their sense of well-being, they can make those thoughts occur more frequently.

Again, this does not imply that people who practice positive self-talk will be a group of “happy campers”. Negative inner speech can and does play a constructive role in helping people create better realties for themselves. As was previously state, negative thoughts can trigger warning signals in high risk situations. The object is to deal with the underlying message, and then move to correct the situation. Negative self-talk, like its label implies, has a downside as well.

McGonicle (1995) categorizes “harmful” negativity as being “awfulisitc” (everything is catastrophic), “absolutistic” (using “must.” “always,” “never’), or should-have self-talk (‘I ‘should have’ done this”).

These also are found on what Braiker lists as “cognitive trap”. Other elements include: all-or-nothing thinking; discounting the positive; emotional reasoning; and personalization and blame. Levine suggest examining “seed thoughts”, sometimes mindlessly – sued clich├ęs, for negative elements - - either emotion or health related. For example, thinking “I’m a nervous wreck,” “I’m eaten up with anger,” “that disease runs in my family,’ and “Only the good die young” can undermine any positive thinking people try to achieve. Therefore, individuals must replace these thoughts with something more constructive.

In a society where people (especially females) are taught to downplay their good points, developing positive self-talk might be difficult at first. It necessitates a ‘reality-check.” Most of the time, people are a lot “better” (performance/health-wise) than they previously concluded. Keeping a journal, using your name as you talk of yourself, and releasing pent-up feelings are some of the ways


Levine recommends becoming aware of and constructively using thoughts.

1.1       STATEMENT OF PROBLEM
Recently, people are realizing that chemotherapy (drug treatment) may not really be the treatment of choice for psychological problems. As a result of this, most people are now looking forward for treatment techniques that does not involve taking of drugs. Psychotherapy, through non-psychopharmacological means, may not give individuals the type of control that they crave for. Hence, individual may resist some form of psychotherapy that puts them directly under the control of the psychotherapy. Such clients prefer therapies that will enable them carryout the treatments themselves after the initial training. Exercising and positive self talk gives them the type of control that they desire. Therefore, the present study seeks to determine whether exercising and talking positively to self will reduce feeling of depression among persons.

1.2       RESEARCH QUESTIONS
The research questions of this study are as follows:

1.                  Will there be any significant difference on effect of exercise in combination with positive self-talk on depression than exercise alone.


2.                  Will there be any significant difference between males and females on the influence of psychotherapy on depression.

3.                  Will there be any significant difference on those administered high exercise than those administered low exercise on reducing of depression.

1.3       PURPOSE OF THE STUDY
The results of this study confirm what has been acknowledged among people but with limited empirical confirmation that exercise has some mental health benefits. The study will also show find out whether talking positively to self will help to reduce a lot of negative thoughts that people hold and that acts as poison to their minds and body.

Furthermore, the study will also know whether non-psychopharmacological treatment techniques can help to reduce depression.

1.4       RELEVANCE OF THE STUDY
This study will be useful to those in the medical and clinical psychology settings and even private persons. This may contribute in better understanding and treatment of depression in our society. Also, it will make people to understand that exercise is not only beneficial to muscle training and weight controls but also to control the psychological state for holistic mental health.

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