824466

research-article20192019
SGOXXX10.1177/2158244018824466SAGE OpenHemati Alamdarloo et al.

Original Research

SAGE Open

The Effect of Cognitive-Behavioral

January-March 2019: 1­–7
© The Author(s) 2019
DOI: 10.1177/2158244018824466
https://doi.org/10.1177/2158244018824466

Therapy on Depression, Anxiety, and journals.sagepub.com/home/sgo

Stress Levels in Iranian Males With

Addiction

Ghorban Hemati Alamdarloo1, Soheila Moradzadeh Khorasani2,

Mahmoud Najafi2, Fatemeh Soosan Jabbari1, and Setareh Shojaee1

Abstract
This study aimed at investigating the effect of cognitive-behavioral therapy on reducing depression, anxiety, and stress levels
of Iranian males with addiction. The participants included 24 Iranian males with addiction selected through convenience
sampling and randomly assigned to the experimental (n = 12) and control (n = 12) groups. Then, Depression Anxiety and
Stress Scale was used as the pretest, posttest, and follow-up tests to assess participants’ levels of depression, anxiety, and
stress. The experimental group received eight sessions of cognitive-behavioral therapy, while the control group did not. The
findings of the study showed that cognitive-behavioral therapy was effective in reducing participants’ levels of depression,
anxiety, and stress. Thus, the findings indicate that the cognitive-behavioral therapy reduced the depression, anxiety, and
stress of Iranian males with addiction.

Keywords
cognitive-behavioral therapy, stress, anxiety, depression, Iranian males with addiction

Introduction
Addiction and substance abuse are among the most severe
psychosocial traumas posing environmental, psychological,
behavioral, and emotional challenges to people. They can
lead to problems for individuals, seriously undermine family
and cultural foundations, and endanger countries’ dynamics
(Lander, Howsare, & Byrne, 2013; Sword et al., 2013). Drug
addiction is a type of brain disorder which can affect an indi-
vidual’s behavior; be identified with mental, behavioral, and
physiological symptoms; and be persisting for a long period
of time despite its harmful and detrimental consequences.
Substance abuse is also dangerous for individuals and can
disturb their social and intellectual lives and affect their com-
patibility with others. It can cause major hazards to individu-
als’ health and lead to negative financial and social
consequences which are beyond health care system. For
instance, it can decrease economic efficiency, as a result of
one’s exit from labor market; can increase crime rates; can
cause malfunction and/or disability; and can, finally, lead to
death (Volkow, 2014). Drug addiction is a serious problem
that can be cured and overcome. Cognitive-behavioral ther-
apy (CBT) is one of the non-medical therapies used to cure
addiction. This form of therapy has been used to cure addicts
in various clinical studies, and its clinical effectiveness has
been proved (Marlatt & Range, 2008; McHugh, Hearon, &
Otto, 2010).
Treatment of substance abuse disorders can be a complex
and multi-dimensional process and often requires long-term
efforts and specialized care because addiction has high
comorbidity with other psychiatric disorders, such as anxiety
and depression. Thus, these disorders should also be consid-
ered in treating addiction. For this reason, the therapeutic
process meets three important targets, namely, stopping
physical and psychological dependence on drugs, decreasing
such non-physical consequences as anxiety and depression
associated with drug abuse, and ultimately preventing relapse
of disease (Momeni, Moshtagh, & Purshahbaz, 2010;
Volkow, 2014). Based on the previous relevant literature,
approximately 90% of drug addicts suffer from mood disor-
ders, and especially depression, anxiety, and stress, which
are among the most common psychiatric complications
1
Shiraz University, Iran
2
Semnan University, Iran
Corresponding Author:
Mahmoud Najafi, Department of Clinical Psychology, School of
Psychology & Educational Sciences, Semnan University, Semnan
19111-3513, Iran.
Email: m_najafi@semnan.ac.ir

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the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages
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2 SAGE Open
(Charney, Palacias-Boix, Negrete, Dobkin, & Gill, 2005;
Hanter, Paddock, Zhou, Watkins, & Hepner, 2013; Hunter,
Witkiewitz, Watkins, Paddock, & Hepner, 2012; Sareen,
Chartier, Paulus, & Stein, 2006; Tatalovic Vorkapic, Dadic-
Hero, & Ruzic, 2013). Stress refers to a real or imagined
threat to human physical/mental homeostasis. Disturbed
homeostasis causes stress and activation of the central and
peripheral neuroendocrine mechanisms responsible for dif-
ferent adaptive behaviors and responses. Today, stress is con-
sidered as an inevitable and inseparable part of human life. It
can steadily increase vulnerability to addiction (Andreou
et al., 2011; Goeders, 2003; Schwabe, Dickinson, & Wolf,
2011; Sinha, 2001). The relationship between stress and
addiction is highly complex. Indeed, evidence suggests that
there is a bidirectional causal relationship between the two,
that is, internal and external stress can result in addiction, as
one tries to avoid an unpleasant state, and addiction, in turn,
can cause an unpleasant state and lead to internal stress
(Wand, 2008).
Depression is also another disorder which has high
comorbidity with addiction and can be regarded as the prin-
cipal cause of disability and social harm in the world. Based
on Beck’s Cognitive Theory of Depression, depression is a
pathological disorder that causes a change in the emotional,
motivational, behavioral, cognitive, and physical aspects of
one’s life. It is one of the most prevalent psychiatric disor-
ders with a lifetime prevalence of 15.8% and is identified
with low levels of positive emotions, such as happiness and
confidence (Tran, Tran, & Fisher, 2013). Anxiety, with a life-
time prevalence of 28.8%, is yet another common psychiat-
ric disorder. It is an unpleasant feeling of vague fear of an
unknown origin experienced by the individual and encom-
passes uncertainty, helplessness, and physiological arousal.
Worrisome and concern are common symptoms of anxiety,
while depression is characterized by a deep decline in one’s
willingness to be involved in daily activities, be socialized,
recreate, play sports, eat, and have sexual desire (Hofmann,
Wu, & Boettcher, 2014; Khaledian, Kamar Zarin, & Jalalian,
2014). Concerning the comorbidity of depression and anxi-
ety with addiction, three factors can be simultaneously
solved through CBT. Results of studies by Hamzeh Pour
(2014); Hoffman and Smits (2008); Hollon, Stewart, and
Strunk (2006); Jayasvasti et al. (2011); Momeni et al. (2010);
Riper et al. (2014); Toneatto and Calderwood (2015); and
Watkins et al. (2011) reveal that CBT can be effective in
reducing depression and anxiety. Furthermore, researchers
have also shown that CBT can reduce stress, anxiety, and
depression in people with addiction (McHugh et al., 2010;
Osilla, Hepner, Muñoz, Woo, & Watkins, 2009; Sugarman,
Nich, & Carroll, 2010).
It is assumed in cognitive behavioral theory that depres-
sion can be caused by negative schemas about the self, the
world, and the future created in the early stages of an indi-
vidual’s life as a result of traumatic experiences. Accordingly,
the therapy in the present study aimed at removing negative
schemas and replacing them with positive ones. In this
regard, cognitive restructuring, which implies replacing dys-
functional thoughts with efficient beliefs, can be effective in
treating depression. In addition, learning new and appropri-
ate behaviors can develop a sense of mastery and empower-
ment in people, which, in turn, can help people to adopt
positive perspectives in dealing with problematic issues.
From this point of view, familiarity of clients with problem-
solving skills can help them to recognize that consideration
of most of contextual factors and the major steps leading to
the final solution are mostly based on their instincts, feelings,
and emotions (Johnco, Wuthrich, & Rapee, 2014; Taylor &
Marshall, 1997; Weersing & Brent, 2006).
One of the reasons for the effectiveness of CBT is that it
emphasizes identification and correction of cognitive devia-
tions, application of correct thinking, and development of
necessary skills for carrying out assessment and making
accurate judgment of negative thoughts which can help
reduce levels of anxiety, depression, and other psychological
disorders (Hamzeh Pour, 2014).
It is assumed in CBT that psychological problems are the
result of negative schemas (Christner, Stewart, & Freeman,
2007; Moore & Garland, 2003) and persist by processing
biased and negative information and dysfunctional beliefs.
This therapy is designed to help patients to think more adap-
tively, and thus to improve their behaviors. Such patients are
taught how to recognize their negative thoughts and how to
explore the relationship between their thoughts and their
behaviors. During the treatment schedule, patients gradually
learn to identify and assess their dysfunctional assumptions
and decide if they are valid or not. In addition, the therapist
teaches them some adaptive skills, such as how to break
major problems down into smaller and more manageable
problems. Indeed, decision making based on loss–profit
analysis, timing of activities, and step-by-step tasks can help
patients overcome their problems and difficulties (Butler &
Beck, 1995; Parker, Roy, & Eyers, 2003). Different tech-
niques are used in CBT. For instance, behavioral techniques
mainly entail avoidance of anxiety-provoking situations and/
or effective changes in response to such stimuli. The use of
muscle relaxation techniques and new and appropriate rein-
forcement methods at the time of severe anxiety, instead of
taking drugs, are also recommended in this treatment. These
techniques are taught to help clients look at these relation-
ships and the situations from a new point of view (Momeni
et al., 2010).
Based on the aforementioned materials, it can be claimed
that CBT is effective in reducing depression and anxiety in
individuals with drug abuse. In addition, treatment of
depression is highly important in patients with addiction
because depression may be one of the high-risk factors or
even an obstacle to abstinence in addiction treatment and
may lead to addiction relapse (Khaledian et al., 2014).
Accordingly, this study is to answer the following research
question:
Hemati Alamdarloo et al. 3

Table 1.  Summary of Therapy Sessions.

Session Content
First Introduction of the members to each other and presentation of the group rules; definition of depression, anxiety, and
stress; explanation of wrong beliefs about stress and anxiety; conduct of the relevant tests
Second Explanation of the events stimulating depression, stress, and anxiety; somatic, behavioral, emotional, and cognitive
symptoms of depression; identification of the factors stimulating stress; performing stress removal program based on
Benson’s method; break and gravity; homework assignment
Third Checking homework, stress control program, pause and relaxation, explaining negative self-representation and an
analysis of its reasons, homework assignment
Fourth Checking homework, explaining periods of depression as well as stress and anxiety, break and gravity, guided image,
discussions and exchange of ideas, and homework assignment
Fifth Checking assignments, progressive relaxation of muscles, discussion of the proposed points, thought interruption, and
homework assignment
Sixth Checking homework, discussion of the proposed points, training of Albert Ellis’s ABCD model, exercising decisiveness
as well as self-esteem and self-respect, homework assignment
Seventh Checking assignments, reviewing learned materials, training of coping methods, break and gravity, and homework
assignment
Eighth Evaluation, review of the proposed points, discussion and exchange of ideas, test administration, break and gravity,
improving concentration, conclusion of all sessions

Research Question 1: Does CBT significantly affect
depression, anxiety, and stress in Iranian males with
addiction?
Method
Population, Sample, and Sampling Procedure
The participants of this study were 24 males selected from all
20- to 40-year-old Iranian males with addiction (N = 89)
who were going to addiction treatment centers in Tehran,
Iran, in 2016. The participants were selected through conve-
nience sampling and randomly assigned to the experimental
(n = 12) and control (n = 12) groups. The Ethical Review
Board of the Regional Welfare Organization approved the
research.
Depression Anxiety and Stress Scale (DASS)
Lovibond and Lovibond (1995) developed a 21-item
Depression Anxiety and Stress Scale (DASS-21). The
DASS-21 is self-report questionnaire which is designed
to measure severity of some symptoms common to both
depression and anxiety. The participants were required to
indicate severity of symptoms over the week before fill-
ing out the questionnaire. The items were designed on a
3-point Likert-type scale, from 0, indicating that the par-
ticipant had not experienced the symptom over the last
week at all, to 3, indicating that the participant had expe-
rienced the symptom commonly or most of the time over
the past week (Gomez, 2014). Tran et al. (2013) reported
Cronbach’s alpha coefficients of .72, .77, and .70 for the
subscales of Depression, Anxiety, and Stress, respec-
tively. Viqnola and Tucci (2014) also obtained the
Cronbach’s alpha coefficients of .92, .90, and .86 for the
subscales of Depression, Anxiety, and Stress, respec-
tively. In addition, Asghari, Saed, and Dibajnia (2008)
reported Cronbach’s alpha coefficients of .85, .85, and
.87 for the subscales of Depression, Anxiety, and Stress,
respectively. They also found the test–retest reliability of
.77, .89, and .85 for the subscales of Depression, Anxiety,
and Stress, respectively.
Procedure for CBT
CBT program consists of two components: anger manage-
ment programs based on cognitive-behavioral theory
(Reilly & Shopshire, 2014), and practical stress manage-
ment program (McNamara, 2000, 2003). To implement the
two aforementioned programs, the selected participants
were randomly assigned to the experimental and control
groups, first. The DASS (Lovibond & Lovibond, 1995) was
administered to both groups as a pretest. Next, the experi-
mental group was given CBT during eight 45-min sessions
(two sessions per week, for a total duration of 4 weeks).
The control group, however, received no intervention. After
eight sessions, the DASS was administered to both groups,
as a post-test this time. Furthermore, the two groups
received third administration of the test, as a follow-up
measurement to examine sustainability of changes in
behaviors, 1 month later. The obtained data were then sta-
tistically analyzed. It should be noted here that, in an
attempt to adhere to ethical principles, the control group
also received the treatment after the completion of this
study. It is also noteworthy that the intervention program
was run by the present researchers. Table 1 presents sum-
maries of the therapy sessions.
4 SAGE Open

Table 2.  The Effect of Cognitive-Behavioral Therapy on the Level of Depression, Anxiety, and Stress in Iranian Males With Addiction.

Descriptive statistics

Pretest Posttest Follow-up

Variable Groups M (SD) M (SD) M (SD)

Depression Experimental 17.50 (2.19) 8.83 (2.20) 9.66 (2.18)
Control 14.41 (2.06) 12.83 (1.94) 11.16 (3.01)
Anxiety Experimental 17.16 (2.55) 10.50 (2.31) 8.33 (1.37)
Control 13.83 (1.85) 12.16 (1.33) 11.00 (2.13)
Stress Experimental 17.00 (3.04) 9.16 (2.40) 9.58 (1.92)
Control 13.58 (2.15) 12.66 (1.77) 12.58 (3.26)

Table 3.  MANCOVA Results for Depression, Anxiety, and Stress in Experimental Group and Control Group in Post-test.

Dependent variable Sum of squares Degrees of freedom M of sum of squares F Significant

Depression 29.74 1 29.74 8.35 .001
Anxiety 20.34 1 20.34 7.20 .001
Stress 58.69 1 58.69 11.95 .001

Table 4.  MANCOVA Results for Depression, Anxiety, and Stress in Experimental Group and Control Group in Follow-up.

Dependent variable Sum of squares Degrees of freedom M of sum of squares F Significant

Depression 40.48 1 40.48 8.04 .01
Anxiety 37.22 1 37.22 6.67 .01
Stress 41.10 1 41.10 5.21 .03

Results based on the descriptive and inferential statistical results,

Table 2 shows the mean values for severity of depression,
anxiety, and stress for the experimental and control groups.
To determine whether changes in the mean values were
statistically significant or not, a MANCOVA was run.
Accordingly, the pretest scores were considered as covari-
ates. Prior to running MANCOVA, the Levene test was used
to examine whether the assumptions of homogeneity of vari-
ance were proved or not. The result was not statistically sig-
nificant for any of the variables (stress: F = 2.65, p > .05;
anxiety: F = 2.38, p > .05; depression: F = 0.48, p > .05).
Therefore, MANCOVA could be run. Furthermore, to study
homogeneity of covariance matrices, the Box’s M Test was
used. The result was statistically significant (M Box = 11.00,
F = 1.56, p > .05). Therefore, the variance–covariance
matrices of the dependent variables were equal in the two
groups.
MANCOVA results (Table 3) showed a significant dif-
ference in the posttest mean scores of the variables of
depression, anxiety, and stress between the two groups
after removing the pretest effect (Wilks’s lambda = 0.467;
F = 6.48; p < .0001).
As one can see from Table 3, the groups were different
in severity of depression, anxiety, and stress. Therefore,
CBT was effective in reducing depression, anxiety, and
stress.
In addition, follow-up measurement was performed and
MANCOVA was run to investigate differences between the
groups in severity of the relevant variables. To this end,
prior to running MANCOVA, the Levene test was used to
examine if the assumptions of homogeneity of variance
were proved. The results were not statistically significant
for any of the variables (stress: F = 0.925, p > .05; anxiety:
F = 1.25, p > .05; depression: F = 0.418, p > .05); there-
fore, MANCOVA could be run. In addition, to examine
homogeneity of covariance matrices, Box’s M test was per-
formed. The result was not statistically significant (M Box
= 11.00, F = 1.56, p > .05). Accordingly, the variance–
covariance matrices of the dependent variables were equal
in the two groups.
MANCOVA results (Table 4) showed a significant differ-
ence in severity of depression, anxiety, and stress between
the two groups after removing the pretest effect (Wilks’s
lambda = 0.489; F = 5.92; p < .0001).
Table 4, on the results of follow-up measurement, shows
that there have been significant differences between the
groups in severity of depression, anxiety, and stress after
controlling for the effect of the pretest.
Hemati Alamdarloo et al. 5
Discussion
The main objective of this study was to investigate the effect
of CBT on depression, anxiety, and stress levels in Iranian
males with addiction. The result revealed that the use of CBT
led to a reduction in the levels of depression, anxiety, and
stress of the participants. This was in line with the findings of
Hamzeh Pour (2014); Hoffman and Smits (2008); Hollon
et al. (2006); Jayasvasti et al. (2011); Momeni et al. (2010);
Riper et al. (2014); and Watkins et al. (2011). The research-
ers reported that CBT, whether of individuals or groups, was
effective in reducing depression.
In fact, research results has indicated that CBT is highly
effective in reducing depression in the experimental group,
as compared to the control group (Beltman, Oude Voshaar,
& Speckens, 2010; van Straten, Geraedts, Verdonck-de
Leeuw, Andersson, & Cuijpers, 2010). The reason might be
that CBT can be effective in Iranian males with addiction
who are changing attitudes and beliefs of people with addic-
tion, in increasing their self-esteem, and in developing their
logical thinking (Khodai, Khazai, Kazemi, & Aliabadi,
2012; McGinn, 2000; Momeni et al., 2010; Okunna,
Rodriguez-Monguio, Smelson, & Volberg, 2015; Schwartz
& Petersen, 2009). Iranian males with addiction can learn to
modify their negative thoughts and internalize behavioral
planning skills, social skills, and self-assertiveness through
the use of CBT techniques. These can help them to over-
come their depression (Hunter et al., 2012; Khaledian et al.,
2014; McGinn, 2000).
Concerning the effectiveness of CBT on reducing anxiety
levels in Iranian males with addiction, it should be stated that
CBT is the first treatment option for treating anxiety disor-
ders and has been considered very effective in this regard
(Ghahramanlou, 2003; Hofmann & Smits, 2008). Indeed,
CBT can help Iranian males with addiction to create new
thinking networks and adapt behaviors which can challenge
maladaptive networks and memories. CBT benefits from
such techniques as relaxation and cognitive restructuring. By
cognitive restructuring, Iranian males with addiction can
learn how to challenge the truth of anxiety-producing
thoughts through considering some pieces of evidence
against those thoughts (Arch & Craske, 2008). Moreover,
relaxation exercises decrease muscle tension, heart rate, and
breathing rate of Iranian males with addiction. Iranian males
with addiction who produce these bodily responses report a
decrease in their anxiety level (Miltenberger, 2011). In addi-
tion, promoting relaxation can improve blood circulation and
brain function, and thus reduce anxiety (Shaw et al., 2013).
The results of this study also showed that CBT was effec-
tive in reducing stress levels in Iranian males with addiction.
In general, many previous studies have confirmed that CBT
can be extremely effective in reducing stress (Kim, 2007;
Richardson & Rothstein, 2008; van der Klink, Blonk,
Schene, & van Dijk, 2001). Regarding this, CBT can help
Iranian males with addiction learn coping strategies.
Developing coping styles can develop individuals’ ability to
adapt to stressful situations and to reduce their stress.
Besides, CBT can reduce levels of stress in Iranian males
with addiction through supporting them and helping them to
understand that they are not left alone with their problems.
Moreover, CBT includes stress management training because
stress managing can reduce anxiety and stress (Shaw et al.,
2013).
The overall results of this study showed that CBT can be
effective in reducing depression, anxiety, and stress.
However, to conclude that CBT was definitely effective in
reducing depression, anxiety, and stress, more studies are
needed. With regard to the high comorbidity of these disor-
ders with substance abuse and considering the fact that these
factors can be posed as obstacles to drug abuse treatment, it
is necessary for professionals to consider them in the healing
process.
The present study was conducted on Iranian males with
addiction; it is suggested that future studies be done to exam-
ine the effect of CBT on depression, anxiety, and stress levels
in Iranian females with addiction. The sample size of this
study was small. This can threaten generalizability of the
study’s findings. It is recommended, therefore, that future
studies benefit from more participants.
Convenience sampling was used for the selection of par-
ticipants of this study. Therefore, generalizability of the
results to the statistical population should be made with
caution.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Ghorban Hemati Alamdarloo earned a PhD in special education
from Tehran University. He is an associate professor in department
of special education at Shiraz University, Shiraz, Iran. He teaches
courses in special education, intellectual and developmental dis-
abilities, and learning disabilities. He has scholarly publications on
issues around people with special needs.
Soheila Moradzadh Khorassani earned a MA in general psychol-
ogy from Semnan Branch, Islamic Azad University. She has schol-
arly publications on issues around addiction.
Mahmoud Najafi earned a PhD in psychology from Allameh
Tabataba’i University. He is an assistant professor in department of
clinical psychology at Semnan University, Semnan, Iran. He
teaches courses in personality and developmental psychology. He
has scholarly publications on issues around addiction and positive
psychology.
Fatemeh Soosan Jabbari earned a PhD in curriculum develop-
ment from Shiraz University. She is an assistant professor in depart-
ment of special education at Shiraz University, Shiraz, Iran. She
teaches courses in curriculum and special education, learning dis-
abilities and emotional and behavioral disorders. She has scholarly
publications on issues around children with special needs and cur-
riculum development.
Setareh Shojaee earned a PhD in special education from Tehran
University. She is an assistant professor in department of special
education at Shiraz University, Shiraz, Iran. She teaches courses in
special education, intellectual and developmental disabilities, and
learning disabilities. She has scholarly publications on issues
around people with special needs.