See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/328171419

Effectiveness of Acceptance and Commitment Therapy on Reducing

Depression among People Living with HIV/AIDS

Article · October 2018

DOI: 10.11910/2227-6394.2018.06.03.04

CITATIONS READS

6 1,480

5 authors, including:

Seyedahmad Seyedalinaghi Fabrício Voltarelli

Tehran University of Medical Sciences Universidade Federal de Mato Grosso (UFMT)
547 PUBLICATIONS   3,654 CITATIONS    208 PUBLICATIONS   1,626 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

- ‫ ﺑﺮرﺳﯽ رﻓﺘﺎرﻫﺎی ﺗﮑﺎﻧﺸﮕﺮاﻧﻪ و ﺗﺼﻤﯿﻢ ﮔﯿﺮی ﻣﺨﺎﻃﺮه آﻣﯿﺰ در ﻣﻌﺘﺎدﯾﻦ در دو ﮔﺮوه‬HIV ‫ ﻣﺜﺒﺖ و ﻣﻨﻔﯽ‬View project

‫ ﺑﺮرﺳﯽ ﻓﺮاواﻧﯽ ﺗﻈﺎﻫﺮات رﯾﻮی در ﺑﯿﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﻋﻔﻮﻧﺖ‬HIV/AIDS ‫ﻣﺮاﺟﻌﻪ ﮐﻨﻨﺪه ﺑﻪ ﻣﺮﮐﺰ ﻣﺸﺎوره ﺑﯿﻤﺎری ﻫﺎی رﻓﺘﺎری ﺑﯿﻤﺎرﺳﺘﺎن اﻣﺎم ﺧﻤﯿﻨﯽ و ﺑﺮرﺳﯽ ﻋﻮاﻣﻞ ﻣﺮﺗﺒﻂ ﺑﺎ آن ﻃﯽ‬
88-89 ‫ ﺳﺎل ﻫﺎی‬View project

All content following this page was uploaded by Fabrício Voltarelli on 09 October 2018.

The user has requested enhancement of the downloaded file.

Journal of International Translational Medicine, September 2018, Vol.6, No.3 ·125·

·Original Article·
doi: 10.11910/2227-6394.2018.06.03.04

Effectiveness of Acceptance and Commitment

Therapy on Reducing Depression among People
Living with HIV/AIDS
Matin FAEZIPOUR1, Afsaneh GHANBARIPANAH1, SeyedAhmad SEYEDALINAGHI2,
Mahboubeh HAJIABDOLBAGHI2, Fabricio VOLTARELLI3
1
Department of Psychology, Education and Psychology Faculty, Central Tehran Branch, Islamic Azad University (IAU);
2
Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical
Sciences, Tehran, Iran; 3Graduation Program of Health Sciences, Faculty of Medicine, Federal University of Mato Grosso, Cuiabá,
Brazil

Abstract
Background: Depression is prevalent among People Living with HIV/AIDS (PLHA). Reducing depression is effective in
improving health care and it slows down the progression of the infection.
Objectives: We aimed to determine the effectiveness of Acceptance and Commitment Therapy (ACT) on reducing depression
in HIV/AIDS patients.
Methods: This quasi-experimental study was performed through pretest-posttest with the experimental and control groups.
The study population consist of all HIV/AIDS patients who referred to Imam Khomeini Hospital in 2016. Twenty four patients
(16 men and 8 women) were selected by convenience sampling and assigned to the experimental and control groups. All the
participants were evaluated in the first and last session by Bech Depression Inventory (BDI-II). Participants supposed to get at
least 14 scores in the BDI-II and they must had mild depression. The experimental group received eight training sessions of ACT
that each lasted 60 minutes. The control group received no intervention. In order to determine the effectiveness of ACT, the
results of pretest and posttest were compared together. Data analyses were conducted by SPSS (version 21).
Results: According to the results, mean of depression scores was reduced in posttest in the experimental group. However, there
was no significant difference in scores of the control group. The one way covariance analysis showed a significant difference in
depression scores in the experimental group compared to the control group (P = 0.004).
Conclusions: The study indicated that acceptance and commitment therapy is an effective approach on reducing depression
among PLHA.
Key words Depression; Acceptance and Commitment Therapy; HIV; AIDS

Background Depression is one of the most prevalent psychological

HIV/AIDS is a chronic disease and a global pandemic[1].
According to the estimations, as of 2020 approximately
200 million people will have HIV/AIDS worldwide. Which
the third world countries will have substantial portion of
this amount because of poor health facilities[1,2]. HIV/AIDS
stigma has major impact on People Living with HI V/
AIDS (PLHA) social lives through ostracism, rejection,
discrimination and avoidance[3]. A considerable number
of PLHA necessitate more actions on varied contexts such
as reducing psychological effects on their normal lives.

C or re s pond i ng aut hor : S e y e d A h m a d S E Y E DA L I N AG H I , E -m a i l :
s_a_alinaghi@yahoo.com
disorders among PLHA and affects 20%-30% of them[4].
Significance of this study is appreciated as having depression
may reduce cooperation level of hygiene and prevention,
however; increase sex ual risk behav ior [5, 6] . Moreover,
reduction of depression has inf luential role in HIV/AIDS
treatment adherence[7].
Accept a nce a nd Com m it ment T herapy (ACT) is
considered as a treatment for depression. ACT mechanisms
including acceptance, presence in the moment, awareness
raising, desensitization, and observing without judgment
decrease disorder symptoms as well as increasing the
effectiveness[8]. ACT is a psychological intervention based
on experience. ACT employs acceptance and awareness
strategies accompanied by commitment and changing
·126·
behavior strategies for increasing psychological flexibility[9].
Psychological flexibility is the ability to contact the present
moment more fully as a conscious human being, and to
change or persist in behavior when doing so serves chosen
values[10-13].
Some studies have reported the efficacy of ACT for reducing
and treating depression[11,14]. Rajabi and Yazdkhasti’s study
(2014) indicated that ACT was effective on anxiety and
depression treatment in female patients with Multiple
Sclerosis (MS)[15]. Wasler et al. (2015) concluded in their
research that veterans receiving ACT decreased depression
severity and decreased odds for suicidal ideation[16].
Objective
The objective of present study was to determine the
effectiveness of ACT on reducing depression among HIV/
AIDS patients in Tehran Positive Club affiliated to Iranian
Research Center for HIV/AIDS.
Methods
This quasi-experimental study was performed through
pretest-posttest with the experimental and control groups.
Twenty four volunteer patients who attended Tehran Positive
Club were selected by convenience sampling in 2016. Tehran
Positive Club was founded with the participation PLHA
in 2006. This organization provides positive prevention
and psychosocial support with the aim of empowering and
developing the capacities of PLHA for the management and
improvement of life skills as well as reduction of stigma and
discrimination in Iran[17].
Study measures
The Beck Depression Inventory-II (BDI-II): This self-report
test was introduced by Aron. T Beck and et al. in 1961 and
published in 1978. This test revised for developing wide range
of symptoms. The BDI-II contains 21 items; each answer
being scored on a scale value of 0-3. Total scores indicate the
depression’s severity as follows: 0-13 minimal depression,
14-19 mild depression, 20-28 moderate depression and 29-63
severe depression[18]. Studies have revealed high validity in
0.89 to 0.94 range. The test also shown to have a high one
week test-retest reliability (r = 0.93)[19]. In addition, Dabson
and Mohammadkhani found 0.93 coefficient validity for each
21 items[20].
Study procedure
At first 35 patients attending to Tehran Positive Club
were screened by the BDI-II. Participants supposed to
get at least 14 scores in the BDI-II and they must had
Journal of International Translational Medicine, September 2018, Vol.6, No.3
mild depression. Afterward, 24 patients were selected to
undertake the research (Figure 1). Eight sessions of ACT
held for the experimental group. Each session lasted 60
minutes. In a mean time the control group did not receive
any interventions. After completing group therapy sessions
of ACT all the participants filled out the BDI-II once more.
Finally, in order to determine the effectiveness of ACT,
the results of pretest and posttest were compared together.
Contents of ACT sessions are mentioned briefly in Table 1.
Ethical considerations
All participants provided informed consent.
Statistical analysis
Data analyses were conducted by SPSS (version 21), using
covariance analysis (ANCOVA), frequency distribution,
mean and standard deviation.
Results
All the participants, 16 men (67%) and 8 women (33%),
aged between 21-62 years. Mean age was 42 (standard
deviation = 10) in the experimental group and 39 (standard
deviation = 9) in the control group. Education level of six
participants (50%) was high school diploma and the other six
(50%) were educated at the high school level or below in the
experimental group. Five participants (42%) had high school
diploma and seven participants (58%) were educated at the
high school level or below in the control group. The most
frequent HIV transmission route was injection drug use
(33%) in the experimental group and sexual contact (50%) in
the control group.
According to Table 2, mean of depression scores was
reduced in posttest in the experimental group. However,
there was no significant difference in scores of the control
group.
According to Table 3, F in independent variable obtained
10.628 and was significant in P < 0.05 level (P = 0.004).
It means after removing the pretest effect, there was a
significant difference between mean depression scores in the
experimental and the control groups. In addition, according
to Eta coefficient, ACT explains 34% variance of posttest
scores.
Discussion
We found that ACT could be considered as an effective
intervention for reducing depression among PLHA. The
study assumption which ACT is effective on reducing
depression among HI V/A IDS patients, was confirmed
with 95% confidence. The findings of current study are in
Journal of International Translational Medicine, September 2018, Vol.6, No.3 ·127·

Assessed for eligibility

(n = 35)

Excluded (n = 11)

Enrollment Not meeting inclusion criteria

Randomized (n = 24)
16 men and 8 women

Experimental group (n = 12) Control group (n = 12)

Allocation
10 men and 2 women 6 men and 6 women
Received ACT treatment Did not received any treatment

Analyzed (n = 12) Analyzed (n = 12)

Analysis
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Figure 1 Flow of the participants

Follow-up Lost to follow-up (n = 0) Lost to follow-up (n = 0)
through study

Table 1 Content of each session of Acceptance and Commitment Therapy (ACT)

Session Content
Session 1 Providing the opportunity for clients to become familiar with each other and the treatment aims, Making therapeutic
relationship, Introducing the creative hopelessness, Assigning homework.
Session 2 Reviewing homework, Continuing discussion about the creative hopelessness, Helping clients recognize the dysfunctional
control strategies, Explaining differences between clean and dirty discomfort, Assigning homework.

Session 3 Reviewing homework, Discussing about“Control is the problem, not the solution”, Introducing the acceptance (willingness)
concept as an alternative to control, Assigning homework.

Session 4 Reviewing homework, Training mindfulness practices, Introducing the cognitive defusion, Assigning homework.
Session 5 Reviewing homework, Continuing mindfulness practices, Introducing the conceptualized self and self as context, Assigning
homework.

Session 6 Reviewing homework, Continuing mindfulness practices, Introducing the value concept, Helping clients indentify their values,
Explaining differences between goals and values, Assigning homework.

Session 7 Reviewing homework, Continuing mindfulness practices, Identifying goals and behavior models for reaching values, Predicting
and decreasing barriers in doing actions, Assigning homework.

Session 8 Reviewing homework, Continuing mindfulness practices, Emphasizing the committed action, Summarizing group therapy
sessions.

consistent with several studies, including: Gholamhoseini
et al. (2015) confirmed that ACT leads to the reduction of
depression and increase perception of body image in women
with obesity[11]. The study of Hor et al. (2012) revealed that
ACT is an effective approach for treating depression in
diabetic patients[12]. Bohlmeijer et al. (2011) reported that
an early intervention based on ACT is effective on reducing
depressive symptomatology [13]. The study of Livheim et
al. (2015) suggested that ACT seems to be a promising
intervention for reducing stress and depressive symptoms
among adolescents[14].
Behavioral therapies based on Acceptance have shown
·128· Journal of International Translational Medicine, September 2018, Vol.6, No.3

Table 2 Descriptive statistic scores of depression in the experimental and the control groups, Tehran Positive Club, 2016
Group Maximum Mean Std. Deviation P
Experimental Pretest 45 28.8 11.3 0.007
Posttest 36 19.2 11.0
Control Pretest 58 34.1 14.9 0.640
Posttest 58 34.5 16.5

Table 3 Results of covariance analysis, Tehran Positive Club, 2016

Score Type III sum of squares df Mean square F Sig. Partial eta squared
Pre-test 3,045.796 1 3,045.796 50.250 0.001 0.705
Groups 644.211 1 644.211 10.628 0.004 0.336
Error 1,272.871 24 60.613
Total 23010 24

the efficacy on wide spectrum of psychological disorders. Conclusion

Applying Dialectical Behavior Therapy for eating disorders
treatment[21], ACT for treating substance abuse[22] decreasing
psychotic symptoms[23] , treatment of obsession, anxiety
a nd depression [2 4 , 2 5] , I nteg rat ive Behav iora l Couple
Therapy (IBCT) for increasing marriage satisfaction[26] ,
are few samples of behav iora l therapy inter ventions
based on acceptance impacts. The purpose of this study
was determining the effectiveness of ACT on reducing
depression among HI V/A IDS patients. ACT is a form
of behavioral therapy aimed to increasing psychological
f lexibility[27]. Psychological f lexibility is established with a
focus on six core processes: acceptance, cognitive defusion,
self as context, contact with the present moment, values
and committed actions[10]. Acceptance refers to accepting
undesired internal experiences and irreversible external
events as they are, not the way they appear. Other factors in
ACT intervention model help the emergence of acceptance,
since they are as corners of a hexagon and practice highly
interdependent [9] . A n irreversible fact that cannot be
changed or denied is HIV/AIDS in sample of this study.
HIV/AIDS related stigma is cited as a major barrier accessing
prevention, care and treatment[28]. Moreover, because of this
false belief that being infected equals end of life, losing hope
and depression is common among PLHA[29]. Group therapy
sessions of ACT were aimed to reducing depression through
training the six core processes to HIV/AIDS patients. For
clarifying these factors metaphors, examples, practices and
homework had been employed.
There are a number of limitations with current study.
Result follow-up were not conducted. Two entrance criteria,
gender and history of mental disorders, were not controlled.
Since sampling method was convenience, some caution
should be undertaken for generalizing the results.
ACT is a shor t ter m, constr uctive inter vention that
establishes contacting the present moment and causes
actions to reaching values for clients. Also, eight sessions of
ACT provided social support for PLHA who suffers from
rejection and judgmental attitudes. Therefore, ACT can be
considered as a proper intervention for decreasing depression
in PLHA.
Conflict of interest
The authors have no conflict of interest.
Clinical trial registration statement
T h is st udy is reg istered under t he I ra n ia n Reg istr y
of Cl i n ica l Tr ia ls (I RCT) ava i lable at ht t p://w w w.
i rc t . i r/. T he re g i s t r at ion ident i f ic at ion nu mber i s
IRCT201701304076N20.
Acknowledgments
We extend our appreciation to the staff in Iranian Research
Center for HIV/AIDS (IRCHA) and Tehran Positive Club
for their help.
References
1 Kallings LO. The first postmodern pandemic: 25 years of HIV/AIDS. J
Intern Med, 2008, 263(3): 218-243.
2 Lari M M, Lari MS, Hosseini FF. HIV/AIDS infection. Mashhad: Astan
ghods razavi publication. 2003.
3 Judgeo N, Moalusi KP. My secret: The social meaning of HIV/AIDS
stigma. SAHARA J, 2014, 11: 76-83.
4 Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and
drug use among human immunodeficiency virus-infected adults in the
Journal of International Translational Medicine, September 2018, Vol.6, No.3
United States. Arch Gen Psychiatry, 2001, 58(8): 721-728.
5 O'Cleirigh C, Newcomb ME, Mayer K H, et al. Moderate levels of
depression predict sexual transmission risk in HIV-infected MSM: a
longitudinal analysis of data from six sites involved in a “prevention for
positives” study. AIDS Behav, 2013, 17(5): 1764-1769.
6 Lennon CA, Huedo-Medina TB, Gerwien DP, et al. A role for depression
in sexual risk reduction for women? A meta-analysis of HIV prevention
trials with depression outcomes. Soc Sci Med, 2012, 75(4): 688-698.
7 Gonzalez JS, Batchelder AW, Psaros C, et al. Depression and HIV/AIDS
treatment nonadherence: a review and meta-analysis. J Acquir Immune
Defic Syndr, 2011, 58(2): 181-187.
8 Marlatt GA, Donovan DM. Relapse prevention: Maintenance strategies
in the treatment of addictive behaviors: Guilford Press. 2005.
9 H ayes SC , St rosa h l K D. A prac t ic a l g u ide to accept a nce a nd
commitment therapy: Springer Science & Business Media. 2004.
10 Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment
therapy: Model, processes and outcomes. Behav Res Ther, 2006, 44(1):
1-25.
11 Gholamhoseini B, Koolaee A K, Taghvaee D. The Effectiveness of
acceptance and commitment group therapy on depression and body
image in women with obesity. Community Health, 2016, 2(2): 72-79.
12 Hor M, Aghaei A, Abedi A, et al. The effectiveness of acceptance and
commitment therapy on depression in patients with type 2 diabetes. J
Res Behav Sci, 2013, 11(2): 121-128.
13 Bohlmeijer ET, Fledderus M, Rok x TA, et al. Efficacy of an early
intervention based on acceptance and commitment therapy for adults
with depressive symptomatology: Evaluation in a randomized controlled
trial. Behav Res Ther, 2011, 49(1): 62-67.
14 Livheim F, Hayes L, Ghaderi A, et al. The effectiveness of acceptance
and commitment therapy for adolescent mental health: Swedish and
Australian pilot outcomes. J Child Fam Stud, 2015, 24(4): 1016-1030.
15 Rajabi S, Yazdkhasti F. The effectiveness of acceptance and commitment
group therapy on anxiety and depression in women with MS who were
referred to the MS association. J Clin Psycol, 2014, 6(1): 29-38.
16 Walser RD, Garvert DW, Karlin BE, et al. Effectiveness of Acceptance
and Commitment Therapy in treating depression and suicidal ideation
in Veterans. Behav Res Ther, 2015, 74: 25-31.
17 SeyedAlinaghi SA, Sudhinaraset M, Koochak HE, et al. In: Current
Studies in HIV Research; SeyedAlinaghi SA Ed. Bentham Science
View publication stats
·129·
Publishers: U.A.E, 2016, Vol. 2: 268-278.
18 Groth-Marnat G. Handbook of psychological assessment: John Wiley &
Sons. 2009.
19 Beck AT, Steer R A, Brown GK. Beck depression inventory-II. San
Antonio, 1996, 78(2): 490-498.
20 Dabson K, Mohammad K P. Psychometric characteristics of Beck
depression inventory-II in patients with major depressive disorder. 2007.
21 Lenz AS, Taylor R, Fleming M, et al. Effectiveness of dialectical behavior
therapy for treating eating disorders. J Counsel Develop, 2014, 92(1):
26-35.
22 Lanza PV, García PF, Lamelas FR, et al. Acceptance and commitment
therapy versus cognitive behav ioral therapy in the treatment of
substance use disorder with incarcerated women. J Clin Psychol, 2014,
70(7): 644-657.
23 Gaudiano BA, Herbert JD. Acute treatment of inpatients with psychotic
symptoms using Acceptance and Commitment Therapy: Pilot results.
Behav Res Ther, 2006, 44(3): 415-437.
24 Bluett EJ, Homan KJ, Morrison KL, et al. Acceptance and commitment
therapy for obsessive compulsive disorder and obsessive compulsive
spectrum disorders: A review. J Anxiety Disord, 2014, 28(6): 612-624.
25 Mohabbat-Bahar S, Maleki-Rizi F, Akbari ME, et al. Effectiveness of
group training based on acceptance and commitment therapy on anxiety
and depression of women with breast cancer. Iran J Cancer Prev, 2015,
8(2): 71-76.
26 Christensen A, Doss BD. Integrative behavioral couple therapy. Curr
Opin Psychol, 2017, 13: 111-114.
27 Herber t J D, For ma n E M . T he evolut ion of cog n it ive behav ior
therapy. Acceptance and mindfulness in cognitive behaviour therapy.
Understanding and applying the new therapies, 2011: 3-25.
28 SeyedAlinaghi S, Paydary K, Kazerooni PA, et al. Evaluation of stigma
index among people living with HIV/AIDS (PLWHA) in six cities in
Iran. Thrita, 2013, 2(4): 69-75.
29 Charles B, Jeyaseelan L, Pandian AK, et al. Association between stigma,
depression and quality of life of people living with HIV/AIDS (PLHA)
in South India-a community based cross sectional study. BMC Public
Health, 2012, 12: 463.