Introduction
The current treatment of depression is sub-optimal, thereby identifying a need for novel evidence-based treatment techniques (Ceskova and Silhan, Reference Ceskova and Silhan2018). Evidence-based psychological treatments for depression are often complex, costly to deliver and require highly trained therapists. Furthermore, given that depression has a profound impact on an individual’s quality of life (QoL) and hope (Hofmann et al., Reference Hofmann, Curtiss, Carpenter and Kind2017), and improvements in depression do not always fully equate to improvement in QoL, it is important that studies investigating novel techniques for depression also consider the influences on the enhancement of QoL and hope (Hofmann et al., Reference Hofmann, Curtiss, Carpenter and Kind2017).
Overgeneral memory (OGM) is a cognitive marker of depression. Those with depression have problems recalling personal memories of discrete events that happened at a certain place and time (specific memories), but rather retrieve general, categoric memories (OGM) (Williams et al., Reference Williams, Barnhofer, Crane, Hermans, Raes, Watkins and Dalgleish2007). In depression, OGM is associated with impaired social problem-solving, problems imagining future specific events and rumination (Williams et al., Reference Williams, Barnhofer, Crane, Hermans, Raes, Watkins and Dalgleish2007). Thus, OGM impacts everyday cognitive and social functioning and ongoing negative mood (Williams et al., Reference Williams, Barnhofer, Crane, Hermans, Raes, Watkins and Dalgleish2007). Clinical efforts targeting OGM present as an exciting potential novel therapeutic approach in depression.
Emerging research indicates that OGM is modifiable, and a brief training, MEmory Specificity Training (MEST), targeting OGM can have positive outcomes in depression, including alleviating depression, improving social problem-solving and reducing rumination (Neshat-Doost et al., Reference Neshat-Doost, Dalgleish, Yule, Kalantari, Ahmadi, Dyregrov and Jobson2013; Raes et al., Reference Raes, Williams and Hermans2009). However, this area of clinical research is still in its infancy. Further research is needed at all stages of treatment development, including exploration of the feasibility of MEST in different populations. MEST has primarily been investigated in depressed patients from Belgium, the Netherlands and the UK. MEST is an attractive, accessible therapeutic option that has potential appeal for the treatment of depression in low- and middle-income countries (often with poor health infrastructure). Second, it is important to investigate the influence of MEST on the enhancement of QoL and hope (Hofmann et al., Reference Hofmann, Curtiss, Carpenter and Kind2017) and on the cognitive domains associated with OGM (social problem-solving, rumination). We report the findings of two pilot randomized controlled trials (RCT) investigating the feasibility and preliminary effectiveness of MEST in two samples of depressed Iranian women. Our aims were based on a pilot study, conducted by Eigenhuis and colleagues (Reference Eigenhuis, Seldenrijk, van Schaik, Raes and van Oppen2017), which investigated the feasibility and effectiveness of MEST in an out-patient setting in the Netherlands. Thus, we investigated the feasibility of MEST by focusing on; the perspective of the patients/participants and that of the group facilitators. We also explored whether there was preliminary support for MEST being able to reduce depression and improve social problem-solving (Study 1), QoL, hope and rumination (Study 2) in these samples.
Study 1
Participants
In both studies sample size was based on current recommendations (see extended report) and participants provided informed consent. Participants (aged 24-62 years) were Iranian females with major depressive disorder recruited from the general community. Twenty-seven women were screened for the trial and met major depressive disorder diagnostic criteria according to the Iranian version of the Structured Clinical Interview for DSM-5. One participant was excluded due to current substance use and two participants declined to participate in MEST as they felt MEST was not the appropriate intervention for them. Twenty-four participants agreed to participate and were randomly allocated to the control (n = 11) or MEST (n = 13) groups. The two groups did not differ significantly in age, education or baseline depression (Table 1).
Means (standard deviations) for study variables
*p<.05; **p<.01. ‘—’ represents data presented in text. ‡For post-training analyses, baseline scores were included as a covariate. See extended report in Supplementary material for 95% confidence intervals.
MEST
Trained clinical psychologists delivered MEST at a local health service in Isfahan. The manualized training package was delivered over 5×60 minute sessions to groups of 5–8 individuals (extended report).
Procedure
Both RCTs had ethical approval from the University of Isfahan (174862/96). Following Eigenhuis and collegaues (Reference Eigenhuis, Seldenrijk, van Schaik, Raes and van Oppen2017), we examined the feasibility of MEST by focusing on the perspectives of the patients and group facilitators. This information was collected using feedback from the patients and was gathered in an unstructured way in the last session of MEST. Group facilitator feedback was collected in an unstructured way by asking them about their experiences after finishing MEST. In terms of assessing preliminary effectiveness of MEST on our outcome variables, we adopted a similar approach to Eigenhuis and colleagues. Researchers blind to group status tested participants for depression symptomatology and social problem-solving at the university on three occasions: baseline, post-training and 2-month post-training follow-up (see extended report in Supplementary material). The assessors were not involved in the delivery of MEST and were blind to group allocation. Following baseline assessment, participants were randomly allocated by an independent research assistant, to either the MEST or control group (no additional contact).
Results
In terms of compliance, 11 patients (85%) in the MEST group completed MEST. Two patients in the MEST group dropped out following the second session due to finding employment and not being able to attend the sessions. Patients reported that MEST helped change their thinking about their memories and increased a sense of empowerment, and that they benefited from the group format. Patients noted that they were motivated to actively participate in MEST and support group members.
Group facilitators reported that their positivity for MEST increased as MEST progressed, patients became more involved and motivated over the course of MEST, and patients enjoyed listening to others’ memories. They noted that at times improvement seemed slow and MEST appeared too rigid, patients needed breaks mid-session, the rationale for MEST needed to be repeatedly outlined to the group, and there were initial difficulties with the homework tasks that were resolved by session 3. There were no important harms or unintended effects.
Table 1 shows the mean depression and social problem-solving scores. We used a 2 (group; MEST vs control) × 2 (time; post, follow-up) analysis of covariances (ANCOVAs), with baseline data as a covariate and depression and social problem-solving as the dependent variables. The group main effects were significant for depression symptoms, F (1,19) = 6.61, p = .02, ηp2 = .26, meandifference = –6.05, SE = 2.35, 95% CI [–10.97 to –1.13], and there was a trend towards significance for social problem-solving, F (1,19) = 4.07, p = .06, ηp2 = .18, meandifference = 3.31, SE = 1.14, 95% CI [–.09 to 4.70]; the MEST group reported significantly fewer symptoms of depression and tended to have greater social problem-solving than controls. For both depression and social problem-solving, the time main effects and interactions were non-significant. Compared with baseline, the MEST group had significantly fewer depression symptoms and improved problem-solving at post-training and follow-up (see extended report in Supplementary material).
Study 2
Participants
Undergraduate female students residing in a University of Isfahan dormitory were screened for the trial. We randomly selected 24 participants with moderate depression, who were randomly allocated to the control (n = 12) or MEST (n = 12) groups. The groups did not differ in age or baseline scores, with the exception of the control group reporting greater role limitations due to physical health than the MEST group (Table 1).
Procedure
Feasibility was assessed as in Study 1. In terms of effectiveness, researchers blind to group status tested participants individually, using measures of QoL, rumination and hope, at the university at baseline and post-training (see extended report in Supplementary material). The assessors were not involved in the delivery of MEST and were blind to group allocation. Following the baseline assessment, participants were randomly allocated by an independent research assistant to either the control (no additional contact) or MEST group.
Results
All participants in the MEST group completed MEST. Participants reported that MEST assisted in the recovery of personal specific memories, they enjoyed the group meetings, and felt that MEST had improved their depression and quality of life and this ongoing improvement was a significant motivator for completing MEST. Group facilitators were positive about MEST and reported that participants appeared to enjoy learning from others in the group. They also reported that some flexibility in sessions assisted with participant compliance and motivation. They noted there were some initial difficulties with homework but from session 3 all participants completed all homework tasks with no reported difficulties. Facilitators highlighted the importance of continually presenting the rationale for MEST, as this assisted with participant motivation and participation. There were no important harms or unintended effects.
A one-way (MEST vs control) multivariate analysis of covariance, with QoL scores as the dependent variables, and baseline scores as covariates, revealed a group main effect, Wilks’ lambda = .03, F (6,8) = 22.86, p = .001, ηp2 = .97. As shown in Table 1, the MEST group reported significantly greater QoL in all domains. The MEST group had less rumination, F (1,21) = 18.56, p < .001, ηp2 = .47, meandifference = 20.80, SE = 4.83, 95% CI [–30.83 to –10.76], and greater hope, F (1,21) = 183.42, p < .001, ηp2 = .90, meandifference = 12.48, SE = .92, 95% CI [10.56 to 14.40], than controls. Compared with baseline, the MEST group post-training had significantly less rumination and greater hope and QoL in all domains except general mental health and pain (see extended report in Supplementary material).
Discussion
Overall, we found that MEST was feasible as an intervention for depression in samples of Iranian women with depression. In both studies, MEST was associated with low drop-out rates. Participants reported that MEST assisted in changing their ways of thinking and recalling memories, increased their sense of empowerment, improved symptoms and that they liked the group format. Group facilitators reported that they felt positive about MEST, participants appeared to enjoy learning from others in the group, and that participants became more involved and motivated over the course of MEST. They noted that at times improvement seemed slow. Additionally, some flexibility within sessions and frequently outlining the rationale for MEST assisted with participant motivation and participation. In both studies, facilitators reported some initial difficulties with homework. However, by session 3 all participants were effective at independently completing the homework tasks.
There was preliminary evidence that MEST may bring about clinical benefit in terms of depression, social problem-solving (Study 1), QoL, rumination and hope (Study 2). We found that compared with baseline, the MEST group had significant improvements in depression, social problem-solving, QoL (with the exception of mental health and pain), rumination and hope. In Study 2 MEST was not associated with improvements in mental health. This may reflect the mental health items on the measure of QoL assessing both anxiety and depression; OGM is associated with depression but not anxiety (Williams et al., Reference Williams, Barnhofer, Crane, Hermans, Raes, Watkins and Dalgleish2007).
These studies provide further evidence that MEST, as a novel technique, may be a feasible therapeutic option that has potential appeal for the treatment of depression in low- and middle-income countries. Additionally, these studies provide further evidence that MEST may bring about clinical benefit in terms of depression and QoL and support growing evidence that MEST may improve social problem-solving and rumination. Given that autobiographical memory is fundamental to identity, problem-solving and social-bonding (Williams et al., Reference Williams, Barnhofer, Crane, Hermans, Raes, Watkins and Dalgleish2007), training patients in memory specificity may in turn improve areas pivotal to human functioning, such as improving QoL.
There are several limitations. First, the sample size was small and the findings remain preliminary. Second, the absence of an autobiographical memory measure means we cannot be certain of the mechanisms of change. Finally, given the nature of the sample, generalizability of the findings is limited. Despite these limitations, the findings highlight the need for further evaluations of MEST in depression.
Acknowledgements
We would like to acknowledge Baran Rahmat who assisted with conducting the MEST groups in Study 1 and the students of the University of Isfahan that participated in Study 2.
Financial support
None.
Conflicts of interest
None.
Ethics statement
This research abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. Both studies had ethical approval from the University of Isfahan (174862/96).
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1352465820000417
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