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Psychological findings of the multifaceted lifestyle interventions
effectiveness for depression are scant. The aim of the present study is
evaluating the effectiveness of an educational intervention targeting lifestyle
habits based Islamic teachings in patients with depression. Twenty-four
patients with the major depressive
disorder were randomly assigned to 10 sessions of group Islamic lifestyle psychoeducational
intervention (ILPI) or 8 sessions of a behavioural activation group therapy.
The depressive symptoms (including Beck
depression inventory-II, Beck hopelessness
scale and Penn state worry questionnaire) of both groups was improved
significantly at the end of the treatment. The ILPI proved to be as efficacious as behavioural activation in mood improvement
of patients with the major depressive disorder. Given the easy
implementation and cost-effectiveness of Islamic lifestyle psychoeducational
intervention, such intervention represents an effective nonpharmacological
intervention to manage depression in patients with the
major depressive disorder.

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Islamic lifestyle, Lifestyle intervention, Psychoeducation, Major depressive



















Major depression is one of the main cause of disability worldwide (Ripoll et al., 2015). Given the increasing number of depressed patients which their response to first-line antidepressant
interventions (pharmacological or psychological) is not satisfactory, the identification of modifiable factors that
contribute to development, maintenance and improvement of depression is
necessary (Sarris, O’Neil, Coulson, Schweitzer,
& Berk, 2014).
The etiopathology of major depression is related to different biopsychosocial
factors that many of them are associated with lifestyle (Hidaka, 2012; Lopresti, Hood, &
Drummond, 2013).

Some research has shown that targeting lifestyle factors can be useful
in depression improvement and recurrent prevention (Bersani et al., 2017; Goracci et al.,
2016; Lopresti et al., 2013; Sarris et al., 2014).
The effect of sleep (Baglioni et al., 2011; Hayley et al.,
physical activity (Conn, 2010; Da Silva et al., 2012; Song,
Lee, Baek, & Miller, 2012),
dietary modification (Kiecolt-Glaser, Jaremka, & Hughes, 2014;
Quirk et al., 2013; Sánchez-Villegas, Ruíz-Canela, Gea, Lahortiga, &
Martínez-González, 2016) and
light exposure (Even, Schröder, Friedman, &
Rouillon, 2008; Milaneschi et al., 2014) has been studied separately, but just a few
studies have investigated the effects of integrated multicomponent lifestyle
interventions for depression (García-Toro et al., 2012; Goracci et
al., 2016).

To our knowledge, only two RCTs studied the influences of multifaceted lifestyle
interventions in patients with the major
depressive disorder. In the first study, Garcia-Toro et al (2012) compared the
effectiveness of four specific dietary-hygienic recommendations with four generic
recommendations in eighty outpatients with non-seasonal depression, the results
showed a significant reduction of depressive symptoms in the active treatment group.
In the second study (Goracci et al., 2016),
one hundred-sixty outpatient with
recurrent unipolar depression or bipolar disorder were recruited after
achieving full remission or recovery from the most recent depressive episode, were
randomly assigned to 3-months of usual care or to an intervention aimed at
promoting a healthy lifestyle (HLI). Authors reported that the overall
percentage and the risk of relapse were
significantly lower in HLI group compare to control groups.

On the other hand, research has
shown that incorporating religious practices and beliefs into psychological
treatment for depression is associated with positive treatment outcomes (Mir et al., 2015). It seems that religious interventions for Muslim patients can result in earlier remission of
depressive symptoms compares to secular
interventions (Hook et al., 2010; Mir et al., 2015). While
Islam is the world’s second-largest
religion with over 1.8 billion adherents, the role of its practices and
beliefs in the therapeutic process of
depression is ignored (Hodge, Zidan, & Husain, 2015).  

The aims of the
present study are to assess the efficacy of a lifestyle psychoeducational
intervention based Islamic teachings compared with behavioural activation
treatment in improving the symptoms of
depression in patients with the major depressive
disorder. We expected that the depressive symptoms among patients assigned to the
Islamic lifestyle psychoeducational intervention would be as lower as patients assigned
to behavioural activation treatment during
the intervention period. 


The present
study sample consisted of 24 patients aged 20 to 50, with a diagnosis of major depressive
disorder as stated by the DSM-5 (APA, 2013), mild to moderate depressive
symptoms (based on Beck Depression Inventory-II) for at least two months of
duration who have sufficient physical and cognitive ability to understand and
give written informed consent. Patients who were suffering from any other psychological
disorders and being under psychotherapy or medicine for major depressive
disorder were excluded. Patients were recruited from psychological services

The Isfahan
university research ethics
committee approved the study (IR.UI.REC.1396006). All participants provided
written, informed consent prior to beginning
their involvement in the trial.

equally and randomly were assigned to the Islamic lifestyle psychoeducational
intervention (ILPI) or behavioural activation treatment group. Patients
assigned to the ILPI received 10 sessions weekly basis of group psychoeducation
focused on healthy lifestyle based Islamic teachings. The behavioural
activation treatment group received 8 sessions weekly basis of group therapy.

The Islamic
lifestyle psychoeducational intervention (ILPI) consisted of ten sessions
delivered weekly to patients on the following topics: 1) the importance of life
balance for physical and mental health and providing psychoeducation about
depression (its prevalence, symptoms, causes, course and treatments), 2) the
importance of taking an appropriate diet and its potential role in improving
depression, 3) the importance and role of physical exercise (specially aerobic exercise)
in depression improvement , 4) providing education about adequate and high-quality
sleep plus the importance role of religious practices and beliefs in depression
management, 5) the importance and role of 
social interaction in mental health, 6) providing information about the
role of recreational activities in mental and physical health, 7) reviewing
diet and physical exercise advices, 8) reviewing sleep and religious
recommendations, 9) reviewing recommendations about social interaction and
recreational activities and 10) preparing to terminate intervention and
providing education about relapse-preventing strategies.  Each session comprised: 1) A 20–30 minutes
summary of the previous week topics with a discussion on how participants had
tried to implement that habit during the previous week, 2) a 30–40 minutes
presentation on the new topic(s), and 3) a 20–30 minutes group discussion on
the new topic(s). At the end of each session, participants were given a booklet
summarizing the information of that session and were encouraged to monitor
their mood related to the new topic(s) during the following week. The overall target
of this psychoeducational intervention, based on previously published evidence (Bersani et al., 2017; Goracci et al., 2016), was to help
patients to build and keep a healthy and active lifestyle. But in the present study, the content of the sessions was provided
using Islamic teachings (Quran and Hadith) about the above-mentioned lifestyle

The behavioural
activation group intervention comprised of eight 90 minutes weekly sessions
based on the latest manual of brief behavioural activation treatment for
depression (Lejuez, Hopko, Acierno, Daughters, & Pagoto,

The validated
Persian version of 1) Beck Depression Inventory-Second
edition (BDI-II) (Ghassemzadeh, Mojtabai, Karamghadiri, & Ebrahimkhani,
2005), 2) the Beck
Hopelessness Scale (BHS) (Dejkam, 2005) and 3) Penn State Worry Questionnaire
(PSWQ) (Borjali, Sohrabi, Dehshiri, & Golzari, 2010) were administered to all
participants. Socio-demographic variables such as gender,
age, marital status, education level and occupation were also collected.
The first one is a 21-item instrument that widely used as it allows patient
self-rating of depressive symptoms, avoiding evaluation bias, and determines a
cut-off for mild or moderate
depression (Beck, Steer, &
Brown, 1996). The second one is a 20-item self-report
scale that was designed to measure three major aspects of hopelessness:
feelings about the future, loss of motivation, and expectations (Beck & Steer, 1988). The last one is a 16-item questionnaire that measures of worry phenomena and has been demonstrated valid in
cross-cultural populations (Meyer, Miller, Metzger, & Borkovec, 1990). 

Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY) was
used for statistical calculations. All tests were two-tailed with an alpha=0.05.
The differences between two groups’ depressive symptoms were analysed using multivariate
analysis of covariance (MANCOVA).



The two groups didn’t significantly differ in gender, age, years of
education, marital status, and occupation. They have also no significant
differences in depressive symptoms prior to commencing their involvement in the



Many studies
have shown the effectiveness of different lifestyle elements such as sleep
hygiene, physical exercise, healthy diet and light exposure independently on
the reduction of depressive symptoms (Ripoll et al., 2015). The two RCTs which had
implemented a multicomponent lifestyle intervention for depression showed promising results in depressive symptoms
reduction and depression relapse-prevention (García-Toro et al., 2012; Goracci et al., 2016).

Hence, we
expected that a multifaceted lifestyle intervention that was based on dietary
modification, physical exercise, sleep hygiene, adherence to religious
practices, social interaction and recreational activity would have considerable
and clinically important positive mental health outcomes for patients with the
major depressive disorder.

The results
of the present study showed that the Islamic lifestyle psychoeducational
intervention (ILPI) can be as efficacious as behavioural activation in the reduction of depressive symptoms of patients
with the major depressive disorder. This finding is consistent with the literature
evidence indicating that lifestyle modifications can result in stress reduction, anxiety decreasing, mood and sleep
improvement and boosting of self-esteem (Sarris et al., 2014; Walsh, 2011). The results of the present
study are also consistent with García-Toro et al. (2012) and Goracci et al. (2016) that the findings of both
indicated a significant reduction of
depressive symptoms in patients with depression.

We believe
that physical activity, sleep hygiene, adherence to religious practices on a regular base and dietary modification are the
key elements for reduction of depressive symptoms of ILPI participants.
Unfortunately, a number of depressed patients just receive anti-depressants
medicine without receiving adjunct behavioural or cognitive interventions (Olfson et al., 2002). As a result, many of
patients do not receive appropriate education about how nonpharmacologic
strategies can help them manage and prevent the symptoms of their depression.

Many changes have
occurred in the
lifestyle of a significant proportion of the population during recent decades. The
level of their physical activity has reduced, they have a less healthy diet,
their exposure to sunlight is decreasing, they don’t have adequate and
high-quality sleep at night, and the social interactions between people is
reducing (Hidaka, 2012). Research showed that such
changes in lifestyle have an influence on brain physiology that may rise
depression vulnerability (Bourre, 2006; Sarbadhikari & Saha, 2006). While it seems that
depressed patients are aware of these faulty aspects of their lifestyle that
its modification can help them improve their mood, they often don’t change
their lifestyle spontaneously (Morgan, Jorm, & Mackinnon, 2012).

The mechanism
that can illustrate the causes of lifestyle modification on depression
improvement is complicated. Lifestyle modification include changes in
biopsychosocial levels that can help depressed patients to improve. Physical activity
can change the balance of serotonergic, dopaminergic and noradrenergic systems
in the opposite direction as stress (Pareja-Galeano et al., 2016). It also increases self-efficacy
and self-esteem and reduces the negative thoughts and rumination (Dowd, Vickers, & Krahn, 2004). Research have showed that adherence
to Mediterranean diet (include consumption of abundant plant foods, fresh and varied fruits, olive oil and fish) seems able to change brain
monoamine levels and even BDNF (brain derived neurotrophic factor), the elements
that reduce in patients with depression (Sánchez-Villegas et al., 2016). 

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