Efficacy of Positive Psychotherapy (PPT) in Reducing the Symptoms of Depression and Improving Life Satisfaction among University Students

1. INTRODUCTION

Mental health has always been a public health concern which is particularly challenging in low- and middle-income countries (LMICs) including Pakistan (Albarqi et al., 2024). Evidence in this reference, retrieved from Global Burden of Disease Study data for 1990–2019, showed a significantly increased mental health burden in Pakistan over three decades. It has also been observed that depressive disorders are most commonly occurring and contribute significantly to disability-adjusted life-years, demanding the attention of mental health stakeholders (Alvi et al., 2023).

With a growing concern surrounding mental health, the young population has been a focus of research over the past few years across the globe. These years are crucial for education, employment, and social relationships (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019). Evidence suggests that depression and anxiety are among the common mental health conditions experienced by adolescents globally (Silva et al., 2020). It has been estimated that 24 to 34% university students experience depressive symptoms across the globe (Akhtar et al., 2020; Tam et al., 2019). Despite the current global interest in the mental health of the young population, studies from LMICs, with Pakistan being no exception, are scarce (Khan et al., 2021).

It has been documented (Khan et al., 2021) that approximately 29% of the Pakistani population consists of young adults (15-29 years), which is also the age where the onset of depression is reported to be the highest (Substance Abuse and Mental Health Services Administration [SAMHSA], 2022). According to a systematic review, about 43% of university students in Pakistan have been experiencing symptoms of depression, which is alarming (Khan et al., 2021). Likewise, a survey reported the prevalence of depression among 53% university students, followed by the prevalence of anxiety in 43% (Muneer et al., 2024). Recent cross-sectional data obtained from the general population have suggested that almost 20% of the young population in Pakistan suffers from mood disorders, with depressive disorders being highly reported (Rahman et al., 2024). A similar study with young adults has also reported that about 40% of this population in Pakistan is suffering from depression (Ullah et al., 2022).

For this population, the chance to experience psychopathology is particularly higher in the presence of risk factors, which could be biological, psychological, social, academic, or related to lifestyle (Mofatteh, 2020). Evidence suggests that the high prevalence of depression indicates it as a common risk factor for reduced satisfaction with life (Lukaschek et al., 2017), with the young student population being no exception (Bukhari & Saba, 2017). Satisfaction with life is also considered an important predictor of depression, anxiety (Liu & Wang, 2024), and positive affect (Saldivia et al., 2023). Data obtained from studies based on students suggest that depression and anxiety negatively predict students’ satisfaction with life (Liu & Wang, 2024), while students with a higher level of satisfaction with life score low on depression and anxiety (Ooi et al., 2022). In addition to reduced satisfaction, these mental health conditions can predispose to severe consequences. For example, suicidal behaviors among students (Kabir et al., 2024) particularly after experiencing distress (Bilal & Riaz, 2020). Depression, in particular, is a potential threat to the physical as well as the mental well-being of the students (Irie & Yokomitsu, 2019). Taken together, evidence suggests that depression and other common mental health conditions, such as anxiety and stress, among students often impact their mental well-being and academic performance (Storrie et al., 2010). This warrants the attention of academic and mental health stakeholders.

Among many academic stressors experienced by students, failure to achieve an academic goal can be a major source of distress. A single experience of failure can result in extreme emotional disturbance (Johnson et al., 2017). Considering the Pakistani context, the mental health of students who failed to secure admission to a medical college due to lower scores on the entrance exam for admission in medical colleges is a burning issue (Bilal & Riaz, 2020; Fatima et al., 2021). The field of medicine is highly regarded in Pakistan, however, the positions in medical colleges are limited, which makes it challenging for aspirants to get through the exam and secure admission (Bilal & Riaz, 2020). Therefore, one of the potential reasons for poor exam performance or failure could be the pressure or distress experienced by the students, as in the case of students taking MDCAT (Bilal & Riaz, 2020). This distress can significantly affect their academic performance and manifest itself in the form of mental health issues like depression (Deng et al., 2022), which is a commonly experienced issue among students. Evidence suggests that students often experience depression due to emotional disturbance resulting from poor academic outcomes, failures, worries about the future, and career related concerns (Erschens et al., 2018; Feng et al., 2022; Mathew et al., 2015; Moir et al., 2018; Sinval et al., 2024; Yousef et al., 2017). Factors like failure to achieve a goal (e.g., to get admission in MBBS/BDS due to poor MDCAT performance), subject selection choice, or concerns related to career, therefore, can be extremely distressing for students and may lead to depression, which is supported by available literature (Erschens et al., 2018; Fatima et al., 2021; Yousef et al., 2017).

In response to the higher prevalence of depression among the student population, increasing efforts to detect and treat depression among students have been carried out with the aim of societal benefits. These efforts aim to control the outcomes of depression, for instance, higher academic withdrawals (Cuijpers et al., 2016). For the treatment or management of depression, one of the important questions is the availability of evidence-based psychotherapies. For this, several evidence-based therapeutic modalities are available; many of these therapies are typically based on cognitive approaches, while some incorporate multiple orientations. Although the intent is generally to implement a therapy across multiple settings, it is important to consider the therapeutic orientation in terms of its applicability to the patient as well as the provider (Cook et al., 2017). In this context, a lack of supporting evidence exists regarding the utility of evidence-based psychotherapies with the youth or student populations, as they may respond differently to the routine treatment (Barnett et al., 2022; Cuijpers et al., 2016). This could be particularly challenging in LMICs where accessibility to the mental health services is a challenge in itself. These challenges may be related to various factors, including financial resources, organization and planning, policies, access and availability of appropriately adapted evidence-based interventions and training. Such factors are influenced by a specific population's cultural belief system and worldview regarding mental health and illness. This interplay may serve as both a strength and a weakness, yet it undeniably affects service utilization (Rathod et al., 2017) in conjunction with mental health stigma (Ahmad & Koncsol, 2022).

Considering the need to address this issue, context, and functions of psychological phenomena of depression, the present study provides evidence on the utility of positive psychotherapy (PPT) for the student population suffering from depression. Theoretically based on the Seligman’s positive psychology, PPT emphasizes that constructing and strengthening positive emotions, meaning (i.e., belonging to and serving something greater than the self), and engagement in life can undo psychopathology (Seligman, 2002). It assumes that an individual has an inherent tendency to seek growth, fulfillment, and happiness. An effective therapeutic relationship can be developed through the manifestation of these positive resources that are as real as the symptoms of psychopathology (Seligman, 2011). By focusing on both strengths and weaknesses of an individual, PPT offers an incremental change to the deficit-oriented approach of traditional therapies. The fundamental aim of this therapeutic approach is to increase positive affect, meaning in life, and personal engagement (Rashid, 2014). In this regard, PPT appears to be a useful modality for the Pakistani collectivistic cultural context which emphasizes values, connection, engagement, and meaningfulness in relationships (Ford et al., 2015; Liu et al., 2021; Memon et al., 2021).

Literature provides significant evidence supporting the effectiveness of PPT in reducing the symptoms of depression, and increasing the life satisfaction (Asl et al., 2016) with a comparable efficacy to CBT (Hoppen & Morina, 2021; Seligman et al., 2006). In fact, evidence is available that shows PPT is more effective in treating depression in comparison to CBT (Asgharipoor et al., 2012). Additionally, delving on the theoretical evidence, PPT seems to be promising in improving life satisfaction. As suggested by Fredrickson’s (2004) broaden-and-build theory, positive emotions broaden an individual’s attention and thinking style resulting in flexibility and creativity. PPT enhances positive emotions that broaden cognition and build psychological resources. As a result, individuals are more likely to appraise their lives positively and report greater life satisfaction.

Although the efficacy of PPT has been mainly investigated in terms of treating depression, there are some studies that target other clinical populations. For instance, it has been evaluated for individuals with psychosis (Schrank et al., 2015), anxiety (Goodwin, 2010), borderline personality (Uliaszek et al., 2016), breast cancer (Dowlatabadi et al., 2016), and habitual smoking (Kahler et al., 2014). In the indigenous Pakistani context, there exists a lack of studies on PPT; only one published study could be found that examines the efficacy of PPT with adult females who had mild to moderate depression. Their study reported that PPT was effective in reducing depression and improving happiness (Mazhar & Riaz, 2020). In conclusion, these findings support the assumption that PPT leads to an enhancement of happiness, positive emotions, and well-being, and concurrently results in a decrease in psychopathology. The application of PPT in interventional research is heterogeneous in terms of both the modifications to the original manual as well as the conditions targeted by PPT as intended by the PPT developers (Walsh et al., 2017).

Method

The present study was carried out between Jan-July, 2021, and used a quasi-experimental design (pre-post) to test the efficacy of PPT. The study participants were divided into treatment and control group as presented below.

CONSORT Flow Diagram

The study participants were approached online through advertisement on social media platforms, and the researchers targeted four high merit departments of a public university in Lahore city. Using purposive sampling strategy, students were initially screened for inclusion criteria using a Google Form. Among the initially approached students, 22 participants could be enrolled in the study and were evenly classified in the treatment (n = 11) and control (n = 11) groups (see Figure 1).

The participants who studied pre-medical at college, recently appeared in the entrance exam of medical colleges (MDCAT) for admission in MBBS/BDS but couldn’t get admission due to their lower aggregate, and had mild to moderate levels of depression were included. All these participants were ≥ 18 years and currently enrolled as regular students in their first year of university. Those with age above 23 years, who had appeared in the entrance exam twice or more, were undergoing treatment for depression, or had disability or co-morbid psychological disturbance were excluded.

An information sheet was used to gather demographic information such as age, gender, education, socioeconomic status, family, medical college entrance exam, physical or psychological issues, etc.

The PHQ-9 was used for a quick assessment of depression and its severity (Kroenke et al., 2001). It consisted of 9 items, which were rated on a “0” (not at all) to “3” (nearly every day) Likert scale. The score on PHQ-9 ranged from 0 to 27, with a diagnostic cutoff being 10. The score on this questionnaire, computed by adding individual item scores, provided information regarding the different severity levels of depression that ranged from minimal to severe. Evidence suggests that PHQ-9 is a psychometrically sound tool for the assessment of depression across populations (Kim & Lee, 2019; Kroenke et al., 2001). In the present study, it has shown an alpha value of .86 proving it to be a reliable measure.

The MSLLS was used to assess the participants’ level of satisfaction with life (Huebner, 2001). This scale consists of 40 items divided into five subscales tapping satisfaction with life: Self, school, friends, family, and living environment. Each item is rated on a Likert scale marked from “1” (strongly disagree) to “6” (strongly agree). The scoring of each subscale is done by summing individual item ratings in a subscale and then dividing the sum by the number of items in that subscale. The MSLLS has been evident as a valid and reliable measure of assessment (Huebner, 2001; Schnettler et al., 2017). In the present study, the scale proved to be a reliable measure with an alpha value of .90. The alpha values for individual subscales were observed as the following: Family (.87); Friends (.84), School (.89), Environment (.84), and Self (.85).

The study used PPT (Rashid & Seligman, 2018) protocol that is based on Seligman’s happiness theory (Seligman, 2002) and focus on three main components of happiness: 1) pleasure or positive emotion, 2) engagement in activities, and 3) meaning in life.  Considering Seligman et al. (2006)’s work, a six-session therapeutic plan was developed after slight modifications (techniques were chosen from PPT manual based on their relevancy to study participants and purpose, instead of following the exact plan mentioned in Seligman et al. (2006). This plan was approved by the original authors and aimed to enhance positive emotions, interpersonal relationships, engagement and meaning of life, rather than directly targeting presenting symptoms of depression. The present research is designed to assess the effectiveness of six group-based sessions of PPT intended to lessen depressive symptomatology by increasing pleasure, engagement, and focusing on meaning in life. In addition, it aimed at improving satisfaction with life among students.

Before carrying out the study, it was first approved by the ethics committee of the Centre for Clinical Psychology, University of the Punjab. Following the approval, the study participants were approached online through advertisements using social media platforms due to the prevailing COVID situation. Those students who met the criteria and provided a written consent were included in the study. The participants were divided in two groups that were matched on the basis of age, gender, education, and intensity of depression. Both groups were assessed at pre-intervention level using measures of depression and satisfaction with life. Later, the treatment group was given six sessions of PPT in a group setting that were audio-recorded. This was carried in accordance with the guidelines provided in the PPT manual. However, the mode of intervention was online (with permission of the original authors), keeping in view the academic schedules of the students, their safety, and the concerns surrounding Coronavirus as well as the similar evidence from the literature (Yurayat & Seechaliao, 2021).

The sessions were held twice a week, with each session consisting of 90 minutes. The sessions were carried out by a trainee clinical psychologist who was practicing traditional therapies. Although no specific training was required to administer the PPT protocol, to ensure the integrity of the process, the sessions were supervised by a consultant clinical psychologist who had more than ten years of experience in the field and manual adherence ratings by an independent field expert. To examine the efficacy of PPT in reducing depressive symptomatology and improving life satisfaction, both treatment and control groups were assessed at post-intervention level and their scores were compared. In addition, participants were asked to provide their subjective feedback on the four areas of well-being (individual, social, interpersonal, & general well-being) on a 0-10 scale following the PPT intervention.

The study data was analyzed using SPSS V23 by calculating descriptive statistics and through Mann-Whitney U and Wilcoxon signed rank tests.

Results

At first, the data were screened and then descriptive statistics and reliability values (i.e., Chronbach’s alpha) were calculated for assessment measures and their dimensions.

Descriptive Statistics and Reliability for Patient Health Questionnaire (PHQ-9) and Multidimensional Students’ Life Satisfaction Scale (MSLSS) and its Dimensions (N=22)

Table 1 shows that both PHQ-9 and MSLSS are psychometrically reliable measures to assess depression and satisfaction with life.

Mann-Whitney U Test Comparing Experimental and Control Group on Depression and Satisfaction with Life and its Domains at Pre-Intervention Level (N=22)

Note. PHQ-9=Patient Health Questionnaire, MSLSS= Multidimensional Student’s Life Satisfaction Scale, U= Mann-Whitney U Test

The findings provided in Table 2 show that there was no significant difference between control and experimental groups when they were compared on the score of depression and satisfaction with life at pre-intervention level. This suggests that both groups were comparable.

The Wilcoxon Signed Rank Test Comparing Experimental Group on Depression and Satisfaction with Life and its Domains at Pre and Post -Intervention Levels (N=11)

Note. PHQ-9=Patient Health Questionnaire; MSLSS= Multidimensional Student’s Life Satisfaction Scale; Z= Wilcoxon signed rank.

Table 3 is showing the pre and post-assessment observations for the experimental group after 6-sessions of PPT. The findings showed that experiment group participants' scores differed in the post-intervention assessment. A significant decrease in depression was observed, along with an increased score in life satisfaction and its domains, including self, friends, living environment, and education.

The Wilcoxon Signed Rank Test Comparing Control Group on Depression and Satisfaction with Life and its Domains at Pre and Post -Intervention Levels (N=11) 

Note. PHQ-9=Patient Health Questionnaire; MSLSS= Multidimensional Student’s Life Satisfaction Scale; Z= Wilcoxon Signed Rank

In comparison to the data presented in Table 3, the above Table 4 shows the pre and post-assessment scores for the control group, which was a no-treatment group. It was observed that the scores of participants in this group remained almost similar on both depression and satisfaction with life. There was no significant change in control group scores across the two points of observation. Overall, the findings suggested that the PPT proved to be effective in lowering the level of depression and enhancing satisfaction with life across various domains, including satisfaction with family, self, educational institute, friends and living environment.

Discussion

The present study was carried out with university students, and examined the utility of a PPT, which is considered a renowned therapy for cultivating positive emotions, engagement and meaning in life, and improving interpersonal relationships. The study investigated the efficacy of PPT in reducing the symptoms of depression and improving life satisfaction. While providing the evidence on the efficacy of PPT, the present study particularly focuses on the student population and highlights the need to address the mental health challenges that increasingly surface within academic organizations.

The findings of the study suggested that PPT can significantly reduce the symptoms of depression and lead to improvement in life satisfaction among the students. These findings are in alignment with the principles of PPT that emphasize positive emotions, strengths, and personal growth (Seligman, 2002; Seligman & Csikszentmihalyi, 2000). Additionally, considering the strong emphasis of PPT on a client’s strengths, growth, and well-being, it is convincing that PPT could be an efficacious and culturally sensitive approach, unlike other therapies focusing on symptoms of illness, for individuals living in collectivistic cultures like those in Asia. In such conventional cultures, harmony in relationships, integrity, and well-being of the group members are promoted (Shavitt & Zhang, 2004), which is also the focus of PPT. Furthermore, the current study evidence is significantly supported by previous studies, which tested the efficacy of PPT with various pathological conditions, including depression (Asgharipoor et al., 2012; Goodwin, 2010; Mazhar & Riaz, 2020; Schrank et al., 2015; Uliaszek et al., 2016). It highlights that PPT is an effective approach to reduce symptoms of psychopathology and improve satisfaction with life and well-being of individuals.

It has been tested previously that PPT significantly improves the positive psychological traits such as happiness and resilience, while promoting post-traumatic growth and reducing symptoms of depression (Woo et al., 2022). This suggests that PPT not only reduces symptoms of pathology but also equips an individual with a set of traits and emotions that assist them in dealing with the aftermath of challenging events. Like in the present case, PPT has significantly reduced depression, and improved students’ satisfaction with their lives. This is supported by sufficient evidence from the previous literature (Asgharipoor et al., 2012; Asl et al., 2016; Furchtlehner et al., 2024; Hoppen & Morina, 2021; Mazhar & Riaz, 2020; Seligman et al., 2006). Depression is a reaction to adverse life events, such as experiencing a loss or failure (Freud, 1917; Jones et al., 2013).  In that, the present findings suggest that students receiving PPT could utilize their strengths in building confidence and resilience to win over their psychological distress resulting from MDCAT failure and deal with their current challenges, e.g., academic pressure, career related concerns, etc. This is because psychological factors like resilience buffer against the emotional turmoil experienced due to failures or mistakes (Johnson et al., 2017). Another important factor which should be considered here is spiritual beliefs and coping, which have strong influence on improving the emotional well-being of the individuals (Rani & Ghazi, 2023; Salman et al., 2020). It is likely that PPT remained efficacious in the current study because it strongly aligns with the spiritual beliefs and practices followed by majority of the people in Pakistan, for instance, gratitude and openminded attitude toward difficulties.

Evidence reports that mental illnesses such as depression are a prevalent issue in emerging economic countries, majorly due to low mental health literacy (Alvarez-Huerta et al., 2021). The same goes for Pakistan as documented (Albarqi et al., 2024; Alvi et al., 2023). In this context, the findings of this study call the attention of mental health stakeholders, policy makers, and the families to take necessary steps towards prevention of prevailing mental health difficulties among the student population, such as depression resulting from academic and family stressors. This is important because these stressors significantly influence their academic careers (Deng et al., 2022).

The findings of this study also indicate PPT as a brief, cost-effective, and preventive approach that could be utilized with the Pakistani population, sometimes with slight modifications, to meet the specific population needs. Being a brief and strength-focused approach, PPT could be especially useful with the student population for accommodating their academic schedules and equally acknowledging their strengths and weaknesses in order to ensure their therapeutic engagement. Additionally, this perspective also encourages the use of PPT in sensitive situations where individuals are resistant and the chances of dropouts are higher.  

Despite many strengths, the present study has a few limitations. First, this study was conducted with a smaller sample of students using the English version of the protocol. So, it cannot be generalized that the translated version of the PPT protocol would be equally effective with other population groups as the original English version. In addition, the study didn’t use randomization and has a potential for bias which further limits its generalizability. Furthermore, the researchers used a brief protocol and made efforts to ensure therapeutic alliance; however, the use of a digital mode of delivery might have influenced this process and, consequently, the study’s findings. In the future, studies should focus on working with larger and different sample groups to test the efficacy of PPT. Moreover, comparative studies can be carried out to evaluate PPT in relation to conventional therapies that are currently practiced by clinicians, as well as different modes of therapeutic administration. This would provide valuable evidence on emerging therapies and help address gaps in the indigenous literature. The study also remained limited as researchers could not follow up with the participants. However, future studies could be planned with post therapy follow ups to track the efficacy of the PPT intervention.

Conclusion

In conclusion, the findings of the study suggested that PPT is an efficacious approach in managing depression and improving life satisfaction among the students who are experiencing mental health challenges due to emotionally debilitating experiences such as failures or trauma. The study contributes to the literature and encourages using PPT for its brevity and friendly approach.

Author Contribution

Amina Shahzadi: conceptualization, methodology, data curation, formal analysis, writing – original draft, writing – review & editing, visualization, project administration. Faiza Safdar: supervision, conceptualization, methodology.

Conflict of Interest

The authors of the manuscript have no financial or non-financial conflict of interest in the subject matter or materials discussed in this manuscript.

Data Availability Statement

The data associated with this study will be provided by the corresponding author upon request.

Funding Details

No funding has been received for this research.

Generative AI Disclosure Statement

The authors did not used any type of generative artificial intelligence software for this research.