مقایسه اثربخشی آموزش تنظیم شناختی هیجانی و تحریک الکتریکی مستقیم فراجمجمه‌ای در تاب‌آوری، انعطاف‌پذیری شناختی و نشخوار فکری زنان سالمند با اختلال افسردگی اساسی

The present study aimed to compare the effectiveness of Emotion Regulation Training (ERT) and Transcranial Direct Current Stimulation (tDCS) in enhancing resilience and cognitive flexibility, as well as in reducing rumination, among women diagnosed with Major Depressive Disorder (MDD) in later stages of life. This quasi-experimental study employed a pretest-posttest design with a control group. The study population consisted of women formally diagnosed with MDD and residing in assisted nursing homes that collaborated with the research. A total of 45 eligible participants were selected through convenience sampling based on inclusion criteria of the study. They were then randomly assigned to one of three groups, namely ERT, tDCS, and control, using simple random allocation. Each intervention group received eight weekly 50-minute individual sessions. Data were collected using the Connor-Davidson Resilience Scale, the Cognitive Flexibility Questionnaire, and the Ruminative Responses Scale. The data were analyzed using univariate analysis of covariance (ANCOVA) and Tukey’s post hoc test, with a significance level set at .05, using SPSS-27 software. The ANCOVA results revealed significant differences among the three groups regarding the dependent variables. Tukey’s post hoc analysis showed that only the ERT group demonstrated significant improvements in resilience and cognitive flexibility, as well as reductions in rumination, compared to the control group. These findings underscore the effectiveness of ERT as a cognitive-based intervention in promoting mental health among older adults with MDD.
EXTENDED ABSTRACT
 Introduction
Major depression disorder (MDD) in older adults is one of the most prevalent psychological disorders, exerting profound negative effects on quality of life, cognitive functioning, and mental health within this age group. This condition leads to reduced resilience, diminished cognitive flexibility, and increased rumination. Resilience, as a crucial coping factor, plays a significant role in reducing the severity of depressive symptoms, whereas cognitive flexibility refers to an individual’s ability to shift perspectives and adapt to new circumstances. Additionally, rumination, recognized as a maladaptive cognitive style, contributes to the persistence and reinforcement of MDD. Cognitive-behavioral interventions, along with innovative psychological and neuropsychological techniques, can effectively improve these dimensions. Emotion regulation training (ERT) is a promising intervention that focuses on enhancing adaptive strategies while reducing maladaptive responses. Furthermore, transcranial direct current stimulation (tDCS), a non-invasive method for modulating brain activity, has garnered considerable attention, particularly in the treatment of psychological disorders. However, limited research has compared the effectiveness of these interventions in individuals with MDD at later stages of life. This research gap highlights the necessity of examining novel interventions, such as ERT and tDCS, to enhance resilience and cognitive flexibility, and to reduce rumination in this population.
Method
The present was a quasi-experimental with a pretest-posttest design and a control group. The study population consisted of 45 women (ages 61 to 82) diagnosed with MDD, who were randomly assigned to three groups with 15 participants (two experimental groups and one control group). Inclusion criteria included (1) a diagnosis of MDD made by a psychiatrist or psychologist at the care facility, based on DSM-5-TR, (2) an age range between 60 and 85 years, (3) informed consent obtained from both the participant and their legal guardian, and (4) a minimum level of literacy, defined as at least six years of formal education. Exclusion criteria included (1) comorbid psychotic features, (2) the presence of metallic implants in the body or head, or intracranial devices, (3) a history of traumatic brain injury or symptoms indicative of any form of dementia, (4) receipt of medical or psychological interventions aimed at treating depression within the month preceding the study, and (5) a history of epilepsy or traumatic brain injury. The first experimental group received ERT in an individual format over eight weekly 50-minute sessions. This protocol, adapted from James Gross’s Handbook of Emotion Regulation (2015), included skills such as cognitive reappraisal, acceptance, mindfulness, identifying negative thoughts, and increasing pleasurable activities. The second experimental group underwent tDCS using the NEUROSTIM-2 device, with a 2-milliampere intensity applied for 30 minutes per session across eight weekly sessions. The anodal electrode was placed over F3 (left prefrontal cortex), while the cathodal electrode was positioned at Fp2 (right prefrontal cortex). The stimulation aimed to enhance cognitive flexibility and reduce rumination in the first four sessions and improve resilience in the subsequent four sessions. Data were collected before and after the interventions while ensuring ethical confidentiality, using resilience, cognitive flexibility, and rumination questionnaires, and analyzed with SPSS version 27. Participants were excluded if they missed more than two sessions or withdrew from the study. The control group received no intervention.
Results
Descriptive analysis indicated that the mean scores for resilience and cognitive flexibility increased in the experimental groups during the post-test phase, while mean rumination scores decreased. To conduct a more precise analysis and control for the effects of the pre-test, univariate analysis of covariance (ANCOVA) was employed. Prior to performing this analysis, all necessary assumptions were examined. These included normal data distribution (Shapiro-Wilk test), homogeneity of variances (Levene’s test), and homogeneity of regression slopes, all of which were confirmed. Additionally, a significant correlation was observed between pre-test and post-test scores across all variables. The results of ANCOVA (Table 1) indicated that, after controlling for the pre-test effect across all three variables, the overall impact of the interventions on the dependent variables in the post-test phase was statistically significant. Follow-up analyses revealed that the ERT intervention significantly enhanced resilience and cognitive flexibility while reducing rumination. In contrast, the tDCS did not show a significant effect on any of the dependent variables. Based on these findings, it can be concluded that ERT is an effective intervention for improving psychological indicators in older individuals with MDD.
Conclusion
The primary objective of this study was to compare the effectiveness of two non-pharmacological interventions, ERT and tDCS, in improving resilience and cognitive flexibility, and in reducing rumination in older women diagnosed with MDD. The first hypothesis proposed that ERT significantly enhances resilience and cognitive flexibility while reducing rumination in women with MDD. The second hypothesis suggested that tDCS has a significant impact on improving resilience and cognitive flexibility, and on reducing rumination. The results supported the first hypothesis, confirming that ERT was effective in improving resilience and cognitive flexibility, and in reducing rumination. This outcome suggests that ERT, as a psychological intervention based on modifying cognitive and emotional patterns, directly contributes to the enhancement of psychological resilience. A fundamental assumption in this area is that individuals with MDD tend to engage in negative and maladaptive thought patterns, which can lead to increased rumination and decreased resilience. ERT helps individuals reframe their perspective on stressful situations through techniques such as cognitive reappraisal, problem reinterpretation, and emotion acceptance, ultimately strengthening their psychological coping abilities. In contrast, the second hypothesis, regarding the effectiveness of tDCS in improving resilience and cognitive flexibility, and reducing rumination was not supported by the results. This finding suggests that, while tDCS is recognized as a novel intervention for cognitive and psychological disorders, various factors may have impeded its expected impact on individuals with MDD in older adults.
Ethical Consideration
Ethical Code
This study was conducted in accordance with ethical principles for scientific research and the standards set by institutional ethics committees.
Financial Support
This study did not receive any financial support.
Authors’ Contributions
M.N.H: Conceptualization, writing - review & editing, methodology, project administration; A.N: Conceptualization, writing - review & editing, software, formal analysis, data curation; E.S.D: Supervision; M.N: Supervision
Conflict of Interest
The author had no conflicts of interest.
Acknowledgments
The authors express their gratitude to all individuals who contributed to the execution of this research.
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