Self-Determination Focused Acceptance Bibliotherapy (SAB) in Telemedicine on the Symptoms of Depression Among Adolescents

Depression is a severe mental illness that has a negative impact on social functioning, family connections, and academic achievement in adolescents [1]. Adolescence is a transitional stage in life when a person goes through physical, psychological, and developmental changes from puberty to adulthood [2]. The World Health Organization revealed that various physiological, neurological, psychological, and social changes could occur in an individual’s life during adolescence. This period is particularly vulnerable due to potential changes in schooling and social life [3]. Adolescents represent approximately 21% of the Indian population, and 40 percent of adolescents suffer from depression [4]. A recent study conducted by Sinha and his colleagues [5] found that the prevalence of depression has been alarmingly high in India and has become one of the most severe national illnesses. Studies have shown that depression has a significant negative impact on the psychological well-being of adolescents. In other words, an increase in depression contributed to a decrease in psychological wellbeing [6]. A study conducted by Pervin & Ferdowshi [7] found that depression affects an individual’s motivational factors, including a lack of desire to continue the tasks, loss of ambition, spontaneity, personal life, family life, work, and social life. It also affects health, such as sleeping and eating habits. Grant and his colleagues [8] revealed that having more severe depressive symptoms is linked to a lower sense of well-being. In particular, the study found that individuals who reported lower baseline well-being showed substantial increases in symptom scores of depression over time. A research study suggested that it is essential to integrate culturally relevant psychological interventions into preventing and treating depression in school-aged adolescents [9].

Theory of Self-determination [10], addressing basic psychological needs enhanced motivation, which addressed the three universally important and psychological aspects of autonomy, competence, and relatedness. Adolescents’ well-being improved as their motivation strengthened. The inability to meet psychological needs adequately often reduces motivation and increases the risk of depression [11]. Acceptance and Commitment Therapy (ACT) is a model that encourages flexibility and improves the skills needed to effectively reduce depression symptoms and enhance adolescents’ PWB [12]. Bibliotherapy incorporates CBT’s basic concepts and includes exercises to assist readers in resolving unpleasant emotions [13]. It provides relevant and practical solutions for preventing and decreasing the participants’ depressive moods [14]. The “Self-determination focused Acceptance Bibliotherapy” (SAB) was developed to fill the gaps in the ongoing research for an effective intervention program to address depression. Its main goals were to reduce the symptoms of depression and improve the psychological well-being of selected adolescents in India. Experts evaluated the eight-module intervention program (Table 1), which was efficacious and well received by participants in the pilot and experimental studies. This proved that the modules created for the program that combined the three theories, Selfdetermination, theory, Acceptance, and Commitment Therapy model and Bibliotherapy, were reliable, feasible, and effective when tested on a large group of adolescents at risk of depression. The following are some of the hypotheses that were established during its development and efficacy testing:
i. Negative cognition affects psychological well-being,
ii. Depression predicts poor psychological well-being, and
iii. The SAB as an intervention program is effective in improving psychological well-being.

Table 1:SAB modules and objectives.

It has a long-term impact in lowering the level of depression and enhancing adolescents’ psychological well-being. The SAB, an eight-module intervention program designed to be completed in six weeks (three hours per module, twice weekly), was then put through an experimental study to see how effectively the modules performed.

Researchers looked at existing related literature and the current situation to analyze the issue’s relevance, effect, and potential. Following the discovery of a link between depression and psychological well-being and a thorough analysis of its dimensions, the SAB intervention program was created by combining the concepts of three cognitive theoretical models: Selfdetermination theory, Acceptance, and commitment therapy model and bibliotherapy. The intervention aims to reduce adolescent depressive symptoms and improve their psychological wellbeing to function productively at home, in school, and in other aspects of their lives. Self-determination theory indicates that for a person to feel an enduring sense of integrity and well-being. Competence, autonomy, and relatedness are the basic needs and to be fulfilled across the individual’s life span [15]. Self-determination also predicts numerous positive outcomes, including reduced depression. Acceptance Commitment Therapy highlighted unique learning skills, such as decreasing experiential avoidance, increasing cognitive defusion, acceptance, and interaction with the present moment [16]. The acceptance and commitment therapy model will aim to improve adolescents’ behavioral capacity by modifying how they respond to distressing symptoms by slowly increasing their ability to open and stay present to thoughts, feelings, and body sensations [17]. Bibliotherapy encourages and empowers the patient as they go through the book and help explain any questions or concerns that the patient might have [18]. It uses a self-help book to direct and inspire people to challenge unhelpful thoughts and behaviors, resulting in better self-management rather than simple information being given [19].

With SAB’s use, the researcher attempts to explain the theories that described the possible approaches and skills such as enhancing positive attitudes, beliefs, and feelings, being aware of their recent experiences, recognizing their present thought, reducing stressrelated problems. This can make them happy and accept the reality of life. Self-determination-focused Acceptance Bibliotherapy (SAB) was developed to enhance positive mental health, positive emotions, and character development that predicts well-being. The intervention program focuses on the optimal functioning and wellbeing of adolescents. Thus, the integration of Self-determination theory, the Acceptance and Commitment Therapy model, and Bibliotherapy became instrumental in reducing depression and improving adolescents’ psychological well-being. A pilot study was conducted, with the results indicating that an experimental investigation should be conducted. The depression and PWB measures’ mean scores and standard deviation values, pre-test vs. post-test, indicated a decrease in depression and a rise in PWB, signifying a reduction in depressive symptoms and increased psychological well-being after the feasibility study. The ‘Wilcoxon signed-rank test was employed to examine the adolescents’ pre and post-test results for statistical analysis. The results revealed a substantial difference between the pre-test and post-test depression levels and PWB.

Furthermore, feedback from participants during the pilot test phase was gathered in order to improve SAB before this experimental study was conducted. The program was well appreciated by the participants, who expressed satisfaction and appreciation. They said they had fewer symptoms from depression, increased attention, connect with others more and looked forward to their future goals. The SAB was assessed for inter-rater reliability and content validity by six mental health experts who were not part of the focus group discussions. The expert’s employed standard evaluation guidelines, which were an adapted version of a technique created and used by the US Agency for International Development (USAID). After a proper evaluation, the experts unanimously assigned the program an ‘A’ grade, indicating that the SAB is sound, relevant, and feasible. The SAB was shown to be consistent and reliable in an interrater reliability test of expert ratings. Inter-rater consistency was calculated as a coefficient of 0.78.

The experts’ validation assured that the program is reliable and has a high likelihood of being effective in bringing about positive changes. Prior to the start of the experimental validation, expert comments and recommendations on technical and conceptual elements were taken into account when constructing the program structure. The experts recommended reducing the time spent on each module from three and a half to three hours to keep the momentum going and prevent the participants from becoming tired from too much exercise. The study’s findings revealed that the intervention program’s modules are reliable, practicable, and effective when tested on a larger group of adolescents at risk of depressive symptoms. The field of telemedicine was established in the 1960’s with the merging of advances in information technology, electronic communications technology, telecommunications, computers, and mobile technology with medicine. With the rise of new health issues that necessitate fast diagnosis and treatment, the internet facility now plays an essential role in communication and providing these services to patients in real-time.

Design and participants

To determine the efficacy of the intervention program, a fundamental experimental research approach with two independent groups as subjects were adapted. Prior approval was obtained from the UST Graduate School Ethical Review Committee to support the observance of ethical standards during the conduct of this study. Of those who met the inclusion criteria, forty (40) adolescents were chosen. Each of the experimental and control groups received twenty (20) adolescents at random. The participants were selected based on the following criteria for inclusion:
i. Adolescent students from the southern part of India who is studying in higher secondary schools and has a moderate level of depression (as measured by the BDI-II) and low psychological well-being (as measured by the RSPW);
ii. Adolescent boys and girls between the ages of 14 and 18; iii. Adolescents currently enrolled in schools in the state of Kerala, India;
iv. Adolescents who are staying/living with biological parents/guardians

Measures

Demographic Information Form/Personal Data Sheet (DIF): The researcher utilized a researcher-made Personal Data Sheet/DIF to compile the following socio-demographic profile of the respondents: age, gender, and education level. The personal data sheet/demographic questionnaire also includes an informed consent question.

Instruments

Ryff’s Scale of Psychological Well-being (RSPW): The Ryff’s Scale of Psychological Well-being (RSPW) contains 42 statements that reflect the six categories of psychological well-being: autonomy, environmental mastery, personal growth, positive interpersonal relationships, life purpose, and self-acceptance (Ryff, 1989). On a scale of 1 to 6, respondents score the statements, with 1 indicating significant disagreement and 6 indicating strong agreement. Higher scores on each scale imply greater happiness in that area (Ryff &Keyes, 1995). The internal consistency values with co-efficient alpha for each dimension ranged from 0.86 to 0.91, confirming the scale’s good reliability [21].

Pre-experimental, experimental, and post-experimental data were obtained for this research. Adolescents were chosen from among students who met the inclusion requirements using the purposive sampling technique. Participants were informed of the study’s confidentially and requested to sign an informed permission form, which included their parents/legal guardians, as well as complete the depression and PWB scales. Interviews and focus group discussions were conducted to attain valuable information for this study. The individuals chosen for the experimental phase were divided into experimental and control groups and given an overview of the intervention program SAB before it was implemented. The intervention program SAB was not given to the control group. The program was finished in six weeks, and the control group received the same treatment following the post-test for ethical reasons. The scores before and after the intervention were subjected to statistical analysis for evaluation in the postexperimental phase. Table 2 shows the effect of SAB on subjects utilizing variance analysis in MANOVA. The considerable difference in post-test scores between the experimental and control groups is due to the intervention program’s effect, indicating that the SAB effectively reduces depressive symptoms (p=.001; F=596.64) and enhances adolescents’ psychological well-being (p=.001; F=5373.624). The SAB’s efficacy after post-test in lowering the level of depressive symptoms and increasing the psychological well-being of the experimental group was measured using Cohen’s d test.

Table 2: MANOVA results from the post-test scores of the experimental and control groups in terms of BDI-II and PWB.

Source: SD: Standard Deviation; BDI-II: Beck’s Depression Inventory-II; PWB: Psychological Well-being; PR: Positive Relations; AU: Autonomy; EM: Environmental Mastery; PG: Personal Growth; PL: Purpose in Life; SA: Self-Acceptance.

The goal of this study was to see if the intervention program would lead to a significant reduction in depression symptoms and an increase in psychological well-being. Interviews and focus group discussions were conducted with those who completed the need assessment questionnaire and fulfilled the inclusion and exclusion criteria. In semi-structured interviews, 40 adolescents shared their problems, allowing the researcher to better understand the subjective experiences of adolescents who experience depressive symptoms. According to the post-test scores, the study resulted in a significant change in the participants’ behavior.

The low score in depression and high score in PWB measures among the adolescents in the experimental group only shows that some symptoms of the disorder have been reduced in the level of depressive behavior and psychological well-being has improved. During the pre-test, it was found that both the experimental and control groups’ mean depression scores were high and nearly identical. Both groups’ pre-test means scores on PWB measure also reflected to be at almost the same low level. Remarkably, the post-test on mean scores and standard deviation values for the experimental group revealed a significant decrease in depression (Exp: M=11.2, SD=1.4) and an increase in PWB (Exp: M=132.7, SD=5.22). During the post-test, the control group’s mean scores and standard deviation values for depression and PWB measures remained relatively constant (BDI-II- Ctrl: M=23.2, SD=1.6) and PWB-Ctrl: M=78.11, SD=4.74) is at the time of the pre-test. The overall result of the MANOVA test on the difference between the experimental and control groups’ mean scores and standard deviation values during the post-test indicates significant differences.

The researcher created an effective, relevant, and suitable intervention program called Self-determination-focused Acceptance Bibliotherapy to assist adolescents in reducing depressive symptoms, improving psychological well-being, and preventing them from developing a higher level of depression (SAB). When adolescents’ depression symptoms are reduced, they become a more productive and better concentrate on their education and everyday activities. Because depressed symptoms and psychological well-being are linked, individuals who are free of depressive symptoms have a sense of well-being within themselves. It had a significant effect on reducing the level of depression and improving the psychological well-being of adolescents. This further affirms that the Self-determination focused Acceptance Bibliotherapy (SAB) program was largely effective for adolescents. This study recommends that Telemedicine adopt the SAB in addressing depression. Telemedicine provides a new perspective in treating adolescents with depressive symptoms, considering the person’s well-being, preventing serious consequences in daily life, and its mission to ensure that patients receive the best health care service available in real-time whenever possible. The study’s findings indicated substantial differences in both depression symptoms and psychological well-being after implementing the eight modules of SAB. The study’s findings revealed that Selfdetermination- focused Acceptance Bibliotherapy is an effective intervention tool for reducing depressive symptoms and improving psychological well-being.

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