Integrated Cognitive, Interpersonal, and Systemic Treatment for Women with Depression: Development and Efficacy Evaluation

Document Type : Research Paper


1 Department of Clinical Psychology, Faculty of Psychology and Social Sciences, Islamic Azad University, Roodehen Branch, Tehran, Iran.

2 Department of Psychology, Faculty of Psychology and Social Sciences, Islamic Azad University, Roodehen Branch, Tehran, Iran.

3 Department of Clinical Psychology, Institute of Management and Planning Studied. Tehran. Iran.


The purpose of this research was to develop and evaluate the efficacy of an integrated package of cognitive, interpersonal, and systemic therapy on the depressive symptoms and coping skills of women with depression. The research design is an extended pre-test-post-test design with multiple groups. The statistical population of the study consisted of the women referred to the Atieh treatment center in Tehran in 2017 and 2018, and 60 of them were randomly divided into four groups of 15 participants.Following grouping, the first group received cognitive therapy, the second group received interpersonal therapy, the third group received systemic therapy, and the fourth group received an integrated bundle of cognitive, interpersonal, and systemic therapy over the course of 12 weekly 90-minute sessions. Data was collected using the Beck Depression Inventory-Second Edition (BDI-II) and the Coping Responses Scale (CRI). The data were analyzed using SPSS-23 statistical software and mixed variance analysis. Post-test results indicated that integrated treatment package training has a significant impact on reducing depressive symptoms and enhancing coping skills among depressed women (P<0.001), but these results were not substantiated during the follow-up phase. This study is founded on the utilization of integrated treatment packages to improve Depression supports services.


حسینی قدمگاهی، ج.، دژکام، م.، بیان‌زاده، ا.، و فیض، ا. (1377). کیفیت روابط اجتماعی، میزان استرس و راهبردهای مقابله با آن در بیماران عروقی قلب. مجلۀ روان‌پزشکی و روان‌شناسی بالینی ایران. 4(1)، 25-14.
دابسون، ا. ک.، محمدخانی، پ.، و مساح‌چولابی، ا. (1386). مختصات روان‌سنجی پرسشنامۀ افسردگی بک-۲ در یک نمونۀ بزرگ مبتلایان به اختلال افسردگی اساسی. مجلۀ توان‌بخشی. ۸(39)، 86-80.
دلاور، ع. (1380). مبانی نظری و عملی پژوهش در علوم انسانی و اجتماعی. تهران: رشد.
فتی، ل.، بیرشک، ب.، عاطف وحید، م. ک.، و دابسون، ک. ا. (1384). ساختارهای معناگذارطرحواره‌ها، حالت‌های هیجانی و پردازش شناختی اطلاعات هیجانی: مقایسۀ دو چارچوب مفهومی. مجلۀ روان‌پزشکی و روان‌شناسی بالینی ایران. ۱۱(۳)، ۳26-۳12.
ونتلینگ، ت. ال. (1375). برنامه‌ریزی آموزشی اثربخش. ترجمۀ محمد چیذری. تهران: دانشگاه تربیت مدرس.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Babl, A., Holtforth, M., Heer, S., Lin, M., Stähli, A., Holstein, D., Belz, M., Egenolf, Y., Frischknecht, E., Ramseyer, F., Regli, D., Schmied, E., Flückiger, C., Brodbeck, J., Berger, T. y Caspar, F. (2016). Psychotherapy integration under scrutiny: investigating the impact of integrating emotion-focused components into a CBT- based approach: a study protocol of a randomized controlled trial. BMC Psychiatry, 16(1), 423.
Baert, S., De Raedt, R., Schacht, R., & Koster, E. H. W. (2010). Attentional bias training in depression: therapeutic effects depend on depression severity. Journal of Behavior Therapy and Experimental Psychiatry. 41(3), 265-274.
Beck, A. T. (1967). Cognitive therapy and the emotional disorders. New York, NY: International University Press.
Beck, A. T. (2008). The evolution of the cognitive model of depression and its neurobiological correlates. American Journal of Psychiatry, 165(8), 969–977.
Beck, A. T., & Dozois, D. J. A. (2011). Cognitive therapy: current, status and future directions. The Annual Review of Medicine, 62, 397–409.
Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck depression inventory–II [Database record]. APA PsycTests.
Bell, C. M., Ridley, J. A., Overholser, J. C., Young, K., Athey, A., Lehmann, J., & Phillips, K. (2018). The Role of perceived burden and social support in suicide and depression. Suicide Life Threat Behav, 48(1), 87-94.
Billings A. G., & Moos R. H. (1984). Coping, stress and social resources among adults with unipolar depression. Journal of Personality and Social Psychology, 46(4), 877-891.
Bowen, M. (1978). Family therapy in clinical practice. New York: Jason Aronson
Boswell, J. F., Nelson, D. L., Nordberg, S. S., McAleavey, A. A., &Castonguay, L. G. (2010). Competency in integrative psychotherapy: Perspectives on training and supervision. Psychotherapy: Theory, Research, Practice, Training, 47(1), 3–11.
Browning, M., Holmes, E. A., Charles, M., Cowen, P. J., & Harmer, C. J. (2012). Using
attentional bias modification as a cognitive vaccine against depression. Biological Psychiatry. 72(14), 572-579.
Buckman, J. E. J., Underwood, A., Clarke, K., Saunders, R., Hollon, S. D., Fearon, P., & Pilling. S. (2018). Risk factors for relapse and recurrence of depression in adults and how they operate: A four-phase systematic review and meta-synthesis. Clinical Psychology Review.64,13–38.
Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion, 6(4), 587–595.
Castonguay, L. G., Eubanks, C. F., Goldfried, M. R., Muran, J. Ch., & Lutz, W. (2015). Research on psychotherapy integration: building on the past, looking to the future, Psychotherapy Research, 25(3), 365-382.
Coifman, K. G., & Summers, C. B. (2019). Understanding emotion inflexibility in risk for affective disease: integrating current research and finding a path forward. Frontiers in Psychology, 10. Article 392.
Chow, K. W., & Lo, B. C. (2017). Parental factors associated with rumination related metacognitive beliefs in adolescence. Frontiers in Psychology, 8, 536.
Cuijpers, P., van Straten, A., Andersson, G., & van Oppen, P. (2008). Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology, 76(6), 909–922.
Dajani, D. R., & Uddin, L. Q. (2015). Demystifying cognitive flexibility: implications for clinical and developmental neuroscience. Trends Neurosciences, 38(9), 571–578.
Delawar, A. (2001). Theoretical and practical foundations of research in humanities and social sciences. Tehran: Roshd Publications.
Dobson, K. S., Mohammadkhani, P., & Massah-Choulabi, O. (2007). Psychometrics characteristic of beck depression inventory-ii in patients with magor depressive disorder. Iranian Journal of Rehabilitation in Mental Disorders, 8, 80-86. (In Persian)
Everaert, J., Grahek, I., & Koster, E. H. W. (2017). Individual differences in cognitive control over emotional material modulate cognitive biases linked to depressive symptoms. Cognitive Emotion, 31(4), 736–746.
Fata, L., Birashk, B., Atef-vahid, K., & Dobson, K. (2005). Meaning assignment structures/ schemas, emotional states and cognitive processing of emotional information: comparison of two conceptual framework. Iranian Journal of Psychiatry and Clinical Psychology, 11(3), 312-326. (In Persian)
Folkman, S., & Moskowitz, J. T. (2004). Coping: Pitfalls and promise. Annual Review of Psychology, 55, 745–774.
Fonagy, P., Lemma, A., Target, M., O’Keeffe, S., Constantinou, M. P., Wurman, T. V., ... & Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 50(6), 1010-1019.
Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist. 35(11), 991–999.
Goldfried, M. R., Pachankis, J. E., & B ell, A. C. (2005). A history of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.). Oxford University Press.
Grahek, I., Everaert, J., Krebs, R. M., & Koster, E. H. W. (2018). Cognitive control in depression: toward clinical models informed by cognitive neuroscience. Clinical Psychological Science, 21(67), 1–17.
Greenberg, L., Rice, L., & Elliott, R. (1993). Facilitating emotional change. The moment by moment process. New York: Guilford Press.
Gross, J. J. (2015). The extended process model of emotion regulation: elaborations, applications, and future directions. Psychological Inquiry, 26(1), 130–137.
Hammar, A., & Ardal, G. (2009). Cognitive functioning in major depression - a summary. Frontiers in Human Neuroscience, 3, 26.
Heffer, T., & Willoughby, T. (2017). A count of coping strategies: A longitudinal study investigating an alternative method to understanding coping and adjustment. PLOS ONE, 12(10), e0186057.
Hertel, P. (2004). Memory for emotional and nonemotional events in depression: a question of habit? In Memory and Emotion, Eds. D. Reisberg, & P. Hertel (186-216). New York, NY: Oxford University Press.
Hertel, P. T., & Mathews, A. (2011). Cognitive bias modification: Past perspectives, current findings, and future applications. Perspectives on Psychological Science, 6(6), 521-536.
Hofmann, W., Schmeichel, B. J., & Baddeley, A. D. (2012). Executive functions and self regulation. Trends Cognitive Science, 16(3), 174–180.
Holubova, M., Prasko, J., Ociskova, M., Grambal, A., Slepecky, M., Marackova, M., Kamaradova, D., & Zatkova, M. (2018). Quality of life and coping strategies of outpatients with a depressive disorder in maintenance therapy – a cross-sectional study, Neuropsychiatric Disease and Treatment, 14, 73–82.
Hosseini Kadamgahi, J., Dezhkam, M., Bayanzadeh, A., & Faiz, A. (1997). The quality of social relationships, the amount of stress and coping strategies in cardiovascular patients. Iranian Journal of Psychiatry and Clinical Psychology, 4(1), 14-25.
Hsu, K. J., Caffey, K., Pisner, D., Shumake, J., Risom, S., Ray, K. L., & Beevers, C. G. (2018). Attentional bias modification treatment for depression: Study protocol for a randomized controlled trial. Contemporary Clinical Trials. 75, 59-66.
Huibers, M. J. H., Cohen, Z. D., Lemmens, L. H. J. M., Arntz, A., Peeters, F. P. M. L., Cuijpers, P., & DeRubeis, R. J. (2016). Correction: Predicting optimal outcomes in cognitive therapy or interpersonal psychotherapy for depressed individuals using the personalized advantage index approach. PLOS ONE, 11(2), 0148835.
Hyde, J. S. & Mezulis, A.H. (2020). Gender differences in depression: biological, affective, cognitive, and sociocultural factors. Harvard Review of Psychiatry, 28(1), 4-13.
Jones, E. B., & Sharpe, L. (2017). Cognitive bias modification: a review of meta-analyses. Journal of Affective Disorders, 223, 175–183.
Joormann, J., & Tanovic, E. (2015). Cognitive vulnerability to depression: Examining cognitive control and emotion regulation. Current Opinion in Psychology, 4, 86–92.
Kazdin, A. E. (2007). Mediators and Mechanisms of Change in Psychotherapy Research. Annual Review of Clinical Psychology, 3(1), 1–27.
Kendler, K., Kuhn, J., & Prescott, C. (2004). Childhood sexual abuse, stressful life events and risk for major depression in women. Psychological Medicine34(8), 1475-1482.
Kendler, K. S., Thornton, L. M., & Gardner, C. O. (2000). Stressful life events and previous episodes in the etiology of major depression in women: an evaluation of the “kindling” hypothesis. American Journal of Psychiatry, 157(8), 1243-1251.
Kovacs, L. N., Takacs, Z. K., Toth, Z. O., Simon, E., Schmelowszky, A., & Okonyei, G. K. (2020). Rumination in Major Depressive and Bipolar Disorder – a Meta-analysis. Journal of Affective Disorders, 276, 1131-1141.
Leahy, R. L., Tirch, D., & Napolitano, L. A. (2012). Emotion regulation in psychotherapy: A practitioners guide. New York: Guilford Press.
Lemmens, L. H. J. M., Arntz, A., Peeters, F., Hollon, S. D., Roefs, A., & Huibers, M. J. H. (2015). Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: Results of a randomized controlled trial. Psychological Medicine, 45(10), 2095–2110.
Lewinsohn, P. M., Allen, N. B., Seeley J. R., & Gotlib, I. H. (1999). First onset versus recurrence of depression: differential processes of psychosocial risk. Journal of Abnormal Psychology, 108(3), 483-489.
Liu, D. Y., & Thompson, R. J. (2017). Selection and implementation of emotion regulation strategies in major depressive disorder: An integrative review. Clinical Psychology Review, 57, 183–194.
Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLOS Medicine, 3(11), e442.
Markowitz, J. C., & Weissman, M. M. (2004). Interpersonal psychotherapy: principles and applications. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 3(3), 136–139.
Michl, L. C., McLaughlin, K. A., Shepherd, K., & Nolen-Hoeksema, S. (2013). Rumination as a mechanism linking stressful life events to symptoms of depression and anxiety: Longitudinal evidence in early adolescents and adults. Journal of Abnormal Psychology, 122(2), 339–352.
Min, J. A., Lee, N. B., Lee, C. U., Lee, C., & Chae, J. H. (2012). Low trait anxiety, high resilience, and their interaction as possible predictors for treatment response in patients with depression. Journal of Affective Disorders, 137(1-3), 61–69.
Morris, M. C., Evans, L. D., Rao, U., & Garber, J. (2015). Executive function moderates the relation between coping and depressive symptoms. Anxiety, Stress, & Coping, 28(1), 31–49.
Norcross, J. C., & Goldfried, M. R. (2005). Handbook of psychotherapy integration (2nd ed.) Oxford: Oxford University Press.
Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: a systematic review and meta-analysis. Frontier in Psychology, 9, 2211.
Nolen-Hoeksema, S., & Jackson, B. (2001). Mediators of the gender difference in Rumination. Psychology of Women Quarterly, 25(3), 37–47.
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 400–424.
Orzechowska, A., Zajączkowska,M., Talarowska, M., & Gałecki, P. (2013). Depression and ways of coping with stress: A preliminary study. Medical Science Monitor, 19, 1050–1056.
Preston, J. (2003). Integrative brief therapy: Cognitive, psychodynamic, humanistic, and neurobehavioral approaches (Vol. 2). Impact Publishers.
Qualls, S. H., & Edwards, L. (2019). Family systems therapy. Oxford: Oxford University Press.
Rodríguez-Alejo, D. I., Cisneros-Ramos, M. C., & Robles-Cedeño, L. A. (2018). Integrative psychotherapy in a case of persistent depressive disorder. Electronic Journal of Psychology Iztacala, 21(1), 355-385.
Sheppes, G., Suri, G., & Gross, J. J. (2015). Emotion regulation and psychopathology. The Annual Review of Clinical Psychology, 11(9), 379–405.
Sarokhani, D., Parvareh, M., Hasanpour Dehkordi, A., Sayehmiri, K., & Moghimbeigi, A. (2018). Prevalence of Depression among Iranian Elderly: Systematic Review and Meta-Analysis. Iran J Psychiatry, 13(1), 55-64.
Siegle, G. J., Thompson, W. K., Collier, A., Berman, S. R., Feldmiller, J., Thase, M. E., & Friedman, E. S. (2012). Toward clinically useful neuroimaging in depression treatment: Prognostic utility of subgenual cingulate activity for determining depression outcome in cognitive therapy across studies, scanners, and patient characteristics. Archives of General Psychiatry, 69(9), 913-924.
Stange, J. P., Alloy, L. B., & Fresco, D. M. (2017). Inflexibility as a vulnerability to depression: A systematic qualitative review. Clinical Psychology: Science and Practice, 24(3), 245–276.
Teasdale, J. D. (1988). Cognitive vulnerability to persistent depression. Cognition & Emotion, 2(3), 247-274.
Van Rijn, B. Y., & Wild, C. (2013). Humanistic and integrative therapies for anxiety and depression: practice-based evaluation of transactional analysis, gestalt, and integrative psychotherapies and person-centered counseling. Transactional Analysis Journal. 43(2), 150-163.
Ventling, T. L. (1995). Effective Educational Planning. Translated by M. Chizari. Tehran: Tarbiat Modares University. (In Persian)
Villalobos, D., Pacios, J., & Vázquez, C. (2021). Cognitive control, cognitive biases and emotion regulation in depression: A new proposal for an integrative interplay model. Frontier in Psychology, 12, 628416.
Wante, L., Mueller, S. C. D., Emeyer, I., Naets, T., & Braet, C. (2017). Internal shifting impairments in response to emotional information in dysphoric adolescents. Journal of Behavior Therapy and Experimental Psychiatry, 57, 70–79.
Watson, J. C., & Bedard, D. L. (2006). Clients’ Emotional Processing in Psychotherapy: A Comparison Between Cognitive-Behavioral and Process-Experiential Therapies. Journal of Consulting and Clinical Psychology, 74(1), 152–159.
Wells, T. T., & Beevers, C. G. (2010). Biased attention and dysphoria: manipulating selective attention reduces subsequent depressive symptoms. Cognition & Emotion, 24(26), 719-728.
Wiser, S. L., & Goldfried, M. R. (1993). Comparative study of emotional experiencing in
psychodynamic-interpersonal and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 61(5), 892–895.
World Health Organization. (2013). Mental health: suicide prevention (SUPRE).
Yang, Y., Cao, S., Shields, G. S., Teng, Z., & Liu, Y. (2017). The relationships between rumination and core executive functions: a meta-analysis. Depression and Anxiety. 34(10), 37–50.
Yang, W., Ding, Z. H., Dai, T., Peng, F., Zhang, J. X. (2015). Attention bias modification training in individuals with depressive symptoms: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 49(10), 101-111.