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Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1709-1713
The effect of acceptance and commitment therapy on the mental health of women patients with typeII diabetes

1 Department of Midwifery, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Research Center for Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran

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Date of Web Publication11-Jan-2018


Background: Diagnosis of diabetes will have a significant impact on patients' psychosocial functioning and patients should devote sufficient time and energy to self-manage the disease. This study aimed to evaluate the effectiveness of treatment based on acceptance and commitment model on the mental health of women with diabetes typeII. Methods: The present study is an experimental study with pretest-posttest control group design. The sample consisted of 26 women with diabetes from Kermanshah who were recruited using convenience(availability) sampling and were randomly divided into experimental and control groups. All patients completed the 28-item general health questionnaire before and after the intervention. Data were analyzed using univariate analysis of covariance and applying SPSS version23. Results: The results clearly showed that the posttest scores of mental health in the experimental group were significant compared to the control group(P<0.05). Conclusions: According to the results of the study regarding the effectiveness of treatment based on acceptance and commitment-based model on mental health, it can be used as a complementary treatment to enhance mental health and the overall mental state of patients with diabetes along with drug therapy.

Keywords: Acceptance and commitment therapy, diabetes, mental health

How to cite this article:
Kaboudi M, Dehghan F, Ziapour A. The effect of acceptance and commitment therapy on the mental health of women patients with typeII diabetes. Ann Trop Med Public Health 2017;10:1709-13

How to cite this URL:
Kaboudi M, Dehghan F, Ziapour A. The effect of acceptance and commitment therapy on the mental health of women patients with typeII diabetes. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Jul 6];10:1709-13. Available from:

   Introduction Top

One of the most common chronic diseases is diabetes. Diabetes is a heterogeneous group of diseases of the metabolism that is characterized by the chronic hyperglycemia and impaired metabolism of carbohydrates, fats, and proteins and is caused as a result of defects in insulin secretion or insulin functioning.[1] The main symptom of diabetes is high blood sugar(hyperglycemia) that varies over time. This reflects the severity of the underlying traumatic process that may progress or regress or remain stable. With these changes, the effect of treatment varies, too, but it does not indicate a change in the nature of the disease process.[2]

Insulin is a hormone produced by the beta cells of the pancreatic islet cells and is necessary for the body to metabolize glucose in the blood flow.[2] The World Health Organization has identified four major types of diabetes: typeI diabetes, typeII, gestational diabetes, and diabetes secondary to other conditions.[3]

Approximately 90%–95% of patients with diabetes mellitus typeII that is “non-dependent diabetes mellitus” (NIDDM) is suffering since the pancreas which also produces at least some amount of insulin, and the treatment often does not involve insulin injection.[4] Most patients with NIDDM can often control their blood sugar without insulin injection and through constant and special diet and drug use. Although NIDDM may occur at any age, it usually occurs after age 40. Most patients with NIDDM are overweight and it appears that their body produces high level of insulin; however, their body seems to be resistant to controlling the blood sugar using the body insulin. In addition, studies have shown that complications are common in these patients, especially long-term complications such as retinal damage and blindness, peripheral neuropathy, pain in the feet and legs, stroke, myocardial infarction, peripheral vascular diseases, kidney disease end stage, mutilation and psychological problems, and individual, family, and social complications which are among the side effects of diabetes.[5] Patients and governments are faced with the direct and indirect and heavy costs of eradicating these problems.[6] The most important of these complications are psychological disorders that influence the patient's ability to perform and continue the recommended medical care negatively.[7]

Psychological stress can trigger or worsen glucose levels through activating hypothalamic-pituitary-adrenal.[8] Although chronic diseases are accompanied with an increased incidence of depression, anger, and stress, this is about three times more common in diabetic patients and the prevalence of depression in these patients is 63.3%.[9] Common emotional response at the time of diagnosis is anxiety and anger, but with the progression of the disease, psychological disorders are more pronounced.[3]

For the treatment of psychological disorders and chronic patients, especially diabetics, in addition to drug treatments, psychological treatments have been developed over consecutive years.[10] Despite strong evidence regarding the effectiveness of known standard and usual therapies(treatment as usual), multiple results suggest the use of, for example, cognitive-behavioral therapy, for many of the therapists and patients with chronic disease, is difficult and often medical intervention, even with the most careful planning and execution are not met with good response.[11],[12] Today, we are facing the third generation of these treatments that can be generally called acceptance-based models such as cognitive therapy based on mindfulness(Mindfulness-based cognitive therapy), Metacognitive treatment, and acceptance and commitment therapy(ACT).[13] In this treatment instead of cognitive change, attempt is made to increase one's thoughts and feelings(10). One of the treatments that have recently been the focus of several researchers is ACT.[14]

The main purpose of the ACT is mental flexibility that is enabling the patients to practically make the best choice rather than imposing an action on them to avoid thoughts, emotions, memories, or chaotic tendencies.[13] The first attempt in this treatment is to try to increase mental acceptance of perceptions and to reduce ineffective control measures mutually. The patient is taught that every attempt to avoid or control these undesirable mental perceptions is ineffective or has adverse effect and would result in their reinforcement. Therefore, they must completely accept the experience without any internal or external reaction to remove them.[14]

In the second phase, the mental awareness is increasing in the moment, that is, people will be aware of all psychological moods, thoughts, and behaviors. In the third stage, the person is taught to separate from these mental experiences(cognitive separation) so that they can act independent of the experience. Fourth is the effort to reduce excessive focus on self-image or personal story that one has in his/her mind. Fifth includes assisting the individual to recognize and distinguish his/her personal values and change them to behavioral goals(transparency of values). Finally, comes the motivation to act responsibly that is the activity focused on the goals and values identified with the adoption of mental experiences.[15] While empirical evidence regarding the effectiveness of psychological treatment for multiple disorders such as depression, obsessive–compulsive disorder, trichotillomania, anxiety, borderline personality and eating, and chronic pain is increasing,[6],[16] relatively few studies have examined this type of therapy in the treatment of psychological symptoms and improving life satisfaction in chronic patients, especially TypeII diabetes.

Considering the novelty of this method, examining its effectiveness in psychological health, especially in the chronic disease is necessary because it can make a difference in the mental treatment of the patients' disorders and result in its improvement. According to the mortality rate of these disorders(approximately 2% of mortality), a review of literature related to access to the most useful treatment options seems necessary. In this regard, although primary prevention is not always efficient and effective, the evidence suggests that secondary prevention(treatment interventions) can significantly reduce psychological, social, health, and economic future,[17] and the empirical evidence on the effect of ACT on multiple disorders is on the rise. Therefore, this study aimed to investigate the effect of ACT on mental health of patients with diabetes.

   Methods Top

This is a quasi-experimental study applying pre-and post-test design with the control group, in which after determining and random selection of control and experimental groups, eight intervention sessions each lasting 1.5h(90min) were applied to the experimental group, and after therapy sessions, both the control and experimental groups were assessed. The population consisted of women with TypeII diabetes referred toTaleghani Speciality and Subspecialty Clinic and Training Center in Kermanshah. Using availability sampling, 26patients were selected, and applying complete random drawing, even and odd numbers were put in the experimental group(n=13) and the control groups(n=13), respectively.

General health questionnaire

The questionnaire contained 28 questions and four subscales. Questionnaire subscales included: somatization, anxiety syndrome and insomnia, social dysfunction, and depression syndrome. The overall score of each individual was the sum of individual scores obtained on the four subscales.

Multiple-choice type questions were based on the Likert scoring methods and options were scored as 0, 1, 2, and 3. Rating of 0 to 27was considered as a sign of good general health, 28–55 was average general health, and 5–84 was a sign of undesirable general health.[18] In a study Palahang etal., who examined validation of the 28-item general health questionnaire, the reliability(assessed through test) was reported to be 0.91.[19]

Training sessions

The protocol of the training sessions were taken based on the research done by Hayes, Streswell and Wilsonm in 8 sessions of 90 minutes. The summary of the content meeting of each session is presented below [Table 1].
Table 1: The acceptance and commitment therapy protocol

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   Results Top

A total of 26 women with the age range of 25–65years were selected from the intended population and were included in the research. About 43.66% were in the age range of 25–35years, 45% were in the age range 36–46, and 12.34% were 46years and older.

The descriptive findings of the present study including statistical indices such as mean and standard deviation of the variable studied, is presented in [Table 2]. In order to evaluate the presumptions of the analysis of covariance (ANCOVA), firstly the homogeneity of slopes of pretests and posttest scores were calculated. Multivariate ANCOVA was used to compare experimental and control groups with respect to mental health scores. The results showed that the tests were significant (P<0.01) [Table 3]. This means that there was a significant difference at least between two groups. The results are shown in [Table 4]. Considering the Eta square of 0.91, it can be said that 91% of the changes in the dependent variable was due to effectiveness of the independent variable [Table 2], [Table 3], [Table 4], [Table 5].
Table 2: Mean and standard deviation mental health scores

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Table 3: Results of the Leven's test to examine the equality of variances in mental health scores

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Table 4: Results obtained from multivariate analysis of covariance on mean scores of posttest of variables in two groups

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Table 5: Results obtained from multivariate analysis of covariance: Mean scores of posttest of mental health dimensions in the experimental and control groups

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   Discussion Top

This study aimed to investigate the effect of ACT on mental health of patients with diabetes. The results of this study using covariance analysis showed that the difference between mental health scores by group membership(two experimental and control groups) in the posttest was significant(P<0.05). Therefore, intervention by acceptance and commitment(ACT) model had a significant impact on mental health in the experimental group(P<0.05). The findings of the study are consistent with the results of most previous studies including Graham et al.,[15] Levin etal.,[20] Johns et al.,[17] Rigi Kootesh et al.,[21] Yazdanbakhsh et al.,[22] Baeati etal.,[2] Lindholm-Olinder et al.,[23] Behrouz et al.,[24] and Ziapour and Kianipour.[25]

ACT has been largely and successfully used in improving psychological well-being and coping styles in clients. To explain how this type of therapy affects the mental health indices in chronic patients, especially TypeII diabetic patients, it can be said that with respect to clinical observations by referring to the treatment protocol used in this study, the cause can result from change of attitude in thoughts and cause of thoughts, irrational and negative cycle, and faulty thinking. The goal of treatment is, therefore, to start training based on knowledge and creative helplessness compared to previous solutions from the start and subjects'(patients) acceptance of this novel attitude. According to the findings of the study, since variable of psychological acceptance increased before a significant decrease in indicators of mental health, it can be concluded that the variable of acceptance and increased attention and action value act as mediators in change and are effective in improving the indicators of psychological acute diabetes.

Another process that is emphasized in ACT and has an outstanding role in the treatment protocol is emphasis on committed action. Encouraging chronic patients to clarify the values, goals, anticipate obstacles, and the commitment to carrying out actions to achieve goals and moving toward values, despite illness and obstacles, leads to the realization of the goals and the resulting happiness that affects enhancing and improving the health possible.This, in turn, relieves the individual from getting stuck in a loop of negative thoughts and feelings of lack of control of values and the inability to save lives. In general, the effectiveness of ACT treatment in mental health scores in TypeII diabetic patients is justifiable based on the principles of staying in the present, observation without negative judgment, acceptance and raising awareness of the experience, and creating adaptive response.

   Conclusions Top

The findings of this study were consistent with previous studies on the effectiveness of ACT chronic mental health patients, especially TypeII diabetes. Moreover, the findings showed the importance and necessity of providing solutions for the treatment and prevention of chronic diseases, especially diabetes given that it is one of the most serious diseases in the world. Treatment based on acceptance-and commitment-based model on mental health, it can be used as a complementary treatment to enhance mental health and the overall mental state of patients with diabetes along with drug therapy.


The authors of the present study would like to extend their sincerest thanks and appreciation to the personnel of Kermanshah University of Medical Sciences as well as the participants in the study and all the people contributing to this research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Fateme Dehghan
Department of Midwifery, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_607_17

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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