Recruitment and attrition
A total of 210 patients were approached. 53(21.2%) participants did not provide informed consent, 38(15.2%) participants did not complete the initial screening, 159(63.6%) were assessed for eligibility, and 118 met the study inclusion and exclusion criteria. The total attrition rate was 72(61.02%), and 46(38.98%) were excluded for a due variety of reasons (Fig. 1).
Sample characteristics and baselines assessment
The sample characteristics are described in the Table 1. The chi-square and one-way ANOVA analyses reveal the in-significant differences among PTh, CBT and IBIs on Gender (X2=.112, p >..945), marital status (X2=.433, p >.805), education (X2=1.8320 p >.767), referral source (X2=1.719, p >.423), duration of illness (X2=.498, p >.974), family system (X2=.561, p >.755), age (F=.780, p>.461) and monthly income (F=1.404, p>.250). further, group comparisons were investigated using one-way ANOVA among treatment groups and in-significant differences were found on PHQ-9 (F=.452, p>.637); PAS (F=.149, p>.862), NAS(F=.360 , p>.450), LSS=(F=1.493 , p>.362), DSS(F=.087 , p>..917), SPM(F=.356 , p>.701), SES(F=.899 , p>.410), DMQ(F= .256, p>.775).
Table 1 Baselines sample characteristics of the participants
Variables
|
Category
|
overall
|
Groups
|
|
|
Characteristics
|
|
PTh
|
CBT
|
IBIs
|
X2/F
|
p
|
N Allocated
|
118
|
40(33.80%)
|
39(33.10%)
|
39(33.10%)
|
|
|
N Dropout
|
46
|
14(30.44%)
|
15(32.61%)
|
17(36.95%)
|
|
|
N final
|
72
|
26(36.1%)
|
24(33.3%)
|
22(30.6%)
|
|
|
Age, M(SD)
|
118
|
30.85(6.90)
|
29.89(6.20)
|
29.94(7.14)
|
.780
|
.461
|
Monthly Income M(SD)
|
118
|
81885.00
(42966.62)
|
99384.62
(52598.08)
|
88871.79 (44233.34)
|
1.404
|
.250
|
Sex
|
Female
|
52
|
17(32.69%)
|
17(32.69%)
|
18(34.62%)
|
.112
|
.945
|
|
Male
|
66
|
23(34.85%)
|
22(33.34%)
|
21(31.82%)
|
|
|
Marital
|
Single
|
37
|
14(37.84%)
|
11(29.73%)
|
12(32.43%)
|
.433
|
.805
|
Status
|
Married
|
81
|
26(32.10%)
|
28(34.57%)
|
27(33.33%)
|
|
|
Education
|
Intermediate
|
42
|
11(26.19%)
|
16(38.09%)
|
15(35.72%)
|
1.832
|
.767
|
|
Graduate
|
35
|
13(37.14%)
|
11(31.43%)
|
11(31.43%)
|
|
|
|
Post-G
|
41
|
16(39.03%)
|
12(29.27%)
|
13(31.70%)
|
|
|
Referral
|
Self approached
|
51
|
14(27.45%)
|
18(35.29%)
|
19(37.26%)
|
1.719
|
.423
|
Source
|
Referred
|
67
|
26(38.81%)
|
21(31.35%)
|
20(29.84%)
|
|
|
Duration
|
< 1 Months)
|
68
|
24(35.29%)
|
21(30.88%)
|
23(33.83%)
|
.498
|
.974
|
Of Illness
|
1-2 Months)
|
27
|
8(29.63%)
|
10(37.04%)
|
9(33.33%)
|
|
|
|
< 4 Months
|
23
|
8(34.78%)
|
8(34.78%)
|
7(30.44%)
|
|
|
Family
|
Nuclear
|
70
|
23(32.86%)
|
22(31.43%)
|
25(35.71%)
|
.561
|
.755
|
System
|
Joint
|
48
|
17(35.42%)
|
17(35.42%)
|
14(29.16%)
|
|
|
Note: M(SD)=Mean(Standard Deviation); PTh= Pharmacotherapy; CBT: Cognitive Behavior Therapy; IBIs= Islam-based Interventions
Table 2 Mean (standard deviation) and mixed-design ANOVA of clinical scores during pre- and post-test interventions
|
Groups
|
|
|
|
Partial
Squared
Eta
ηp2
|
|
PTh
|
CBT
|
IBIs
|
|
|
Pretest
|
Post-Test
|
Pretest
|
Post-Test
|
Pretest
|
Post-Test
|
F
|
M(SD)
|
M(SD)
|
M(SD)
|
M(SD)
|
M(SD)
|
M(SD)
|
PHQ-9
|
20.31(1.13)
|
12.69(3.76)
|
19.71(2.29)
|
7.63(4.45)
|
19.79(1.76)
|
4.55(5.68)
|
294.85***
|
.810
|
PAS
|
26.27(3.94)
|
35.96(8.72)
|
25.75(7.21)
|
41.00(8.95)
|
26.19(5.67)
|
53.09(5.65)
|
312.98***
|
.819
|
NAS
|
34.85(3.36)
|
21.31(3.58)
|
35.84(5.32)
|
12.63(3.23)
|
33.23(5.76)
|
19.09(7.54)
|
613.43***
|
.899
|
LSS
|
10.88(2.13)
|
15.93(2.17)
|
10.46(2.77)
|
23.08(2.15)
|
11.77(2.73)
|
23.14(6.29)
|
314.14***
|
.820
|
DSS
|
8.27(2.33)
|
13.08(1.85)
|
9.63(2.61)
|
20.92(2.11)
|
9.91(2.53)
|
16.73(3.62)
|
366.08***
|
.841
|
SPM
|
40.96(23.50)
|
52.31(20.31)
|
40.63(16.17)
|
62.08(18.71)
|
40.91(12.31)
|
60.22(23.48)
|
78.70***
|
.533
|
SES
|
12.50(2.94)
|
13.58(3.75)
|
12.25(2.59)
|
18.29(1.97)
|
12.09(2.23)
|
19.14(2.17)
|
116.06***
|
.627
|
TD
|
14.38(2.06)
|
15.69(3.72)
|
14.34(1.79)
|
17.58(4.59)
|
14.05(2.35)
|
17.14(1.73)
|
21.49***
|
.237
|
CD
|
12.69(1.55)
|
12.07(2.67)
|
13.13(1.78)
|
20.79(4.91)
|
13.50(1.95)
|
21.10(2.67)
|
116.54***
|
.628
|
HD
|
10.96(2.15)
|
11.07(1.63)
|
12.46(3.04)
|
11.38(1.58)
|
13.09(2.02)
|
11.22(1.69)
|
10.32***
|
.130
|
SRD
|
9.50(2.05)
|
10.19(3.34)
|
10.42(1.74)
|
13.63(2.50)
|
9.64(2.61)
|
12.50(1.37)
|
27.09***
|
.282
|
PD
|
7.38(1.92)
|
8.43(1.14)
|
7.58(3.09)
|
10.42(2.21)
|
7.27(2.47)
|
9.88(2.04)
|
49.37***
|
.417
|
ID
|
6.66(1.77)
|
7.31(1.29)
|
6.71(0.55)
|
9.25(1.48)
|
6.73(1.16)
|
9.00(1.27)
|
67.28***
|
.494
|
ID
|
6.73(1.32)
|
6.85(1.26)
|
7.29(1.61)
|
8.96(1.33)
|
7.14(1.88)
|
8.95(1.33)
|
33.08***
|
.324
|
DMQ
|
66.69(4.22)
|
68.46(15.95)
|
66.92(8.65)
|
96.91(13.93)
|
66.50(6.17)
|
94.73(11.05)
|
148.30***
|
.682
|
Note: ηp2:Partial Squared Eta; PHQ-9=Patients Health Questionnaire; PAS=Positive Affect Scale; NAS=Negative Affect Scale; LSS=Life Satisfaction Scale; DSS=Digit Span Scale; SPM=Standard Progressive Matrices; SES=Self-Esteem Scale; TD=Thoroughness Domain; CD=Control Domain; HD=Hesitancy Domain; SD=Social Resistance Domain; PD=Perfectionism Domain; ID=Idealism Domain; ID=Instinctiveness Domain; DMQ=Decision Making Questionnaire; PTh=Pharmacotherapy; CBT=Cognitive Behavior Therapy; IBIs=Islam-based Interventions
Significant mean difference between baseline and post-testing scores was found on depression with large effect size (i.e. F (2, 56) = 294.85, p<.000, η2= .810). Significant mean differences were found between baseline and post-testing scores on PAS, NAS and LSS (i.e. F(2,56)= 312.98, p<.000, η2= .819; F(2,56)= 613.43, p<.000, η2= .899; F(2,56)= 314.14, p<.000, η2= .820 respectively) with large effect size. Furthermore, significant mean differences were investigated between baseline and post-testing scores on DSS, SPM, and SES with large effect size (i.e. F(2,56)= 366.08, p<.000, η2= .841; F(2,56)= 78.70, p<.000, η2= .533; F(2,56)= 116.06, p<.000, η2= .627 respectively). Significant mean difference was found between baselines and post-testing scores on DMS (i.e. F(2,56)= 148.30, p<.000, η2= .682) and on subscales i.e. thoroughness, control, hesitancy, social resistance, perfectionism, idealism and instinctiveness among all groups (i.e. F(2,56)= 21.49, p<.000, η2= .237; F(2,56)= 116.54, p<.000, η2= .628; F(2,56)= 10.32, p<.000, η2= .130; F(2,56)= 27.09, p<.000, η2= .282; F(2,56)= 49.37, p<.000, η2= .417; F(2,56)= 67.28, p<.000, η2= .494; F(2,56)= 33.08, p<.000, η2= .324 respectively) with large effect size (see Table 2).
Table 3 The severity of depressive symptoms after medication, cognitive behaviour therapy, and Islamic interventions with MDD-m
Variables
|
PTh
|
CBT
|
IBIs
|
Total
|
Symptoms fully treated
|
2(7.7%)
|
6(25.0%)
|
10(45.5%)
|
19(26.4%)
|
Symptoms sig decreased
|
3(11.5%)
|
14(58.3%)
|
6(27.3%)
|
21(29.2%)
|
Symptoms managed
|
15(57.7%)
|
1(4.2%)
|
3(13.6%)
|
18(25.0%)
|
Symptoms remain same
|
6(23.1%)
|
3(12.5%)
|
3(13.6%)
|
14(19.4%)
|
Note: PTh=Pharmacotherapy; CBT=Cognitive Behavior Therapy; IBIs=Islam-based Interventions
Findings reveal that after treatment interventions significant decrease in symptoms severity was found. Symptoms fully treated with medication 2(7.7%), CBT 6(25.0%) and IBIs 10(45.5%). Symptoms significantly decreased with medication 3(11.5%), CBT 14(58.3%) and IBIs 6(27.3%). Psychotropic medication was found an effective intervention to manage depressive symptoms 15(57.7%) as compared to CBT 1(4.2%) and IBI 3(13.6%). Depressive symptoms remain the same as among patients who used medication 6(23.1%), CBT 3(12.5%), and IBIs 3(13.6%), respectively (see Table 3).
Results reported depressive symptoms severity significantly reduced on PHQ after PTh, CBT, and IBIs among patients with MDD-m. Pre-and post-test analysis indicates a substantial change in depressive symptoms. For example, a maximum of patients perceived no signs after treatment. Some participants observed a significant decrease in depressive symptoms, some were able to manage their symptoms, and others perceived the severity of the same symptoms (see Figure 2).
Further findings reported that patients after treatment interventions decreased the intensity of depressive symptoms. Participants who received medications reduced lower intensity of depressive symptoms than those who received CBT and IBIs. Furthermore, patients who received IBIs were found to have lower intensity of depressive symptoms than medication and CBT post analysis (see Figure 3).