Author’s Accepted Manuscript Comprehensive self-control training benefits depressed college students: a six-month randomized controlled intervention trial Xueling Yang, Jiubo Zhao, Yu Chen, Simeng Zu, Jingbo Zhao www.elsevier.com/locate/jad

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S0165-0327(17)30348-8 https://doi.org/10.1016/j.jad.2017.10.014 JAD9279

To appear in: Journal of Affective Disorders Received date: 15 February 2017 Revised date: 7 September 2017 Accepted date: 1 October 2017 Cite this article as: Xueling Yang, Jiubo Zhao, Yu Chen, Simeng Zu and Jingbo Zhao, Comprehensive self-control training benefits depressed college students: a six-month randomized controlled intervention trial, Journal of Affective Disorders, https://doi.org/10.1016/j.jad.2017.10.014 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Comprehensive self-control training benefits depressed college students: a six-month randomized controlled intervention trial Xueling Yang1*, Jiubo Zhao1, Yu Chen2, Simeng Zu3, Jingbo Zhao1* 1

Department of Psychology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), 1838 Guangzhou Road, Guangzhou, China 2

School of Nursing, Southern Medical University, 1838 Guangzhou Road, Guangzhou, China

3

Mental Health Education Center, JiNan University, No.601, West Huangpu Avenue, Guangzhou, China *Corresponding Author: Jingbo Zhao, Department of Psychology, School of Public Health, Southern Medical University, 1838 Guangzhou Road, Guangzhou, China; Email: [email protected] Telephone: +8602061689536 Xueling Yang, Department of Psychology, School of Public Health, Southern Medical University, 1838 Guangzhou Road, Guangzhou, China Email:[email protected] Telephone: +8602061648238

1

Abstract Background: Depressive disorder was associated with dysfunctional self-regulation. The current study attempted to design and test a comprehensive self-control training (CSCT) program with an overall emphasis on behaviral activation in depressed Chinese college students. Methods: Participants included 74 students who had diagnosed with major depression, they were randomly assigned to one of the two groups: intervention group (n=37), and control group (n=37). The intervention participants received an eight-week CSCT and four-month follow-up consolidation program, as compared to the control group who received only pre-post-and-follow-up measurements. All participants measured Beck Depression Inventory (BDI-Ⅱ) and Self-control Scale (SCS) at three time points: baseline, post-training, and four-month follow-up. Results: The dropout rates were 6 (8.1%) in the intervention group and 3 (4.1%) in the control group at the end of six-month intervention. The general linear model repeated measures analysis of variance revealed that comparing with the control group, the intervention group participants had more increase in their trait self-control score, at the meantime, their depressive symptoms had significantly improved. Univariate and logistic regression analyses revealed that participants with milder baseline depressive symptoms were more likely to benefit from CSCT interventions; depression improvement was also associated with the number of sessions attended. Limitations: The main limitation was related to the small sample size which consisted of college students who were relatively young and well educated. Conclusions: The current study demonstrates that CSCT program could temporarily enhance self-control capacity as well as improve depressive symptoms; participants who are mildly to moderately depressed, and who could adhere to the training protocol are more likely to benefit from the intervention. Key words: self-control; self-regulation; depressive disorder; self-control training

1. Introduction Some theorists hold that dysfunction of self-regulation is a risk factor for depression (Karoly, 1999; Klenk et al., 2011). In line with these theories, Strauman (2002) proposes a self-regulation model of depression, postulating that the initial episode of depression could be viewed as a functional disorder of the promotion system resulting from failure of self-regulation. Such self-regulatory dysfunction may result from a single experience or an accumulation of experiences. The core symptoms of depression might reflect dysregulation within the promotion system (e.g., mood, appetite, anhedonia, energy, concentration, worthlessness, hopelessness, low self-esteem) or dysregulation of reciprocal inhibition between the promotion and prevention systems (e.g., sleep disturbance, guilt, agitation/anxiety) (Strauman, 2002). Study also found that chronic self-perceived failure in promotion goal pursuit was associated with vulnerability to depression, and self-system therapy (SST), a brief, structured psychotherapy aiming at enhancing promotion goal pursuit could improve depression (Strauman et al., 2006). SST conceptualizes depression as a failure of self-regulation, the structure and strategies of SST are developed to address depressive symptoms in individuals manifesting specific problems in self-regulation (Vieth et al., 2003). 2

Chronic or catastrophic regulatory failure (inability to make good things happen via progress toward their promotion goals, and/or difficulty to keep bad things from happening) is often associated with dysphoric mood and anxious affect, could increase one’s vulnerability to develop depression (Strauman et al., 2006). The consequences of self-regulatory failure also includes weakened self-control over impulsive behaviors, leading people more vulnerable to alcohol and drug abuse, more prone to irrational impulsive behavior, and more likely to yield to the temptations (Baumeister, 2014) , and even more procrastination (Rebetez et al., 2016). Studies have shown that the bad feelings associated with self-regulation failure (guilty, self-criticism, and loss of control) could bring people to even more self-regulation failure, a phenomenon called “what-the-hell-effect”, i.e., when people yield to smaller temptation, it will lead to greater loss of control (Cochran and Tesser, 1996). Daily regulatory failure, such as breaking diet plan, or not completing the study objectives, may undermine people’s self-esteem and self-efficacy, making people more vulnerable to depression (Nowak et al., 2005). Studying depression from a self-regulatory perspective could facilitate the understanding of how depression develops and progresses. The term self-regulation and self-control have similar connotation and are often used interchangeably by some researchers. Self-regulation is the process of purposefully directing one’s actions, thoughts, and feelings toward a goal, i.e., an intended outcome, as compared to immediate or hedonic goals (Carver and Scheier, 2011). Self-regulation includes not only overriding or inhibiting prepotent responses but also directing behavior toward wanted responses, usually in the face of prepotent alternative responses or mere inertia (Berkman, 2016). Self-control refers to the process by which the individual adjusts his or her own thoughts, behaviors and emotions in a timely manner to align with their self-goals (Inzlicht et al., 2014). Self-control involves the ability to prevent or override unwanted thoughts, behaviors, and emotions and is essential to successful navigation of daily life (Muraven et al., 1999). Vandellen, Hoyle, & Miller (2012) tried to make a distinction between the concept of self-regulation and self-control. They view self-regulation as the general process of managing thoughts, behaviors, goals, and identity; whereas view self-control as a specific type of self-regulation that occurs only when people consciously and effortfully attempt to override prepotent, or dominant responses to situations. Unlike other forms of self-regulation, which are largely automatic (Bargh et al., 2001), self-control is a conscious process in which people are aware of what they are doing that requires an exertion of effort (Vandellen et al., 2012). Self-regulation is thus a broader concept, which requires a range of skills including self-control, planning, and other executive functions, but is not limited to those skills. Although much of the current study’s theory was based on both self-regulation and self-control literatures, our focus was primarily pertinent to self-control rather than to self-regulation. Studies have found that self-control relies on a limited resource that could be easily depleted, a phenomenon labeled ego-depletion. According to the strength model of self-control, self-control operates like a muscle that gets tired after repeated exertion (Baumeister, 2003; Baumeister and Tice, 2007; Baumeister and Vohs, 2016). Ego-depletion effect has been verified in many studies, using a great variety of tasks and measures (Hagger et al., 2010). Some studies found a moderating effect of trait self-control, such that people high in trait self-control showed less self-control failure under conditions of ego-depletion, compared to those low in trait self-control (Dewall et al., 2007; Muraven et al., 2005). Sufficient trait self-control are found to be associated with several positive long-term outcomes, such as good adjustment, less pathology, better grades 3

and interpersonal success (Tangney et al., 2004). On the other side, feeling bad could undermine people’s valuable self-control capacity. When people are in a bad mood (anger, sadness, self-doubt, anxiety, and stressed), the reward-seeking brain areas will be activated, they will experience more intense cravings and especially susceptible to temptations such as eating, alcohol, cocaine, shopping, and whatever substance or activity that associates with the promise of reward (Mcgonigal, 2013). Binge eaters who feel ashamed of their weight and lack of control around food tend to eat more food to fix their bad feelings (Kelly and Carter, 2013). Study found that depressed patients had inhibition deficits ---a major domain of executive functioning deficit---measured by behavioral tasks, indicating depression was associated with worse self-regulatory capacity (Bredemeier et al., 2016). Psychotherapies aimed at relieving depression could also improve perceived failure in self-regulation (Strauman et al., 2001). The strength model of self-control predicts that just as physical exercise could make muscles become stronger, self-control/regulation could also be improved by training (Baumeister and Tice, 2007). Evidences have shown that trait self-control capacity is amenable to intervention in childhood, continuing through late adolescence, and even early adulthood (Berkman et al., 2012; Muraven, 2010). For example, Muraven (2010) found that practicing self-control by cutting back on sweets or squeezing a handgrip brought significant improvement in self-control performance, they argued that the particular self-control task being practiced was unimportant, providing it required the individual to override or inhibit a response. Self-control/regulation training programs also have been developed to ameliorate particular psychological disorders, include using self-monitoring cards to reduce alcohol consumption (Miller and Taylor, 1980), training control over aggressive impulses to reduce aggressive behavior in female adolescents (Meepien et al., 2010). In general, previous self-control/regulation training programs are mainly focused on specific problem behaviors, such as addiction or aggressive behavior, in order to enhance self-control over these problem behaviors. However, an integrated conceptual model underlying these techniques tends to be underspecified and imprecise. For example, in Meepien et al. (2010) study, the authors did not describe how they trained their participants and what factors might contribute to the beneficial effect. Now we raise the question that whether self-control/regulation training could be tailored for depressive patients? Previous studies have found that feeling bad were associated with lower self-control capacity (Berkman et al., 2012). Unlike single-problem-behavior such as addictive and aggressive behaviors, depressed patients tend to show a wide range of self-regulation deficiency manifested in both promotion system and inhibition system (Strauman, 2002), a single behavioral training program might have little effect on depressive symptoms. Self-control training programs for depressive patients need to take full account of the pathological spectrum of depression. We could reasonably speculate that characteristics in depression patients, such as loss of interest, inertia, might present special difficulty on long-term training programs. For example, study found that women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program (Brachel et al., 2014). Thus an intervention program tailored for people with depressive disorder must find ways to reduce dropout rate and to improve adherence. A study published in The Lancet found that behavioral activation (BA) was on par with cognitive behavioral therapy (CBT) in reducing depressive symptoms in a large randomized controlled clinical sample with major depression (Richards et al., 2016). The authors argued that BA should be recommended as an intervention to 4

address the adherence problem in the treatment of depressive disorders as it was less demanding and costly on the part of patients. This study suggests that to effectively improve depressive symptoms, activating behavior and promoting adherence is equally essential as treating automatic negative thoughts. The aim of the current study was to develop a theory-based intervention program tailored for depressed patients to strengthen their self-control capacity and to improve their depressive symptoms. We would conduct a randomized controlled trial (RCT) to test whether a comprehensive self-control training (CSCT) program would be efficacious for depressed college students, and what factors might contribute to the efficacy. We would test two hypotheses: a) that whether trait self-control could be enhanced by CSCT and b) that whether depressive symptoms could be improved by enhancing self-control. We also tried to delineate what factors might contribute to the therapeutic effects of the training program. 2. Methods 2.1. Study design The study was a RCT design with one intervention group and one control group. The study was approved by the first author’s institutional review board before participant recruitment. After complete description of the study, written informed consent was obtained from all participants. 2.2. Participants screening and recruitment 2.2.1. Participants recruitment We recruited participants with a range of depressive symptoms from Sep. 2014 to Dec. 2015 using Self-rating Depression Scale (SDS). During the fifteen-month period, 412 college students whose SDS standardized score were equal to or higher than 50 (Mean SDS = 55.62 ± 5.65) were identified from a total of 5978 first-year college students who were screened for a range of psychological disorders by the university counseling center of the first author. Using MINI-International Neuropsychiatric Interview (M.I.N.I.), the screened students were diagnosed by certified psychiatric doctors. 350 students attended the diagnostic interview, 62 students refused to participate the interview, 108 students were diagnosed with depressive disorders. We excluded 21 students who were acutely suicidal or attempted suicide in the previous two months, or who had bipolar disorder or psychotic symptoms, or who were cognitively impaired, or who were currently receiving psychotropic or psychological intervention. Among the 87 eligible participants, 74 of them agreed to enroll in the present study (see Fig.1.). The average age of the participants was 18.5±1.0, with a range of 16 to 21 years. 30 (40.5%) of them were male, 44 (59.5%) were female. INSERT FIGURE 1 AROUND HERE 2.2.2 Screening instruments 2.2.2.1. Self-rating Depression Scale (SDS) Chinese version The Chinese version of SDS was translated and modified by Wang and Chi (1984) from the original English version of SDS (Zung, 1967). It consists of 20 items using 4-point Likert scale; higher score indicates more depressive symptoms. The SDS is widely used to measure depressive 5

symptoms both in English (Ghayas et al., 2014) and in Chinese (Duan and Sheng, 2012) population with satisfactory reliability and validity. In this study, the Cronbach’s alpha was .72. In Chinese samples, the standardized score of 50-59 represents minor depression, 60-69 represents moderate depression, 70 or more represents severe depression (Wang and Chi, 1984). 2.2.2.2 MINI-International Neuropsychiatric Interview (M.I.N.I.) Chinese version M.I.N.I. is a simple, effective and reliable tool for interviewing and diagnosing mental disorders of Diagnostic and Statistical Manual Fourth Edition (DSM-IV) and the International Handbook on Statistical Classification of Mental Disorders (ICD- 10), including 130 questions screening for 16 axis I mental disorders and one personality disorder (Sheehan et al., 1998). Studies showed that M.I.N.I had acceptable reliability and validity, the current study used a Chinese revised version of M.I.N.I (Si et al., 2009). 2.3. Procedures Screening assessments and enrollment were conducted by study associates who were blind to the randomization and allocation process. After the participants were enrolled and signed the informed consent, they were randomized into the intervention group (n=37) and control group (n=37) in a 1:1 ratio using a permuted blocked randomization procedure with a fixed block of size 4. The allocation sequence was generated by a digital random number generator. The baseline assessments took place after randomization in the two groups. Post-training assessments took place right after the eighth session. Follow-up assessments took place at the end of six-month program. There was no significant difference in demographic or baseline clinical characteristics between the two groups, or between assessment completers and non-completers. The intervention participants received an eight-week CSCT training followed by a four-month follow-up consolidation intervention; the control group received no particular intervention during the same period except taking pre-post training and four-mouth follow-up assessments. By the end of the eight-week training, there were 5 (6.8%) dropouts in the intervention group, 2 (2.7%) dropouts in the control group, there was no significant difference of dropout rates between the two groups, Pearsonχ2 = 1.42, df = 1, P = .233; by the end of four-month follow-up, there were 6 (8.1%) dropouts in the intervention group, 3 (4.1%) dropouts in the control group, there was no significant difference of dropout rates between the two groups, Pearsonχ2 = 1.14, df = 1, P = .286. We conducted either face-to-face, or telephone, or email interview at the end of the six-month intervention program to attain the main reasons of premature dropout. The main reasons for dropouts were: hospitalization for treatment (3 people), suspension from school (1 people), too stressed out to find time completing the training program or measurements (3 people) and unspecified dropout reasons (2 people). On average, the intervention group participated a mean of 7.5±1.0 sessions during the eight-week training period, participated a mean of 10.5±2.0 sessions during the six-month intervention period, 14 (37.8%) of the intervention participants attended all the 12 sessions. All the participants could, as their wish, take a free psychological counseling at the university counseling center, or receive medical treatment following by their psychiatrist’s prescription during the six-month intervention period. Information on participants’ individual treatment history was obtained from the university counseling center, which was staffed by licensed psychologists or psychiatrists. By the end of the program, there were 6 in the intervention group and 9 in the control group received individual psychological counseling or other kinds of 6

treatment (see Fig. 1. for specific information). 2.4. Outcome measures The changes on scores of the following scales were chosen as outcome measures. The primary outcome measure was Beck Depression Inventory (BDI-Ⅱ) Chinese version. BDI-Ⅱ is the most widely used self-rating scale for evaluating depressive symptoms. It could be used both in depressive patients as well as for screening normal population. It contains 21 items, 0-3 scored; the higher score suggests more severe symptoms of depression. Total score of 0-13 indicates no depression, 14-19 indicates mild depression, 20-28 indicates moderate depression, and 29-63 indicates severe depression. Studies showed that BDI-Ⅱ Chinese version had good reliability and validity (Yang et al., 2014; Yang et al., 2012). The alpha coefficient of the scale in this study was 0.80. The secondary outcome measure was Self-control Scale (SCS) Chinese version. The original SCS was developed by Rosenbaum (1980) to measure trait self-control. It was modified into Chinese by Zhai (2006). SCS Chinese version includes 13 items, 5-point Likert scaled, 1 = very disagree, 5 = very agree, with a total score of 65, higher score indicates stronger self-control (Rosenbaum, 1980; Zhai, 2006). In the present study, the Cronbach’s alpha was .84. These scales were conducted collectively at baseline, post-eight-week training and post-four-month follow-up in a face-to-face manner. 2.5. Intervention protocol CSCT was designed to translate recent self-control and self-regulation research (Alberts et al., 2011; Baumeister, 2003, 2014; Baumeister and Tice, 2007; Berkman, 2016; Berkman et al., 2012; Carver and Scheier, 2011; Crescentini et al., 2016; Francis et al., 2012; Friese et al., 2012; Mcgonigal, 2013; Meepien et al., 2010; Tang et al., 2007; Tice et al., 2007) into an intervention program for enhancing self-control and improving depressive symptoms in the current study. CSCT was also designed so that within an overall emphasis on behaviral activation, specific interventions from other therapies could be incorporated, taking full consideration of the characteristics of depressed patients. For example, in order to increase compliance of depressed participants, we made sure that each module was easy to master. In the goals setting module, we helped participants to set specific and easy-to-comply hierarchical behavior goals. We also encouraged the participants to rank the goals from 1 to 5 by degrees of ease. A binge-eating depressed participant originally planned not to eat any high-calorie food for a month as her final goal, however, we found her goal was too difficult to accomplish and susceptible to self-regulation failure, and after discussion with her, the goal was finally modified that allowing high-calorie food only at supper time. When participants missed one or more session(s), the researchers would warmly remind them of their self-regulation goals and reaffirm their achievement, encouraging them to continue the training program. Moreover, in order to reduce the dropout rate, we designed a self-monitoring and reward module, with the purpose of increasing participants’ compliance and enhancing their self-efficacy. CSCT could be summarized in 3 pre-training modules (psychological education, behavioral analyses, and goals setting) and 5 training modules, followed by a four-month follow-up consolidation module, see table 1. Table 1 also lists the main focus of content for each module. The intervention participants were assigned to one of the groups consisting of seven or eight members. They received training sessions in a group therapy room for one and a half hour per 7

week in the first eight weeks. In the following four months, the group members met once a month for one and a half hours. The training was delivered by one licensed psychologist who was specialized in both individual and group psychotherapy. When participants completed one module or one behavioral objective, he or she would be rewarded by the trainer, and continued the next module, without giving up previously gained skills. The training content would be fine-tuned to adapt to the participant’s unique characteristics. For example, one participant liked meditation very much; her meditation usually lasted for more than five minutes per day. Another participant must listen to a particular Buddhist music when she practiced meditation. If participants missed a training session, we would remind them for the absence, and encouraged them to reschedule an individual session with the trainer. If a participant absented for two and more sessions during the eight-session training, or absented for up to four sessions during the six-month period, whether or not he or she had provided valid assessments data, this case would be defined as a dropout. INSERT TABLE 1 AROUND HERE 2.6. Statistical analyses Analyses were conducted using IBM SPSS Statistics 20.0. Descriptive statistics of SCS and BDI scores were reported at three time-points: baseline, post-eight-week-training and post-four-month follow-up. A per protocol analysis was performed including only those participants who completed the intervention protocol and measurements, thus the analyses were based on 74 cases who had provided baseline measures, 67 valid cases who had completed the eight-week training protocol and provided post-training measures (2 cases were considered dropout because of insufficient number of completed sessions), and 65 valid cases who had completed the six-month intervention protocol and provided follow-up measures (1 case was considered dropout because of insufficient number of completed sessions). Independent-sample t-tests were conducted to detect differences between groups, with 95% confidence interval of differences and Cohen’s d as indicators of effect size. As a general guideline, a Cohen’s d of 0.2 was considered small, 0.5 was considered medium, and 0.8 and more was considered large when interpreting the effect of an intervention (Cohen, 1988). However, our outcome measures were repeated measure data; general linear model (GLM) repeated measures analyses were more sensitive to detect group differences of change scores over multiple time points. Group was the between-subject factor with 2 conditions; Time was the within-subject factor with 3 time point. Partial η2 was calculated as effect size indicator. In order to delineate what factors might contribute to the intervention efficacy, a logistic regression model was employed to identify factors that might significantly associate with the improvement of depressive symptoms. It was also of interest to know how many participants in the intervention group showed clinically important improvement of depressive symptoms. According to previous study, the minimal clinically important difference (MCID) on the BDI-II is dependent on baseline severity, is best measured on a ratio scale. The authors recommended an at least 17.5% reduction as the MCID (Button et al., 2015). In the current study, we defined MCID as a reduction of 20% or more of baseline BDI scores both in post-training and four-month follow-up measurements. Thus we classified the intervention participants into two classes: whose depressive symptoms showed MCID and whose not, according to the primary outcome measure — BDI scores. The demographical and clinical characteristics between the two classes of participants were compared using Pearson 2 tests or independent-sample t-tests. 8

3. Results 3.1. Descriptive statistics of outcome measures and independent-sample t tests between intervention and control groups As shown in table 2, the baseline measures of BDI and SCS were comparable between the intervention and control groups. The BDI baseline scores in both groups revealed moderate depressive symptoms of the current participants (22.12 ± 5.63). However, the BDI scores of the intervention group in post-training and four-month follow-up measures were significantly lower than their control counterparts; the SCS scores of the intervention group in post-training and four-month follow-up measures were significantly higher than their control counterparts. The Cohen’d revealed that the group differences were about of medium size. INSERT TABLE 2 AROUND HERE 3.2. GLM repeated measures analyses on BDI and SCS scores GLM repeated measures analyses were conducted to detect group differences of changes on outcome measures over three time points. Tests of within-subjects effects on BDI scores (with Greenhouse-Geisser correction) revealed that the main effect of Time was significant, F (2, 121) = 17.84, p ＜ .001, ηp2 = .221; the interactive effect of Time by Group was also significant, F (2, 121) = 14.52, p ＜ .001, ηp2 = .187, indicating that the BDI scores of the two groups had changed differently over time, i.e., compared to the control group, the BDI scores of the intervention group had significantly decreased over time (see Fig. 2.). INSERT FIGURE 2 AROUND HERE Tests of within-subjects effects (with Greenhouse-Geisser correction) on SCS scores revealed that the main effect of Time was significant, F (2, 104) = 12.74, p ＜ .001, ηp2 = .168; the interactive effect of Time by Group was also significant, F (2, 104) = 6.61, p = .004, ηp2 = .095, indicating that the SCS scores of the two groups had changed differently over time, i.e., compared to the control group, the SCS scores of the intervention group had significantly increased over time (see Fig. 3.). INSERT FIGURE 3 AROUND HERE 3.3. Demographical and clinical factors that contributed to the intervention efficacy To investigate what factors might contribute to the observed intervention efficacy, we created a new variable named “MCID” by grouping the participants of the intervention group into two classes: 1 = who showed minimal clinically important difference of depressive symptoms (defined as a reduction of 20% or more of baseline BDI score both in post-training and four-month follow-up measurements, n = 13, valid percent = 35.1%), and 0 = who showed no minimal clinically important difference of depressive symptoms (all the other cases in the intervention group, including 6 dropout cases, n = 24, valid percent = 64.9%). Table 3 listed the comparison of demographical and clinical characteristics between the two classes of participants. We found that baseline BDI score was associated with intervention efficacy: participants with milder depressive symptoms were more likely to benefit from CSCT interventions. Total sessions attended during the six-month period was another factor that contributed to the intervention efficacy, participants whose depressive symptoms were clinically improved attended significantly more sessions than 9

those not. We also performed a binary logistic regression model to delineate factors that might contribute to clinical depression improvement after eliminating any overlap effects between predictors, using “enter” as the entry method. The dependent variable was “MCID”, the predictors included: gender, age, baseline BDI score, baseline SCS score, and total sessions attended. A test of the full model versus a model with intercept only was statistically significant. Table 4 showed the logistic regression coefficient, Wald test, p value, and odds ratio for each of the predictors. Employing a .05 criterion of statistical significance, we found that “baseline BDI score” and “total sessions attended” had significant partial effects on the dependent variable. INSERT TABLE 3 AND 4 AROUND HERE 4. Discussion The current study conducted a six-month randomized controlled trial to test the efficacy of CSCT intervention. We found that CSCT program was effective in increasing self-control capacity as well as decreasing depressive symptoms in depressed college students. The current study provides evidence for the efficacy of an ecologically valid self-control training intervention. This study may inform clinical professionals to incorporate self-control training within their specialized therapies to address the self-regulation/control problems in their depressed patients. The current CSCT program incorporated techniques from a number of empirically supported psychotherapies, primarily BA and CBT. Previous research documented that BA for depression was not inferior to CBT in terms of reduction of depression symptoms and was more cost-effective than CBT (Richards et al., 2016; Tindall et al., 2017), so we placed behavioral analyses and behavioral activation at the center of the program. By encouraging the participants to keep a diary, we helped them to identify their daily self-regulation failures and successful self-regulation events, to analyze the common causes and clues of self-regulation failure in the pre-training module. Based on their personal behavioral goals, we helped participants to activate the positive behaviors step by step toward their desired goals. Behavioral activation here was used in the service of enhancing participants’ promotion goal pursuit, because depressed patients often have difficulty to pursue their promotion goals effectively (Strauman et al., 2006). To ensure small setback and minor self-regulation failure would not make the participants become too discouraged to fall into the vicious cycle of “what-the-hell” effect, we encouraged the participants to develop a hierarchical behavioral training plan, started straining from easier goal and got rewarded timely as soon as the goal was achieved. At the cognitive level, when a participant failed to accomplish a particular behavioral goal, we encouraged them to develop a self-forgiveness and self-compassion attitude to themselves, rather than self-criticism. Such an attitude could serve as a resilience factor that protected against the development and maintenance of depressive episodes (Ehret et al., 2015). The CSCT program was designed to translate recent self-control/regulation findings into operable self-control training techniques. For example, short-term meditation was found to be an effective way to counteract self-control depletion (Friese et al., 2012), long-term meditation was associated with increased gray matter density (Luders et al., 2014) and improved behavioral self-regulation (Lykins and Baer, 2009). So in the early stage of training, the mindfulness meditation module was introduced, with the purpose of enhancing participants’ self-awareness of their negative unreasonable thought about self-regulatory failure and negative emotions ensued. The meditation practice was encouraged throughout the whole intervention to facilitate the 10

participants to aware and break their usual automatic cognitive-behavioral-emotional response patterns. Previous studies found that suppressing emotion would decrease self-control performance (Friese et al., 2013), so in the coping improvement module, we trained participants to express emotion rather than to repress emotion when strong negative emotion arose. Previous findings indicated that rumination on provoking events would exhibit less self-control resource and more aggressive behaviors (Hahm, 2011; White and Turner, 2014), so when a participant found herself ruminating on an anger-provoking event, we encouraged her to change a different coping strategy: talking to a friend and seeking more social support, or reappraising the situation from a different perspective. The current CSCT program was also tailored for depressed patients, taking full account of the deficient behavioral activation system manifested in many depressed ones (Li et al., 2015). As a participant recalled, “at the beginning of the program, the idea of participating a long-term intervention intimidated me. I knew I would give up whenever things started to become difficult. I hate myself for never successfully insisting in any significant things.” For such a participant, we assured her that we would try together to make the program become easier and interesting, when she really gave up, we would warmly remind her long-term goals and reaffirm her achievement, encouraging her to continue the training program from an easier step. Meta-analysis study revealed that the average dropout rates for individual psychotherapy for major depression were as high as 17.5-19.9% (Cooper and Conklin, 2015), the dropout rate in the current study was relatively low when taking into account the long duration of the intervention program. Realizing the important role of positive reinforcement played in behavioral activation interventions, we added a self-monitoring and reward module to strengthen participants’ motivation and to enhance their compliance, and in the long run, to reduce the dropout rate. In line with our practice, a recent study found that positive reinforcement mediated the relationship between behavioral activation and depressive symptoms improvement among late adolescents (Takagaki et al., 2016). This module encouraged participants to conduct self-monitoring and reward as well as to invite others participating in the process. The CSCT program also included a four-month consolidation module, with the purpose of consolidating what has been achieved in the previous eight training sessions, and persisting in their behavioral goals. This module is essential in strengthening the long-term benefit of the CSCT program, because it requires long-term repetitive exercises to make a new behavior pattern becomes an automated prepotent response. Univariate and logistic regression analyses revealed that participants with milder baseline depressive symptoms were more likely to benefit from CSCT interventions; depression improvement was also associated with the number of sessions attended. The results imply that the severity of depressive symptoms and participation enthusiasm simultaneously and interactively influence the intervention efficacy. At the end of six-month intervention, mildly depressed participants (defined as baseline BDI score ≤ 19, n = 13) participated an average of 11.2±1.5 sessions, versus 10.6±1.5 sessions in moderately depressed participants (defined as baseline BDI score = 20-28, n = 19), and 8.2±3.0 sessions in severely depressed ones (defined as baseline BDI score ≥ 29, n = 5). Therefore, the causal relationship might be that the less sever the depression, the higher the enthusiasm of participation; and the latter results in greater depression improvement. This finding makes sense because in general, mildly depressed patients usually respond better to psycho-behavioral interventions than severely depressed ones, and the more sever the depressive symptoms, the more likely they would prematurely terminate a psycho-behavioral intervention 11

program (Ramos-Grille et al., 2014). The current results suggest that the most appropriate subjects of CSCT intervention are those with mild to moderate depressive symptoms, especially those with a strong motivation to enhance their self-control and could adhere to the training protocol. CSCT is a translational intervention; therefore, there are certain overlaps and distinctions between CSCT and previously validated self-regulation-based psychotherapy for depression, e.g., SST. Below we would summarize the main similarities and distinctions between the CSCT and SST. First, the conceptual model underlying CSCT overlaps with that of SST. SST is based on the hypothesis that chronic or catastrophic failure to meet promotion goals is a contributory causal factor in the onset and maintenance of depressive episodes for individuals with a strong promotion focus (Vieth et al., 2003). Therefore, the primary rationale for SST is that increasing successful self-regulation could help individuals recover from depression. The CSCT approach views that chronic failure of self-regulation is associated with dysphoric affect and symptoms of depressive disorder, self-regulation failure may result in, accompany with, or be a consequence of depressive symptoms. Daily self-regulation failure could lead to a downward spiral of social functioning in depressed patients. Therefore, the primary rationale for CSCT is that breaking the vicious cycle of self-regulation failure and dysphoric mood at any point could contribute to depression improvement. Second, SST is designed for depressed individuals unable to pursue promotion goals effectively (Strauman et al., 2006); SST’s primary targets are depressed patients with a poor promotion socialization history who have difficulty pursuing promotion goals; CSCT is designed to address the self-control problem of depressed individuals, CSCT’s best targets are mildly to moderately depressed patients whose initial episode was caused by, or whose depressive symptoms were exacerbated by chronic or catastrophic self-regulation failure. In general, depressed individuals are more likely to exhibit self-control problems (Bredemeier et al., 2016; Rebetez et al., 2016) and particularly, undergo more promotion goal pursuit failures (Strauman et al., 2006). Thus the target population for both SST and CSCT overlaps. Third, SST emphasizes the use of behavioral activation (Vieth et al., 2003), as do the CSCT. In SST, behavioral activation is used in the service of enhancing promotion goal pursuit; in CSCT, behavioral activation lies in the core of the intervention package, and serves a similar purpose as it does in SST, i.e., activating positive behaviors step by step toward their desired promotion goals. Fourth, both of SST and CSCT incorporate techniques from other empirically supported psychotherapies for depression, in the service of addressing comprehensive self-regulation difficulties that exist in depressed individuals. Specifically, SST incorporates techniques from cognitive therapy, interpersonal psychotherapy, and BA; whereas CSCT borrows a number of specific interventions from mindfulness meditation, CBT and BA. Fifth, SST’s is developed in the form of individual psychotherapy with a relatively flexible, personalized protocol, whereas CSCT is more manualized and more suitable for group intervention. Last, the specific techniques used in CSCT and SST differ in several ways. SST would examine and modify the patient’s beliefs about the actual self, their promotion goals and standards, and the strategies used to pursue their goals; in contrast, CSCT would help participants to identify their daily self-regulation failures and successful self-regulation events, to analyze the common causes and clues of self-regulation failure, and to adhere to a hierarchical behavioral training plan according to their individualized goals. CSCT emphasizes the effort of improving self-control to achieve a desired long-term goal, ignoring trainee’s psychopathologic aspect of depression. In the process of training, participants 12

would gradually elevate their confidence to self-regulation, rather than focus one’s attention on the pathophysiology of depression. In a similar pattern, the current training also minimizes the stigma of depression on the part of trainee. The current study enriches the self-regulation model of depression, and at the same time, has significant clinical implications. First, we developed a new comprehensive approach to enhance trait self-control, and demonstrated that self-control capacity was amenable to training. The strength model of self-control postulates that when the self-control capacity is strengthened through training, it means a domain-general improvement in self-control resource and the improvement could be generalize to different tasks that require self-control (Baumeister and Tice, 2007). Second, we tested that enhancing self-control helped to improve depressive symptoms; therefore, the current study provides a new perspective to the treatment of depressive disorders. However, our research is not without limitations. First, the sample size of the present study was relatively small, even though we have recruited almost all of the eligible participants. We did not exclude those who had received other individual psychological or medical interventions during the CSCT program, instead we made a record of who had received whatever interventions. Second, the study involved participants from a student sample who were relatively young and well educated. In order to increase the external validity of our results, future research should examine the extent to which the current findings hold in a different population. For example, could older participants benefit from a CSCT program? Or is it possible that younger participants are more likely to benefit from the program than older ones? Studies showed that age was a critical factor that influenced the development of self-control strength and intervention efficacy (Berkman et al., 2012). Third, we neglected to measure some important mediating or moderating variables such as cognitive and emotion regulation styles, previous studies showed that these variables were playing important roles in the development and maintenance of depressive disorders (Besharat et al., 2013; Garnefski and Kraaij, 2007). Future studies could further examine the role of these variables. Similarly, future research will be very meaningful if tapping into the brain plasticity change brought by long-term CSCT program. Finally, Berkman et al. (2012) proposed that effective ecological interventions targeted at enhancing domain-general self-control typically involved multiple components (e.g., cognitive, emotional, and behavioral tasks). The current study included multiple modules (e.g., behavioral activation, cognitive correction, coping improvement), these modules might act individually or synergistically with the intervention gains. Therefore, it is hard for us to provide an unambiguous way to identify which component of the intervention do or do not affect the intervention gains. Future research could try to delineate what intervention component contributes to what exact effect using refined intervention design and multiple study methods, e.g., neuroimaging method. The last limitation is that the duration of the intervention effects was not checked by the current study. In the four-mouth consolidation period some aspects of the intervention still have taken place. In conclusion, the current study demonstrates that CSCT program is effective in enhancing self-control capacity and improving depressive symptoms in depressed patients, especially in those with mild to moderate depressive symptoms and greater participation enthusiasm. Acknowledgement We would like to thank all the students participated in the current study, whose enthusiasm continued to inspire us to refine our intervention program. 13

Contributors Xueling Yang and Jiubo Zhao designed the study and the intervention procedure, Yu Chen and Simeng Zu participated in the intervention and collected the data; Jingbo Zhao helped recruit the participants and participated in the intervention; Xueling Yang analyzed the data and wrote the manuscript. All authors contributed to and have approved the final manuscript. Role of the Funding The work was supported by the “12th Five - Year Plan” of Philosophy and Social Science of Guangdong Province, China (GD14CXL02) and the Humanities and Social Sciences Research of Ministry of Education, China (14YJA190013). Conflicts of interest none

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17

Screening for potential psychological disorders in first-year college students (n = 5978)

SDS standardized score equal to or higher than 50 (n = 412)

Refused to participate the interview (n = 62)

Agreed to attend the diagnostic interview (n = 350)

Excluded (n = 21) Diagnosed with depressive disorders (n = 108)



Were Acutely suicidal or attempted suicide in the previous two months (n = 4)



Eligible participants (n = 87)

Had bipolar disorder or psychotic symptoms (n = 4)

Agreed to enroll and signed informed consent (n = 74)



Were cognitively impaired (n = 7)



Were currently receiving psychotropic or psychological intervention (n = 6)

Randomization

Intervention group

Control group

n = 37

n = 37

Baseline assessments

Dropout (n = 5)

Dropout (n = 2)

Valid cases (n = 32)

Valid cases (n = 35)

Dropout (n = 6)

Dropout (n = 3)



Hospitalization (n = 2)



Hospitalization (n = 1)



Having no time (n = 2)



Having no time (n = 1)



Unspecified reasons (n = 2)



Suspension from school (n = 1)

Valid cases for analyses (n = 31)

Valid cases for analyses (n = 34)





Received no other intervention (n = 25)



Received individual

Received medication therapy (n = 1)

Four-month follow-up assessments

Received no intervention (n = 25)



counseling (n = 5)



Post-training assessments

Received individual counseling (n = 6)



Received medication therapy (n = 3)

Fig. 1. Flow Diagram of participants from screening to analysis

18

Estimated Marginal Means of BDI Total Score

25

Group

24

Intervention

23

Control

22 21 20 19 18 17 16 15 Baseline

Post-training

Four-month follow-up

Time Fig. 2. Changes of BDI total scores over three time points

19

Estimated Marginal Means of SCS Total Score

40

Group

39

Intervention

38

Control

37 36 35 34 33 32 31 30 Baseline

Post-training

Four-month follow-up

Time Fig. 3. Changes of SCS total scores over three time points

Table 1 Content of comprehensive self - control training program for depressive participants. Sessions

Modules

Main focus of the training content

Week 1

Psychological education

Week 2

Behavioral analyses

Week 3

Goals setting

Week 4

Mindfulness meditation

Week 5

Behavioral activation

Week 6

Self-monitoring

What is self-control/regulation; the main findings and theoretical models of self-control/regulation; under what circumstances people are prone to self-regulation failure, and how to improve willpower. By keeping a diary, help participants identify daily self-regulation failures and successful self-regulation events, analyze the common causes and clues of self-regulation failure. Help participants develop personalized behavioral self-regulation goals. For example, to reduce the occurrence of binge-eating, or to increase the English reading time. The behavioral goals should be specific and easy to comply, and rank-ordered by difficulty. Teach the participants meditation theories and practice skills, including 5-minutes mindful breathing and body scanning technique as well as distraction handling skills; help participants develop an acceptant, non-judgemental awareness. Help participants adhere to a hierarchical behavioral training plan according to their individualized goals; when an easy behavioral goal is achieved, then goes to the next less easy behavioral goal; when a participant find it difficult to accomplish a particular goal, then revises the goal to an easier one. Help participants develop personalized self-monitoring and reward 20

and reward

Week 7

Cognitive correction

Week 8

Coping improvement

Month 3-6

Consolidation

plans. Encourage participants to reward themselves timely when they accomplish a behavioral self-regulation goal; invite others to participate in their self-monitoring and reward plan. Help participants identify their cognitive styles that could lead to self-regulation failures, such as self-criticism. Encourage participants to develop self-forgiveness, self-compassion and self-affirmation. Help participants identify ineffective coping under stress, to use effective coping style instead. For example, when negative emotion rises, try to express emotion rather than to suppress it; replace rumination on provoking events by social support seeking or cognitive reappraisal. Consolidate what has been achieved in the previous eight sessions, and persist in the behavioral goals and self-monitoring and reward plans. The group members meet once a month to discuss their training achievement, the trainer help the participants to fine-tune the training content.

21

Table 2 Descriptive statistics of outcome measures (M±SD) and independent-sample t tests between intervention and control groups M ± SD Variables

95% CI of Difference

Cohen's d

Intervention

Control

t(df)

p

Lower

Upper

Baseline

22.00±5.15

22.24±6.13

-0.19(72)

.854

-2.87

2.38

0.04

Post-training

17.00±6.13

21.74±5.66

-3.29(65)

.002

-7.62

-1.87

0.80

Four-month follow-up

16.65±6.57

21.21±5.60

-3.02(63)

.004

-7.61

-1.52

0.75

Baseline

33.70±6.74

33.51±6.78

0.12(72)

.905

-2.94

3.32

0.03

Post-training

38.13±5.35

34.29±6.03

2.75(65)

.008

1.05

6.63

0.67

Four-month follow-up

38.13±5.33

34.56±6.01

2.52(63)

.014

0.74

6.40

0.63

BDI

SCS

Note: BDI = Beck Depression Inventory total score; SCS = Self Control Scale total score; CI = Confidence Interval.

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Table 3 Comparison of demographical and clinical characteristics between intervention participants who showed minimal clinically important difference of depressive symptoms and who showed no minimal clinically important difference (M±SD or frequency). Variables

Class one

Class two

Chi-square or t(df)

p

Gender Male Female Age Baseline BDI score Baseline SCS score Total sessions attended

13 2 11 18.9±1.2 18.0±2.9 35.5±7.1 11.8±0.4

24 9 15 18.6±0.9 24.2±4.8 32.8±6.5 9.8±2.1

1.97(1)

.160

0.96(35) -4.20(35) 1.17(35) 3.42(35)

.342 ＜.001 .248 .002

Note: BDI = Beck Depression Inventory total score; SCS = Self Control Scale total score; Class one = participants in the intervention group who showed minimal clinically important difference of depressive symptoms (defined as a reduction of 20% or more of baseline BDI score both in post-training and four-month follow-up measurements, n = 13); Class two = participants in the intervention group who showed no minimal clinically important difference of depressive symptoms (all the other cases in the intervention group, including 6 dropout cases, n = 24).

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Table 4 Binary logistic regression predicting minimal clinically important difference of depressive symptoms among the intervention group participants. S.E.

Wald

df

Sig.

Exp(B)

95% C.I. for EXP(B)

Predictors

B

Gender Age Baseline BDI score Baseline SCS score Total sessions attended Constant 2 (5, N = 37) = 28.54, p

-0.06 1.60 0.00 1 .972 0.95 0.04 21.93 0.40 0.67 0.36 1 .551 1.49 0.40 5.53 -0.56 0.28 4.05 1 .044 0.57 0.33 0.99 -0.10 0.13 0.65 1 .419 0.90 0.70 1.16 2.34 1.20 3.79 1 .051 10.40 0.99 109.89 -19.54 17.64 1.23 1 .268 0.00 ＜ .001, Cox & Snell R2 = .538, Nagelkerke R2 = .740

Lower

Upper

Note: BDI = Beck Depression Inventory total score; SCS = Self Control Scale total score; Gender were coded as categorical variable, 1 = male, 2 = female. Dependent variable = meaningful depression improvement: 1 = whose depressive symptoms showed minimal clinically important difference (defined as a reduction of 20% or more of baseline BDI score both in post-training and four-month follow-up measurements, n = 13), 0 = whose depressive symptoms showed no minimal clinically important difference (all the other cases in the intervention group, including 6 dropout cases, n = 24).

Highlights    

Depressive disorder is associated with weakened self-control capacity and dysfunctional overall self-regulation. Self-control capacity is amenable to intervention, and practicing self-control could increase self-regulation strength. Comprehensive self-control training programs (with a special emphasis on behavioral activation) could enhance trait self-control capacity. Enhancing self-control capacity helps to improve depressive symptoms.

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