Exercise and Epstein's TARGET for treatment of depressive symptoms: A randomized study

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www.elsevier.es/ijchp

International

Journal

of

Clinical

and

Health

Psychology

ORIGINAL

ARTICLE

Exercise

and

Epstein’s

TARGET

for

treatment

of

depressive

symptoms:

A

randomized

study

José-Antonio

Cecchini-Estrada

a

_,

_Antonio

_{Méndez-Giménez}

a,∗

_,

Christian

Cecchini

b

_,

_Michael

_Moulton

c

_,

_Celestino

_Rodríguez

a a_Universidad_de_Oviedo,_Spain

b_South_Side_Jr._High/Pelican_Virtual_School_Denham_Springs._Louisiana,_USA c_Northwestern_State_University,_USA

Received23January2015;accepted8May2015 Availableonline7June2015

KEYWORDS Depression; Physicalactivity; Intervention; Experimental-trials

Abstract Thisstudywasdesignedwithadualgoal:(1)tocomparethechangeinthescores ofdepressive symptomsbymeans oftheimplementation ofthreeinterventionprogramsin comparisontoacontrolgroup:a)basedonEpstein’sTARGET(ET),b)withoutTARGETstrategies (NET), andc)underconditionsofactiveexercise(AE);and(2)toanalyzewhetherthe Self-determination Index (SDI)predicts the reductionofdepressive symptoms. The participants (N=106;68femalesand38males),agedbetween18-30years,wererandomlyassignedtoone ofthegroups.Eachtreatmentlasted8weeks(3hours/week).OftheETparticipants,59.26% showedatherapeuticresponse,deﬁnedasa50%reductioninthereferencescore,versus25.93% fortheNET,19.23%fortheAE,and3.84%forthecontrolgroup.Aftersixmonths,theETgroup increasedtheir percentageoftherapeuticresponsebyslightlymorethan10%,whichdidnot occurintheothergroups.SDIpredictedlowerlevelsofdepressivesymptoms,andourﬁndings indicatethatTARGETstrategiescanhaveadirecteffectondepressivesymptomsatthetime ofinterventionandanindirecteffectatalaterstageduetotheirimpactonfuturelevelsof physicalactivity.

© 2015Asociación Espa˜nolade Psicología Conductual. Publishedby Elsevier España, S.L.U. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/). PALABRASCLAVE Depresión; actividadfísica; intervención; experimento

EjercicioyTARGETdeEpsteinparaeltratamientodelossíntomasdepresivos:un estudioaleatorio

Resumen Esteestudiofuedise˜nadocondobleobjetivo:(1)compararelcambiodelas puntua-cionesdesíntomasdepresivosmediantelaimplementacióndetresprogramasdeintervención: a) basado en el TARGET de Epstein (ET), b) sin estrategias del TARGET (NET) y c) bajo

∗_{Corresponding}_author:_Facultad_de_Formación_del_Profesorado_y_Educación,_Universidad_de_Oviedo,_C/Aniceto_Sela_s/n,_Despacho_219,

33005Oviedo(Spain).

E-mailaddress:[email protected](A.Méndez-Giménez).

http://dx.doi.org/10.1016/j.ijchp.2015.05.001

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condicionesdeejercicioactivo(AE),asícomo,d)ungrupo-control;y(2)analizarsielÍndice de Autodeterminación(SDI) predicela reducción de síntomasdepresivos. Los participantes (N=106;68 mujeres y 38 varones),con edadesentre 18-30 a˜nos, fueronasignados al azar aunode losgrupos.Cada tratamiento duró8semanas (3horas/semana). El59,26% delos participantesenelgrupoETtuvounarespuestaterapéutica,deﬁnidacomounareduccióndel 50%enlapuntuacióndereferencia,frenteal25,93%,19,23%y3,84%paralosgruposNET,AEy control,respectivamente.Seismesesdespués,elgrupoETaumentóelporcentajederespuesta terapéuticamásdel10%,loquenoocurrióenlosotrosgrupos.ElSDIpredijonivelesmásbajos desíntomasdepresivos.LasestrategiasdelTARGETpuedentenerunefectodirectosobrelos síntomasdepresivosdurantelaintervenciónyunefectoindirectoposteriordebidoasuimpacto sobrelosnivelesfuturosdeactividadfísica.

Depressionis an alltoo frequentmental disorder, with morethan350millionpeopleofallagessufferingfromthis disorderandpredictionsindicatingthatitwillbecomethe secondleadingcauseofdisabilityworldwideby2020(World HealthOrganization [WHO], 2012). Although thereis evi-dencetosupporttheclinicalefﬁcacyofapproachessuchas pharmacological,somaticand/orpsychologicaltreatments fortreatingdepression,theseapproacheshaveseveral limi-tations(Pérez-Wehbe,Perestelo-Pérez,Bethencourt-Pérez, Cuéllar-Pompa, & Pe˜nate-Castro, 2014). An alternative approach to treating mental health disorders is physical activity(PA)andexercise.AlthoughthequantityofPAvaries betweenthestudiesreviewed,theevidencesuggeststhat evenlowdosesofPAcanprotectagainstdepression(e.g.,

Baumanetal.,2012; Josefsson,Lindwall,& Archer,2014; Teychenne, Ball, & Salmon, 2008). Most of the interven-tionshavefocused onvarioustypesofaerobicPA,suchas cycling,runningorwalking,butotherformsofPA(suchas trainingwith weights, yoga, or stretches) have been less explored(Mammen&Faulkner,2013).However,no widely-acknowledgedevidenceisavailablewhichendorsesspeciﬁc PAprograms that areeffective against depression (Pomp, Fleig, Schwarzer, & Lippke, 2013). Moreover, only a few studieshave analyzed theassociation between depressive symptomsandthetypeofPAwithinsocialcontexts,suchas participationinteamsports(Sabistonetal.,2013),andno studythatweareawareof hasyet exploredtheeffectof interactionswiththeteacherand/orwithclassmatesinPA therapysessions.

Analysis of the influence of the social relations that are generated (or can be generated) in PA upon depres-sive symptoms is of great relevance, because common symptoms of depression include isolation and avoidance of social interaction-related activities (Seime & Vickers, 2006).Anothersymptomofdepressionisalackof motiva-tiontoundertakeactivities thatpreviouslygavepleasure. Forthisreason,recentresearchhighlightsthepossible ben-eficialroleofthetheoryofmotivationinordertoexpand, informandenrichtherapeuticapproachesandinterventions inclinicalpractice(McBrideetal.,2010).Anewanalytical factor,‘autonomousmotivationfortherapy’(definedasthe degreetowhichpatientsexperienceparticipationin ther-apyasa freelychosen option),hasalsobecomeknownas anotherpowerfulfactor whichcanpredict treatment out-come(Patrick&Williams,2012).

Withinthiscontext,theself-determinationtheory(SDT) has emergedasarelevant contemporary approachtothe design of interventions and PA programs and to better understand theprocessesleadingtosustainedmotivation. A sub-theory within the SDT framework, ‘the theory of basic needs’(Deci& Ryan,2000),argues thatsatisfaction ofthebasicpsychologicalneedsofcompetence,autonomy andrelatednesspromotesgreaterautonomousmotivation, whichinturnleadstomorepositiveoutcomes.Indeed,there isconsiderableevidenceoftheimpactofautonomous moti-vation onparticipationinPA (Teixeira, Carrac¸a,Markland, Silva,&Ryan,2012),aswellasonchanginghealth-related behaviors(Ngetal.,2012).Fromtheviewpointofthe the-oryofbasicneeds,contextualfactorsareconsideredcritical topromote theprocesses andoutcomesof motivation. In particular,itisassumedthatpositiveinteractionswith sig-niﬁcantothers(whichtendtopromoteandsupportgreater autonomy and satisfaction with social-relationships, thus increasingtheperceptionofself-competence)shouldhave a positiveandhealthy effectonpeople(Ngetal., 2012). In arecentstudy,Duda etal. (2014)comparedtwo inter-ventionstopromoteexercise:1)astandardprovision;and 2) anSDT-based intervention(autonomy support), showed thatchangesinself-determinedmotivationwerenegatively associatedwithdepressivesymptoms.

The incidence of contextual factors in sports (more specifically,Epstein’sTARGETstrategies)(Epstein,1988)on the psychological mediators, such as types of motivation andbehavioralconsequences,haverecentlybeenevaluated byCecchini,Fernandez-Río,Méndez-Giménez,Cecchiniand Martins(2014).The resultsshowedthatcontextualfactors hadasignificanteffectonanathlete’spsychologicalneed for self-satisfaction, self-determined motivation, as well aspersistenceandeffort.Anotherstudyalsoanalyzedthe impactofEpstein’sTARGETonPAinadolescents(Cecchini, Fernandez-Rio,&Méndez-Giménez,2014),andthefindings supportedtheefficacyofincreasinganadolescent’sintent toperformPA,aswellasthetimededicatedtoPAintheir freetime.

With respect to the above ﬁndings, it is likely that the motivational climate constructed by the teacher (or ‘coach’) in PA sessions can also have a beneﬁcial effect on participants’ depressive symptoms. In fact, the man-ner in which motivation is offered affects the way in whichpeoplepursuephysicalhealthgoals(Gallagheretal.,

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2012).ThetermTARGET(Epstein,1988)isanacronymfor: Task(designof activities);Authority(locationof decision-making);Recognition(wayofdistributingrewards,suchas praise); Grouping (selection criteria of the workgroups); Evaluation (performance standards that are considered important); and Time (learning rhythm). Various investi-gations have analyzed the effects of TARGET onathletes andphysicaleducationstudents’attitudes,knowledge,and behaviors(e.g.Braithwaite,Spray,&Warburton,2011),and someofthesestudieshaverelatedmotivationalclimateto anxiety(Cecchinietal.,2001).

Accordingly, to determine the importance of motiva-tionalclimate,wecomparedtheresultsofanintervention basedonEpstein’sTARGETwiththoseobtainedusingother typesofPA.Usingthescoresofdepressivesymptomsasan outcome measure (Choi, Patten, Gillin, Kaplan,& Pierce, 1997), the goals of the present study were the follow-ing:1)toverifywhetheraPAinterventionprogram based onEpstein’sTARGET strategies(ET)generatesa significan-tlyhigherreductionindepressivesymptomsscoresthan a PAinterventionprogramwithoutimplementingtheTARGET strategies(NET),or thanindividualphysical exercise(AE), aswell asplacebophysical exercise;and 2)todetermine whether SDI predictsa significant reductionof depressive symptoms.Ifthisisso,it couldbearelevant findingwith respect toaddressing andreducing depressive symptoms, asitwouldnotonlyconfirmtheimportanceofperforming PA, but also, it would especially show that doingPA in a motivationallysuitablecontextiscrucial.

Method

Participants

Thestudy’sparticipantsweredrawnfromacohortof univer-sitystudentsfromacityinnorthernSpain.Afteraselection processbeginningwithpreliminaryinterviewsof1,975 col-legestudents(1,179womenand796men),theﬁnalsample was made up of 106 subjects (68 females and 38 males) agedbetween18 and30 years,eachof whomhadscored between 29and 34onthe adaptedself-report depression scaleestablishedbyKandelandDavies(1982).

Participants witha score of 29 or higher onthis scale were classified as having significant depressive symptoms (Choietal.,1997).Otherinclusioncriteriawere:(a)being sedentary(definedasvigorousexerciselessthanthreetimes perweek for at least20minutesaday); (b)not receiving anytreatment for depression;and (c)giving theirwritten informedconsent.The exclusioncriteriawerethe follow-ing:(a) consumption ofmore than21 alcoholicbeverages per week, (b) hospitalizationfor a psychiatricdisorder in thepast5years,(c)currentparticipationinotherclinical trials,(d)druguse,(e)inabilitytoparticipatedueto medi-calprescription,and(f)forthefemales,plannedorcurrent pregnancy.

Selectionprocess

Participants were selected by means of a prior interview andtwoscreeningvisits(SV1,SV2).The preliminary inter-views were administeredby the authors, withthe aimof

recruitingawide-enoughsamplesizeforthestudy. Prospec-tiveparticipants were informed of the types of activities tobecarriedoutuponbeingaccepted totake partinthe study,theexclusioncriteria,andthepotentialbeneﬁtswith respecttoparticipation(includingcreditsgranting). Screen-ingvisitswereintendedtoassessdepressivesymptomsand sedentariness(SV1),andtoverifythattheycouldperform physicalexercise safely (SV2).After SV2,108 participants were selected assessment of their capacity to adhere to regularphysicalexercise(1-week),andalsotoassesstheir self-determinedmotivation (Figure1). Thisprocess lasted forsixmonths.Arestrictedrandomizationdesignwasused, which was based on three blocks (gender, age, and BMI) aimedatreachingabalancebetweengroup-sizeandother physicalcharacteristics.Theparticipantsgavetheirwritten informedconsent,andthe studywasconducted in accor-dancewithThe Helsinki Declaration ofthe WorldMedical Association(2008),withﬁnalapprovalforthestudyobtained fromtheEthicalCommitteeoftheUniversity.

Instruments

Depressivesymptoms. An adaptation of the six-item self-reportscaledefinedbyKandelandDavies(1982)wasusedin thepresent study.Thisscale assessessixdepressive symp-tomsexperienced duringthe past12 months(Choi etal., 1997). The responses to the items are added, providing a depressive symptomatology score ranging from 6 to 24 points.Thesescoreswereadaptedby10pointstoproduce anewrangebetween16and34points(Choietal.,1997). Responsetotreatmentisdefinedasareductionof depres-sivesymptomsingeneralbyatleast50%oftheinitialscores onthedepressivemoodscale(Brunoni,Lopes,Kaptchuk,& Fregni,2009).TheCronbachalphaobtainedwas.72.While therearemorepowerfulassessmenttoolstoevaluatethis component,givenitspsychometricpropertiesandthefact thatthe depression scale administered offers a briefand generaldetectionmeasure,thisinstrumentwaschosenfor twokeyreasons:a) itallowsidentification ofparticipants with depression symptoms easily; b) it has been used in previousstudies which werealsofocused onthe relation-ship between physical activity and depressive symptoms, thusmakingitpossibletocarryoutadditionalbroad-scoped comparisons(e.g.,Sabistonetal.,2013).

Self-determined motivation. The Situational Motiva-tion Scale (SIMS), as defined by Guay, Vallerand and Blanchard (2000), is a measure of situational (or state) motivationtowardsachosenactivity.Thisself-report inven-tory consists of four items for each subscale and was designedtomeasure intrinsic motivation,identified regu-lation, external regulation, and amotivation. Participants respond to the stem, ‘‘Why are you currently involved in this activity?’’ Each item is rated on a 7-point Lik-ert scale, ranging from 1 (not at all in agreement) to 7 (completely in agreement). As the subscales of the SIMS assesstypesof motivationonaself-determination contin-uum, a self-determination index(SDI) can be calculated. Inthis study,SDI is computed bymultiplying thescore of each SIMS subscale by a factor that represents its posi-tionontheconstructoftheself-determinationcontinuum: SDI=2*intrinsicmotivation+identifiedregulation-external

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Assessed for eligibility

N=1975

Interview prescreen – ineligible

N=1011

Refused to participate (n=984) Not meeting inclusion criteria (n=27)

Interview prescreen – eligible (n=964)

SVI – ineligible (n=845) Refused to participate (n=41)

Not meeting inclusion criteria (n=804)

SV2 – ineligible (n=11)

Refused to participate (n=6)

1-week run-in – ineligible (n=2)

Refused to participate (n=2)

Group 2 n=27 Woman (n=17), Men (n=10) Age (SD) = 19.57 (1.57) BMI (SD) = 22.25 (4.67) Group 3 n=26 Woman (n=17), Men (n=9) Age (SD) = 19.77 (3.78) BMI (SD) = 23.34 (3.77) Group 4 n=26 Woman (n=17), Men (n=9) Age (SD) = 19.88 (1.61) BMI (SD) = 22.75 (5.01) Group 1 n=27 Woman (n=17), Men (n=10) Age (SD) = 19.23 (1.57) BMI (SD) = 22.33 (2.96) Randomized SVI – eligible (n=119) SV2 – eligible (n=108)

1-week run-in – eligible (n=106)

N=106

Figure1 Participantﬂowfromenrollmenttoprescreeninterview. Note.Age,p=.47;Gender,p=.98;BMI,p=.71.

regulation - 2 * amotivation) (Guay et al., 2000). The following Cronbach alphas were obtained: intrinsic motivation=.94;identiﬁed regulation=.88;external regu-lation=.78;andamotivation=.78.

Physical activity. The International Physical Activity Questionnaire (IPAQ)was developed asan instrument for cross-nationalcontrolofPAandphysicalinactivity.TheIPAQ hasreasonable measurement properties for screening the populationlevelsofPAbetweenages18-65yearsindiverse settings(Craigetal.,2003).Inthepresentstudy,weused the shortversion, which provides informationabout time spentonmoderatetovigorousphysicalactivity(MVPA).The MVPAindicatorisexpressedinmetabolicequivalents(METs) -minutes/weekofMVPA(i.e.METs-MVPA).TheIPAQhas rea-sonablepropertiestocontrolthelevelsofPA.TheIPAQin Spanishwasobtainedfromthewebsite:www.ipaq.ki.se.

Design

Weusedanexperimentaldesigninwhichparticipantswere randomlydividedintofourgroups(ET,NET,AE,&Control). The authors of the present manuscript selected partici-pants and assigned the sample randomization sequence, whichwasimplementedby wayofsequentially numbered opaquesealed envelopes. The four groups were indepen-dent,andeachindividualgroupwaspreventedfromknowing

the existence of the remaining groups. For this purpose, intervention wascarriedouton differentdays.Allgroups wereequivalent,thustheydidnotshowstatistically signif-icantdifferencesinage,genderorBMI(Figure1).

For8weeks(24one-hoursessions),GroupETengagedin aninterventionprogrambasedonEpstein’sTARGET strate-giestaughtbyaphysicaleducationteachertrainedtothat effect.During thesame timeinterval, Group NETcarried outtheirusualprogrammedtrainingsessionswithout imple-mentingEpstein’sTARGETstrategies.Alsoduringtheabove timeframe, Group AE carriedout thesame scheduled PA sessions,butwithouttheinterventionofaphysical educa-tionteacher.Lastly,thecontrolgroupcarriedoutplacebo physicalexercise,definedas3daysaweekofstretchingand flexibilityexercisesfor60minutespersession.The partici-pantswererandomlyassignedtotheexperimentalgroupsor controlplaceboexercisegroup.Inthissense,theabsence of attrition rates is explained by a study-credit awarded to students for their participation,and adherence of the participantsmotivatedbybenefitsprogram.

Procedure

TheinterventionprogramdesignedfortheETexperimental groupwasadaptedfromthemodeldevelopedbysuccessive authors (Cecchiniet al.,2001; Duda& Balaguer, 2007)to

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generate a task-involving motivational climate within the sixTARGETdimensionsdescribedbelow:

Task. The instructor used open or predominantly per-ceptivetasksthatwerepresented globally,in theformof problem-situations.Atalltimes,teachersattemptedto pro-vokeinterestinPA,usingvaried,amusing,andmotivating proposals.

Authority.Theinstructortookintoaccounttheuniversity students’interests,andthestudentsparticipatedactively inthedecisions.Thistypeoflearningislargelydetermined bythestudent’sperceptionofcausativelocus,choice,and freewill.

Reward.Individualprogresswasrewardedorrecognized bytheinstructor.Theymadesurethatallthesubjectswere treated equally, regardless of their initial level, and that theyallhadthesameexpectations inrelationtopersonal success.

Groupings. Small, cooperative, ﬂexible, and hetero-geneous groups were established. Learning, personal improvement,teamwork,andaclassclimatepromoting pos-itivesocialinteractionswereencouraged.

Assessment.Theachievementofindividualandcollective goalswasevaluatedasafunctionofpersonalimprovement criteria.

Time.Lastly,thestudentswereallowedtoparticipatein thedecision-makingprocessrelatedtolearningrhythmand thetimeassignedtoeachtask.

Two teacherssupervisedtheET andNETgroups in this study,however,theAEandplacebogroups didnotrequire teacher-participation.Eachteacherwasrandomlyassigned toeithertheETorNETexperimentalgroup(Montero&León, 2007), and each oneremained withtheir assigned group. The participant instructors had at least 5 years of prior teaching experienceand also agreed toattend a speciﬁc seminar to trainin TARGET strategies beforestarting the implementationphase.Theseminarconsistedof20hoursof theoryand10hoursofpracticaltraining,andincluded pre-designed lessons, which were subsequently analyzed and discussed.Whilecarryingouttheinterventionprogram,the instructorhadtoattendaweeklymeetingwiththeresearch group.Oneteachingsessionfromeachparticipantgroupwas recorded each week in orderto checkthe ﬁdelity of the process.Forthispurpose,alistofinterventionscodedfor each groupwasestablished.Researchersandteachersdid the coding independently of each other. Recordings were checkedbytheresearchgroupinordertoguaranteethatthe sessionsproceededaccording tothe established program. Ultimately,acombinationoftrainingseminars,pre-designed sessions,andanalysisofvideostoprovideadequatetraining wasused(Braithwaiteetal.,2011).Inaddition,the progres-sionoftheexperimentwascloselymonitoredbythestudy’s chiefinvestigators.

Dataanalysis

AllthedatawereanalyzedusingtheSPSS19.0program(IBM, Chicago, IL). In all threeexperimental groups, PA wasof moderate-to-vigorous intensity and was monitored by the researchgroupin each andeverysession sothatit would beadequatelybalanced(e.g.schedulesanddevelopmentof thesessions).Forthispurpose,theactivitieswereclassiﬁed

asafunctionoftheirintensity,andthiswasmultipliedbythe durationoftheactivity.Student’st-testsandpairedt-tests wereused.Hedges’gwasselectedasameasureoftheeffect sizetoprovideanestimationoftheeffectduetothesize ofthesamples.Thecalculationsofthepowerofthesample sizewerebasedonG*Power,3.1.Intheanalysisof clini-calefﬁcacy,theassessmentoftheeffectsofthetreatment ondepressivesymptomscoresandSDIwasbasedon gener-alizedestimationequations(GEEs)for repeatedmeasures. Themodelwasadjustedtoallowforparticipants’age, gen-der,andbodymassindex(BMI).Inthesixmonthsbetween post-test1andpost-test2,theparticipantswereallowedto practicePAintheirsparetimeiftheywishedto.Participants wereclassiﬁedintwogroups:(A)thosewhoperformedPA, atleastmoderately,followingthecriteriaestablishedinthe InternationalPhysicalActivityQuestionnaire(IPAQ);and(B) thosewhohadnotmettheminimalcriteriaofmoderatePA. Assessmentoftheeffectsonthedepressivesymptomscores (post-2)andSDIwasbasedonGEEsforrepeatedmeasures. None of the questionnaires had more than 8% missing data,sononewereeliminated;10questionnaireshadless than8%missingdataandwerethereforerandomlyimputed withvaluesderivedfromamultipleregressioninwhichthe scoresofthreeitemsfromthesameseriesofindicators(that is,theitemsthatmeasurethesameconstruct) wereused aspredictorvariables(Byrne,2008).

Results

Preliminaryanalyses

Ofthe1975preselectedparticipants,5.36%wererandomly assignedtothetreatment.Allthosewhobegantreatment ﬁnishedit andattendedatleast 22sessions(91.7%ofthe totaltreatment).Mostoftherandomlyassignedparticipants werefemale(64.16%).Beforethe intervention,no signiﬁ-cantpretestgroupdifferenceswereobservedindepressive symptoms(p=.98)orintheSDI(p=.16).

Pre-postinterventiondifferences

Significant improvements in depressive symptoms were observedbetweenpre-testandpost-test1inallthegroups (ET, NET, and AE, p<.001; control, p<.01) and between pre and post-2 in the experimental groups (ET, NET, and AE,p<.001; control, p>0.1). Inthe ET group, significant changeswerealsoobservedintheSDI betweenpre-post-1 and pre-post-2 (p<.001). In addition, no significant dif-ferencesbetweenpost-1 andpost-2 wereobserved inthe ET group, but they were found in the remaining groups (Table1).

Likewise, statistically signiﬁcant differences were observed in depressive symptoms at post-1 and post-2 betweentheETgroupandtherestofthegroups(p<.001). All groups showed reductions in symptoms during the 8 weeksoftreatment.Sixmonthslater(atPost-2),onlytheET groupremainedstable(Figure2).Nosigniﬁcantdifferences wereobserved between the NETand AE groups either at post-1(p=.78)orat post-2(p=.52),butdifferenceswere found between these two groups and the control group, both at post-1 (NET, p<.01; AE, p<.01), and at post-2

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22

Pre Post 1 Post 2

Control AE NET ET 23 24 25 26 27 28 29 30 31

Figure2 Depressivesymptombytreatments.

Note: ET=TARGET-based intervention program, NET=interventionprogramwithoutimplementationofTARGET strategies,AE=programunderconditionsofactiveexercise. (NET, p<.01; AE, p<.05). Regarding the SDI, signiﬁcant differences were observed at post-1 and post-2 between the ET groups and the rest of the groups (p<.001). No signiﬁcantdifferences wereobservedbetween therest of thegroupseitheratpost-1oratpost-2(Table1).

Analysisofclinicalefﬁcacy

Table2showstheGEEforrepeatedmeasuresatpost-1and post-2 in depressivesymptoms. More than 59% of the ET groupshowedatleasta50%reductionoftheirinitialscore atthebeginningofthestudy,andtheirresponseto treat-menthadimproved byafurther10%sixmonthslater.The responses ofthe NETand AE groups weresimilar toeach

other.The SDIpredicted depressivesymptoms(post-1 and post-2).Age(post-1,p=.99,post-2,p=.74),gender (post-1,p=.94,post-2,p=.10),andBMI(post-1,p=.26,post-2, p=.12)werenotsigniﬁcant.

AsshowninTable3,participantswhopracticedmoderate tovigorousPA(post-2)werelesspronetohavedepressive symptoms than those whodid not. Mostof these partici-pants belonged to the ET group (n=17), followed by the NETgroup(n=13),AE(n=12),andcontrol(n=9),p<.001. TheSDIalsopredictedlowerlevelsofdepressivesymptoms. Age(p=.65),gender(p=.57)andBMI(p=.06)werenot sig-niﬁcant.

Discussion/conclusions

Themainfindingofthisstudyisthatthepositiveeffectsof PAondepressivesymptomscanincreaseinincidence signi-ficantlyifPAtakesplaceinasuitablemotivationalcontext. Firstly,itwasobservedthattheinterventionprogrambased onEpstein’sTARGETstrategies(Epstein,1988)isan effica-cioustreatment for university students whohave notable depressive symptoms. Fifty-nine percent of the partici-pantsintheETtreatmentconditionsshowedatherapeutic response tothetreatment [defined asa50% reduction of the baselinescoreof depressivesymptoms (post-1)]. Sec-ondly,inpriorstudiesreportingasignificanteffectofPAon depressionorondepressivesymptoms,theeffectsizeshave rangedfrom.05to1.75(Teychenneetal.,2008).Thus,the presentinterventionprogram(baseduponEpstein’sTARGET strategies-appliedbyaphysicaleducationteacher)showed acomparativelyveryhigheffectsize(1.70),whichwasfar higherthanintheNETandAEtreatments.

Table1 Means,standarddeviation,effectsizeandsample sizepowerinthepre,post-1 andpost-2 phasesfor thethree treatmentgroupsandthecontrolgroup.

Depressivesymptoms SDI

M SD ESd _Powere _M _SD _ESd _Powere ET 2.31 1.00 1.70 1.00 Pre 30.81a _1.84 _6.41a _3.14 Post-1 22.19b _3.25 _12.14b _3.10 Post-2 22.23b _3.97 _12.09b _2.93 NET .77 .99 0.18 .25 Pre 30.70a _1.79 _6.67a _3.35 Post-1 26.11b _3.65 _6.85a _4.03 Post-2 26.85c _3.17 _6.98a _4.17 AE .77 .99 0.22 .34 Pre 30.65a _1.74 _4.75a _3.30 Post-1 26.38b _3.39 _5.19a _4.29 Post-2 27.47c _3.61 _5.04a _4.51 Control - - - -Pre 30.77a _1.80 _5.75a _3.42 Post-1 28.76b _2.50 _6.13a _3.85 Post-2 29.92a _2.93 _6.17a _4.08

Note:ET=TARGET-basedinterventionprogram,NET=interventionprogramwithoutimplementationofTARGETstrategies,AE=program underconditionsofactiveexercise.

abc_p_<_.05

d_ES,_Hedges_g_was_selected_as_the_measure_of_effect_size_to_provide_an_estimate_of_effect_due_to_sample_sizes. d_Power,_Sample_size_power_calculations_are_based_on_G*Power_3.1.

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Table2 Zanalysis-scoresat8weeks(Post1)andsixmonthslater(Post2). Depressivesymptomsa

Post-1 Post-2

OR 95%CI Responseb _OR _95%CI _Response

ET .011** _[.032,_.365] _59.26% _.085** _.020-.360 _70.37%

NET .034* _[.127,_.900] _25.93% _.307* _.098-.964 _11.11%

AE .021* _[.063,_.689] _19.23% _.057* _.055-.604 _15.38%

Control 1.000 - 3.84% 1.000 - 7.69%

SDI .730** _[.642,_.829] _- _.683** _.603-.774

-Note:ET=TARGET-basedinterventionprogram,NET=interventionprogramwithoutimplementationofTARGETstrategies,AE=program underconditionsofactiveexercise.

b _Percent_with_≤_50%_reduction_of_{participant’s}_score_at_baseline.

* _p_<_.01

** _p_<_.001

Statistically signiﬁcant differences were also observed inthe SDIbetween theETtreatment groupandtheother groups. This is consistent withprevious researchthat has examined the effectsof TARGET on theSDI in other con-texts(Cecchini,Fernandez-Río,&Méndez-Giménez,2014). For the past 15 years, a growing body of research test-ing the applicability of the SDT in health contexts has emerged (Patrick & Williams, 2012). Globally, the results ofthesestudieshave shownthenecessary roleofsupport andautonomousself-regulationinavarietyofphysicaland mentalhealthoutcomes,suchasdepression(Ryan,Patrick, Deci, & Williams, 2008). In this study,the SDI wasa sig-niﬁcant andnegativepredictorofdepressivesymptomsin universitystudents;consistentwiththoseobservedbyDuda etal.(2014).

Thetrueimportanceofanytreatmentliesinitslong-term effects.Sixmonthsaftercompletingtheintervention,some of the ETtreatment participants had improved their out-comesevenfurther.Thepercentageofparticipantsscoring ≤50%oftheirinitial(baseline)scoreindepressivesymptoms followingthe8-weekETtreatmenthadincreasedby10%at thesix month follow-up. Webelieve thatthe explanation canbe found inthe numberof participantswho indepen-dently decided to continue the practice of moderate or vigorousPAat leastthreedaysaweek in theirfreetime. Prior studiesfound thattheSDI predictsthe future inten-tion tocontinue to practice PA(Cecchini, Fernández-Río, &Méndez-Giménez,2014),andthisiswhatseemstohave happenedin the ETtreatment condition, in which 63%of theparticipantschosetocontinueactivelypracticingPA.In fact,atpost-2,theSDIwasagainasigniﬁcantpredictorof lowlevelsofdepressivesymptoms.

TARGETstrategiescanhaveadirecteffectondepressive symptomsatthetimeoftheintervention,andan indirect effectaftercompletionbecauseof theirimpactonfuture levelsofPA.The directeffectoccursduringthe interven-tion and can be explainedby its incidence on the levels of self-determined motivation associated with weekly PA (Gourlan, Trouilloud, & Sarrazin, 2013), which translates intoadecreaseofdepressivesymptomsatpost-1.The indi-recteffectislong-term,andoccursaftertheintervention becausetheincreaseoftheSDIatpost-1predictshigher lev-elsofPAatpost-2and,consequently,anadditionaldecrease

Table 3 DepressivesymptomsatPost-2as afunction of PracticeorNon-practiceofPA.

Post-2Depressivesymptoms

OR 95%CI n(%)

GroupA(Practice) .221** _.092-.533 ₅₁_(48.1) GroupB(Nopractice) 1.00 - 55(51.9)

PostSDI .676** _.599-.764

-**_p_<_.001

ofdepressivesymptoms.Onthewhole,thegroupthatwas providedwithEpstein’sTARGETstrategiesreachedaclinical efficacyofaround70%afterafollow-upperiodofsixmonths. It is exceedingly difficult to find similar efficacy rates in theliterature.Well-establishedtreatmentsfordepression, suchasthe‘‘CopingwithDepressionCourse’’ofLewinsohn, Antonuccio, Steinmetz and Teri (1984), ‘‘Cognitive Ther-apy’’byBeck(1991),and‘‘InterpersonalPsychotherapy’’by

KlermanandWeissman(1993),allhavedifficultiesreaching theselevelsof effectiveness.Webelieve thatthereasons behind these results are related to the junction among physicalexercise, external support, andautonomous self-regulation skills. Previous research (e.g., Dunn, Trivedi, Kampert,Clark,&Chambliss,2007),whichusedthe Hamil-tonRating Scale for Depression, and included treatments based on aerobic physical exercise exclusively, showed a clinical efficacy of 31% (three days per week, during 12 weeks),and64%(fivedaysperweek,during12weeks).In thefirstcase,resultsaresimilartothosefoundintheNET group(i.e.,25.93%ofefficacy;threedaysperweek,during 8weeks).Inthesecondcase,however,theefficacyinthe ETgroupwasslightlylowerafteraperiodofsixmonths.

Previousstudies have relatedtheTARGET strategies to theincreaseinthestudents’perceptionsofskillandeffort, competence, and motor skills (Martin, Rudisill, & Hastie, 2009), which can lead to an increase of PA in their free time.In their review of studies on motivational climate,

Braithwaiteetal.(2011)reportedthatTARGET-based inter-ventionshadsigniﬁcanteffectsonsomeindicatorsofhealth and physical ﬁtness, such as heart rate, cardiovascular capacity,frequencyofexercise,andnutritionalbehaviors.

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ThepresentstudyquestionsthattheincidenceofPAon depressivesymptomsonlydependsondosageandintensity. Motivational climate is a key issue, as it can be used to break the isolation by promoting social interaction in the depressive population (Seime & Vickers, 2006). The practice of PA should be carried out in a pleasant and amusingenvironmentin ordertopromotesocial relations. TheeffectsofPAcanbegreatlyenhancedbythoseadded effects which can be derived from the pleasure of its practiceinanintegrativesocialcontext.

A recent theoretical framework has attempted to conceptualizeandrelatePAandmood,andithasbeen sug-gestedthatmoderate-intensityexerciseisassociatedwith morepositiveoutcomesbecauseitisrelatedtothepleasure of practicing, whereas vigorous intensities areassociated with a negative affect, or dislike (Lind, Joens-Matre, & Ekkekakis,2005).Inthisstudy,weproposethatmoodismore closelyrelatedtothemotivationalclimatethantothe inten-sity of practice.In fact, people whoare more motivated alsomakeagreatereffortandtheseimprovementsaredue, atleastinpart,tothemutualsupportandsocial relation-shipsprovidedwhen participatingin PAwithotherpeople (Méndez-Giménez,Cecchini,&Fernández-Río,2014).

Duetothefactorsthathavebeenoutlinedabove, inter-ventions in PA to alleviate depressive symptoms should: (a) propose varied and ﬂexible tasks that pose personal challenge and promote active participation; (b) create an appropriate training environment to meet individual and collective demands; (c) foster participation in the decision-making process; (d) help participants to assume the responsibility of their own personal development by teachingself-managementandself-controlskills;(e) recog-nizeindividualprogress,effortandimprovement;(f)ensure equalopportunities;(h)useﬂexibleandcooperative group-ings; (i) promote helping others; (j) emphasize creative solutionstotrainingproblems;(k)developassessment crite-riabasedoneffort,improvement,persistence,andprogress towardsindividualgoals;(l)acknowledgethatparticipants donottrain,learn,ordevelopatthesamespeed;(m) pro-vide enough time before moving on to the next stage in thedevelopmentofcompetences;(n)trytospendthesame timewithalltheparticipants;(o)helpparticipantsto estab-lishlong-termtrainingprograms(Duda&Balaguer,2007).

Certain potential methodologicalproblems and limita-tionsofthepresentinvestigationshouldalsobementioned. Firstly,thesample wassmall.Secondly, onlystudentswho reachedascoreof29ormoreandwhowerecharacterized byhavingnotable symptomsof depressionwereselected, and therefore, the results might only be generalizable tothese specific students. Thirdly, the average follow-up periodwasonlysixmonths.Fourthly,thestudywasbasedon self-reportmeasures,whichmayincludeerrorsofjudgment, difficulties and incorrect interpretation of the questions, andthepossibilityofsociallydesirableanswers.Finally,itis necessarytoconductfurtherresearch,usingmorespecific measurementinstruments,andwithgreaterclinicalutility.

Funding

ThisstudyhasbeenconductedthankstotheI+D+Iresearch grant#DEP2012-31997fundedbytheMinisteriodeEconomía yCompetitividadofSpain.

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