Cognitive intervention based on Positive Emotion-Engagement Relationship-Meaning-Achievement theory in patients with depression and insomnia: Application value

Abstract

BACKGROUND

Depression and insomnia are highly prevalent mental disorders with a significant comorbidity rate, each exacerbating the severity and course of the other in a bidirectional relationship. Current clinical interventions, including pharmacotherapy and traditional cognitive-behavioral therapy, primarily focus on alleviating negative symptoms and correcting misconceptions. However, these approaches often neglect the crucial aspect of cultivating patients’ positive psychological resources. The Positive Emotion-Engagement Relationship-Meaning-Achievement (PERMA) framework offers a novel perspective by encouraging individuals to focus on positive aspects of life, thereby fostering personal growth and helping them maximize their inner potential. While its application shows promise in various fields, research on the efficacy of cognitive interventions based on the PERMA model specifically for patients with comorbid depression and insomnia remains insufficient, necessitating further exploration.

AIM

To explore the effect of PERMA theory-based cognitive intervention on depressive mood, sleep quality and quality of life in patients with depression complicated with insomnia.

METHODS

A total of 106 patients with depression combined with insomnia who received treatment in Ganzhou People’s Hospital from January 2022 to January 2024 were selected for the study. According to the blind selection method, 106 patients were evenly divided into the control group and the observation group. The control group received conventional cognitive intervention, and the observation group was based on the PERMA theory. After 2 months of continuous intervention in both groups, the following were assessed: depression severity (17-item Hamilton Depression Scale, Self-rating Depression Scale), sleep quality (Pittsburgh Sleep Quality Index), cognitive function (Neuropsychological Status Rating Scale), social functioning (Chinese version of Personal and Social Functioning Scale), and quality of life (World Health Organization Abbreviated Quality of Life Scale) before and after the intervention.

RESULTS

Following the intervention, the observation group demonstrated significantly reduced scores on both the 17-item Hamilton Depression Scale (9.41 ± 2.80) and Self-rating Depression Scale (44.25 ± 2.71) compared with the control group (P < 0.05). All domain scores and the total score of the Pittsburgh Sleep Quality Index were markedly lower after treatment in the observation group than in the control group (P < 0.05). After intervention, the Repeatable Battery for the Assessment of Neuropsychological Status scores in the observation group (160.21 ± 15.17) were significantly higher than those in the control group (145.69 ± 12.58) (P < 0.05). After intervention, the observation group had a significantly higher total score on the Chinese version of the Personal and Social Functioning Scale (70.86 ± 6.92) compared with the control group (60.14 ± 11.52) (P < 0.05). Similarly, the observation group demonstrated significantly better outcomes on the World Health Organization Abbreviated Quality of Life Scale than the control group (P < 0.05).

CONCLUSION

PERMA-based cognitive intervention demonstrates superior effectiveness in patients with depression and comorbid insomnia. It effectively alleviates depressive symptoms, improves sleep quality, enhances cognitive and social functioning, and elevates overall quality of life, supporting its value for broader clinical implementation.

Key Words: Positive Emotion-Engagement Relationship-Meaning-Achievement theory; Cognitive intervention; Depression; Insomnia; Sleep quality

Core Tip: This randomized controlled trial demonstrates that cognitive intervention based on the Positive Emotion, Engagement, Relationships, Meaning, Achievement (PERMA) theory significantly improves outcomes in patients with comorbid depression and insomnia. Compared to conventional therapy, the PERMA-based approach reduced depressive symptoms (17-item Hamilton Depression Scale/Self-rating Depression Scale), enhanced sleep quality (Pittsburgh Sleep Quality Index), and improved cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status), social performance (Chinese version of the Personal and Social Performance Scale), and quality of life (World Health Organization Abbreviated Quality of Life Scale). The findings highlight PERMA’s dual-action benefits - addressing both psychological distress and sleep dysfunction - through positive psychology principles, offering a novel, non-pharmacological strategy for this high-comorbidity population. Clinical adoption could optimize holistic patient recovery.

INTRODUCTION

In the past three decades, the incidence of depression in China has increased 20-30 times[1]. Despite the growing number of available mental health treatment approaches, the global incidence of depression continues to rise each year[2]. In recent years, relevant studies have found that most patients with depression have problems of interrupted sleep continuity and reduced sleep depth[3]. Moreover, Raman et al[4] found that there is a bidirectional relationship between depression and insomnia symptoms across time, and the synergistic strengthening effect of multiple interrelated symptoms is significantly detrimental to patients’ disease recovery. Therefore, it is particularly important to implement effective intervention measures for patients.

At present, the clinical treatment of depression primarily involves drug intervention and individualized cognitive-behavioral interventions[5]. Cognitive behavioral therapy, as a targeted approach, can help patients develop a more accurate understanding of the illness and its treatment by modifying maladaptive cognitions and behavioral patterns[6]. However, traditional interventions primarily address negative emotions, such as fear and distress, from a psychological perspective, while overlooking the crucial role of patients’ positive psychological resources. The Positive Emotion, Engagement, Relationships, Meaning, Achievement (PERMA) theory guides patients to focus on the beautiful aspects of life from five core aspects: Positive emotion, Engagement, Relationship, Meaning and Achievement. By applying psychological therapy methods, it further promotes the positive growth and subjective experience of patients, maximizing their inner positive potential[7], and significantly improves the insufficient exploration of psychological resources in traditional intervention. However, the application research of this model in patients with depression complicated with insomnia is still insufficient.

Therefore, this study seeks to further examine the application of PERMA theory-based cognitive intervention in patients with comorbid depression and insomnia and to evaluate its effects on reducing negative emotions and improving quality of life. The findings are presented below.

MATERIALS AND METHODS

General information

A study was conducted on 106 patients with depression and insomnia who received treatment at Ganzhou People’s Hospital from January 2022 to January 2024. This study has been approved by the in-house ethics committee.

Inclusion criteria: (1) Meets the diagnostic criteria for depression[8]; (2) Meets the diagnostic criteria for compound primary insomnia[9]; (3) Age > 18 years old and able to communicate normally; (4) No intellectual disabilities, able to complete questionnaire filling; and (5) All patients comply with the principle of informed consent and voluntarily sign the informed consent form.

Exclusion criteria: (1) Presence of other types of mental and physical illnesses; (2) Individuals with depression or anxiety symptoms caused by medication or other reasons; (3) Alcohol and drug abusers; (4) Presence of olfactory and auditory impairments; (5) Individuals who commit suicide or self-harm; and (6) History of using antidepressants or sleep-improving medications within the first 3 months of enrollment.

According to the blind selection method, the patients were evenly divided into the observation group and the control group, with 53 cases in each group. There was no significant difference in the general data between the two groups of patients (P > 0.05), which provided a basis for the research to be carried out (Table 1). Both groups of patients received routine nursing interventions, which mainly included health education, disease risk assessment, medication guidance, and daily life care.

Table 1 Implementation process of cognitive intervention based on Positive Emotion-Engagement Relationship-Meaning-Achievement.

Intervention content	Concrete implementation process
Positive self-perception	Understand patients’ awareness of depression and encourage them to speak their minds
	Use a professional perspective to clearly explain the knowledge of depression and insomnia for patients
	To patiently answer the doubts raised by the patient, and correct the patient’s misunderstanding of the disease
Positive emotion	Psychological counselors guide patients to view the current state of the disease from a positive perspective and make them aware of the importance of positive cognition
	Nursing staff guide patients to use positive language to motivate themselves and give timely recognition to their positive performance
	Recommend patients to watch movies that enhance their confidence, while also asking them to pay attention to events that cause negative emotions and list their thoughts after the event, and find ways to refute negative views
	Nursing staff should provide appropriate recognition and support when patients exhibit any positive emotions
Input activity importance	Introduce the positive effects of “Fuliu” on patients, and guide them to actively participate in healthy entertainment activities, such as painting and listening to music, based on their condition and personal interests
	At the same time, encourage patients to cultivate their interests and hobbies
Build good relationships	By organizing role-playing activities with four different response types: Proactive, proactive, passive, and passive, we aim to enhance patients’ awareness of family, friendship, and social responsibility
	Understand the patient’s interpersonal relationships, guide them to reflect on grateful moments in their life, motivate them to pay attention to warm moments in their daily lives, and suggest that they record them through writing a diary or sharing on social media
	Introduce communication skills to patients and guide them to practice actively responding to interpersonal communication
Meaning of human life	Understand patients’ understanding of the meaning of life, and help them form a positive outlook on life by guiding them to delve into the deeper meaning and intrinsic value of life
	Assist patients in discovering their inner growth significance, and based on the actual progress of their condition, jointly set practical and feasible life goals, encourage patients to look forward to the future with an optimistic attitude, and continuously strengthen their determination to recover
	At the same time, guide them to recognize their own value and help enhance their sense of social responsibility
Achievements and goals	Based on the different stages of the patient’s condition, work together with the patient to develop detailed short-term and long-term personal development goals from two aspects: Dynamic exercise and emotional management
	Closely track the progress of each patient’s goals and provide timely encouragement for every point of improvement
	Actively encourage patients to engage in activities they are good at and love

Control group and observation group

Control group: Patients received cognitive intervention, including: (1) A comprehensive assessment of the patient’s specific condition, accompanied by correction of misconceptions regarding depression; (2) Targeted guidance delivered through group lectures, multimedia resources, video materials, and images to educate patients and their families, helping them develop a more positive attitude toward the illness; (3) Support in establishing healthy lifestyle habits, such as avoiding caffeinated beverages and vigorous exercise before bedtime, encouraging warm milk or warm-water foot soaking, and creating a quiet and comfortable sleep environment; and (4) encouraging family members to increase interaction and communication with the patient, offer them respect and understanding, and help the patient experience emotional warmth and support.

Observation group: Patients received PERMA-based cognitive intervention, including: (1) An intervention team, where the department head nurse serves as the team leader, while one attending physician, one psychological counselor, and three ward nurses form the team members. The group members jointly participate in the patient’s ward round process, and through communication and exchange with the patient, understand the patient’s actual situation and provide targeted intervention measures; (2) a personalized intervention plan for the patient; (3) Implementation of the intervention process focused on six aspects: “Positive self-awareness”, “positive emotions”, “importance of engaging in activities”, “building good interpersonal relationships”, “meaning in life”, and “achievements and goals” (Table 2). The above intervention is performed twice a week, with each content controlled for about 30 minutes. For discharged patients, intervention is through WeChat, phone and other forms, and patients are encouraged to engage in positive self-suggestion every day to improve their quality of life; and (4) Quality control: A weekly meeting to discuss quality control results, problems in the intervention process, and timely adjustments to intervention measures. Both groups received nursing intervention for 2 months.

Table 2 Comparison of general data between the observation group and the control group, n (%).

Groups	Gender		Age, mean ± SD	Disease duration, mean ± SD	Education level
	Male	Female			Primary school	Junior/senior high	College
Control group (n = 53)	31 (58.49)	22 (41.51)	46.21 ± 2.96	4.33 ± 0.89	11 (20.75)	27 (50.94)	15 (28.31)
Observation group (n = 53)	30 (56.60)	23 (53.40)	46.30 ± 2.94	4.51 ± 0.86	12 (22.64)	26 (49.06)	15 (28.30)
χ2/t	0.039		0.157	1.059	0.062
P value	0.844		0.875	0.292	0.969

Observation indicators

Depression level: Depression severity was assessed before and after intervention using the 17-item Hamilton depression Scale (HAMD-17)[10] and the Self-Rating Depression Scale (SDS)[11]. The HAMD-17 scale evaluated patients across 17 items, with a total score ranging from 0 to 52. A score less than 7 is considered normal, a score of 7 to 17 may indicate mild depression, a score of 18 to 24 may indicate moderate depression, and a score of 24 or above may indicate severe depression. The SDS scale consists of 20 items and takes 53 points as the critical value. A score of 53 or above indicates that the patient is experiencing depression. Both scales indicated that the higher the score, the more severe the depression. Among them, the Cronbach’s α coefficient of the HAMD-17 scale was 0.714, and the Cronbach’s α value of the SDS scale was 0.73.

Sleep quality: The Pittsburgh Sleep Quality Index (PSQI)[12] was used to assess the sleep status of the two patient groups before and after intervention. The index consists of seven dimensions and 18 items, including sleep time, efficiency, and quality, and each item is evaluated using a four-point rating system ranging from 0 point to 3 points, with a maximum total score of 21 points. The patient’s score is inversely proportional to their sleep quality. The Cronbach’s alpha of PSQI scale is 0.791.

Cognitive function: Patients’ cognitive function before and after intervention was evaluated by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)[13], which contains 12 items. That is, five core levels: Attention, immediate memory, visual-spatial/structural ability, language function, and delayed memory. The total score of the scale ranges from 40 points to 160 points. A higher score indicated better cognitive function performance. The Cronbach’s α coefficient of the RBANS scale was 0.90.

Social function: The social function of the two patient groups was assessed before and after intervention using the Chinese version of the Personal and Social Performance Scale (PSP-CHN)[14]. This scale is an effective tool for assessing the social function of patients with mental disorders. It analyzes from four aspects: Maintenance of personal and social relationships, self-care, anti-interference ability, and aggressive behavior, comprehensively reflecting the social function status of patients. The maximum total possible score is 100 points, and the patient’s score is directly proportional to their social function status. The Cronbach’s α coefficient of the PSP-CHN scale was 0.71.

Quality of life: The World Health Organization Quality of Life BREF (WHOQOL-BREF)[15] was used to evaluate patient quality-of-life before and after intervention from four levels (24 items): Physiological field, psychological field, social, and environmental. The scale score was proportional to their quality-of-life. The Cronbach’s alpha coefficient of WHOQOL-BREF scale is ≥ 0.7.

Statistical analysis

All the data in this study were analyzed using SPSS 27.0, while GraphPad Prism 8.0.2 was used to generate plots. All measurement data conform to normal distribution after normality test, are expressed in the form of mean ± SD, and are compared between groups and within groups by independent t and paired t tests, respectively. All statistical data were expressed in the form of “n (%)” and compared between groups with χ². Bilateral tests were performed on all results, and the significance of statistical results was set as P < 0.05.

In this study, the scales were guided by uniformly trained researchers to patients in the same environment to ensure the consistency of the assessment process and the repeatability of the results.

RESULTS

Comparison of depression levels among patients

At baseline, there were no statistically significant differences in HAMD-17 or SDS scores between the two patient groups (P > 0.05). Following intervention, both patient groups showed improvement in the above scale scores. However, the observation group had significantly lower HAMD-17 and SDS scores compared to the control group (P < 0.05) (Figure 1).

Figure 1 Comparison of depression levels among patients. ^aP < 0.05 vs pre-intervention; ^bP < 0.05 vs control group. A: Comparison of 17-item Hamilton Depression Scale scores among patients; B: Comparison of Self-rating Depression Scale scores among patients. HAMD-17: 17-item Hamilton Depression Scale; SDS: Self-rating Depression Scale.

Comparison of sleep quality among patients

Prior to the intervention, there were no significant differences in any PSQI dimension or in the total score between the two patient groups (P > 0.05). Following intervention, both groups showed a significant reduction in all assessed indicators; moreover, the total PSQI scores in the observation group were significantly lower than those in the control group (P < 0.05) (Figure 2).

Figure 2 Comparison of patient sleep quality. ^aP < 0.05 vs pre-intervention; ^bP < 0.05 vs control group. A: Comparison of patient sleep quality scores; B: Comparison of patient sleep time scores; C: Comparison of patient sleep disorder scores; D: Comparison of patient hypnotic drug scores; E: Comparison of daytime functional impairment scores among patients; F: Comparison of patient sleep time scores; G: Comparison of patient sleep efficiency scores; H: Comparison of total Pittsburgh Sleep Quality Index scores among patients.

Comparison of cognitive function among patients

There were no significant baseline differences in RBANS scores between the two groups prior to the intervention (P > 0.05). Following treatment, both groups exhibited improved RBANS performance; however, the observation group demonstrated significantly greater improvement compared to the control group (P < 0.05) (Figure 3).

Figure 3 Comparison of Repeatable Battery for the Assessment of Neuropsychological Status scores among patients. ^aP < 0.05 vs pre-intervention; ^bP < 0.05 vs control group. RBANS: Repeatable Battery for the Assessment of Neuropsychological Status.

Comparison of patients’ social functions

At baseline, the two groups demonstrated comparable total PSP-CHN scores (P > 0.05). Post-intervention, significant improvements in PSP-CHN scores were observed in both groups; however, the observation group achieved a significantly higher total score compared to the control group (P < 0.05) (Figure 4).

Figure 4 Comparison of Chinese version of Personal and Social Functioning Scale total scores among patients. ^aP < 0.05 vs pre-intervention; ^bP < 0.05 vs control group. PSP-CHN: Chinese version of Personal and Social Functioning Scale.

Comparison of patient quality of life

Prior to the intervention, the two groups showed no statistically significant differences in any domain of the WHOQOL-BREF scale (P > 0.05). Following intervention, both groups exhibited a significant increase in WHOQOL-BREF scores; however, the observation group displayed significantly higher scores compared to the control group (P < 0.05) (Figure 5).

Figure 5 Comparison of patient quality of life. ^aP < 0.05 vs pre-intervention; ^bP < 0.05 vs control group. A: Comparison of total scores of patient quality of life; B: Comparison of physiological field of patients; C: Comparison of patient psychological scores; D: Comparison of patient social relationship evaluations; E: Comparison of scores in the field of patient environment.

DISCUSSION

Insomnia and depression are the two most common mental illnesses, with prevalence rates of approximately 10%[16] and 5% to 10%[17], respectively. Meanwhile, comorbidities between insomnia and depression are very common, with approximately two-thirds of depression patients suffering from insomnia at the same time[18]. For patients with depression combined with insomnia, a single treatment for depression is usually not sufficient to reduce comorbid insomnia. At the same time, residual insomnia after depression treatment can further increase the risk of depression recurrence. Therefore, insomnia intervention is a key method for preventing disease development in patients with depression and insomnia. Multiple studies have shown that cognitive intervention has a good therapeutic effect on insomnia and can enhance patients’ self-well-being to a certain extent to treat comorbid depression[19,20]. However, patients still lack understanding of the therapeutic effects of cognitive interventions through psychological mechanisms. Therefore, to reduce patients’ negative emotions and improve their quality of life, it is crucial to find suitable nursing intervention models.

Recent advances in positive psychology have placed greater emphasis on enhancing patients’ subjective well-being as a core component of personalized care. The PERMA model, which outlines five fundamental elements of well-being, serves as a foundation for designing structured psychological interventions. These programs encourage patients to focus on positive aspects of life, constructively engage with their health status, gradually reframe negative thoughts, and strengthen overall happiness while coping with challenges[21]. Clinical evidence indicates that the PERMA approach relies primarily on self-management, reduces the need for intensive therapist involvement, minimizes resistance, and effectively engages both patients and their families in the therapeutic process, thereby improving acceptance and adherence[22].

This study demonstrated that following intervention, the observation group exhibited significantly lower HAMD-17 and SDS scores than the control group, suggesting that the PERMA theory-based cognitive intervention was more effective in reducing depressive symptoms compared to conventional approaches. This outcome is consistent with data reported by Yao et al[23].

The main reason for the analysis is that cognitive intervention based on PERMA theory, on the one hand, explores good emotions, cultivates gratitude and positive qualities through disease cognitive conversation and cognitive behavior intervention, enriches patients’ reflection on life, and helps to enhance their understanding of the disease. On the other hand, through peer support, communication, and role-playing, it help patients build confidence in overcoming the disease. At the same time, practicing positive language can transform patients’ negative emotions into positive emotions, promote the development of their positive qualities, and transcend ingrained patterns of thought, emotion, and behavior, instilling positive beliefs at a deeper psychological level. This process assists patients in rediscovering their identity, transforming maladaptive emotions and cognitions, strengthening their confidence in disease management, and facilitating personal growth and self-reconstruction[24]. Moreover, under the intervention mode of PERMA theory, patients can explore the causes of their negative emotions and enrich their reflection on life by sharing their views on the events that occurred, which helps to cultivate their positive qualities and alleviate negative emotions. Sleep is an important way for the body to rest. When patients have serious psychological problems, they often experience varying degrees of sleep disorders, which further exacerbate negative emotions and enter a vicious cycle[25]. The results of this study indicate that the observation group demonstrated significantly greater improvement across all dimensions of the PSQI compared to the control group, indicating that PERMA theory-based cognitive intervention is more effective in improving sleep quality compared with traditional intervention methods. The reason for the analysis is that PERMA theory-based cognitive intervention can alleviate the psychological burden of patients by improving their negative emotions, thereby increasing their confidence in facing problems and eliminating the interference of negative psychological factors on sleep, thereby improving their sleep quality.

Secondly, results from this study showed that the observation group achieved significantly higher RBANS scores post-intervention than the control group, suggesting that the PERMA-based cognitive intervention is more effective at enhancing cognitive function in patients compared to conventional intervention methods. The reason for the analysis is that in the PERMA mode, nursing staff carry out active self-awareness intervention to timely correct patients’ erroneous cognition. On the other hand, by jointly setting personal development goals with other patients, encouraging them to participate in activities they love, conducting “Fuliu” exercises and role-playing, etc., patients can experience the joy of life and discover the value of life, thereby guiding them to form a healthy outlook on life, causing plasticity changes in brain activity, promoting the reorganization of neuronal connections, and improving patients’ cognitive function. Moreover, previous studies have shown that brain activity is closely related to emotion regulation and cognitive function[26]. Additionally, this study revealed that the observation group obtained significantly higher PSP-CHN scores following the intervention compared to the control group, demonstrating that the PERMA theory-based cognitive intervention was more effective in enhancing patients’ social functioning than traditional intervention approaches. In the PERMA mode, nursing staff actively communicate with patients during treatment, thereby being able to timely understand patients’ emotional changes and true inner thoughts. At the same time, nursing staff guide patients to cultivate their interests and hobbies through painting, listening to music, and other methods, which can help patients shift their attention, encourage the recognition of positive aspects in daily life, facilitate gradual acceptance of treatment regimens, alleviate negative emotional states, and foster the development of optimistic and positive psychological qualities. Related studies have found that the secretion of cortisol, the final product of the hypothalamic pituitary adrenal axis in the human body, can be increased by stimulating prefrontal cortex activity on the inner side of the brain, thereby regulating emotions, arousing positivity, eliminating negative thinking, ensuring the balance of the nervous system, maintaining physical and mental health, and improving social function[27]. On the other hand, in PERMA-based intervention, nursing staff deepen patients’ understanding of interpersonal relationships from the perspective of “establishing good interpersonal relationships” and “life meaning” through organizational role-playing and other methods. By guiding patients to form a positive outlook on life, they help patients enhance their sense of social responsibility and improve their social function. In addition, this study found that the WHOQOL-BREF scores of both patien groups increased after intervention, with the observation group showing a more significant increase, indicating that PERMA theory-based cognitive intervention has a more prominent effect on improving patients’ quality of life. The reason for this is that under the PERMA model, nursing staff can improve patients’ subjective initiative and treatment compliance by providing systematic and continuous health education, thereby promoting patients’ active participation in the self-care treatment process. At the same time, nursing staff pay attention to eye contact, gestures, and physical communication during interviews with patients, maintain their good mood, and improve their quality of life.

CONCLUSION

In summary, PERMA theory-based cognitive intervention has a more significant effect on patients with depression and insomnia. It can effectively alleviate patients’ depressive emotions, improve their sleep quality, enhance their cognitive and social functions, and improve their quality of life. It is worth promoting and applying in clinical practice. However, this study also has certain shortcomings: (1) The limited sample size may reduce the generalizability of the findings; (2) The observation indicators in this study were evaluated using scales, and the scoring results may be influenced by subjective factors of the patients; (3) This study has not yet conducted follow-up work on patients after intervention and cannot clarify the long-term effects of cognitive intervention based on PERMA theory on patients; and (4) This study only explored the application effect of nursing intervention mode in patients with depression and insomnia and has not yet explored the specific mechanism of action. Therefore, future studies should incorporate multi-center designs with larger sample sizes and multiple assessment indicators, complemented by long-term follow-up, to enhance the reliability and validity of the finding. Meanwhile, further analysis of the possible mechanisms of action will be conducted through basic experiments to ensure the scientific validity of the research results.

ACKNOWLEDGEMENTS

The authors would like to thank all the patients who participated in this study. We also extend our gratitude to the medical staff of the Department of Psychiatry at Ganzhou People’s Hospital for their support and assistance throughout the intervention and data collection process.