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The effects of positive psychology and physical activity on depression, anxiety, and stress among students with premenstrual syndrome: a single-blind, randomized controlled trial

BMC Women's Health volume 24, Article number: 499 (2024) Cite this article

Abstract

Background

Premenstrual syndrome affects many women in their reproductive years and often disrupts their social connections and work. This study aimed to compare the effects of positive psychology and physical activity on depression, anxiety, and stress among students with premenstrual syndrome.

Methods

In this four-group parallel clinical trial with blinded data analysis, 120 eligible students who experienced premenstrual syndrome were recruited based on inclusion/exclusion criteria and randomly allocated to four groups (n = 30) including three experiment groups as positive psychology, physical activity, and positive psychology, physical activity, and control group, using a simple randomization method. All four groups completed premenstrual syndrome screening and the DASS-21 questionnaire before the intervention. Then, the positive psychology intervention group received eight sessions of 70–90 min weekly intervention, the second group received eight weeks of aerobic physical activity intervention, and the third group received positive psychology and physical activity intervention for eight weeks. The control group did not receive any interventions. The DASS-21 was completed immediately after the intervention and two months later by all four groups. In this study, the participants and investigators were not blinded; however, the analysts were. The recruitment process took place from September 2018 to March 2019. One hundred twenty participants fulfilled the study. The Data were collected and analyzed using SPSS (v18).

Results

Before and immediately after the intervention, there was no statistically significant difference in depression, anxiety, and stress mean scores among the positive psychology, physical activity, positive psychology, and physical activity and control groups (p ≥ 0.05). However, two months after the intervention, a significant difference was observed between the four groups so there was a difference between the scores of the three intervention groups and the control group (p < 0.05). There was no significant difference between positive psychology, and physical activity groups. No significant adverse events or side effects were observed.

Conclusion

Our findings supported the use of aerobic physical activity and educational interventions based on positive psychology as non-pharmacologic interventions to reduce anxiety, depression, and stress. This research should be replicated in different settings.

Trial registration clinical trials

Iranian Registry of Clinical Trials; https://irct.behdasht.gov.ir/trial/32363 (IRCT20130812014333N97), registered (11/08/2018).

Peer Review reports

Introduction

Premenstrual syndrome (PMS) is a set of various physical, emotional, and behavioral symptoms that may occur due to hormonal changes during menstruation [1]. These symptoms can negatively affect daily life, including physical performance, mood, cognitive abilities, and social interactions, ultimately threatening overall well-being [2]. Research shows that about 53% of women in Ethiopia, 80% of women in Saudi Arabia, and 70.8% of women in Iran experience PMS [3, 4].

While the exact cause of PMS is still unknown, it is believed to be linked to sensitivity to hormonal changes during menstruation in certain women [5]. The relationship between ovarian cycle activity and PMS symptoms can be inferred from the effectiveness of ovulation suppressants in reducing symptoms during pregnancy and after menopause [6]. Furthermore, PMS symptoms may be alleviated using antidepressant or anxiolytic drugs that regulate neurotransmitters such as serotonin and affect GABA activity. Therefore, it appears that PMS symptoms are strongly influenced by the activity of these neurotransmitters [7].

PMS includes a range of physical symptoms like bloating, breast tenderness, headaches, increased appetite, and palpitations, as well as psychological and behavioral symptoms such as depression, irritability, fatigue, aggression, suicidal tendencies, poor concentration, mood swings, and social isolation. Symptoms like stress, mood changes, loss of control, depression, irritability, sleep disturbances, impaired coordination, and alterations in sexual desire emphasize the importance of addressing and treating PMS [2]. Consequently, numerous studies in recent years have focused on exploring the prevalence, causes, and management of PMS [7, 8].

While there is still no clear understanding of the exact causes of PMS, managing its symptoms involves a combination of non-pharmacological structured techniques [9, 10], antidepressant medications [11], cognitive-behavioral therapies [10], and hormonal treatments [12].

Positive psychology, a burgeoning field, aims to enhance people’s well-being and improve their quality of life through deliberate actions or therapeutic strategies that foster optimistic emotions, behaviors, and thoughts and reinforce desirable personality traits [13]. Studies have shown that positive psychology-based interventions reduce depression, anxiety, and stress in healthcare workers [14, 15]. The results of a study showed that online positiveoriented counseling alleviated PMS symptoms [16]. In another study, positive cognitive-behavioral therapy (P- CBT) was associated with significantly higher rates of clinically significant or reliable change for depression, negative affect, and happiness [17]. The results of a study showed that positive group counseling reduced physical symptoms, anxiety, and sensitivity in interpersonal relationships, and aggression associated with PMS, but no significant reduction was observed in depression [18].

Engaging in regular physical activity can be beneficial in the neurological and psychological realms [19, 20]. Exercise stimulates the release of endorphins, reduces pain, and induces feelings of satisfaction and happiness [19, 21]. It also helps regulate hormone levels, leading to fewer mood fluctuations. Additionally, physical exercise can lower cortisol levels, decreasing stress and associated psychological symptoms [22,23,24].

In a study conducted on university students, aerobic gymnastic physical activities were found to have a greater reduction effect on specific psychological symptoms related to PMS compared to a control group [25]. Similarly, in a clinical trial involving 35 women with PMS, a walking program for two months during two menstrual cycles resulted in improvements in various mood-related symptoms such as irritability, restlessness, weakness, fatigue, crying, depression, and desire to stay at home, and anxiety symptoms [26].

The hypothesis of the current study posits that non-pharmacological interventions could offer viable treatment options for women who either cannot tolerate or are non-compliant with antidepressant or hormonal medications, or for those who seek alternative or supplementary treatments to enhance the management of premenstrual syndrome. Additionally, there is a lack of clarity regarding the comparative effectiveness of these interventions for women suffering from PMS. Consequently, this study aims to evaluate and compare the efficacy of aerobic physical activity and positive psychology interventions in mitigating depression, anxiety, and stress in women with PMS.

Methods

Design

This four-group parallel clinical trial was conducted after obtaining ethical approval from the Ethics Committee of Kermanshah University of Medical Sciences, under the code KUMS.REC.1397.136. The trial was prospectively registered on 11 August 2018 with the Iranian Registry of Clinical Trials under the registration ID IRCT20130812014333N97, titled “A comparative study of the effect of the educational intervention based on positive psychology and exercise on depression, anxiety, and stress in students with premenstrual syndrome.”

The study was designed, conducted, and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines. All procedures adhered strictly to these standards to ensure transparency, reproducibility, and integrity of the research findings.

Participants

Out of the 180 screened students, 120 were recruited, and 60 were excluded due to a lack of inclusion criteria or a lack of desire to participate in the study. The participants were students at the Faculty of Literature and Human Sciences of Razi University of Kermanshah province - west of Iran.

The Premenstrual Symptoms Screening Tool (PSST), validated by Hariri et al. (2017), in Iran, and Gynecologist approval (third author) were the criteria that allowed the identification of students who could potentially be enrolled in the study. The recruitment process took place from September 2018 to March 2019.

Inclusion criteria were age 20 to 24, regularity of menstruation, length of menstrual cycle between 22 and 35 days, number of bleeding days between 3 and 8 days, body mass index less than 30, obtaining a mild and moderate score (8–14) on the DASS21 questionnaire, and scoring 18 or higher on the premenstrual syndrome symptoms questionnaire.

The exclusion criteria were diagnosis of Premenstrual dysphoric disorder (PMDD) by the Gynecologist (third author), history of traumatic events or loss of loved ones and divorce in the last three months, failure to participate in two positive intervention sessions and three physical activity sessions, severe and very severe cases of depression - subscales (21 and above), anxiety (15 and above), and tension (26 and above) and unwillingness to continue participating in the study.

Sample size calculation

The sample size was calculated using a similar study [27] considering the first type error (α) of 0.05, 95% confidence level, a test power of 80% (β = 0.2)), and a dropout rate of 120 participants.

$$\:n=\frac{\left(z\right(1-\frac{\alpha}{2})+z(1-\beta\left)\right)2({\sigma1}^{2}+{\sigma2}^{2})}{(\mu2-\mu1)2}$$

Randomization

A total of 120 eligible students with premenstrual syndrome, who achieved a mild to moderate score (ranging from 8 to 14) on the Depression, Anxiety, and Stress Scale (DASS-21) questionnaire, were selected through random sampling. These participants were then randomly assigned to one of four groups: three experimental groups (physical activity, positive psychology, and a combination of physical activity and positive psychology) and one control group, each consisting of 30 participants (see Fig. 1).

Fig. 1
figure 1

Flowchart of the study

Full size image

To accomplish this, 120 identical cards were prepared, with 30 cards marked with the code 1 representing the “positive psychology intervention,” 30 cards with code 2 representing the “physical activity intervention,” 30 cards with code 3 representing the “combined intervention,” and 30 cards with code 4 representing the “no intervention” (control group). Each qualified participant then randomly selected one of these cards to determine their group allocation. Importantly, the participants were blinded to the allocation design to maintain the integrity of the randomization process. The recruitment process was conducted from September 2018 to March 2019.

Research procedures

The first author invited eligible female students to participate and explained the project. A person who had no role in the study generated the random allocation sequence and assigned participants to interventions. To prevent biases in the filling of records by the investigators a person who had no role in the study, and was unaware of the participant’s group allocation, received training to collect data.

Interventions

The positive psychology intervention

The positive psychology intervention group received eight weekly 70–90 min educational intervention sessions by the first author, under the guidance of the fourth author. The multiple groups activated for a total of 30 subjects (each group including ten students). The group was led by a Ph.D. in Psychiatric Nursing (fourth author). The content of the sessions is shown in Table 1.

Table 1 Positive psychology intervention Sessions
Full size table

Physical activity

In the physical activity experimental group, a regular physical activity program consisting of 20–30 min sessions, conducted three days a week over eight weeks, was implemented in coordination with the Dean of the Department of Physical Education at Razi University. This program took place in the university’s sports facility and included five minutes of warm-up exercises at the beginning, 15 –10 min of light jogging with rest intervals, and concluded with five minutes of cooling down stretches and relaxation exercises. The exercise program was supervised and guided by the first author and a sports coach. The training protocol was based on the guidance of the Integrative Body Mind Information System (IBIS), which was developed in 2002 [28].

The third experimental group received both the sports activity intervention and the educational intervention based on positive psychology for eight weeks, the fourth group was the control group with no intervention.

Measures

A demographic form was completed by the participants at baseline including age, age of first menstruation, body mass index, and days of bleeding in menstruation.

The Premenstrual Symptoms Screening Tool (PSST), validated by Hariri et al. (2017), in Iran, was utilized to diagnose PMS. PSST Consists of 19 symptoms that are evaluated using a Likert scale, the responses vary depending on the severity of each symptom, including 0 (absent), 1 (mild), 2 (moderate), and 4 (severe). Obtaining a score of 18 and above on this questionnaire was considered positive premenstrual syndrome. This question has been psychometrically evaluated in Iran, and Cronbach’s alpha has been reported as 0.93 [29].

Depression, stress, and anxiety levels were measured using the questionnaire (DASS-21). The DASS21, an evaluation tool for assessing depression, anxiety, and stress, was created in 1995 and comprises 21 items [30]. Items 3, 5, 10, 13, 16, 17, and 21 measure depression; items 2, 4, 7, 9, 15, 19, and 20 measure anxiety; and items 1, 6, 8, 11, 12, 14, and 18 measure stress. This question has been psychometrically evaluated in Iran, and Cronbach’s alpha has been reported as 0.79 for anxiety, 0.91 for stress, and 0.93 for depression, respectively [31].

The questionnaire (DASS-21) was completed before the intervention, immediately after (at the end of the last intervention session), and two months later (two months after the last intervention session), by all four groups. In this study, the participants and investigators were not blinded; however, the analysts were.

Outcome measures

Primary outcome

Depression, stress, and anxiety levels before, immediately after, and two months after the completion of the intervention, the questionnaire (DASS-21) was completed by the participants of the four groups.

Ethical considerations

The first and second authors visited Razi University after securing the Ethics Committee and IRCT’s approvals. At first, the participants were briefed about the study and signed a written informed letter of consent. This study with clinical trial code: IRCT20130812014333N97 was based on an MSc Dissertation in counseling and midwifery under the ethics code: KUMS.REC.1397.136, Kermanshah University of Medical Sciences approved on 12 June 2018 by the Research Ethics Committee. Written informed consent was obtained from all participants after the briefing.

Data analysis

The collected data was analyzed in SPSS version 18 using descriptive and analytical statistical indicators. Kolmogorov Smirnov (k-s) test was used to check the normality of quantitative variables. If the variables followed a normal distribution, the one-way ANOVA and Toki test were used, otherwise, the Kruskal-Wallis test was employed. The Wilcoxon test was used to discriminate differences in cases where the Kruskal-Wallis test had p-values less than 0.05.

For qualitative variables, the chi-square test was employed for homogeneity, and in case of an insufficient number of samples, Fisher’s test was used (P < 0.05). Changes in mean scores of stress, depression, and anxiety across different time intervals were investigated using repeated measures test.

Results

The results of the Kruskal-Wallis test showed that before the intervention, there was no significant difference between the four investigated groups in terms of mean age, the average age of first menstruation, and average number of days of menstrual bleeding (p > 0/05). Moreover, the results of the one-way analysis of variance did not show a statistically significant difference in terms of the mean body mass index and the mean scores of the PSST questionnaire in the four studied groups (p > 0.05) (Table 2).

Table 2 Demographic information of the participants of the studied groups
Full size table

According to the results of the Kolmogorov-Smirnov test, the scores of depression, anxiety, and stress before, immediately after, and two months after the interventions did not follow the normal distribution (P < 0.05). Therefore, non-parametric tests were used in this study.

The study results indicated that the stress mean scores of the first, second, and third experimental groups, and the control group were 20.53, 15.3, 17.93, and 13.6, respectively, before the intervention. These mean scores immediately decreased after the intervention to 14.7, 12.26, 13.54, and 14.23. Two months after the intervention, the mean scores of the groups were 12, 11.23, 12.93., and 14.33(Table 3).

Table 3 Mean and standard deviation of depression, anxiety, and stress scores before, immediately after, and two months after the intervention in the four studied groups
Full size table

The study results indicated that the anxiety mean scores of the first, second, and third experimental groups, and the control group were 22, 20, 20.46, and 19.7, respectively, before the intervention. These mean scores immediately decreased after the intervention to 17.93, 16.86, 17.06, and 19.16. Two months after the intervention, the mean scores of the groups were 15.6, 15.7, 15.86., and 19.13 (Table 3).

The study results indicated that the depression mean scores of the first, second, and third experimental groups, and the control group were 15.87, 13.43, 13.93, and 12, respectively, before the intervention. These mean scores immediately decreased after the intervention to 11.4, 10, 10.4, and 11.7. Two months after the intervention, the mean scores of the groups were 9.13, 9.06, 9.73, and 11.86 (Table 3).

The Kruskal-Wallis test was used to check any significant difference between the depression, anxiety, and stress scores of the four groups before and immediately after the intervention. The results of the test do not show a statistically significant difference between the four groups (P > 0.05). However, two months after the intervention, the results of the Kruskal-Wallis test showed a statistically significant difference between the four studied groups in terms of depression (P < 0.001), anxiety (P < 0.001), and stress (P < 0.001).

The post hoc Mann-Whitney test showed that the mean anxiety score two months after the intervention was significantly different between the positive psychology group and the control group (p < 0.001), between the physical activity group and the control group (p < 0.001), and between the simultaneous intervention group and the control group (p = 0.02).

According to the Mann-Whitney post hoc test, the mean depression score two months after the intervention between the positive psychology group and the control group (p = 0.006), between the physical activity intervention group and simultaneous intervention (p = 0.007), and between the physical activity and control group (p < 0.001) had a significant difference.

In addition, the Mann-Whitney post hoc test showed the average stress score two months after the interventions between the positive psychology group and the control group (p < 0.001), between the physical activity intervention group and the control group (p < 0.001), and between the simultaneous intervention group and the control group (p = 0.007) had a significant difference. Two months after the intervention, no statistically significant difference was observed in terms of anxiety, depression, and stress scores between the two groups of physical activity intervention and positive psychology (p > 0.05) (Table 3). Based on the results of the repeated measures test, the trend of changes in the mean scores of stress, depression, and anxiety was significant in the three interventional groups (p < 0.05) (Table 3). No significant adverse events or side effects were observed.

Discussion

The results of the present study indicated that all three interventions—aerobic physical activity, positive psychology, and the combined intervention of positive psychology and physical activity—were effective in alleviating symptoms of depression, anxiety, and stress among university students with premenstrual syndrome. And the mean of depression, anxiety, and stress scores in the three interventions groups was significantly lower than that of the control group. Furthermore, the effects of physical activity intervention and positive psychology on alleviating symptoms of depression, anxiety, and stress were the same.

A review of the literature revealed an absence of studies that examined the same interventions as those investigated in the current research. Therefore, this section compares the results of the present study with the findings from related studies that have explored similar but not identical interventions. The findings of a study indicated that positive-oriented online counseling significantly alleviated premenstrual syndrome symptoms among participants [16]. A different study found that positive cognitive-behavioral therapy (P-CBT) led to notably higher rates of clinically significant or reliable changes in depression, negative affect, and levels of happiness [17]. Another study demonstrated that positive group counseling was effective in reducing physical symptoms, anxiety, interpersonal sensitivity, and aggression associated with PMS, though it did not significantly alleviate depression [18]. The effectiveness of positive psychology in treating depression, anxiety, and stress was further supported by other studies [15, 32], which found that the effectiveness of therapeutic interventions comes from two significant factors. The first factor involves defining interventions that promote pleasure, engagement, and meaning, which are carefully selected justifiable approaches. Another critical aspect is that fostering positive emotions, engagement, and meaning has the potential to reduce the impact of illnesses [33].

The findings of such research are consistent with the fundamental beliefs of positive psychology, which emphasizes the importance of cultivating positive emotions and engagement as essential elements for achieving a satisfying life. Positive psychology also highlights the significance of identifying these factors [34].

Strengthening and developing individuals’ diverse strengths can significantly decrease or eliminate emotional and mental issues [32]. Positive psychology asserts that spotting and defining individuals’ strengths and learning how to apply them effectively can significantly reduce the intensity of depressive symptoms. In general, the stronger the sense of positivism, the lower the risk of depression or anxiety [13].

In addition, it appears that positive psychology can empower individuals by facilitating positive cognitive shifts from negative to positive thoughts and enhancing coping skills. Consequently, one reason for the positive impact of positive psychology may be its direct influence on interpersonal relationships, empowerment of individuals to utilize their capabilities, reinforcement of self-confidence and positive thinking, and reduction of destructive and negative thoughts, thereby improving mood [35, 36].

Top of Form.

Consistent with the present study, the results of studies showed that the aerobic exercise reduced the PMS symptoms, and the impact continued for two months after the study [4, 9, 17, 20,21,22, 35]. Vaghela et al. (2019) found that aerobic physical activity reduced the intensity of pain and PMS symptoms [36], and Vishnupriya and Rajarajeswaram (2011) observed that moderate-intensity aerobic physical activity was effective in managing PMS [37].

Aerobic physical activity leads to a significant increase in serum progesterone levels, which may have beneficial effects in terms of improving mood and reducing stress [38]. Neurotransmitters such as GABA and serotonin are affected by the presence of sex steroids, and the secretion of high levels of endorphins during physical activity is associated with a reduction in pain, anxiety, and depression in women with premenstrual syndrome, which contradicts the decrease in endorphins during the luteal phase [35].

Another potential mechanism for the effectiveness of aerobic physical activity was proposed by Salem (2021) who suggested that the regulatory process of the menstrual cycle depends on the control of leptin [39]. Leptin plays a critical role in managing emotional behaviors, and it increases in women with PMS compared to those without [40]. Psychological symptoms of PMS are associated with increased circulating leptin levels, and several studies have shown that physical activity can lead to a decrease in blood leptin levels, which can reduce behavioral symptoms [41].

A possible general reason for the effectiveness of the interventions in the current study could be attributed to the participants’ lack of prior awareness about PMS and their limited exposure to treatment options before entering the study. It appears that all three interventions were effective in educating the participants about their condition [42,43,44].

Another reason may relate to feasibility of skills and assignments that could be continued individually by women after completion of the interventions. It seems that women had enough time to repeat learned skills individually and obtained more talent. It also seems that positive thinking and positive self-talking with regular practice over time maintain its lasting effect in the mind and increase adaptation and self-regulation, improve relationships with others, forgiveness, and physiologically increase mood-regulating neurotransmitters such as serotonin and endorphins in the body and thus improving mood [33, 42, 43].

Limitations and advantages

The strengths of the current study include a two-month follow-up period post-trial completion to ensure the continued effectiveness of the interventions. Additionally, providing session content as an educational package for future investigators enhances the study’s clinical application. Furthermore, this research used standardized and normalized tools for the Iranian population.

The effectiveness of different short-term interventions suggests viable treatment options for women who prefer alternatives to anti-depressant or hormonal drugs due to concerns about side effects or compliance issues, or who seek complementary treatments for enhanced efficacy in managing PMS.

However, due to some limitations, the results should be generalized with caution. Firstly, the sample size was small; therefore, further research with a larger sample group is recommended. Secondly, due to time constraints, we were unable to conduct any further follow-up actions. The authors suggest that future studies should explore the long-term impact of such interventions with extended follow-up periods. Another limitation of this study was the inability to blind participants and the investigators due to the nature of the interventions, resulting in participants being aware of their assigned treatment, which could potentially affect outcomes.

Conclusion

Among the three non-antidepressant/non-hormonal drug interventions— aerobic physical activity, positive psychology, and the combined intervention of positive psychology and physical activity—all were found to alleviate anxiety, depression, and stress. And the effects of physical activity and positive psychology-based interventions on alleviating anxiety, depression, and stress symptoms in students with premenstrual syndrome were the same. Health care providers, policymakers, and managers are encouraged to incorporate and endorse such interventions in the treatment programs and clinical guidelines for women with PMS.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

PMS:

Premenstrual syndrome

PSST:

The Premenstrual Symptoms Screening Tool

PMDD:

Premenstrual dysphoric disorder

DASS-21:

Depression, anxiety, and stress scale

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Acknowledgements

The authors would like to state their sincerest thanks to the Kermanshah University of Medical Sciences staff and all the people who contributed to this research.

Funding

This research was funded by the Kermanshah University of Medicine Science (grant): 97441. The funder didn’t have any role in the design of the study; collection, analysis, and interpretation of data; and in writing the manuscript.

Author information

Authors and Affiliations

  1. Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Farzane Shavaisi

  2. Department of Reproductive Health, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Sousan Heydarpour

  3. Department of Obstetrics and Gynecology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Nasrin Jalilian

  4. Department of Geriatric and Psychiatric Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Amir Jalali

  5. Social Development and Health Promotion Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran

    Mansour Rezaei

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Contributions

S. Heydarpour and A. Jalali: prepared the manuscript, assisted in designing the study, and helped in the interpretation of the research findings. M. Rezaei: contributed to the design and statistical analysis. F. Shavaisi: participated in most of the steps in the study procedure. N. Jalilian: assisted in designing the study. All authors have read and approved the content of the manuscript.

Corresponding author

Correspondence to Sousan Heydarpour.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Kermanshah University of Medical Sciences (Ref. ID: KUMS.REC.1397.136) and was registered in the Iranian Registry of Clinical Trials; https://irct.behdasht.gov.ir/trial/32363 (ID: IRCT20130812014333N97), registered, 11/08/2018. The participants were fully briefed on the study objectives and procedures and signed an informed written consent. They were assured that their information would remain confidential and that they could withdraw from the study at any stage of the research. The study was conducted in accordance with the Declaration of Helsinki and subsequent.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Shavaisi, F., Heydarpour, S., Jalilian, N. et al. The effects of positive psychology and physical activity on depression, anxiety, and stress among students with premenstrual syndrome: a single-blind, randomized controlled trial. BMC Women's Health 24, 499 (2024). https://doi.org/10.1186/s12905-024-03333-3

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BMC Women's Health

ISSN: 1472-6874

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