The Effectiveness of Group Logotherapy on Middle-Aged Women With Depression
Article information
Abstract
Objective
The aim of this study is to evaluate the efficacy of a group logotherapy-based intervention, the life meaning promotion (LMP) program, in improving psychological outcomes for middle-aged women with depression.
Methods
A randomized, single-blind controlled trial was conducted with 38 women (age 40–59 years) diagnosed with mild-to-moderate major depressive disorder. Participants were randomly assigned to the LMP group (8 sessions of meaning-oriented group therapy over 4 weeks) or a control group (no intervention). Outcome measures—including the Meaning in Life Questionnaire, purpose in life (PIL) scale, Center for Epidemiologic Studies Depression Scale, Self-Efficacy Scale, and Quality of Life scale—were administered at baseline, post-treatment (4 weeks), and follow-up (8 weeks). Between-group differences over time were analyzed using repeated-measures analysis of variance.
Results
The LMP group showed significantly greater improvements than controls on all outcome measures at 4 and 8 weeks (p<0.05). Specifically, participants receiving LMP reported increased meaning and PIL, higher self-efficacy, improved quality of life, and reduced depressive symptoms. These gains were maintained at 8 weeks. The effect sizes for group differences were large, indicating clinically meaningful benefits of the LMP intervention.
Conclusion
A structured, meaning-focused group logotherapy intervention was effective in enhancing meaning in life, purpose, and overall psychological well-being while reducing depression in middle-aged women. The LMP program may be a valuable therapeutic approach to improve mental health outcomes in this population.
INTRODUCTION
The concept of “meaning in life” is defined as both the motivation to seek meaning and the subjective perception that one’s life holds significance [1]. Individuals with a high sense of meaning in life tend to exhibit greater self-efficacy, which is the positive belief that they can make autonomous choices in their actions [2]. A strong sense of meaning in life provides individuals with confidence in their life direction, the foundation for their choices, and the courage to achieve their goals, ultimately enhancing their self-efficacy [3].
Middle-aged women experience various physical, psychological, and social changes as they transition through a critical phase of life [4]. During this period, they undergo physiological changes due to aging, including menopause, as well as shifts in family dynamics, such as children’s academic progression, career transitions, and marriage [4]. These changes often lead to a transformation in their roles within the family and society. Many middle-aged women are known to experience a loss of meaning in life due to a decline in self-esteem and self-efficacy throughout this transitional period [5]. The loss of meaning in life in middle-aged women has been identified as a psychosocial factor contributing to depression [6]. Previous studies have reported a significant negative correlation between meaning in life and depressive symptoms, indicating that individuals with higher levels of meaning in life tend to experience lower levels of depression [7,8].
One of the psychotherapeutic models for treating depression is logotherapy, which aims to reduce the loss of meaning in life and help individuals rediscover their sense of purpose. To date, logotherapy has been studied in various populations, including cancer patients, elderly individuals with depression, alcohol-dependent individuals, and Korean immigrants. Findings from these studies indicate that logotherapy enhances individuals’ sense of meaning in life, reduces physical pain, alleviates anxiety and depression, and promotes positive psychological states such as self-esteem, quality of life (QoL), selfefficacy, resilience, well-being, and hope. Furthermore, research comparing the effectiveness of cognitive-behavioral therapy (CBT) and logotherapy has demonstrated that logotherapy significantly improves depressive symptoms in the elderly. While prior studies have largely validated the efficacy of logotherapy, there is a paucity of studies specifically targeting middle-aged women with depression, who frequently experience a loss of meaning in life due to drastic role transition. In addition, many existing logotherapy interventions lack structured formats, making them challenging to apply effectively in clinical practice. To bridge this gap, we developed a structured, 8-session group logotherapy program called the life meaning promotion (LMP) program based on Stark’s Theory of Meaning, designed to help individuals rediscover meaning in life when faced with existential challenges [9]. The program incorporates three core dimensions of meaning: creative values, experiential values, and attitudinal values.
In this study, we implemented our previously developed LMP program for a 4-week intervention with middle-aged women diagnosed with depression, recruited from the community. The aim of this study was to investigate the effectiveness of this structured LMP program in alleviating depressive symptoms and enhancing psychological well-being in middle-aged women with mild-to-moderated depression.
METHODS
Study participants
Middel-aged women residing in a community in Songpa-gu area, Seoul, Republic of Korea were recruited via public advertisements between January 14 and September 2, 2020. Inclusion criteria were as follows: 1) patients aged between 40 to 59; 2) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnosis of major depressive disorder established with Mini International Neuropsychiatric Interview [10]; 3) mild to moderate depressive symptoms defined by a Korean version of the Patient Health Questionnaire-9 (PHQ-9) [11] score between 5 and 19; and 4) normal cognitive function, ability to communicate, understanding of the study purpose, and provision of written informed consent. Exclusion criteria were: 1) a history of other psychiatric disorders (e.g., schizophrenia, delusional disorder, substance abuse); 2) unstable medical conditions (e.g., cancer, poorly controlled hypertension, angina, or diabetes); 3) non-depressed (PHQ-9 ≤4) or severely depressed (PHQ-9 ≥20) subjects; 4) initiation of psychiatric medication or a change in psychotropic dosage within the preceding 4 weeks; and 5) concurrent participation in another psychological intervention during the study period. The minimum sample size was calculated in G*power 3.1.9 program (Kiel University). Accordingly, the number of samples to be included in the study for 80% power, at the 0.05 α level, 3 for repeated measurements, 2 groups, and 0.4 for the effect size margin of error was determined as 36.
Structured LMP program
In this study, we implemented our previously developed structured 8-session LMP program for middle-aged women to cultivate purpose, agency, and self-transcendence [9]. The brief content of each session was as follows: Session 1 established a safe group climate and introduced LMP; participants chose nicknames and began weekly reflections on Viktor Frankl’s phrases. Session 2 promoted self-discovery through identity mapping, family trees, and recalling peak moments and affirming feedback. Session 3 developed creative values via logodrama (“When you turn 90…”) to envision legacy and courageous, responsible action. Session 4 emphasized experiential values by mapping “mountain ranges” of meaningful encounters and considering how others see them. Session 5 addressed attitudinal values by transforming unavoidable pain into meaning through life graphs, a “joy biography,” and letters to one’s past self. Session 6 highlighted freedom and responsibility using Lukas’s five-step problem-solving and articulating three heartfelt wishes. Session 7 cultivated self-transcendence through prosocial, creative acts. Session 8 consolidated gains with written life goals and a peer “rolling paper,” reinforcing purposeful reflection and small, meaningful actions (Table 1).
Structured life meaning promotion program in this study
Outcome measures
Meaning in life
Meaning in life of study participants was assessed using the Korean version of the Meaning in Life Questionnaire (MLQ) [12,13]. The MLQ is a 10-item self-report measure rated on a 7-point Likert scale and comprises two subscales: search for meaning (5 items) and presence of meaning (5 items). Total scores range from 10 to 70, with higher scores indicating greater meaning in life.
Purpose in life
Purpose in life (PIL) was measured with the Korean version of the PIL scale [14]. The PIL consists of 20 items rated on a 7-point Likert scale (range 20–140), with higher scores reflecting a stronger sense of purpose.
Depression
Depressive symptoms were measured using the Korean version of the Center for Epidemiologic Studies Depression Scale (CES-D) [15]. Participants rated the frequency of depressive symptoms experienced over the past week on a 4-point Likert scale (0–3) across 20 items; higher scores denote greater depressive symptomatology.
Self-efficacy
Self-efficacy was evaluated using the Korean version of the Self-Efficacy Scale comprising 7 items rated on a 4-point Likert scale (1–4). Higher scores indicate greater self-efficacy [16].
QoL
QoL was assessed with the Korean version of the World Health Organization Quality of Life assessment instrument (WHOQOL-BREF) [17]. This instrument includes 26 items rated on a 5-point Likert scale (1–5) and yields scores for overall QoL/general health and four domains: physical health, psychological health, social relationships, and environment. Higher scores indicate better QoL.
Study design
The LMP program intervention was conducted by the researcher of this study, who had years of work experience in psychiatric wards and community mental health welfare centers with first-class mental health nurse qualifications in the community social welfare centers. Participants were randomly assigned to either the LMP or control group in a 1:1 ratio at baseline. The participants were randomized using a permuted block randomization method through SAS version 9.4 (SAS Institute Inc.). All surveys collected data by a single blind method through research assistants, not researchers. Participants in the LMP group completed a pre-treatment baseline assessment, followed by an 8-session LMP program delivered in a group format twice weekly over 4 weeks (90 minutes per session). A post-test was conducted immediately after the 4-week program, and a follow-up assessment was conducted 8 weeks after baseline assessment to examine maintenance effects. The control group underwent assessments at the same three points (baseline, 4 weeks, and 8 weeks) and received no intervention during the study period. This study was conducted in accordance with the International Conference on Harmonization Good Clinical Practice Guidelines. The study protocol was approved by the Institutional Review Board of Ajou University Hospital (approval no. AJIRB-SBR-SUR-19-477). In order to exclude problems and halo effects in the data collection procedure, the survey was measured as a single blind through a research assistant who did not know the assignment of the experimental group and the control group, not the same researcher.
Statistical analysis
Data were analyzed using SPSS Statistics version 23.0 (IBM Corp.). Normality was assessed using the Kolmogorov–Smirnov test. Baseline homogeneity of baseline demographic and clinical characteristics between the intervention and control groups was examined using independent-samples t-tests or chisquare tests. Program efficacy was evaluated with repeatedmeasures analysis of variance (ANOVA). Pairwise comparisons were conducted for pre-vs. post-, pre-vs. follow-up, and post-vs. follow-up assessments, with Bonferroni correction applied to control for multiple comparisons. Effect sizes were reported as partial eta squared (ηp²). A two-tailed α=0.05 was considered statistically significant.
RESULTS
Baseline demographic characteristics
A total of 38 women participated in this study (Table 2). In the LMP group, 33 individuals were initially enrolled; following screening, 13 were excluded, and 20 completed the baseline assessment, program sessions, post-test, and follow-up. In the control group, 23 were initially enrolled; 5 were excluded after screening, and 18 completed all study assessments. Comparisons of demographic variables and baseline clinical scales did not show any statistically significant between-group differences. The mean age was 48.15 years in the LMP group and 46.67 years in the control group. In both groups, the largest proportion had university-level education, and most respondents reported middle perceived economic status. There were no significant differences in baseline clinical characteristics between groups. The mean MLQ total score was 41.90 in the LMP group and 39.00 in the control group (p=0.30). The mean PIL score was 83.75 and 81.17, respectively (p=0.65). The mean CES-D score was 24.60 vs. 23.56 (p=0.68). Self-efficacy averaged 18.50 vs. 20.44 (p=0.10). The WHOQOLBREF total score averaged 84.00 vs. 82.44 (p=0.61).
Baseline demographic and clinical characteristics
Effectiveness of the LMP program
A two (group: LMP vs. control)×three (time: baseline, 4 weeks, 8 weeks) repeated-measures ANOVA showed statistically significant between-group differences during the study period. The MLQ score exhibited a significant time by group interaction (F=16.05, p<0.001), plus main effects of group (F=9.41, p=0.004) and time (F=56.47, p<0.001). The PIL scores showed significant interaction (F=9.61, p<0.001) and main effects of group (F=5.37, p=0.03) and time (F=12.84, p<0.001). The CES-D scores revealed significant interaction (F=13.24, p<0.001), with main effects of group (F=6.02, p=0.019) and time (F=34.41, p<0.001). For self-efficacy scores, only the time ×group interaction was significant (F=10.59, p<0.001); neither the group main effect (F=0.14, p=0.708) nor time (F=2.58, p=0.097) reached significance. The WHOQOL-BREF showed a significant interaction (F=18.53, p<0.001) and main effects of group (F=5.31, p=0.027) and time (F=44.52, p< 0.001). Overall, the LMP group followed more favorable change trajectories than controls across outcomes over 8 weeks.
Effect sizes were estimated as partial eta-squared (ηp²) from the reported F-statistics, using standard degrees of freedom for a two-group, three-timepoint design (within-subject df2=72; between-subject df2=36; total n=38). Interaction ηp² values were MLQ=0.31, PIL=0.21, CES-D=0.27, self-efficacy=0.23, and WHOQOL=0.34—all in the large range. Time effects were also large to very large for MLQ=0.61, WHOQOL=0.55, CES-D=0.49, and PIL=0.26; the time effect for self-efficacy was small (0.07) and not statistically significant. Group main-effect ηp2 values were MLQ=0.21, CES-D=0.14, PIL=0.13, WHOQOL=0.13, and self-efficacy=0.004, indicating medium-to-large between-group differences overall, except for self-efficacy. In sum, the LMP produced large, clinically meaningful differential improvements in meaning, purpose, mood, and QoL over the study period (Figure 1).
Outcome measures changes (A) MLQ score, (B) PIL score, (C) CES-D score, (D) Self-efficacy score, and (E) WHOQOL-BREF score) from baseline, 4 weeks, and 8 weeks. LMP, life meaning promotion (intervention); MLQ, Meaning in Life Questionnaire; PIL, purpose in life; CES-D, Center for Epidemiologic Studies Depression Scale; WHOQOL-BREF, World Health Organization Quality of Life assessment instrument.
DISCUSSION
This randomized, single-blind trial showed that the 4-week group-based, structured LMP program produced significant improvements in psychological and existential functioning among middle-aged women with depression in the community settings. Across three assessments (baseline, 4 weeks, 8 weeks), the LMP group demonstrated statistically significant improvement than controls in meaning in life, PIL, depressive symptoms (CES-D), self-efficacy, and QoL (WHOQOLBREF). Time by group interactions were significant for all outcomes, indicating divergent trajectories favoring the LMP program. Interaction effects were large, suggesting that the observed differences are not only statistically significant but also clinically meaningful over a 4-week trial.
Our findings for meaning in life was in line with the previous logotherapy and meaning-centered therapy studies, which posit that cultivating purpose, values-congruent action, and attitudinal freedom reduced distress and enhanced well-being in the middle-aged women with depression. Previous trials also reported that meaning-centered or logotherapy-based programs reliably increased meaning and related existential outcomes compared with controls [18-20]. The significant increase in the MLQ score in the present study was consistent with prior studies showing that therapies grounded in existential or positive psychology could enhance one’s sense of meaning. A prior study by Sun et al. [18] reported that a 12-week logotherapy-based intervention for depressed patients led to significantly higher meaning in life scores compared to controls. Similarly, group-based meaning-oriented therapies have demonstrated increased perceived life meaning in cancer survivors [19]. We showed that even a relatively brief (4-week) program might be able to yield similar therapeutic effects. A notable strength of our LMP program might be simultaneous targeting life meaning and purpose; this dual focus might be im-portant because PIL had an established inverse relationship with depression in midlife and older adults [21].
There was significant improvement in the PIL score after the 4-week LMP program. From the previous literature, purpose is known to be the goal-directed facet of meaning and inversely associated with depressive symptoms and impaired functioning [21]. In these regards, the structure of the LMP such as self-clarification, values articulation, and prosocial microactions might enhance goal re-engagement, translating existential gains into day-to-day direction in the study participants.
The CES-D reductions observed were consistent with evidence that meaning-focused interventions might be able to relieve depressed mood while enhancing existential resources [18-20]. In mechanistic terms, increases in meaning and purpose might counter hopelessness and passivity, facilitating adaptive reappraisal and behavioral activation. Prior studies showed that changes in personal meaning could mediate the antidepressant effects of life review or meaning-centered treatments [22], suggesting a plausible pathway also operating in the LMP group. The present results added that symptom relief co-occurred with rises in self-efficacy and QoL, indicating that benefits extended beyond mood control to perceived capability and holistic well-being.
After 4-week trial, self-efficacy showed a significant groupby-time interaction, indicating greater improvement in LMP group, a pattern that coheres with social-cognitive theory (mastery experiences, vicarious learning, and verbal persuasion) [23]. Although improving self-efficacy is not a primary aim of classic logotherapy, it appeared to be a beneficial byproduct of the LMP program. Group discussion, logodrama, and responsibility-focused problem solving might create repeated mastery “micro-wins,” bolstering confidence to handle stressors. Similar gains reported in strength- or meaning-based group programs that foreground personal resources and valuecongruent action [24]. Although self-efficacy is not always measured in meaning-centered trials, our results suggest that selfefficacy might be a sensitive and clinically relevant target when the intervention explicitly links purpose to feasible next steps.
QoL also improved significantly more in the LMP group than the control group. This result might be in line with prior meaning-centered psychotherapy trials in serious illness, where enhanced meaning translated into better global life appraisal [19,20]. The QoL scores shifted over a short interval implies that addressing existential needs may have rapid downstream effects on satisfaction, relationships, and role participation, complementing symptomatic improvement.
To date, previous studies did not report equally strong shifts in meaning, purpose, or mood symptoms. When compared with active psychotherapies (e.g., CBT), meaning-centered approaches typically match depression outcomes while surpassing comparators on meaning-specific endpoints [19]. Such patterns help contextualize our results: 1) participants had room to improve on existential and mood metrics, 2) the intervention devoted substantial time to directly building meaning, and 3) group delivery may have amplified effects via belonging and shared narrative reconstruction. Collectively, these factors might play a pivotal role in the robust interactions seen across MLQ, PIL, CES-D, self-efficacy, and QoL.
Despite its positive results, this study has several limitations. Firstly, relatively small sample size limits the generalizability of the findings. Further prospective study with larger sample would increase statistical power and confidence in the stability of the effect size estimates. Secondly, as study design was single-blinded, there was a risk of expectancy effects or pla-cebo influences. Although we attempted to blind the outcome assessors, the lack of a double-blind, placebo-controlled design could introduce some bias in self-reported outcomes. Thirdly, outcomes were only tracked up to 8 weeks. While we found that improvements persisted at 4 weeks after the program, it remains unknown whether these gains are maintained over longer periods such as 6 months or 1 year. Depression often has a recurrent course, and meaning in life can fluctuate with life events; thus, a longer-term follow-up is needed to determine if the LMP program confers enduring resilience or if booster sessions might be required. Lastly, all outcome measures (meaning, purpose, depression symptoms, self-efficacy, and QoL) were self-reported questionnaires. Self-report could be subject to biases like social desirability, especially since participants knew their progress was being monitored. Therefore, future research should incorporate more objective or clinician-rated measures to corroborate the self-reported data.
In conclusion, a short, structured LMP program produced convergent improvements across five core outcomes, higher meaning and purpose, lower depressive symptoms, greater self-efficacy, and better QoL—with large, practically relevant divergences from control over 8 weeks. Future work should consolidate these findings in larger, multi-site randomized trials with active controls and longer follow-up, and clarify underlying therapeutic mechanisms. Until then, the present study offers timely evidence that cultivating meaning might be a viable and scalable path to recovery for depressed midlife women in community settings.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Author Contributions
Conceptualization: Jung A Son, Myeong-hui Choe. Data curation: Jung A Son. Formal analysis: Jung A Son, Myeong-hui Choe. Methodology: Jung A Son. Supervision: Jung A Son. Visualization: Jung A Son, Myeonghui Choe. Writing—original draft: Jung A Son. Writing—review & editing: Jung A Son, Myeong-hui Choe.
Funding Statement
None
Acknowledgments
None