Background
Mental health has traditionally been defined as the absence of psychopathology [
1]: Individuals were seen as either mentally ill or presumed to be mentally healthy. Meanwhile, it is widely recognized that positive mental health (PMH), i.e., a positive sense of well-being, as well as the capacity to enjoy life and deal with life’s challenges (cf., [
1]), and the absence of psychopathology are not the same. It is rather the case that elements of PMH and psychopathology can be present at the same time (“dual factor model of metal health”, e.g., [
2]); as such PMH and psychopathology are not opposite ends of a single continuum; rather they represent different but correlated axes [
3]. In this view, both PMH and psychopathology are required for complete mental health assessments and should be integrated in research and practice. In fact, various studies point to the fact that PMH is a stronger predictor for the course of mental disorder than markers of psychopathology [
4,
5]. Nevertheless, most studies in clinical psychology and psychiatry continue to exclusively focus on negative aspects of mental health. To overcome this deficiency, time-efficient measurement instruments for the assessment of PMH are needed that are equally suitable for use in research and clinical practice.
The Positive Mental Health Scale (PMH-Scale) is such a new, brief, time-efficient and frequently used measure to assess PMH. The scale contains nine items [
6] that capture aspects of subjective well-being (“I enjoy my life”), as well as items that capture aspects of psychological well-being, such as environmental mastery (“I manage well to fulfill my needs”) and self-acceptance (“I am in good physical and emotional condition”). The PMH-Scale thus integrates facets from two traditions of well-being research: The hedonic tradition focusing on positive affect and life-satisfaction and the eudemonic tradition focusing on optimal functioning in everyday life [
1,
7]. In validation studies of the PMH-Scale a unidimensional structure, good to excellent internal consistency (Cronbach’s alpha = .82–.93), good test-retest reliability (≥ .74) and scalar invariance across samples and over time were demonstrated in research from various countries such as Germany [
6], China and Russia [
8], Lithuania [
9], Pakistan [
10], France, Poland, Spain, Sweden, the U.K. and the U.S. [
11]. In correlational analyses, the PMH-Scale was negatively associated with self-report measures of depression, anxiety and stress and positively associated with measures of social support, subjective happiness, and life satisfaction [
6,
8].
In longitudinal predictor studies, PMH, as assessed with the PMH-Scale [
6], was found to be of central importance for the remission of mental disorders in general [
4] and anxiety disorders [
12‐
14] as well as suicidal ideation [
15] in particular. Furthermore, current level of PMH was shown to be a unique predictor not only of the level of future PMH, but also of the level of future mental health problems [
16]. In two recent studies, PMH was identified as a prospective predictor of lower psychological burden experienced by the COVID-19 situation in spring 2020 [
17], as well as of greater adherence and acceptance of COVID-19 related restrictions [
11]. Finally – and most extensively researched – PMH has been shown to moderate the association between various risk factors (e.g., depression, stress, perceived burdensomeness, entrapment, addictive symptoms) and suicide ideation [
18‐
21]. Furthermore, PMH was found to buffer the association between suicide ideation and suicide attempts [
22]. These moderating properties of PMH were shown both in cross-sectional (e.g., [
19]) and in longitudinal studies [
18,
22‐
24]. In a first cross-cultural comparison, Siegmann et al. [
19] found PMH to buffer the effect of depressive symptoms on suicide ideation in German and Chinese students: Students who reported high levels of PMH showed no increase in suicide ideation even as depression levels increased. Taken together, positive mental health seems to be of extensive salutogenetic importance.
In order to facilitate cross-cultural studies, it is essential to have validated measurement tools in different languages [
8‐
11]. The comparison of Western individualistic cultures with more collectivistic cultures, such as Iran, is of particular interest. With the aim of enabling comparative cross-cultural studies of the conditions and significance of PMH, the present study aimed to examine the factor structure, psychometric properties, and construct validity of the Persian version of the PMH-Scale within an Iranian student sample. Furthermore, it was aimed to investigate, whether PMH, as assessed by the Persian version of the PMH-Scale, buffers the impact of depression on suicide ideation/behavior and as such confers resilience against suicide ideation and behavior in a country with a cultural background different from that in Germany and China [
19]. In order to establish comparability with previous studies on the PMH-Scale (e.g., [
6,
8‐
10,
19]) and since suicide ideation/behavior is common in student samples [
25], the validation of the Persian PMH-Scale was performed on a student sample.
Discussion
In the present study, the reliability and construct validity as well as the postulated factor structure of the Persian version of the Positive Mental Health Scale (PMH-Scale) were investigated. In line with the original version of the PMH-Scale [
6] and its various translated versions [
8,
9,
11], the Persian version of the PMH-Scale had a unidimensional factor structure and an excellent internal consistency. These results confirm previous findings from other countries (e.g., [
6,
11] that described the PMH-Scale as a time-efficient instrument for the assessment of positive mental health. Moreover, they extend the research on PMH by providing a valid and reliable Persian language version of this instrument that can be applied in Iranian samples.
Construct validity of the PMH-Scale was supported by expected associations between the PMH-Scale and depressive symptoms, suicide ideation/behavior and social support (cf., [
6,
19]). The finding on significant associations between PMH scores and trauma-related constructs (i.e., post-traumatic symptoms and post-traumatic growth) extends prior work on the PMH and complements findings from a Lithuanian study showing a negative association between PMH, life stressors and adjustment disorder symptoms [
9]. Taken together the present results underscore the relevance of PMH in relation to a broad spectrum of psychopathological symptoms. A possible reciprocal relationship between PMH and post-traumatic growth should be considered in more detail in future studies (cf., [
42]).
PMH scores differentiated between participants with higher vs. lower suicide risk. Furthermore, PMH moderated the association between depressive symptoms and suicide ideation/behavior. Therefore, it was possible to replicate a finding previously shown in samples of German and Chinese students [
19]: Those participants who reported a greater level of PMH were less likely to experience suicide ideation/behavior even at the highest severity of depressive symptoms as compared to participants who reported low level of PMH. This is yet another indication that PMH can be considered as conferring resilience (cf., [
43]).
In terms of practical implications, the results of the current study underscore the importance of accounting for the presence of PMH in addition to aspects of psychopathology. Furthermore, the fact that PMH can significantly alter the impact of depressive symptoms on suicide ideation/behavior may be an important aspect to incorporate in clinical interventions. Finally, preventive programs for student populations may benefit from a focus on the fostering of PMH. Notably, first available studies showed that physical activity and loving kindness meditation have a positive impact on PMH [
44,
45]. With respect to the fact that self-acceptance and environmental mastery are central facets of PMH [
21], clinicians might also focus on fostering self-compassion [
46] and (renewed) access to personal strengths and resources [
47,
48].
Several limitations have to be considered when interpreting the current results. First, since 100% of the sample were students, it is unclear how the findings would generalize to a more diverse and/or clinical population. Yet, with regard both to suicide ideation/behavior [
25] as well as changes in well-being [
49] student populations are a group of special concern. Second, the cross-sectional design of the current study precludes analyses of test-retest reliability and scalar invariance over time. Longitudinal studies on these issues are warranted. In a similar vein, it is necessary to investigate, whether PMH does not only buffer the impact of depressive symptoms on suicide ideation/behavior in a cross-sectional study design, but also in a longitudinal study design (cf., [
24]). Third, the current study utilized only self-report measures of depressive symptoms, post-traumatic symptoms, and suicide ideation/behavior. This method has certain advantages, for example, the measures are economical and easy to administer. However, self-report measures may fail to capture suicide ideation/behavior, depressive symptoms, or post-traumatic symptoms in their full complexity. Fourth, to establish convergent validity, it would have been good if other measures of PMH, such as the Psychological Well-Being Scale [
50] or the Satisfaction with Life Scale [
51], had been available. Fifth, when investigating the factor structure of a scale, an exploratory factor analysis is recommended to be complemented by a confirmatory factor analysis. Both analyses should be calculated with independent samples [
39‐
41]. In the present study, only one sample has been assessed that was used for the exploratory factor analysis. Therefore, future research is advised to further investigate the factor structure of the current Persian version of the PMH-Scale by the calculation of a confirmatory factor analysis in a separate sample. Moreover, the current findings indicate that the cultural invariance of the Persian version of the PMH-Scale can be determined in a next step by the comparison of Iranian data with data gained in other countries [
8,
42].
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