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This study will assign patients to two types of psychotherapies in treating people with a major depression disorder, expressive versus supportive techniques, and will examine their ability to benefit from treatment based on their attachment orientation. This is a four month protocol, with a year follow up period, will compare patients receiving supportive-expressive treatment with either expressive focus or supportive focus.
One hundred patients suffering from major depression will participate in 16 sessions of supportive-expressive treatment. Patients will be randomized to one of two conditions: one that places a greater emphasis on supportive techniques, or one that places a greater emphasis on expressive techniques. These two conditions (supportive vs. expressive) hold the potential of either complementing or counter-complementing patients' attachment orientations (e.g., for a patient with higher levels of attachment anxiety, the supportive condition is complementary while the expressive is counter-complementary; the reverse is true for a patient with higher levels of attachment avoidance). Importantly, this study will employ multiple complementary methods, which will include session-by-session self-report alliance questionnaires from both patient and therapist, as well as a cognitive task assessing patients' relationship expectations, and behavioral observations of therapist-patient interactions. This study will be the first to utilize such a combination of methodologies in psychotherapy research and the first to examine the proposed mediation model. It will also be the first to manipulate the use of techniques in order to experimentally examine whether therapeutic techniques can be utilized to develop more efficient treatment models, based on the two transdiagnostic concepts of attachment and alliance. The findings will contribute both to our understanding of the relevance of attachment theory to psychotherapy research, and to the growing empirical literature on targeting transdiagnostic concepts (here, attachment and alliance) that cut across many disorders and treatment orientations. These transdiagnostic concepts can be utilized in the move towards tailoring existing psychological interventions to specific individuals according to their attachment orientations.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Supportive psychotherapy | Experimental | Participants will receive supportive therapy. |
|
| Supportive-expressive psychotherapy | Experimental | Participants will receive supportive-expressive therapy. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Supportive-Expressive Therapy | Behavioral | Supportive-expressive psychotherapy for depressive disorder for 16 weeks. |
|
| Measure | Description | Time Frame |
|---|---|---|
| Hamilton Rating Scale for Depression (HRSD) | A clinically administered measure assessing the severity of depression. The Hamilton is the standard measure of depression severity for clinical trials. The scoring is based on the first 17-items of the Hamilton. 0-7 = NORMAL 8-13 = Mild Depression 14-18 = Moderate Depression 19-22 = Severe Depression >=23 = Very Severe Depression Hamilton Rating Scale for Depression, developed by Max Hamilton in 1967, is a widely used tool for assessing the severity of depression in adults. 17 items covering various aspects of depression experienced in the past week. Each item is rated on a 3-point or 5-point scale depending on the specific symptom. Total score (sum score) provides an indication of depression severity. The range is 0-52 | Slope from baseline to week 16. |
| Measure | Description | Time Frame |
|---|---|---|
| Beck Depression Inventory (BDI) | Beck Depression Inventory; measuring depression by a self-report measure; higher means worse outcomes. The Beck Depression Inventory consists of 21 multiple-choice questions. Each question presents different statements reflecting varying intensities of a particular depressive symptom. Each question has scores ranging from 0 (no symptoms) to 3 (most severe symptoms). The total score is obtained by summing up the scores of all chosen responses. Based on the total score, there are different interpretations of depression severity: Scores in the 0-13 range suggest minimal or no depression. Scores between 14-19 indicate mild depression. Scores from 20-28 reflect moderate depression. Scores 29 and above suggest severe depression. Range 0-63 |
| Measure | Description | Time Frame |
|---|---|---|
| Inventory of Interpersonal Problems Circumplex (IIP-C) | Inventory of Interpersonal Problems Circumplex; measuring interpersonal problems; higher means worse outcomes Inventory of Interpersonal Problems-Circumplex (IIP-C). The IIP-C is a 32-item self-report questionnaire assessing interpersonal difficulties and distress. Patients rate two types of items: interpersonal behaviors that are "hard for you to do" (e.g., "it is hard for me to let other people know when I am angry") and interpersonal behaviors that "you do too much" (e.g., "I am too afraid of other people"). Ratings of the degree to which each problem is distressing are made on a 5-point scale, ranging from 0 (not at all) to 4 (extremely). Calculated as a sum score. Range 0 -128 |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Sigal Zilcha Mano | University of Haifa | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Haifa | Haifa | Mount Carmel | 31905 | Israel |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 14399272 | Background | HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23(1):56-62. doi: 10.1136/jnnp.23.1.56. No abstract available. | |
| 8290681 | Background | Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull. 1993;29(2):321-6. |
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| ID | Title | Description |
|---|---|---|
| FG000 | Supportive-expressive Psychotherapy | Participants will receive supportive-expressive therapy. Supportive-Expressive Therapy: Supportive-expressive psychotherapy for depressive disorder for 16 weeks. |
| FG001 | Supportive Psychotherapy | Participants will receive supportive therapy. Supportive Therapy: Supportive psychotherapy for depressive disorder for 16 weeks. |
| Title | Milestones | Reasons Not Completed | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
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| ID | Title | Description |
|---|---|---|
| BG000 | Supportive Psychotherapy | Participants will receive supportive therapy. Supportive Therapy: Supportive psychotherapy for depressive disorder for 16 weeks. |
| BG001 | Supportive-expressive Psychotherapy |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Hamilton Rating Scale for Depression (HRSD) | A clinically administered measure assessing the severity of depression. The Hamilton is the standard measure of depression severity for clinical trials. The scoring is based on the first 17-items of the Hamilton. 0-7 = NORMAL 8-13 = Mild Depression 14-18 = Moderate Depression 19-22 = Severe Depression >=23 = Very Severe Depression Hamilton Rating Scale for Depression, developed by Max Hamilton in 1967, is a widely used tool for assessing the severity of depression in adults. 17 items covering various aspects of depression experienced in the past week. Each item is rated on a 3-point or 5-point scale depending on the specific symptom. Total score (sum score) provides an indication of depression severity. The range is 0-52 | Posted | Mean | Standard Deviation | units on a scale | Slope from baseline to week 16. |
|
Active phase - baseline to week 16, and then 2 years
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Supportive-expressive Psychotherapy | Participants will receive supportive-expressive therapy. Supportive-Expressive Therapy: Supportive-expressive psychotherapy for depressive disorder for 16 weeks. |
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Because of COVID, 13 patients were treated remotely. The total number of patients was according to the pre-registration.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Prof. Sigal Zilcha-Mano | University of Haifa | 972-4-8249047 | sigalzil@gmail.com |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Jan 21, 2016 | Dec 17, 2024 | Prot_SAP_000.pdf |
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| ID | Term |
|---|---|
| D003865 | Depressive Disorder, Major |
| ID | Term |
|---|---|
| D003866 | Depressive Disorder |
| D019964 | Mood Disorders |
| D001523 | Mental Disorders |
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| ID | Term |
|---|---|
| D010166 | Palliative Care |
| ID | Term |
|---|---|
| D005791 | Patient Care |
| D013812 | Therapeutics |
| D006296 | Health Services |
| D005159 | Health Care Facilities Workforce and Services |
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| Supportive Therapy | Behavioral | Supportive psychotherapy for depressive disorder for 16 weeks. |
|
| Slope from baseline to week 16. Measured at baseline, every week for 16 weeks of treatment, then once a month for four months and follow up after a year; Scores are provided for baseline and change from baseline to week 16 |
| Outcome Questionnaire (OQ) | Outcome Questionnaire; measuring Symptom Distress, Interpersonal Relationships, Social Role; higher levels mean worse outcome. Outcome Questionnaire-30 (OQ-30; Lambert et al., 1996). OQ-30 is a 30-item self-report measure assessing distress, designed to measure patient progress. Items were rated on a 5 point likert scale ranging from 0 (never) to 4 (almost always). The OQ-30 has three subscales assessing symptom distress, interpersonal relations, and social role performance. A total score is calculated by sum scores. Range 0-120 | Slope from baseline to week 16. Measured at baseline, every week for 16 weeks of treatment, then once a month for four months and follow up after a year; Scores are provided for baseline and change from baseline to week 16 |
| Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and changes from baseline to week 16 |
| Experiences in Close Relationships Questionnaire (ECR) | Experiences in Close Relationships Questionnaire; The measurement data will be aggregated into two sub-scales: anxiety and avoidance; higher scores mean worse outcomes (less secure attachment) Experience in Close Relationships Scale (ECR; Brennan et al., 1998). 36-item self-reported measure. Participants rated the extent to which each item was descriptive of their experiences in close relationships on a 7-point Likert scale ranging from 1 (not at all) to 7 (very much). 18 items assessed attachment anxiety (e.g., "I worry about being abandoned"). 18 assessed attachment avoidance (e.g., "I prefer not to show a partner how I feel deep down"). The reliability and validity of these scales have been repeatedly demonstrated (Brennan et al., 1998; Mikulincer & Shaver, 2007). The score for each subscale is calculated as the average value Range 1-7 | Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and changes from baseline to week 16 |
| Quality of Life Enjoyment and Satisfaction- Short Version (Q-LES-Q) | Quality of Life Enjoyment and Satisfaction- Short Version; measuring quality of life; higher scores mean better outcomes. The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). It's a self-report measure, meaning the person being assessed completes the questionnaire themselves. Purpose: It gauges the degree of enjoyment and satisfaction a person experiences in different areas of their daily functioning. Utilize a 5-point Likert scale, ranging from 1 (very poor) to 5 (very good). Higher scores mean better outcomes. Range 1-5. Average score | Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and change from baseline to week 16 |
| 3204198 | Background | Horowitz LM, Rosenberg SE, Baer BA, Ureno G, Villasenor VS. Inventory of interpersonal problems: psychometric properties and clinical applications. J Consult Clin Psychol. 1988 Dec;56(6):885-92. doi: 10.1037//0022-006x.56.6.885. No abstract available. |
| 41678241 | Derived | Leibovich L, Sadek A, Ben David-Sela T, Khoury Y, Malka M, Midgley N, Zilcha-Mano S. "I too deserve good": A qualitative exploration of corrective relational experiences in psychodynamic therapy for depression. Psychotherapy (Chic). 2026 Mar;63(1):24-32. doi: 10.1037/pst0000607. Epub 2026 Feb 12. |
| 38059944 | Derived | Zilcha-Mano S, Webb CA. Identifying who benefits most from supportive versus expressive techniques in psychotherapy for depression: Moderators of within- versus between-individual effects. J Consult Clin Psychol. 2024 Mar;92(3):187-197. doi: 10.1037/ccp0000868. Epub 2023 Dec 7. |
| 35925745 | Derived | Zilcha-Mano S, Ben David-Sela T. Is alliance therapeutic in itself? It depends. J Couns Psychol. 2022 Nov;69(6):786-793. doi: 10.1037/cou0000627. Epub 2022 Aug 4. |
| 34180691 | Derived | Zilcha-Mano S, Dolev-Amit T, Fisher H, Ein-Dor T, Strauss B. Patients' individual differences in implicit and explicit expectations from the therapist as a function of attachment orientation. J Couns Psychol. 2021 Nov;68(6):682-695. doi: 10.1037/cou0000503. Epub 2021 Jun 28. |
| 30419875 | Derived | Zilcha-Mano S, Dolev T, Leibovich L, Barber JP. Identifying the most suitable treatment for depression based on patients' attachment: study protocol for a randomized controlled trial of supportive-expressive vs. supportive treatments. BMC Psychiatry. 2018 Nov 12;18(1):362. doi: 10.1186/s12888-018-1934-1. |
| Scheduling or change in availability |
|
Participants will receive supportive-expressive therapy.
Supportive-Expressive Therapy: Supportive-expressive psychotherapy for depressive disorder for 16 weeks.
| BG002 | Total | Total of all reporting groups |
| Years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race and Ethnicity Not Collected | Race and Ethnicity were not collected from any participant. | Count of Participants | Participants |
|
| Region of Enrollment | Number | participants |
|
| HRSD | Hamilton Rating Scale for Depression | Mean | Standard Deviation | Unit on a scale |
|
| OG001 | Supportive Psychotherapy | Participants will receive supportive therapy. Supportive Therapy: Supportive psychotherapy for depressive disorder for 16 weeks. |
|
|
|
| Secondary | Beck Depression Inventory (BDI) | Beck Depression Inventory; measuring depression by a self-report measure; higher means worse outcomes. The Beck Depression Inventory consists of 21 multiple-choice questions. Each question presents different statements reflecting varying intensities of a particular depressive symptom. Each question has scores ranging from 0 (no symptoms) to 3 (most severe symptoms). The total score is obtained by summing up the scores of all chosen responses. Based on the total score, there are different interpretations of depression severity: Scores in the 0-13 range suggest minimal or no depression. Scores between 14-19 indicate mild depression. Scores from 20-28 reflect moderate depression. Scores 29 and above suggest severe depression. Range 0-63 | Posted | Mean | Standard Deviation | units on a scale | Slope from baseline to week 16. Measured at baseline, every week for 16 weeks of treatment, then once a month for four months and follow up after a year; Scores are provided for baseline and change from baseline to week 16 |
|
|
|
| Secondary | Outcome Questionnaire (OQ) | Outcome Questionnaire; measuring Symptom Distress, Interpersonal Relationships, Social Role; higher levels mean worse outcome. Outcome Questionnaire-30 (OQ-30; Lambert et al., 1996). OQ-30 is a 30-item self-report measure assessing distress, designed to measure patient progress. Items were rated on a 5 point likert scale ranging from 0 (never) to 4 (almost always). The OQ-30 has three subscales assessing symptom distress, interpersonal relations, and social role performance. A total score is calculated by sum scores. Range 0-120 | Posted | Mean | Standard Deviation | units on a scale | Slope from baseline to week 16. Measured at baseline, every week for 16 weeks of treatment, then once a month for four months and follow up after a year; Scores are provided for baseline and change from baseline to week 16 |
|
|
|
| Other Pre-specified | Inventory of Interpersonal Problems Circumplex (IIP-C) | Inventory of Interpersonal Problems Circumplex; measuring interpersonal problems; higher means worse outcomes Inventory of Interpersonal Problems-Circumplex (IIP-C). The IIP-C is a 32-item self-report questionnaire assessing interpersonal difficulties and distress. Patients rate two types of items: interpersonal behaviors that are "hard for you to do" (e.g., "it is hard for me to let other people know when I am angry") and interpersonal behaviors that "you do too much" (e.g., "I am too afraid of other people"). Ratings of the degree to which each problem is distressing are made on a 5-point scale, ranging from 0 (not at all) to 4 (extremely). Calculated as a sum score. Range 0 -128 | Posted | Mean | Standard Deviation | units on a scale | Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and changes from baseline to week 16 |
|
|
|
| Other Pre-specified | Experiences in Close Relationships Questionnaire (ECR) | Experiences in Close Relationships Questionnaire; The measurement data will be aggregated into two sub-scales: anxiety and avoidance; higher scores mean worse outcomes (less secure attachment) Experience in Close Relationships Scale (ECR; Brennan et al., 1998). 36-item self-reported measure. Participants rated the extent to which each item was descriptive of their experiences in close relationships on a 7-point Likert scale ranging from 1 (not at all) to 7 (very much). 18 items assessed attachment anxiety (e.g., "I worry about being abandoned"). 18 assessed attachment avoidance (e.g., "I prefer not to show a partner how I feel deep down"). The reliability and validity of these scales have been repeatedly demonstrated (Brennan et al., 1998; Mikulincer & Shaver, 2007). The score for each subscale is calculated as the average value Range 1-7 | Posted | Mean | Standard Deviation | units on a scale | Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and changes from baseline to week 16 |
|
|
|
| Other Pre-specified | Quality of Life Enjoyment and Satisfaction- Short Version (Q-LES-Q) | Quality of Life Enjoyment and Satisfaction- Short Version; measuring quality of life; higher scores mean better outcomes. The Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). It's a self-report measure, meaning the person being assessed completes the questionnaire themselves. Purpose: It gauges the degree of enjoyment and satisfaction a person experiences in different areas of their daily functioning. Utilize a 5-point Likert scale, ranging from 1 (very poor) to 5 (very good). Higher scores mean better outcomes. Range 1-5. Average score | Posted | Mean | Standard Deviation | units on a scale | Measured at baseline, six times during the treatment (weeks 1, 2, 4, 8, 12, 16), then once a month for four months and follow up after a year; reports refer to baseline and change from baseline to week 16 |
|
|
|
| 0 |
| 50 |
| 0 |
| 50 |
| 0 |
| 50 |
| EG001 | Supportive Psychotherapy | Participants will receive supportive therapy. Supportive Therapy: Supportive psychotherapy for depressive disorder for 16 weeks. | 0 | 50 | 0 | 50 | 0 | 50 |
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| Anxiety - baseline |
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| Avoidance - baseline |
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