The goal of this clinical trial is to learn whether brief psychoanalytic therapy and cognitive behavioral therapy (CBT) reduce depressive symptoms in adults aged 18 to 65 who have been diagnosed with major depressive disorder. The main questions it aims to answer are:
* Does brief psychoanalytic therapy reduce depression severity more than a waitlist control condition after 18 weeks? * Does CBT reduce depression severity more than a waitlist control condition after 18 weeks?
Researchers will also compare brief psychoanalytic therapy with CBT to explore whether one works better than the other, and will examine whether changes in defense mechanisms and automatic negative thoughts explain improvement in each therapy.
Participants will:
* Be randomly assigned to brief psychoanalytic therapy, CBT, or a waitlist control group (30 participants per group) * In the therapy groups, attend 18 weekly individual therapy sessions of 50 minutes each * In the waitlist group, continue their usual psychiatric care without psychotherapy for 18 weeks, and then be offered one of the therapies * Complete clinical interviews and questionnaires about depression, anxiety, quality of life, thought patterns and coping styles before treatment, at week 9 and at week 18 * In the therapy groups, complete follow-up assessments 6 and 12 months after treatment ends
Primary DSM-5-TR diagnosis of Major Depressive Disorder (single or recurrent episode), established by a psychiatrist and confirmed with the Structured Clinical Interview for DSM-5, Clinician Version (SCID-5-CV)
Hamilton Depression Rating Scale (HAM-D-17) total score of 14 or higher at baseline
Either not taking antidepressant medication, or on a stable antidepressant dose for at least 8 weeks before enrollment and willing to keep the dose unchanged during the 18-week treatment phase
Literate in Turkish and able to attend weekly sessions
Bipolar disorder, schizophrenia spectrum or other psychotic disorder, or major depressive disorder with psychotic features
Moderate or severe substance use disorder within the past 6 months
High suicide risk, defined as active suicidal ideation with plan or intent, or a suicide attempt within the past 12 months
Another primary psychiatric diagnosis requiring different treatment (e.g., posttraumatic stress disorder, obsessive-compulsive disorder, eating disorder, or severe personality disorder)
Parallel
Brief Psychoanalytic Therapy
BehavioralManualized brief psychoanalytic therapy based on Luborsky's supportive-expressive model and the unified protocol for short-term psychodynamic therapy of depression. Delivered as 18 weekly individual 50-minute sessions by licensed clinical psychologists trained in psychodynamic therapy. Focuses on a Core Conflictual Relationship Theme, defenses, self-criticism, loss and aggression, and includes a structured termination phase addressing separation and loss.
Cognitive Behavioral Therapy
BehavioralManualized cognitive behavioral therapy based on Beck's cognitive therapy for depression. Delivered as 18 weekly individual 50-minute sessions by licensed clinical psychologists trained in CBT. Includes psychoeducation, behavioral activation, cognitive restructuring of automatic thoughts, modification of intermediate and core beliefs, relapse prevention, and structured weekly homework.
Change in Depression Severity (HAM-D-17)
Depression severity measured with the 17-item Hamilton Depression Rating Scale (Turkish version), administered by an independent assessor blind to group allocation. Total score ranges from 0 to 52; higher scores indicate more severe depression. Change from baseline to week 18 is compared between each active therapy and the waitlist control.
Change in Self-Reported Depressive Symptoms (BDI-II)
Measured with the Beck Depression Inventory-II (Turkish version). Total score ranges from 0 to 63; higher scores indicate more severe depressive symptoms.
Treatment Response Rate
Percentage of participants achieving a reduction of 50% or more in HAM-D-17 total score from baseline.
Remission Rate
Percentage of participants with a HAM-D-17 total score of 7 or less.
Change in Anxiety Symptoms (BAI)
Measured with the Beck Anxiety Inventory (Turkish version). Total score ranges from 0 to 63; higher scores indicate more severe anxiety.
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