Major depressive disorder (MDD) is one of the most common psychiatric conditions and often remains difficult to treat effectively. Many patients continue to experience residual symptoms or relapse even after receiving established forms of psychotherapy. This study tests whether targeting specific psychological mechanisms can improve outcomes for people with depression. We compare two novel group therapies: (1) Expectation-Focused Psychotherapeutic Intervention (EFPI), which aims to modify rigid, negative expectations that maintain depressive symptoms, and (2) Reward Enhancement and Activation Therapy (REACT), which focuses on increasing sensitivity to positive experiences and strengthening reward-related learning. Both are delivered in a group format to foster peer support and shared learning.
A total of 150 adults with a current MDD diagnosis will be randomly assigned to EFPI, REACT, or a waiting-list control. Participants in the intervention groups receive 10 group sessions over five weeks. Waiting-list participants complete baseline and 3-month follow-up assessments before being offered standard treatment options.
Clinical outcomes are assessed at baseline, immediately after treatment, and at 3- and 6-month follow-ups (for the intervention groups). Primary outcomes are reductions in depressive symptoms measured by clinician ratings and self-report questionnaires. Secondary outcomes include changes in expectation processes and reward sensitivity.
In addition, functional MRI (fMRI) tasks examine brain mechanisms related to expectation updating and reward processing pre- and post-intervention, to help identify neural changes that may underlie symptom improvement.
By directly addressing dysfunctional expectations and reduced reward sensitivity, this study seeks to provide evidence for more targeted psychotherapeutic approaches. If successful, the results may support more personalized treatments and better long-term outcomes in MDD.
Age: 18-80 years
Current diagnosis of major depressive disorder (MDD) according to DSM-5, confirmed by structured clinical interview (e.g., DIPS)
Hamilton Depression Rating Scale (HAMD-21) score ≥ 9
Ability to attend group therapy sessions (2×/week for 5 weeks)
Current or lifetime diagnosis of bipolar disorder, psychotic disorder, or primary substance use disorder
High acute suicide risk requiring immediate intervention
Severe neurological disorder, brain injury, or contraindications for MRI (e.g., metal implants, claustrophobia)
Ongoing psychotherapy or initiation of a new antidepressant medication within the past 4 weeks
Parallel
Expectation-Focused Psychotherapeutic Intervention
BehavioralEFPI is a manualized group psychotherapy for major depressive disorder that directly targets maladaptive expectations. The treatment integrates psychoeducation, cognitive restructuring, and behavioral experiments to modify negative expectancies and reduce cognitive immunization, thereby enhancing adaptive expectation updating. Delivery: Group format (5-10 participants), 10 sessions (twice weekly for 5 weeks).
Reward Enhancement and Activation Therapy
BehavioralREACT is a manualized group psychotherapy for major depressive disorder that focuses on enhancing reward sensitivity and motivation. The intervention combines attentional retraining, savoring techniques, and reinforcement-based strategies to increase engagement with rewarding stimuli and experiences. Delivery: Group format (5-10 participants), 10 sessions (twice weekly for 5 weeks).
Change in Depressive Symptoms (Beck Depression Inventory-II)
Change in depressive symptom severity assessed with the Beck Depression Inventory-II (BDI-II), a 21-item self-report questionnaire measuring cognitive, affective, and somatic symptoms of depression. Total scores range from 0 to 63, with higher scores indicating more severe depressive symptoms. The primary endpoint is the change from baseline to post-treatment (5 weeks). Symptom stability and maintenance will be examined at follow-up assessments.
Change in Depressive Symptoms (Hamilton Depression Rating Scale, 21-item)
Change in clinician-rated depressive symptom severity assessed with the Hamilton Depression Rating Scale (HAMD-21), administered by trained, blinded assessors. Total scores range from 0 to 64, with higher scores indicating more severe depressive symptoms.
Depressive Expectations (Depressive Expectations Scale)
Change in depressive expectations assessed with the Depressive Expectations Scale (DES), a self-report questionnaire measuring negative, situation-specific expectations related to mood regulation, social interactions, performance, and coping. Items are rated on a 5-point Likert scale; higher scores indicate more negative and dysfunctional expectations.
Hopelessness (Beck Hopelessness Scale)
Change in hopelessness assessed with the Beck Hopelessness Scale (BHS), a 20-item self-report questionnaire measuring negative expectations about the future. Total scores range from 0 to 20, with higher scores indicating greater hopelessness.
Socially Negative Expectations (Social Anxiety-Negative Beliefs Scale, SANB-5)
Change in negative social expectations assessed with the Social Anxiety-Negative Beliefs Scale (SANB-5), a 5-item self-report measure capturing fears of negative evaluation and rejection in social contexts. Items are rated on a 4-point Likert scale; higher scores indicate stronger negative social expectations.
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Philipps University Marburg
Lead sponsor
German Research Foundation
Collaborator
