Psychiatry Research 286 (2020) 112804

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Long-term effectiveness of two models of brief psychotherapy for T

depression: A three-year follow-up randomized clinical trial
⁎
Érico Nobre dos Santosa, , Mariane Lopez Molinaa,b, Thaise Mondina,c,
Taiane de Azevedo Cardosoa,d, Ricardo Silvaa, Luciano Souzaa, Karen Jansena
a
Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas (UCPel), Rua Gonçalves Chaves, 373, sala 424 C, Pelotas 96015-560 RS,
Brazil
b
Faculdade Anhanguera do Rio Grande, Av. Rheingantz, 91 – Pq. Residencial Coelho, Rio Grande 96202-110 RS, Brazil
c
Pró-Reitoria de Assuntos Estudantis – Universidade Federal de Pelotas (UFPel), Rua Almirante Barroso, 1202, Centro, Pelotas 96010-280 RS, Brazil
d
Department of Psychiatry and Behavioural Neurosciences, McMaster University, 100 West 5th Street, Research Office G110 ON L8N 3K7 Hamilton, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: Major depressive disorder (MDD) is a disease that severely impairs psychosocial functioning and decreases the
Randomized clinical trial subject's quality of life. Patients who received psychotherapy have a better long-term therapeutic response than
Depression those who have only been treated with antidepressants or have not been treated. There are few studies in the
Major depressive disorder literature that follow the outcomes of psychotherapeutic treatments for depression for more than two years. The
Functional capacity
aim of this study is to compare the therapeutic response of two models of brief psychotherapy for MDD treatment
Functioning
Psychotherapy
(Cognitive Behavioral Therapy and Short-term Psychodynamic Psychotherapy) with naturalistic controls who
Recurrent depression received treatment as usual in a three-year follow-up. This is a sample of 75 outpatients, mostly women (82.7%),
Treatment as usual with a median age of 33 (27–44). The interventions took place in 50-minute sessions once a week for 14 to 16
weeks. Outcomes were assessed at baseline and three years after the intervention. Regarding depressive
symptoms, the therapeutic response was maintained three years after the conclusion of the brief models of
psychotherapy. Functional capacity long-term maintenance depended not only on the intervention but also on
the education level, the work situation and the severity of depressive symptoms at the beginning of the treat-
ment.

1. Introduction
Major Depressive Disorder (MDD) is a disease that severely impairs
psychosocial functioning and decreases quality of life (Malhi and
Mann, 2018). MDD causes significant psychosocial and functional im-
pairment on the individual (Malhi and Mann, 2018; Vanderleur et al.,
2017). This desease is highly recurrent, making recurrence prevention
one of the most challenging tasks in its treatment (Bockting et al.,
2015).
The effects of MDD on functioning are severe and the recovery of
one's functionality may be slower compared to symptomatic improve-
ment during treatment (Oluboka et al., 2018). The concept of func-
tioning is complex and involves many different domains including the
capacity to work, capacity for autonomy, for leisure time, for managing
finances, for maintaining interpersonal relationships and capacity to
study and learn (Rosa et al., 2007; Cuijpers et al., 2019).Literature has
been measuring one or more of these elements and typically fail to take
into account all the other elements necessary for optimal functioning
(Rosa et al., 2007). With that in mind, this work aims to assess the
global functioning of the subjects.
Functional impairment, a decrease in any functional capacity, may
decrease with symptomatic improvement, but it becomes more intense
and chronic when depressive symptoms last for a long time
(Spijker et al., 2004). Therefore, an ongoing functional impairment may
interfere with reintegration into everyday life and the maintenance of
this impairment state may delay complete functional improvement
(Oluboka et al., 2018). During treatment, patients can prioritize im-
provements in their functional capacity over symptomatic improvement
(Zimmerman et al., 2006). They understand that returning to a normal
level of functioning at work, home or school is a highly significant
factor in the perception of recovery from the disorder
(Zimmerman et al., 2006).
Depressive episodes negatively impact not only one's health but also
their economic production (Chisholm et al., 2016). Major expenses of

⁎
Corresponding author.
E-mail address: ericons@gmail.com (É.N. dos Santos).

https://doi.org/10.1016/j.psychres.2020.112804
Received 3 September 2019; Received in revised form 14 January 2020; Accepted 19 January 2020
Available online 27 January 2020
0165-1781/ © 2020 Elsevier B.V. All rights reserved.
É.N. dos Santos, et al.
depression include cost of treatment, costs associated with family care,
and job loss (McCrone et al., 2018). This data is confirmed in
Kessler et al. (2013) observations in which subjects with early-onset
depression (e.g. affected at school age) are more likely to fail to com-
plete high school. The presence of mental illness upon completion of
schooling predicts unemployment and work disability. Depression is
associated with the largest number of lost days between all diseases,
driving subjects away from work, or to a lesser extent decreasing their
work performance. (Kessler et al., 2013) Early onset of the illness also
decreases the likelihood of marriage, a situation that is associated with
benefits such as financial stability and social support. Also, the history
of mental illness before marriage can predict divorce (Kessler et al.,
2013).
The American Psychiatry Association (APA) and the Canadian
Network for Mood and Anxiety Treatments (CANMAT) recommends the
use of antidepressants, psychotherapy or the combination of both for
the treatment of depression in adult patients (APA, 2010;
Kennedy et al., 2016; Parikh et al., 2016). There is substantial evidence
from several randomized clinical trials (RCTs) that psychotherapy is as
effective as antidepressants in short-term results and superior in long-
term results (Leichsenring et al., 2016). Meta-analytic reviews suggest
that patients receiving psychotherapy for depression had a positive
result in symptomatic recovery (Cuijpers et al., 2013; Kolovos et al.,
2016). Cuijpers et al., 2019 analysed the influence of bias on the effects
of psychotherapies for adult depression to determine whether it is ef-
fective or not. The authors found results that suggest that its effects are
small but above the threshold that has been suggested as the minimal
important difference in the treatment of depression. Munder et al., 2019
reanalysed this previous data considering wait-list controls as the most
appropriate estimate of the natural history of depression without in-
tervention. They found that psychotherapy was more effective than
wait-list controls, and more effective than treatment as usual (TAU) and
other control methods. A series of meta-analysis have identified several
types of psychotherapy as being effective in MDD treatment, including
Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy
(IPT), Problem Solving Therapy, Behavioral Activation Therapy and
Short-term Psychodynamic Psychotherapy (STPP) (Cuijpers et al.,
2011a; Cuijpers et al., 2011b; Driessen et al., 2010; in Picardi and
Gaetano, 2014). Of these, CBT and IPT have greater literature support.
Studies show that CBT and especially Cognitive Therapy is the most
effective and specific intervention for the treatment of MDD
(Picardi and Gaetano, 2014).
Regarding the goals of depression treatment, psychotherapy aims
for the complete remission of depressive symptoms and the recovery of
one's functionality (Lambert, 2013; Malhi and Mann, 2018). Thus, the
effectiveness of a depression treatment should be long-term evaluated,
assessing whether there was not only a momentary symptomatic re-
mission but symptom recovery, as well as whether relapses or re-
currences occurred.
In follow-ups of more than three years, Bockting et al. (2009,
2015a), Fava et al. (2004), Knekt et al. (2016, P. 2007),
H.J. Conradi et al. (2007) found that their respective intervention
models were more effective than their respective control groups.
Fonagy et al., 2015 compared a model of psychodynamic psy-
chotherapy with the usual treatment, in its follow-up, the intervention
was no more effective than the post-treatment control, but it was higher
after 24 months. Knekt et al. (2016, 2008, P. 2007) used both long-term
and short-term psychodynamic psychotherapy models and identified
that short-term models had a more immediate and less lasting ther-
apeutic response, while long-term models did not have an immediate
therapeutic response, but over the long term, the response increased,
being superior to the short-term model and usual treatment.
Lopes et al. (2014) did not observe symptom improvement in part of
their sample of subjects who received CBT (29%) or Narrative Therapy
(33%) in a 21-month follow-up, but at 31 months these subjects showed
improvement. Dobson et al. (2008) observed that Cognitive Therapy
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Psychiatry Research 286 (2020) 112804
(CT) would have superior response to the use of only some of its
components, revealing that its components have the same therapeutic
efficacy as the complete model after a 24-month follow-up. In studies
where the therapeutic response was not superior in the intervention
compared to the control, the Mindfulness-Based Cognitive Therapy
models were used (Kuyken et al., 2015; Shallcross et al., 2018; Williams
et al., 2014); Long-term Psychodynamic Psychotherapy, before 24
months or 84 months (Fonagy et al., 2015; Knekt et al., 2016, P. 2007);
Psychoeducation (Conradi et al., 2007, H.J. 2007; Williams et al.,
2014), and a work with CBT (Conradi et al., 2007).
Although improved functionality is a clear marker of the effective-
ness of a treatment for depression, few studies assessing long-term ef-
fectiveness have used this outcome. Knekt et al. (2016, 2008) mea-
suring social and personality functionality, work ability and social
functioning, found a significant improvement, at first, of working per-
formance in the short-term model, but this improvement was not sus-
tained. The long-term model did not show this initial improvement, but
after 10 years it presented better results than the other models im-
plemented in the work. Scott et al. (2000) evaluated the social func-
tioning of individuals who received CT in addition to clinical man-
agement, or only received clinical management. The authors found that
the improvement in social functioning was greater in the group re-
ceiving psychotherapeutic intervention. Finally, Maina et al. (2009)
compared a model of brief psychodynamic psychotherapy with the
same psychotherapy plus the use of antidepressants, not finding dif-
ferences in the global functioning of the subjects in both groups after
four years.
As can be seen, data about long-term effectiveness of psychotherapy
for depression are heterogeneous and scarce, with just some few studies
addressing the matter. Even fewer studies with similar design assessed
functionality. Global functionality was assessed in one study, com-
paring a model of psychotherapy with psychotherapy plus anti-
depressants, being unable to determine if psychotherapy has a better
effect on functional capacity improvement than no therapy or TAU.
Taking these aspects into consideration, this paper aims to compare the
effectiveness of depression treatment regarding symptomatic and global
functional capacity improvement of a model highly supported by the
literature, CBT, and a model of STPP with the region's TAU in a three-
year follow-up.
2. Method
2.1. Patients
Adults from 18 to 60 years old who sought psychotherapeutic
treatment at the Mental Health Research and Extension Clinic (APESM)
of the Catholic University of Pelotas (UCPel). The sample was selected
by convenience. The patients were individuals who voluntarily sought
the psychological service. The therapy was offered at no charge. The
inclusion criteria used were: being between 18 and 60 years old; being
diagnosed with MDD according to Mini International Neuropsychiatric
Interview – PLUS (MINI-PLUS), and; being at least two months without
receiving psychotherapeutic or pharmacological treatment elsewhere.
Exclusion criteria used were being at moderate or severe suicide risk;
having a history of abuse/dependence of psychoactive substances (ex-
cept alcohol and tobacco); having psychotic symptoms, and if the de-
pressive episode was due to the diagnosis of bipolar disorder.
Those who met inclusion criteria were selected to start psy-
chotherapy. For the three-year follow-up, we sought to assess those
patients who completed and responded to the treatments, or those who
dropped out treatment before the fourth session, and were considered
the TAU group, as will be better explained later. The patients that we
could not reach for assessment after three years were considered
dropouts of the study.
É.N. dos Santos, et al.
2.2. Procedure
This is an RCT between two brief psychotherapy models (CBT and
STPP), with a naturalistic control group over a three-year follow-up.
Among the intervention model groups allocation was 1:1. Patients
participated in the study from July 2012 to December 2018. The study
was approved by the Institution's Ethics Committee (protocol 46/2012).
All subjects were informed about the study and agreed to participate by
signing a written informed consent.
2.2.1. Therapists
The therapists were trained psychologists. Masters and Ph.D. stu-
dents from the Graduate Program in Health and Behaviour at UCPel
participated in the study. Therapists had theoretical and practical
training in CBT and STPP. All therapists received initial training for
their therapy models. On a weekly basis, one expert supervisor was
assigned to the CBT group and another one to de STPP group. Both
professionals had advanced specialized training and extensive clinical
practice, as well as teaching experience in the approach under their
supervision.
2.2.2. Interventions
Intervention models consisted of 16 sessions of CBT and 18 sessions
of STPP, with individual sessions once a week lasting fifty minutes and
treatment as usual.
2.2.2.1. Short-term Psychodynamic psychotherapy. We used a protocol
proposed by Lester Luborsky's theory, the Time-limited Supportive-
Expressive Dynamic Psychotherapy as the STPP (Luborsky, 1984;
Luborsky et al., 1995). It consists of 18 sessions in total. The model is
based on the analysis of the central pattern of relationships followed by
each person when conducting their interactions with others. The two
main techniques used are supportive (developed by the therapist to
create a positive, helpful, and empathic relationship with the patient)
and expressive (used by the therapist to help the patient to express, to
understand, and to change problems). The first goal of SE therapy is to
establish a trusting, supportive therapeutic relationship that allows the
patient to explore thoughts and experiences. Within this framework, the
therapist uses the narratives shared during therapy, as well as the
transference as experienced in the therapeutic relationship, to interpret
the patient's core conflictual relationship themes. The main techniques
are: establishing the therapeutic alliance, formulating and responding
to relationship patterns, responding to relationship areas,
contextualizing the symptom in the conflict pattern and working on
separation.
2.2.2.2. Cognitive Behavioral therapy. The CBT handbook was created
by Aaron Beck (1997) and is based on the principle that depressive
symptoms are maintained by the patient due to the dysfunctional way
of interpreting reality. It consists of 16 sessions in total. Each session
follows a script that starts by checking the patient's current mood
symptoms, followed by a resumption of the previous session, setting the
agenda for the session, a review of the homework, and discussion of the
item schedule. Each session ends with a summary and a collaborative
agreement about a homework assignment and return. The therapist
encourages the patients to imagine, using the skills learned in therapy
to cope with the events, feelings, and thoughts, and to anticipate when
and how they can apply the skills learned in therapy for future
situations.
2.2.2.3. Treatment as usual. Subjects who did fulfill the criteria for
inclusion in this RCT but dropped out before the fourth session returned
to the local health system were considered the TAU group. They may or
may not have received treatment, as would normally be done in cases of
symptomatic deterioration or other difficulties.
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Psychiatry Research 286 (2020) 112804
2.3. Measurements
All participants answered a sociodemographic questionnaire in-
vestigating the following: gender, self-reported skin color, age, marital
status, educational level, and employment status. The economic status
of the participants was assessed through the economic classification
scale of the Brazilian Association of Research Companies (ABEP), which
is based on the accumulation of material goods and the level of edu-
cation of the head of the household. This classification places people in
classes (A, B, C, D or E) from the scores achieved. Letter “A” refers to
the highest class and “E” to the lowest. Clinical variables collected
were: use of antidepressants during the follow-up period, alcohol and
tobacco use and age of the first depressive episode. Substance abuse or
dependence was assessed with the Alcohol, Smoking and Substance
Involvement Screening Test (ASSIST), the cutoff for substance abuse/
dependence was four (Group, 2002; Henrique et al., 2004).
2.3.1. Diagnostic Criteria
Diagnostic evaluation was performed by trained psychologists
through the MINI-PLUS (Sheehan et al., 1998). This is a structured
clinical interview based on DSM-IV diagnostic criteria and is ex-
tensively used in clinical practice and research due to its rapid and easy
administration.
2.3.2. Beck Depression inventory (BDI-II)
The BDI-II consists of 21 items aimed at evaluating the intensity of
depression in populational and clinical samples. Each item consists of
four statements arranged in increasing severity of a specific symptom.
These items are in accordance with DSM-IV criteria (APA, 2002). The
original instrument (Beck et al., 1996) and its validated Brazilian ver-
sion (Gomes-Oliveira et al., 2012) have good validity and reliability
coefficients.
2.3.3. Functioning Assessment short test (FAST)
Functioning was assessed using the FAST scale (Rosa et al., 2007),
which aims at evaluating functional impairments. It consists of 24 items
that evaluate six specific areas of functioning: autonomy, work ability,
cognition, finance, interpersonal relationships, and leisure. The total
score of the scale ranges from 0 to 72. Higher scores indicate higher
functional impairment. The coefficients of validity and reliability were
considered good or very good (Cacilhas et al., 2009).
2.4. Data collection
Individuals who sought treatment at APESM during the period of
2012 to 2014 underwent an initial assessment. Those who met the in-
clusion criteria were randomized and then called to begin the ther-
apeutic process in one of the models. Psychotherapy was performed at
the APESM. After the end of the psychotherapeutic process, a post-in-
tervention evaluation was performed and then another one three years
after the end of treatment. The sociodemographic and clinical variables
and the diagnostic evaluation were assessed at baseline and after three
years. BDI-II and FAST were applied at the beginning and at the end of
treatment and after three years.
2.5. Randomization
Subjects who met eligibility were divided by simple randomization
(1:1) between CBT and STPP. Afterwards, a therapist contacted the
patients. Subjects who have met the eligibility criteria for the RCT and
did not adhere to treatment, dropping out before the fourth session
were included in the control group, considering that these subjects re-
turned to the local health system and received TAU.
É.N. dos Santos, et al.
2.6. Blinding
The researcher responsible for randomization did not participate in
the evaluation process. In addition, the team responsible for the base-
line, post-intervention and three-year follow-up assessment were
blinded regarding the intervention model applied.
2.7. Data analysis
Sample characteristics were described by absolute and relative fre-
quencies or medians and interquartile intervals. Mann-Whitney and
Kruskal-Wallis tests were used for bivariate analysis. A hierarchical
model was performed in which sociodemographic variables were in-
cluded in the first level, clinical variables as alcohol and tobacco use/
abuse and the severity of depressive symptoms at the beginning of
treatment at a second level and exposure to the brief psychotherapy
models in a third level. Those variables which were associated with the
outcome in the crude analysis with p < 0.20 were included in the linear
regression. Statistically significant associations were considered when
p ≤ 0.05.
3. Results
The participants’ flowchart from this RCT is shown in Fig. 1, each
participant who did not attend three consecutive sessions was excluded
from the treatment but may have been allocated to the TAU group. For
this study, the participants who refused to participate in the three-year
follow-up were considered losses.
At the end, the study included 75 subjects stratified into three
groups: TAU (n = 35), STPP (n = 20) and CBT (n = 20). In the initial
evaluation, the sample had median age of 33.00 (27.00 – 44.00) years
old, most of the subjects were women (82.7%), had white skin color
(73.3%), had a partner (58.7%), had an educational level equal to or
greater than nine years of schooling (68%), were working (52.0%) and
were in the economic class “C” or lower (62.7%). The median age of the
first depressive episode was 23.00 (17.00 −32.00) years, 20.3% of the
sample presented tobacco abuse or dependence and 21.6% presented
alcohol abuse or dependence.
Randomization was effective for gender, age, marital status, edu-
cational level, socioeconomic class, alcohol abuse/dependence, age of
first depressive episode and subject functional capacity (p > 0.05).
However, there was a difference in the subjects’ distribution regarding
skin color, employment status, tobacco abuse/dependence and severity
of depressive symptoms in the pre-intervention period (p ≤ 0.05;
table 1).
Among responders to the CBT and STPP models, there was no dif-
ferences in baseline and post-intervention BDI-II and FAST scores
(table 2). Therefore, the intervention models will be grouped for sta-
tistical purposes. After three years, subjects who responded to treat-
ment had lower BDI-II (8.00 (3.00 – 16.00); p < 0.001) and FAST
(11.00 (7.00 – 19.00); p = 0.025) scores when compared to the TAU
group (24.00 (9.00 – 34.00); 19.00 (10.00 – 26.00), respectively).
The following variables fulfilled criteria for inclusion in the linear
regression: educational level, employment status and skin color in the
first level, severity of depressive symptom in the second level and ex-
posure to treatment in the third level. The variables that remained with
p ≤ 0.20 were maintained in the hierarchical model. Educational level
(p = 0.017), severity of depressive symptoms at the baseline
(p < 0.001) and exposure to treatment (p = 0.029) had an effect over
the severity of depressive symptoms over the three-year follow-up. This
model explains in 43.4% the variation in the severity of depressive
symptoms after three years.
In the adjusted analysis model for testing the effect of treatment on
functional capacity, we found that educational level, employment
status and severity of depressive symptoms at the beginning of the
treatment and after three years were possible confounders. In this
4
Psychiatry Research 286 (2020) 112804
model, functional capacity after three years does not seem to be in-
fluenced by treatment alone (p = 0.988).
4. Discussion
Our findings indicate the maintenance of the therapeutic response
regarding depressive symptoms three years after the end of the inter-
ventions. Regarding functional capacity, it was found that long-term
maintenance depends not only on the intervention but also on the
educational level, the employment situation and the severity of de-
pressive symptoms at the beginning of treatment. It is noteworthy that
we examined the effectiveness of two models of brief psychotherapy
(CBT and STPP) three years after the end of the interventions by
comparing subjects who responded to treatment with subjects who
received TAU. Respondents of both intervention models were analyzed
together since no significant differences in response rates were found
between the models.
The findings of this study should be considered after the presenta-
tion of some limitations. It is noteworthy that we did not consider
therapist variables and that only unmedicated patients without co-
morbidities or suicide risk were included, being the results of this study
generalizable only for this population. Although this limitation, the
selection of subjects aimed to include a homogeneous group for which
combined therapy would not be recommended as a therapeutic choice
(APA, 2010). Thus, we sought to evaluate the exclusive effect of brief
psychotherapeutic interventions in maintaining the therapeutic re-
sponse.
We had a high dropout rate during the intervention (46.3%), some
of these subjects were allocated to the TAU group, as already explained.
This rate was higher than previously conducted studies such as Jarret's
(2000; 17%) and Lopes’ (2014; 36.5%). A possible explanation for those
results is that we considered dropouts patients who did not attend to
three consecutive sessions without prior contact with their therapist.
This contract was explained to all patients at the beginning of the
treatment. Amongst clients who have contacted their therapists, reasons
for dropout included change of address, the commencement of phar-
macological treatment or personal problems. Thus, another limitation
of our study was that the TAU group was not randomized at the be-
ginning of the RCT but posteriorly selected by convenience. Since this
last group did not finish the interventions, no evaluation was made in
this same period as it was in the subjects who finished their interven-
tion, thus, the outcomes of both groups could be compared only pre-
intervention and after three years. Also, the TAU group had higher
baseline BDI scores than those who responded to treatment, being
possible that the control group subjects had always been more severely
depressed than those who were enrolled in the interventions. Thus,
after three years it can be questioned if the difference of the severity of
depressive symptoms is related do the intervention. However, this
condition was considered in the adjusted analysis, minimizing the ef-
fects of this limitation. One hypothesis for this would be that subjects
with more severe depressive symptoms would be more likely to drop
out of the treatment (Zilcha-Mano et al., 2016).
However, this is one of the few RCTs for depression that aimed at
following the maintenance of long-term therapeutic responses of two
brief psychotherapeutic models. In addition, a strength of this study
was the evaluation of the maintenance of the subjects’ global functional
capacity. Previous studies have assessed personality functioning
(Knekt et al., 2016, 2008), working performance (Knekt et al., 2016,
2008), social functioning (Knekt et al., 2016, 2008; Scott et al., 2000)
and global functional capacity (Maina et al., 2009). We assessed the
global functional capacity of the subjects, being, as far as we know, the
second study with this design to measure this outcome. Long-term
studies of RCTs using psychotherapy are complex and difficult to con-
duct. Although the sample characteristics are restricted, no studies as-
sessing psychotherapy effectiveness only, such as this, were found in
literature.
É.N. dos Santos, et al.
Fig. 1. Patients Flowchart.
We found that subjects who received brief psychotherapy and had
symptomatic improvement through it, when reassessed, had lower de-
pressive symptom scores on BDI-II when compared to subjects who
dropped out of treatment before the fourth session. Considering that
both groups were homogeneous regarding the inclusion criteria for
RCT, it was noticed that receiving either type of intervention reduced
the severity of depressive symptoms in the subjects after three years.
Meeting our results, Fava et al. (2004) and Conradi et al. (2007), in
their RCTs using CBT with a six-year follow-up and clinical manage-
ment control groups and a ten-year follow-up with a TAU group, re-
spectively, found that their interventions were more effective in
symptomatic improvement than their control groups. Knekt et al.
(2016, 2008, P. 2007) used both long-term and short-term psychody-
namic psychotherapy models and identified that short-term models had
a better therapeutic response up to six years after intervention than
long-term psychotherapy. The long-term model was found to be more
effective at reducing the depressive symptoms after seven years, pro-
gressively decreasing them until ten years. The results of these authors
5
Psychiatry Research 286 (2020) 112804
encourage long-term follow-up of the results of brief psychotherapeutic
interventions, in order to understand how long their effectiveness ex-
tends, as well as to compare with other intervention models, and thus,
to help in choosing the most cost-effective form of treatment for MDD.
In clinical practice, in addition to symptom improvement, treatment
aims to improve patient functional capacity and improve their well-
being and quality of life (Lambert, 2013). In our study, subjects who
received psychotherapy had a greater improvement in functional ca-
pacity than the TAU group, however, this result is not only due to the
interventions received, but also due to the educational level, the em-
ployment situation and the severity of depressive symptoms at the be-
ginning of treatment. Although improved functional capacity is a clear
marker of the effectiveness of a treatment for depression, few long-term
studies assessing this outcome have been found. Knekt et al. (2016,
2008, P. 2007) measured personality functionality, work ability, and
social functioning. They found a significant improvement, at first, of
working performance in the short-term model, but this improvement
was not supported by further evaluations Scott et al. (2000) evaluated
É.N. dos Santos, et al. Psychiatry Research 286 (2020) 112804

Table 1
Samples’ sociodemographic and clinical characteristics.
Sample Characteristics Baseline
TAU (n = 35) STPP (n = 20) CBT (n = 20) Test p-value

a
Gender
Male 4 (11.4%) 5 (25.0%) 4 (20.0%) 1.771 0.412
Female 31 (88.6%) 15 (75.0%) 16 (80.0%)
Age (in years)b 33.00 (18.00 – 43.00) 34.00 (27.00 – 43.00) 32.00 (27.00 – 47.00) 0.779 0.677
Skin Colora
White 21 (60.0%) 16 (80.0%) 18 (90.0%) 6.477 0.039
Non-White (Black, Brown, Indigenous, Asian) 14 (40.0%) 4 (20.0%) 2 (10.0%)
Marital Statusa
Single (single, separated, divorced, widow) 13 (37.1%) 8 (40.0%) 10 (50.0%) 0.888 0.642
Not single (dating, engaged, married) 22 (62.9%) 12 (60.0%) 10 (50.0%)
Educational levela
Up to 8 years of study 15 (42.9%) 5 (25.0%) 4 (20.0%) 3.670 0.160
9 or more years of study 20 (57.1%) 15 (75.0%) 16 (80.0%)
Employment Statusa
Not Employed 22 (62.9%) 6 (30.0%) 8 (40.0%) 6.204 0.045
Employed 13 (37.1%) 14 (70.0%) 12 (60.0%)
Economic Status (ABEP)a
A or B class 9 (25.7%) 10 (50.0%) 9 (55.0%) 3.894 0.143
C, D or E class 26 (74.3%) 10 (50.0%) 11 (45.0%)
Abuse/dependence of Tobacco*,a
No 23 (67.6%) 17 (85.0%) 19 (95.0%) 6.301 0.043
Yes 11 (32.4%) 3 (15.0%) 1 (5.0%)
Abuse/dependence of Alcohol*,a
No 29 (85.3%) 14 (70.0%) 15 (75.0%) 1.923 0.382
Yes 5 (14.7%) 6 (30.0%) 5 (25.0%)
Age of first depressive episodeb 24.00 (18.00 – 33.00) 22.00 (17.50 – 35.00) 22.00 (13.00 – 28.00) 1.653 0.438
FAST scoreb 29.50 (18.75 – 35.25) 23.50 (14.00 – 33.50) 24.00 (17.25 – 35.25) 1.198 0.549
BDI-II scoreb 37.00 (26.00 – 45.00) 29.00 (18.25 – 31.75) 31.50 (24.00 – 38.75) 6.628 0.036

⁎
Missing Values; TAU: Treatment as usual; STPP: Short-term Psychodynamic Psychotherapy; CBT: Cognitive Behavioral Therapy; FAST: Functioning Assessment
Short Test; BDI: Beck Depression Inventory-II.
a
Absolute and relative frequency, chi-square test.
b
Median and Interquartile range, Kruskal-Wallis H test.

Table 2 recovery of subjects' functionality, as well as the maintenance of it, is

Comparation between models’ post-intervention effectiveness. important for depressed subjects. It enables the subjects to be active
Baseline members of society again, working or participating in social events,
STPPa CBTb Teste p-value activities that contribute to the improvement of depressive symptoms
(Oluboka et al., 2018). (2) In addition to the depressive symptons de-
BDI-IIc
29.00 (18.25 – 31.50) 31.50 (24.00 – 38.75) 148.500 0.163
crease, we found an improvement in global functioning, whereas stu-
FASTd 23.50 (14.00 – 33.50) 24.00 (17.25 – 35.50) 173.500 0.473
Post-Intervention
dies show that usually symptom improvement does not follow func-
PDSEa TCCb p-value tioning improvement.
BDI-IIc 6.00 (2.25 – 8.75) 3.50 (1.25 – 7.75) 156.500 0.237 In this sample, the subjects' educational level and the severity of
FASTd 8.00 (4.00 – 14.25) 7.50 (3.00 −15.25) 184.500 0.674 depressive symptoms at the beginning of treatment affected the final
a outcomes. Subjects with higher education and milder depressive
Short-term Psychodynamic Psychotherapy.
b symptoms had better long-term therapeutic response. This study does
Cognitive Behavioral Therapy.
c
Beck Depression Inventory-II. not answer how these variables affect the outcomes. It is also unclear
d
Functioning Assessment Short Test. whether these brief treatments, which were effective after three years
e
Mann-Whitney U test. compared with the usual treatment, would remain effective if subjects
were followed for longer and would be as effective as similar long-term
the social functioning of individuals who received Cognitive Therapy in treatments. Another question that arises is how the symptomatic
addition to clinical management or only received clinical management. change was, after three years, in the subjects who did not respond to
The authors found that after sixteen months, the improvement in social brief psychotherapies, and thus, were not followed by this study, and
functioning was greater in the group receiving psychotherapeutic in- what are the characteristics of these subjects. Answering these ques-
tervention. tions may be important for deciding the best treatment model. It is
Previous studies showed that psychotherapies are effective in de- suggested that further studies are conducted with the purpose of an-
pressive symptons reduction when compared with TAU. This study swering the questions raised above. It is also suggested that interven-
presents two important new findings. (1) We observed depressive tion studies with longer follow-up (at least above two years) become
symptons reduction three years after the completion of brief interven- standard.
tions. Although these results are restricted to a population of subjects
who did not have severe depressive symptoms or were not using anti-
depressants, they present the effectiveness of these treatment models CRediT authorship contribution statement
long after their termination. This could mean that the choice for shorter
and thus cheaper treatments may bring significant long-term im- Érico Nobre dos Santos: Conceptualization, Methodology, Formal
provement in depressive symptoms. Therefore, the effects of treatment analysis, Writing - original draft, Writing - review & editing. Mariane
not only happen quickly but are also perceived as lasting. Rapid Lopez Molina: Project administration, Supervision, Investigation.
Thaise Mondin: Investigation, Supervision, Project administration.

6
É.N. dos Santos, et al.
Taiane de Azevedo Cardoso: Formal analysis, Investigation, Writing -
review & editing, Project administration, Supervision. Ricardo Silva:
Conceptualization, Methodology, Supervision, Funding acquisition.
Luciano Souza: Conceptualization, Methodology, Supervision,
Funding acquisition. Karen Jansen: Conceptualization, Methodology,
Formal analysis, Writing - review & editing, Supervision, Funding ac-
quisition.
Declaration of Competing Interest
The authors declare none.
Funding
This work was supported by Brazilian research grant 408313/2013-
7 from CNPq.
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