The Effectiveness of Group Schema Therapy on Reducing Symptoms and Improving Emotion Regulation in Adolescents with Treatment-Resistant Depression: A Randomized Controlled Trial

Hamid Zolfaghari; Mohammad Ali Salary; Erfan Salehi; Mohammadreza Yousefi

Authors

Hamid Zolfaghari Ph.D. in Psychology, Faculty of Educational Sciences and Psychology, Ferdowsi University of Mashhad, Mashhad, Iran Author https://orcid.org/0000-0002-1012-0263
Mohammad Ali Salary Bachelor's Degree in Psychology, Tabaran Institute of Higher Education, Mashhad, Iran https://orcid.org/0009-0009-1169-0880
Erfan Salehi Master of Clinical Psychology, Ha.C., Islamic Azad University, Hamedan, Iran Author https://orcid.org/0009-0008-4455-0895
Mohammadreza Yousefi Master of Clinical Psychology, ToJ.C., Islamic Azad University, Torbat Jam, Iran Author https://orcid.org/0009-0005-9778-5346

Keywords:

schema therapy, group therapy, treatment-resistant depression, adolescents, emotion regulation, early maladaptive schemas

Abstract

This study aimed to evaluate the efficacy of group schema therapy (Group-ST) as an adjunct to treatment as usual (TAU) in reducing depressive symptoms and improving emotion regulation among adolescents with TRD. A parallel-group, randomized controlled trial was conducted with 64 adolescents (aged 13–18) meeting DSM-5 criteria for major depressive disorder and operational criteria for TRD. Participants were randomly assigned (1:1) to Group-ST plus TAU (n = 32) or TAU alone (n = 32). Group-ST consisted of 12 weekly 90-minute group sessions based on Young's schema therapy model, with developmentally sensitive adaptations for adolescents. The primary outcome was depressive symptom severity, assessed with the Children's Depression Rating Scale–Revised (CDRS-R). Secondary outcomes included emotion regulation difficulties (Difficulties in Emotion Regulation Scale; DERS), treatment response (≥50% reduction in CDRS-R), and remission (CDRS-R ≤ 28). Assessments occurred at baseline, mid-treatment, post-treatment, and 3-month follow-up. Intention-to-treat analyses were conducted using mixed-model repeated measures. A significant group × time interaction emerged for CDRS-R scores, F(2, 118.6) = 18.47, p < .001. Group-ST demonstrated significantly greater reductions in depressive symptoms from baseline to post-treatment compared with TAU (mean difference = −12.43, 95% CI [−18.67, −6.19], p < .001, d = 1.10), with gains maintained at 3-month follow-up (mean difference = −11.27, 95% CI [−17.84, −4.70], p = .001, d = 0.95). For emotion regulation, a significant group × time interaction also emerged, F(2, 117.3) = 14.92, p < .001, with Group-ST showing greater improvement in DERS scores at post-treatment (d = 1.06) and follow-up (d = 0.97). Treatment response rates at post-treatment were 59.4% for Group-ST versus 25.0% for TAU (OR = 4.38, 95% CI [1.52, 12.63], p = .005), and remission rates were 34.4% versus 9.4% (OR = 5.06, 95% CI [1.24, 20.64], p = .016). Group schema therapy was associated with significant and durable improvements in depressive symptoms and emotion regulation difficulties in adolescents with treatment-resistant depression. These findings provide preliminary randomized controlled evidence that group schema therapy may address the core mechanisms maintaining treatment resistance in this population.

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