Cognitive Behavior Therapy Among Patients With Major Depressive Disorder-Multiple Episodes.

Primary outcomes

1. Patient Health Questionnaire PHQ-9 (Kroenke, and colleagues, 1999)

   Time frame: at pre-Assessment, after 5 weeks at post-Assessment

   Kroenke, and colleagues (1999) from Columbia University developed Patient Health Questionnaire. In the current study Patient Health Questionnaire 9 item questionnaire translated by (Ahmad, Hussain, Akhtar & Shah, 2018). Each item could be responded to using a 4-point Not at all = 0; several days = 1; More than half the days = 2; nearly every day = 3. The PHQ-9 has 9 items, each of which is scored 0,1,2,3, leading to a maximum score of 27. The total scores of 5, 10, 15 and 20 are taken as mild, moderate, moderately severe and severe in terms of the questioner's depressive illness. Cronbach's alpha for PHQ-9 was 0.91. The reliability was further supported by split-half reliability for PHQ-9; part 1 (r = 0.86), part 2 (r = 0.84) and correlation between two halves (r = 0.77), Spearman Brown coefficient was 0.87, and Guttmann split-half coefficient was 0.8.

2. Generalized Anxiety Disorder 7-item scale (GAD-7)

   Time frame: at Pre-Assessment, after 5 weeks at post-Assessment

   The Generalized Anxiety Disorder 7-item scale (GAD-7) is a widely used self-report screening tool designed to assess the severity of generalized anxiety symptoms. Developed by Spitzer et al. (2006), the scale consists of 7 items, each rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day), with total scores ranging from 0 to 21. Higher scores indicate greater levels of anxiety. The GAD-7 has demonstrated high internal consistency, with a Cronbach's alpha of 0.92, and test-retest reliability of 0.83, making it a reliable instrument for both clinical and research use. In the present study, the GAD-7 will be used to measure anxiety symptoms before and after the intervention, allowing evaluation of the impact of Adapted CBT on comorbid anxiety in patients with Major Depressive Disorder.

3. WHOQOL BREF Scale (WHO; Skevington, Lotfy &Connell, 2004).

   Time frame: at pre-assessment, after 5 weeks at post-assessment

   WHO developed WHOQOL BREF scale. In the current study WHOQOL Brief scale translated by (Ahmad, Hussain, Akhtar & Shah, 2018). The WHOQOL-Brief, still in field trials, is a subset of 26 items taken from the WHOQOL-100. The same steps for the scoring WHOQOL-100 should be followed to achieve scores for the Brief. The four domain scores are scaled in a positive direction with higher scores indicating a higher quality of life. Three items of the Brief must be reversed before scoring.

4. Mental Help-Seeking Attitudes Scale (MHSAS),

   Time frame: at pre-assessment, after 5 weeks at post-assessment

   The Mental Help-Seeking Attitudes Scale (MHSAS), developed by Hammer, Parent, and Spiker (2018), is a 9-item self-report instrument designed to assess individuals' overall attitudes toward seeking help from mental health professionals. Each item is rated on a 7-point semantic differential scale (e.g., harmful-beneficial, useless-useful), with higher scores indicating more positive attitudes toward mental health help-seeking. The MHSAS has demonstrated strong psychometric properties, including high internal consistency with a Cronbach's alpha of approximately .93, and strong test-retest reliability. The scale has also shown construct validity, being significantly correlated with related variables such as stigma, norms, and intention to seek help.

5. Motivation and Attitudes Toward Changing Health (MATCH)

   Time frame: at pre-assessment, after 5 weeks at post-assessment

   The Motivation and Attitudes Toward Changing Health (MATCH) scale, developed by Hessler et al. (2018) at the Behavioral Diabetes Institute, is a concise 9-item self-report measure designed to evaluate patients' readiness for health-related behavior change. It includes three subscales: Willingness to Change, Perceived Ability to Change, and Belief that Change is Worthwhile, each containing 3 items. Responses are rated on a 5-point Likert scale, with some items reverse-scored. The MATCH scale has shown acceptable internal consistency, with Cronbach's alpha values ranging from 0.61 to 0.74 across subscales, and has demonstrated good construct validity.

6. Digit Span Test ( Backward and Forward)

   Time frame: at pre-assessment, after 5 weeks, post-assessment

   The Digit Span Test, a subtest of the Wechsler Adult Intelligence Scale (WAIS), is used to assess attention, concentration, and working memory. It includes two components: Digit Span Forward and Digit Span Backward. In the Forward task, participants repeat a sequence of numbers in the same order as presented, primarily measuring attention span and short-term memory. In the Backward task, participants repeat the numbers in reverse order, assessing working memory and mental manipulation abilities. Typically, performance is higher on the forward span than the backward span due to the increased cognitive demands of the latter. The Digit Span Test has demonstrated adequate internal consistency and reliability, with reported Cronbach's alpha values ranging from .80 to .90, indicating strong psychometric properties for assessing cognitive functioning related to attention and memory.