Effect of Cognitive Behavioral Therapy on symptoms of insomnia, depression and suicide risk

Effect of Cognitive Behavioral Therapy on symptoms of insomnia, depression and suicide risk | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Effect of Cognitive Behavioral Therapy on symptoms of insomnia, depression and suicide risk Dennys Lapenda Fagundes, Everton Botelho Sougey, Tatiana de Paula Santana da Silva This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5823715/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract FAGUNDES, D. Effect of Cognitive Behavioral Therapy for Insomnia in Depression and Suicide [Thesis]. Recife: Health Sciences Center, Federal University of Pernambuco; 2025. INTRODUCTION: There is growing interest in understanding the relationship between sleep and suicide. Although insomnia is commonly cited as a critical risk factor for suicidal thoughts and behaviours, the evidence on the treatment and control of insomnia and its effects on reducing such behaviours is still unclear. OBJECTIVES: To evaluate the effect of CBTi , in patients diagnosed with Unipolar Depression with symptoms of insomnia, on suicidal behaviour. METHODS: This is an intervention, cross-sectional and analytical study. Data was collected using three validated and translated instruments. The study consisted of individuals aged 18 to 60 diagnosed with unipolar depression and who reported suicidal ideation with the intention of dying in the last week and/or attempted suicide in the last month. There were two randomised groups: Group A whose therapeutic protocol included a medication (Amitriptyline 25 mg) and Group B whose protocol included a pharmacological intervention with the medication (Amitriptyline 25 mg) and weekly CBT sessions with a protocol duration of 8 weeks. The primary outcomes included the assessment of insomnia severity (Insomnia Severity Index - ISI), suicide risk (Columbia Suicide Risk Rating Scale - C-SSRS) and the secondary outcomes included the severity of depressive symptoms (Montgomery Depression Scale - MDS). Primary and secondary outcome measures were collected at weeks 0, 2, 4, 6 and 8 of the interventions. RESULTS: The study included 10 individuals selected from psychiatric outpatient care, with a higher prevalence of females and an average age of 30-50 years, who showed improvements in the symptoms mood and sleep, as well as changes in suicidal thoughts over the 8 weeks of observation and intervention. CONCLUSION : The individuals assessed with the pharmacological and psychotherapeutic interventions showed a significant response, with an improvement in depressive symptoms, insomnia and suicidal behaviour in the first few weeks of the study. These data point to the need to take a broader look at patients with mood and sleep-related complaints in psychiatric clinical practice, allowing for a more focused intervention and faster progress in the psychopathological examination and psychiatric condition. Depression Insomnia Suicidal Behavior Preventive Psychiatry Cognitive Behavioral Therapy for Insomnia INTRODUCTION Suicide has become one of the leading causes of death worldwide (WHO, 2018). In 2016, the WHO counted 6.1 suicides per 100,000 inhabitants, equivalent to 62,804 deaths, a number that has increased almost seven times since 2010. Suicide is one of the leading causes of death throughout life; it is estimated that about 703,000 individuals worldwide die by suicide annually (WHO, 2021). Scientists and clinical practitioners strive to prevent and understand the mechanisms of suicide, however recent meta-analyses show that the accuracy of suicide prediction is alarmingly low (Franklin et al. ., 2017; Ribeiro et al., 2019; Woodford et al., 2019). A substantial body of evidence demonstrates that sleep disturbance is a significant risk factor for suicidal behavior (Lavigne et al., 2019; Wang, Cheng, Xu, 2019; Dolsen et al., 2020; Lau et al., 2020; Sher et al., 2020; Harris et al., 2020). In addition, insomnia including difficulties in falling asleep, sleeping or returning to sleep are associated with suicidal ideation mainly among patients with unipolar and bipolar depression, alcohol abuse or dependence, and post-traumatic stress disorder (PTSD). Additionally, it is noteworthy that the increase in the incidence of suicide emphasizes the need to identify and treat associated factors. Suicidal ideation is a precursor of suicide that has been associated with sleep disorders and insomnia (Pigeon, Pinquart, Conner et al., 2012; Mccal, Black et al., 2013; Zuromski, Cero, Witte, 2017). People with depression have many physical symptoms beyond the diagnostic criteria, such as somatic pain, gastrointestinal symptoms and sleep disorders. Sleep disorders, particularly insomnia in depressive patients, are reported as a central symptom and double the risk of developing the disorder. In addition, sleep disorders in depressed patients were significantly associated with a higher risk of consummate suicide (Wang, Cheng, Xu, 2019). This is a study on the effectiveness of intervention from TCCi in patients with depression and suicidal behavior that was conducted at the outpatient clinic of Psychiatry and Sleep Medicine of the Institute of Integral Medicine of Pernambuco (IMIP). The study was conducted according to the guidelines of the checklist of the Consolidated Standards of Reporting Trials ( CONSORT 2010). In addition, the protocol is registered on the National Clinical Trials Plataform ( http://www.ensaiosclinicos.gov.br/rg/.com ) and elaborated according to the provisions stipulated in the Declaration of Helsinki and Resolution no 466/12 of the National Health Council, including its assessment and approval by the Committee of Ethics in Research with Human Beings (BRASIL, 2012). METHODS DESIGN PLACE OF STUDY The IMIP Psychiatric Outpatient Clinic is a service in hospital with academic structure (Faculty of Medicine and Medical Residency in Psychiatry) of reference in the state of Pernambuco that offers patients free care through the Unified Health Service (SUS) network and that have a Teleconsult structure for the need to avoid face-to-face consultations. TARGET POPULATION The study population is composed of patients with a diagnosis of unipolar depression and insomnia, in the age group between 18 and 60 years old, of both sexes, who were treated at the Psychiatric Outpatient Clinic of the Institute of Integral Medicine of Pernambuco (IMIP), in the city of Recife, State of Pernambuco, reference service in health care by SUS in the area of psychiatry. POPULATION-REFERED AND SAMPLE PROCEDURES For entry into the research, all patients with a diagnosis of depression were invited by the researcher to participate, after having been explained the objectives, as well as the rights and duties of the researcher and participants, according to Resolution no 466 of 2012, of the National Health Council that governs research involving human beings (BRAZIL, 2012). Before the participation of the research is signed a Free and Informed Consent (FCL) by the patients expressing their desire to participate in the study. The sociodemographic profile of participants was evaluated from the elaboration of a self-administered questionnaire and with closed questions about personal and social profiles, for example, questions were formulated about age, marital status, housing conditions and income. DIAGNOSIS OF DEPRESSION AND INSOMNIA A two-step evaluation process was implemented to diagnose the presence of Insomnia and Major Depressive Disorder (APA, 2013). Step 1 involves the co-evaluators (volunteer psychiatrists) conducting a face- to-face clinical examination (interview). Patients properly included in the study were enrolled and conducted for evaluation of primary and secondary outcomes criteria. ALLOCATION The allocations were generated for participation of two intervention groups: Group A: Medication for insomnia Amitriptyline 25 mg indicated in the Brazilian Consensus of Insomnia 2023. Group B: Medication for insomnia Amitriptyline 25 mg indicated in the Brazilian Consensus on Insomnia 2023 + TCCi INSTRUMENTS FOR THE EVALUATION OF PRIMARY OUTCOME MEASURES ASSESSMENT OF THE SEVERITY OF INSOMNIA For this outcome, the Montgomery-Asberg Depression Scale was used, validated and translated in 1979. The MADRS scale was chosen for its greater sensitivity to changes in depressive symptoms (Mulder, Joyce, Frampton, 2003). On this scale, scores below or equal to 10 characterize the remission of depressive episode. Higher MADRS score indicates more severe depression, and each item produces a score of 0 to 6. The overall score ranges from 0 to 60. The questionnaire includes questions about the following symptoms: a) apparent sadness; b) expressed sadness; c) internal tension; d) sleep reduction; e) reduced appetite; f) concentration difficulties; g) laxity; h) inability to feel; i) pessimistic thoughts; j) ideas of suicide (Mulder, Joyce,Frampton, 2003). EVALUATION OF SUICIDAL BEHAVIOR AND SUICIDE RISK For this outcome, the Columbia Suicide Risk Assessment Scale (C-SSRS), an instrument developed by Kelly Posner and collaborators in New York at Columbia University in 2007 to assess suicidal ideation, was used, Intensity of suicidal ideation and behavior, differentiating between behaviors with low probability of causing injury and those with higher probability of lethality (Posner et al., 2011). The instrument has an exclusive version to be used in research focusing on outcomes on suicidal behavior. Currently, the scale is available in 103 languages and is validated for Portuguese language and corresponds to one of the few tools that evaluates the entire spectrum of suicidal ideation, based on facts experienced by the individual and behavioral trends. (Posner et al., 2007). The Center for Disease Control and Prevention (CDC) and the Food and Drug Administration (Administração e Drogas - FDA) recommend the use of this scale (Posner et al., 2011). In this study, individuals who had a minimum score on any of the five subitems of the scale during the follow-up period were considered at risk of suicide.INSTRUMENTOS PARA AVALIAÇÃO DAS MEDIDAS DE DESFECHO SECUNDÁRIO ASSESSMENT OF THE SEVERITY OF DEPRESSIVE SYMPTOMS INTERVENTIONS DRUG PROTOCOL FOR INSOMNIA Both groups (group A and group B) received drug protocol for insomnia. Amitriptyline was chosen at 25 mg dosage because it is a medication indicated in the 2023 Brazilian Consensus on Insomnia for drug treatment and by the availability of the medication in the Unified Health System (SUS). PROTOCOL OF TCCi for INSOMNIA Only Group B received the TCCi protocol for insomnia. The Cognitive Behavioral Therapy for Insomnia (TCCi), was performed by a professional in the field of psychology with specific training in Cognitive Behavioral Therapy for Insomnia, master’s degree in the topic addressed, and extensive experience in the care of insomnia patients. Cognitive- behavioral therapy for insomnia (TCCi), in particular, has been shown to be effective in reducing insomnia, as well as mood and anxiety symptoms in several comorbid populations. TCCi is an intervention usually performed in 6–8 weekly face-to-face sessions lasting 30–40 minutes. The treatment manuals describe that the TCCi consists of three main components (Sleep Restriction Therapy, Stimulus Control Therapy and Specific Cognitive Sleep Therapy), along with sleep psychoeducation and sleep hygiene. In this study, participants received eight weekly sessions of 60 to 90 minutes. The TCCi program considers the guidelines of experts in the area with session format and the application of treatment with focused structure (Sadler et al., 2018). The actions proposed in the TCCi protocol include, in the first four sessions, control stimuli (for example, going to bed only when sleepy), sleep restriction (for example, initially limiting time spent in bed to increase sleep efficiency), sleep hygiene (for example, remove stimulating sources from the room such as television / radio / clock) and relaxation (for example, diaphragmatic breathing, guided imagination). Cognitive restructuring of useless sleep beliefs (e.g., thought journals, behavioral experiments) and relapse prevention (e.g., summary of effective skills, maintenance of progress) were implemented in the second half of the program (Sadler et al., 2018). RESULTS The age of the 10 patients analyzed ranged from 22 to 62 years, had an average of 39.60 years, a standard deviation of11.15 years and a median of 36.50 years. In Table 1 are presented the results of the demographic profile of 10 patients and by group, being 4 from the Medication group and 6 from the Medication + Psychotherapy group; From this table it can be highlighted that: 6 patients were 36 to 62 years old and 4 had 22 to 35 , in the younger age group three were from the Medication group and one from the Medication + Psychotherapy group; 7 were female, three from the Medication group and 4 from the Medication + Psychotherapy group; most (7) had High School, three of the group of Medication and one of the group Medication + Psychotherapy, two who had elementary education were from the group Medication and one with higher education was from the group Medication; 4 had no children, two who had a child were from the Medication + Psychotherapy group and 4 had two children, two of each group; 6 had income equal to or higher than R$ 5,000.00 being 3 of each group and the others had income lower than R$ 5,000.00. Table 1 - Evaluation of the demographic profile Group Medication Medication + Psychotherapy Variable Total Group n (%) n (%) n (%) TOTAL 4 (100,0) 6 (100,0) 10 (100,0) Age 22 a 35 3 (75,0) 1 (16,7) 4 (40,0) 36 a 62 1 (25,0) 5 (83,3) 6 (60,0) Gender Masculine 1 (25,0) 2 (33,3) 3 (30,0) Feminine 3 (75,0) 4 (66,7) 7 (70,0) Education Ensino fundamental - 2 (33,3) 2 (20,0) Ensino médio 3 (75,0) 4 (66,7) 7 (70,0) Ensino superior 1 (25,0) - 1 (10,0) Kids 0 2 (50,0) 2 (33,3) 4 (40,0) 1 - 2 (33,3) 2 (20,0) 2 2 (50,0) 2 (33,3) 4 (40,0) Income < 5000 1 (25,0) 3 (50,0) 4 (40,0) ≥ 5000 3 (75,0) 3 (50,0) 6 (60,0) Tables 2 to 7 present the relative results of the scales of variables: index of severity of insomnia, depression and suicide risk (C-SSRS) in numerical form and categorized. Table 2 shows the data of the groups according to the severity of insomnia and week of evaluation. From the results it is possible to verify that both groups presented a reduction in symptoms of insomnia. Additionally, the TCCi + Medication group (Group B) recorded better results with higher indices of reduction of insomnia symptoms throughout the intervention 15.17 (week 0) to 2.50 (week 8), although no significant differences were reported (p > 0.05) in the comparison between groups in none of the evaluations. Table 2 - Statistics of the insomnia severity index by evaluation according to group Group Evaluation Medication Medication + Psychotherapy P Value Total Group Sample Size Average ± SD Average ± SD Average ± SD 0 weeks 14,50 ± 3,32 15,17 ± 1,94 (A) p (1) = 0,429 14,90 ± 2,42 (A) 272 2 weeks 11,00 ± 9,24 9,83 ± 6,01 (A) p (1) = 0,829 10,30 ± 6,99 (A) 705 4 weeks 2,50 ± 2,38 5,33 ± 3,98 (B) p (1) = 0,362 4,20 ± 3,58 (B) 24 6 weeks 2,50 ± 1,73 3,17 ± 1,72 (BC) p (1) = 0,524 2,90 ± 1,66 (B) 110 8 weeks 5,00 ± 6,16 2,50 ± 1,22 (C) p (1) = 1,000 3,50 ± 3,89 (B) 53 P value p (2) = 0,053 p (2) < 0,001* p (2) < 0,001* (*) Significant difference at 5.0% Mann-Whitney test Friedman test with comparisons of the referred test (Conover) Note. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations. Table 3 presents the results of the analysis of the intensity of depressive symptoms, in which an important reduction was noticed in both groups since the beginning of the intervention, where significant differences were recorded between the assessments in each of the groups. Additionally, only a single significant difference between the groups stands out, observed in the first week of intervention. Table 3 - Depression degree statistics by evaluation according to group Group Evaluation Medication Medication + Psychotherapy P value Total Group Sample Size Average ± SD Average ± SD 0 weeks 31,50 ± 9,15 (A) 18,50 ± 8,57 (A) p (1) = 0,043* 23,70 ± 10,67 (A) 9 2 weeks 19,00 ± 14,94 (B) 11,67 ± 7,84 (A) p (1) = 0,486 14,60 ± 11,09 (B) 45 4 weeks 2,00 ± 1,41 (CD) 4,50 ± 4,37 (B) p (1) = 0,762 3,50 ± 3,60 (C) 29 6 weeks 1,50 ± 1,00 (C) 2,67 ± 2,73 (C) p (1) = 0,700 2,20 ± 2,20 (D) 52 8 weeks 3,50 ± 4,43 (D) 1,33 ± 1,03 (C) p (1) = 0,382 2,20 ± 2,90 (D) 38 P value p (2) = 0,019* p (2) < 0,001* p (2) < 0,001* (*) Significant difference at 5.0% Mann-Whitney test Friedman test with comparisons of the referred test (Conover) Note. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations. Table 4 illustrates the averages of the scores related to suicide risk and from this analysis it is found that in both groups there was a reduction in the risk, however in the group Medication +TCCi (group B) the reduction was more expressive although no significant differences between groups were observed in any of the evaluations. Table 4 - Suicide risk scale statistics (Columbia) by group Evaluation Medication Medication + Psychotherapy p-Value Total Group Sample Size Average ± SD Average ± SD 0 weeks 19,25 ± 12,12 (A) 17,00 ± 14,62 (A) p (1) = 1,000 17,90 ± 13,00 (A) 743 2 weeks 11,25 ± 8,46 (A) 12,33 ± 9,16 (B) p (1) = 0,810 11,90 ± 8,41 (B) 1097 4 weeks 6,00 ± 9,52 (AB) 1,33 ± 2,07 (C) p (1) = 0,690 3,20 ± 6,20 (C) 37 6 weeks 2,00 ± 2,31 (B) 1,33 ± 2,07 (C) p (1) = 1,000 1,60 ± 2,07 (C) 178 8 weeks 2,00 ± 2,31 (B) 1,33 ± 2,07 (C) p (1) = 1,000 1,60 ± 2,07 (C) 178 P value p (2) = 0,029* p (2) < 0,001* p (2) < 0,001* (*) Significant difference at 5.0% Mann-Whitney test Friedman test with comparisons of the referred test (Conover) Note. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations. From Table 5 it is emphasized that: the means of the depression scale in the Medication group reduced from W0 to W6 (from 31.50 to 1.50) and from this value increased to 3.50 in W8, while in the Medication + Psychotherapy group the averages reduced with the evaluation from 18.50 to 1.33; the only significant difference between the groups was verified in W0 and significant differences were recorded between the assessments in each of the groups, with differences between: in the Medication group, with the exception of 4 weeks (W4) which was not different from W6 and W8 in the In other pairs, the differences were significant; in the Medication + Psychotherapy group, except between W0 and W2 and between W6 and W8, the other pairs had significant differences; In the total group, with the exception of the pair W6 and W8, the other pairs showed significant differences. Table 5 – Statistics of the degree of depression by assessment according to group Group Assessment medication Medication + Psychotherapy p- value Total Group Sample Size Average ± SD Average ± SD 0 week 31,50 ± 9,15 (A) 18,50 ± 8,57 (A) p (1) = 0,043* 23,70 ± 10,67 (A) 9 2 weeks 19,00 ± 14,94 (B) p (1) = 0,486 45 11,67 ± 7,84 (A) 14,60 ± 11,09 (B) 4 weeks 2,00 ± 1,41 (CD) 4,50 ± 4,37 (B) p (1) = 0,762 3,50 ± 3,60 (C) 29 6 weeks 1,50 ± 1,00 (C) 2,67 ± 2,73 (C) p (1) = 0,700 2,20 ± 2,20 (D) 52 8 weeks 3,50 ± 4,43 (D) 1,33 ± 1,03 (C) p (1) = 0,382 2,20 ± 2,90 (D) 38 p-value p (2) = 0,019* p (2) < 0,001* p (2) < 0,001* (*) Significant difference at 5.0% Mann-Whitney test Friedman test with comparisons of the referred test (Conover) Note. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations. Table 6 shows that: in W0, 6 patients were classified as having mild depression, 5 in the Medication + Psychotherapy group and one in the Medication group, one with moderate depression was in the Medication group and three had severe depression, two in the Medication group and one in the Medication + Psychotherapy group; in the W2 assessment in the Medication group, the mild, moderate and severe categories had frequencies equal to two, one and one respectively, while in the Medication + Psychotherapy group 5 had mild depression and one moderate depression; In assessments W4, W6 and W8, all 10 patients in the study were classified as having mild depression. Table 6 – Degree of depression by assessment and group Group Assessment Medication Medication + Psychotherapy Total Group n (%) n (%) n (%) TOTAL 4 (100,0) 6 (100,0) 10 (100,0) 0 week Light 1 (25,0) 5 (83,3) 6 (60,0) Moderate 1 (25,0) - 1 (10,0) Serious 2 (50,0) 1 (16,7) 3 (30,0) 2 weeks Light 2 (50,0) 5 (83,3) 7 (70,0) Moderate 1 (25,0) 1 (16,7) 2 (20,0) Serious 1 (25,0) - 1 (10,0) 4 weeks Light 4 (100,0) 6 (100,0) 10 (100,0) 6 weeks Light 4 (100,0) 6 (100,0) 10 (100,0) 8 weeks Light 4 (100,0) 6 (100,0) 10 (100,0) Table 7 highlights that: the average suicide risk scores in the Medication group reduced from assessment W0 to W6, from 19.25 to 2.00, they were the same between assessments W6 and W8; in the Medication + Psychotherapy group, the means reduced with the assessment from 17.00 to 1.33 from W0 to W4 and were equal to the aforementioned value in the assessments W4, W6 and W8; no significant differences were recorded between the groups in any of the assessments and significant differences were recorded between the assessments in each of the groups, with differences being observed: in the Medication W0 and W2 group different from W6 and W8; in the Medication + Psychotherapy group and in the total group, the W0 and W2 assessments were different from each other and different from the other three assessments. Table 7 – Suicide risk scale statistics (Columbia) by assessment according to group Group Assessment medication Medication + Psychotherapy p- value Total Group Sample Size Average ± SD Average ± SD 0 week 19,25 ± 12,12 (A) 17,00 ± 14,62 (A) p (1) = 1,000 17,90 ± 13,00 (A) 743 2 weeks 11,25 ± 8,46 (A) 12,33 ± 9,16 (B) p (1) = 0,810 11,90 ± 8,41 (B) 1097 4 weeks 6,00 ± 9,52 (AB) 1,33 ± 2,07 (C) p (1) = 0,690 3,20 ± 6,20 (C) 37 6 weeks 2,00 ± 2,31 (B) 1,33 ± 2,07 (C) p (1) = 1,000 1,60 ± 2,07 (C) 178 8 weeks 2,00 ± 2,31 (B) 1,33 ± 2,07 (C) p (1) = 1,000 1,60 ± 2,07 (C) 178 p-value p (2) = 0,029* p (2) < 0,001* p (2) < 0,001* (*) Significant difference at 5.0% Mann-Whitney test Friedman test with comparisons of the referred test (Conover) Note. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations. Table 8 shows that: in W0, 6 patients in the total group were classified as having a high suicide risk, 3 in each group and the rest having a low risk; in W2, half of the patients were at high risk, 2 in the Medication group and 3 in the Medication + Psychotherapy group and the rest were at low risk; in W4, with the exception of one patient in the Medication group with high risk, all others had a mild risk; in W6 and W8 all 8 patients were classified as mild risk. Table 8 – Columbia Scale that measures suicide by assessment and group Group Assessment Medication Medication + Psychotherapy Total Group n (%) n (%) n (%) TOTAL 4 (100,0) 6 (100,0) 10 (100,0) 0 week Light 1 (25,0) 3 (50,0) 4 (40,0) Serious 3 (75,0) 3 (50,0) 6 (60,0) 2 weeks Light 2 (50,0) 3 (50,0) 5 (50,0) Serious 2 (50,0) 3 (50,0) 5 (50,0) 4 weeks Light 3 (75,0) 6 (100,0) 9 (90,0) Serious 1 (25,0) - 1 (10,0) 6 weeks Light 4 (100,0) 6 (100,0) 10 (100,0) 8 weeks Light 4 (100,0) 6 (100,0) 10 (100,0) DISCUSSION The ten patients allocated in this study showed significant improvements in the three outcomes analyzed after drug and psychotherapeutic interventions. Still in the socio-demographic evaluation we can observe that some patients had educational training of high school and higher education which allowed to work in a more permeable way cognitive interventions. The number of children was also another important factor and deserves to be highlighted, because we realize in the literature and clinical practice that it can be a limiting factor for the improvement and perpetuation of insomnia. (Geiger-Brown JM, Rogers VE, Liu W, Ludeman EM, Downton KD, Diaz-Abad M,2015). It is known in the psychiatric literature that females are associated with higher prevalence of depressive disorder and anxiety disorders (Cantilino et al., 2010 ; Miguel; Gentil; Gattaz, 2011). These conditions, along with high levels of stress, also showed a higher prevalence of female depression in the vast majority of studies (Amr; Hady el Gilany; El-Hawary, 2008; Bassols et al., 2014 ; Brenneisen Mayer et al., 2016; Coentre; Faravelli; Figueira, 2016; Saeed et al., 2016), but not all (Miller; Kemmelmeier; Dupey, 2013). In general, during the life context that presents itself today, there is little time available for other activities besides those related to work and family obligations. This usually generates a high burden of responsibility and collection. In this sense, receiving emotional family and/or professional support can raise life satisfaction and enable the population a source of decreased concern. That is, those who receive this support have a source of less stress. (Amr; Hady el Gilany; El-Hawary, 2008; Bassols et al., 2015; Bore; Kelly; Nair, 2016; Farzianpour et al., 2011; Morrison; Moffat, 2001; Wray; Mccall, 2007). In the general population, insomnia tends to increase with age with less total sleep time and impairment in its quality, because they are more associated, for example, with other sleep disorders such as obstructive sleep apnea and polydrugs. This statement in our study had a positive association with the presence of older patients and sleep impairment. Our sample, however, does not represent the general population. It is a small sample and we should carefully analyze these data. In the first outcome that was evaluated by the insomnia severity index, parameters such as whether the patient has difficulty staying or falling asleep, how much he is satisfied or dissatisfied with the current sleep pattern, and two important points how much the patient considers that poor sleep quality impairs his daily activities and how much he thinks other people perceive his problem, because, commonly, patients present cognitive distortions that end up impairing their perception of sleep. In the literature, we observed that TCCi is an effective method for managing sleep disorders in heterogeneous groups with insomnia and taxam ranging from 42 to 50% (Furukawa Y, Sakata M, Yamamoto R, Nakajima S, Kikuchi S, Inoue M, Ito M, Noma H, Takashina HN, Funada S, Ostinelli EG, Furukawa TA, Efthimiou O, Perlis M, 2023). These findings are also consistent with estimates that cognitive-behavioral therapy is effective in improving sleep patterns in about 70–80% of patients with chronic insomnia (Haurin, 1991; Morin, Culbert and Schwartz, 1993), and that a third of the patients becomeif good sleepers at the end of treatment (Lacks & Powlishta, 1989). Thus we found in the present research the second outcome of evaluation that was in relation to the assessment through the MADRS scale instrument of the unipolar depression framework, It is important to note that the patients included in the research maintained the medications suggested by their psychiatrists, but were not performing any other form of psychotherapeutic intervention, besides Cognitive Behavioral Therapy for Insomnia. A range of previous studies in the population indicates an improvement in mood when associated with psychotherapeutic intervention, and evolution is considered faster in relation to determinant time. (Bray, I,1996, Geiger-Brown JM, Rogers VE, Liu W, Ludeman EM, Downton KD, Diaz-Abad M,2015). We observed in the question of the severity of insomnia here an improvement of the depressive framework in both groups, but without being able to create statistical differences. Sleep disturbances can trigger mental disorders, as well as psychiatric disorders can promote sleep problems (Kumar, 2016; Schnel; Albrech, Sandrelli, 2014). Poor quality of sleep also can lead to attention and functional performance losses. This may also be an explanatory factor of the association between poor sleep and worsening mood picture and suicidal behavior. Particularly in current life situations that society allows itself to function, sleep can be impaired and not compensated for by subsequent breaks, allow bring a greater sense of fatigue and sadness and consequent opening of mental disorders. In the third and final outcome that was to evaluate the risk of suicide through the Columbia scale instrument, we noticed from the analysis that both groups showed improvement in suicidal thoughts, but it is worth to emphasize and highlight that the group that underwent the psychopharmacological and psychotherapeutic interventions the improvement in negative and distorted thoughts was demonstrated earlier than the group with only medication. At this point, I allow during the writing of this passage to appreciate the positive feelings shown by patients and how much these positive responses remained in the course of the eight weeks and also beyond the follow-up after the observational period of the study. In any case, caution is needed in the interpretation of this study on iCCT and unipolar depression, insomnia and suicide risk, because it has some limitations. Our sample has a small representativeness, but it is a sample of patients treated in a reference service of a public hospital in a state of northeastern Brazil (Brazil is a continental country) and a single service. Thus, it may be difficult to extrapolate the results to a population with different characteristics, for example patients from other clinics, or patients with better purchasing power or from other Brazilian regions or other countries, or even younger. The results of our study also lead to reflections on the very nature of mental disorders. The fact that the MADRS and C-SSRS scales show a reduced score in both groups, but without significant difference, leads us to think that psychiatric symptoms, and especially psychiatric diagnoses, are more complex conditions than the simple sum of symptoms and signs. Thus, acting in this dimension seems to be another window of opportunity for the establishment of psychotherapeutic and psychiatric efforts in the mental health network, not only for individuals with access to private services and who may benefit from other drug interventions, but also for other less favoured populations. It is true that one may question whether the effects demonstrated in this work will be maintained in the long term. Further investigations are necessary. However, it is possible to consider that, in the same way that the effect of psychotropic drugs on the treatment of mental disorders requires the continued use of medicines for relatively long periods, it is recommended, or at least desirable, that the techniques taught to participants continue being performed for the prolongation of effects. In fact, this happens with other psychotherapeutic techniques and was oriented to the patients at the end of the intervention. Anyway, our study with the intervention has some limitations that should be considered. The patients were mostly women, which affects most individuals with insomnia and difficulty in adhering to medication and behavioral interventions. The group with the drug intervention was composed of only one man who presented an episode of post-traumatic stress disorder which made it difficult at certain stage of the follow-up to use the dose of the prescribed medication. The fact that some individuals are also patients with a slightly older age group hinders the improvement of sleep quality, because they have greater chances of clinical comorbidities, for example, nocturia and chronic pain that may make it difficult to treat dissonances such as insomnia. The fact that the same researcher evaluated the eight weeks of the medication group and the medication group plus psychotherapy could also have been other bias that contributes to not having as many differences in results in both groups at the end of the follow-up period. In the biweekly evaluations, patients reported that they felt comfortable being questioned by the same professional, i.e., the researcher trained in the psychiatric specialty. Thus, we can also think that what could have been a difficulty seems to have become a strength of the present study. If different investigators had been conducting the investigation in each group, differences in results could have been attributed to possible differences in the quality of the relationship with patients, a bias that would be potentially more difficult to be removed. In any case, despite the mental illness in the general population and sleep disorders such as insomnia being considered globally, there are still few proposals for pharmacological and psychotherapeutic intervention, especially in Latin America and with desirable statistical rigor. CONCLUSION The evaluated patients showed significant improvements in the three parameters of evaluation of the study. Performing leisure activity, associated with changes in behavior and thoughts with the use of a medication with sedative potential potentiates a good quality of sleep, besides worrying less about everyday situations, receive emotional support, being of a lower age, being male allows a favorable context for the non-appearance of symptoms of insomnia. These data signaled the need to create specialized care centers, for example, with access to the general population that has as its only access to mental health care the psychosocial care network, providing an increase in well-being andbe subjective (quality of life) and focusing on complaints related to poor sleep quality, allowing a decrease in symptoms that severely impair functionality. Thus, this research allowed to create a scientific support for other scientific studies in several population niches, promoting an evolution in the treatment of insomnia in the general population. The aforementioned intervention, proposed over eight weeks in patients with unipolar depression and based on a science network and the techniques of cognitive behavioral therapy for insomnia, was promising in increasing quality of life and sleep, although statistically not demonstrate pragmatic and concrete importance. These data indicate the possibility of expanding efforts by health professionals, mental health services and government agencies to build a context for promoting mental health resources. Future research may increase the sample of patients with unipolar depression, insomnia and suicidal behavior and verify the long-term effects of the intervention, analyze whether the intervention is more effective than the findings at this time, finally, extrapolate the findings to different populations. Declarations ETHICAL APPROVAL AND CONSENT TO PARTIPATE The study was carried out in accordance with the Declaration of Helsinki and received approval from the Ethics Committee for Research with Human Beings of the Federal University of Pernambuco (certificate number: 5.167.260 of 12/15/2021) and the Ethics Committee for Research with Human Beings of IMIP (certificate number: 5.307.597 of 03/23/2022). The study protocol was also retrospectively registered in the Brazilian registry of clinical trials (http://www.ensaiosclinicos.gov.br/rg/). Number: RBR-10b889rz/ UTN Number: U1111-1287- 9616 (February 13, 2022). CONSENT FOR PUBLICATION All participants agreed to publish the results. AVAILABILITY OF DATA AND MATERIALS Not applicable. COMPETITIVE INTERESTS There are no competing financial and non-financial interests. FUNDING There are no external funding sources. The protocol and the study are being financed by the researcher with personal resources. References ARISTÓTELES. Ética à Nicômaco . 1. ed. São Paulo: Atlas, 2009. BASSOLS, A. M. et al. First- and last-year medical students: Is there a difference in the prevalence and intensity of anxiety and depressive symptoms? Revista Brasileira de Psiquiatria , v. 36, n. 3, p. 233–240, 2014. CANTILINO, A. et al. Transtornos psiquiátricos no pós-parto. Revista de Psiquiatria Clinica , v. 37, n. 6, p. 278– 284, 2010. CLARK, D. L.; BOUTROS, N. 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Efeitos combinados da depressão e ansiedade sobre o suicídio: Um estudo de autópsia psicológica de caso-controle na China rural. Psychiatry Res. 2019; 271 (1872-7123): 370-373. doi: 10.1016 / j.psychres.2018.11.010 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5823715","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":443413519,"identity":"8603a4c9-bcef-4298-95aa-54faaea7823c","order_by":0,"name":"Dennys Lapenda Fagundes","email":"data:image/png;base64,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","orcid":"","institution":"Federal University of Pernambuco","correspondingAuthor":true,"prefix":"","firstName":"Dennys","middleName":"Lapenda","lastName":"Fagundes","suffix":""},{"id":443413520,"identity":"2c89149e-db5a-476c-94ea-3f4e1e0458b8","order_by":1,"name":"Everton Botelho Sougey","email":"","orcid":"","institution":"Federal University of Pernambuco","correspondingAuthor":false,"prefix":"","firstName":"Everton","middleName":"Botelho","lastName":"Sougey","suffix":""},{"id":443413523,"identity":"b9d7efae-9577-4170-a4e7-3d06401b1120","order_by":2,"name":"Tatiana de Paula Santana da Silva","email":"","orcid":"","institution":"Federal University of Pernambuco","correspondingAuthor":false,"prefix":"","firstName":"Tatiana","middleName":"de Paula Santana da","lastName":"Silva","suffix":""}],"badges":[],"createdAt":"2025-01-14 03:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5823715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5823715/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":94742165,"identity":"788818ad-ea84-419d-ac31-5bba778a5e43","added_by":"auto","created_at":"2025-10-30 08:53:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2426167,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5823715/v1/03a60aa0-4a94-47f8-8e4e-18d063982736.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Cognitive Behavioral Therapy on symptoms of insomnia, depression and suicide risk","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSuicide has become one of the leading causes of death worldwide (WHO, 2018). In 2016, the WHO counted 6.1 suicides per 100,000 inhabitants, equivalent to 62,804 deaths, a number that has increased almost seven times since 2010.\u003c/p\u003e\u003cp\u003eSuicide is one of the leading causes of death throughout life; it is estimated that about 703,000 individuals worldwide die by suicide annually (WHO, 2021). Scientists and clinical practitioners strive to prevent and understand the mechanisms of suicide, however recent meta-analyses show that the accuracy of suicide prediction is alarmingly low (Franklin et al. ., 2017; Ribeiro et al., 2019; Woodford et al., 2019).\u003c/p\u003e\u003cp\u003eA substantial body of evidence demonstrates that sleep disturbance is a significant risk factor for suicidal behavior (Lavigne et al., 2019; Wang, Cheng, Xu, 2019; Dolsen et al., 2020; Lau et al., 2020; Sher et al., 2020; Harris et al., 2020).\u003c/p\u003e\u003cp\u003eIn addition, insomnia including difficulties in falling asleep, sleeping or returning to sleep are associated with suicidal ideation mainly among patients with unipolar and bipolar depression, alcohol abuse or dependence, and post-traumatic stress disorder (PTSD). Additionally, it is noteworthy that the increase in the incidence of suicide emphasizes the need to identify and treat associated factors. Suicidal ideation is a precursor of suicide that has been associated with sleep disorders and insomnia (Pigeon, Pinquart, Conner et al., 2012; Mccal, Black et al., 2013; Zuromski, Cero, Witte, 2017).\u003c/p\u003e\u003cp\u003ePeople with depression have many physical symptoms beyond the diagnostic criteria, such as somatic pain, gastrointestinal symptoms and sleep disorders. Sleep disorders, particularly insomnia in depressive patients, are reported as a central symptom and double the risk of developing the disorder. In addition, sleep disorders in depressed patients were significantly associated with a higher risk of consummate suicide (Wang, Cheng, Xu, 2019). This is a study on the effectiveness of intervention from TCCi in patients with depression and suicidal behavior that was conducted at the outpatient clinic of Psychiatry and Sleep Medicine of the Institute of Integral Medicine of Pernambuco (IMIP). The study was conducted according to the guidelines of the checklist of the Consolidated Standards of Reporting Trials ( CONSORT 2010). In addition, the protocol is registered on the National Clinical Trials Plataform ( \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ensaiosclinicos.gov.br/rg/.com\u003c/span\u003e\u003cspan address=\"http://www.ensaiosclinicos.gov.br/rg/.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e and elaborated according to the provisions stipulated in the Declaration of Helsinki and Resolution no 466/12 of the National Health Council, including its assessment and approval by the Committee of Ethics in Research with Human Beings (BRASIL, 2012).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDESIGN\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003ePLACE OF STUDY\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe IMIP Psychiatric Outpatient Clinic is a service in hospital with academic structure (Faculty of Medicine and Medical Residency in Psychiatry) of reference in the state of Pernambuco that offers patients free care through the Unified Health Service (SUS) network and that have a Teleconsult structure for the need to avoid face-to-face consultations.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eTARGET POPULATION\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe study population is composed of patients with a diagnosis of unipolar depression and insomnia, in the age group between 18 and 60 years old, of both sexes, who were treated at the Psychiatric Outpatient Clinic of the Institute of Integral Medicine of Pernambuco (IMIP), in the city of Recife, State of Pernambuco, reference service in health care by SUS in the area of psychiatry.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePOPULATION-REFERED AND SAMPLE PROCEDURES\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor entry into the research, all patients with a diagnosis of depression were invited by the researcher to participate, after having been explained the objectives, as well as the rights and duties of the researcher and participants, according to Resolution no 466 of 2012, of the National Health Council that governs research involving human beings (BRAZIL, 2012). Before the participation of the research is signed a Free and Informed Consent (FCL) by the patients expressing their desire to participate in the study. The sociodemographic profile of participants was evaluated from the elaboration of a self-administered questionnaire and with closed questions about personal and social profiles, for example, questions were formulated about age, marital status, housing conditions and income.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eDIAGNOSIS OF DEPRESSION AND INSOMNIA\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA two-step evaluation process was implemented to diagnose the presence of Insomnia and Major Depressive Disorder (APA, 2013). Step 1 involves the co-evaluators (volunteer psychiatrists) conducting a face- to-face clinical examination (interview). Patients properly included in the study were enrolled and conducted for evaluation of primary and secondary outcomes criteria.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eALLOCATION\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe allocations were generated for participation of two intervention groups:\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGroup A: Medication for insomnia Amitriptyline 25 mg indicated in the Brazilian Consensus of Insomnia 2023.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGroup B: Medication for insomnia Amitriptyline 25 mg indicated in the Brazilian Consensus on Insomnia 2023\u0026thinsp;+\u0026thinsp;TCCi\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eINSTRUMENTS FOR THE EVALUATION OF PRIMARY OUTCOME MEASURES\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF THE SEVERITY OF INSOMNIA\u003c/h2\u003e \u003cp\u003eFor this outcome, the Montgomery-Asberg Depression Scale was used, validated and translated in 1979. The MADRS scale was chosen for its greater sensitivity to changes in depressive symptoms (Mulder, Joyce, Frampton, 2003). On this scale, scores below or equal to 10 characterize the remission of depressive episode.\u003c/p\u003e \u003cp\u003eHigher MADRS score indicates more severe depression, and each item produces a score of 0 to 6. The overall score ranges from 0 to 60.\u003c/p\u003e \u003cp\u003eThe questionnaire includes questions about the following symptoms: a) apparent sadness; b) expressed sadness; c) internal tension; d) sleep reduction; e) reduced appetite; f) concentration difficulties; g) laxity; h) inability to feel; i) pessimistic thoughts; j) ideas of suicide (Mulder, Joyce,Frampton, 2003).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEVALUATION OF SUICIDAL BEHAVIOR AND SUICIDE RISK\u003c/h2\u003e \u003cp\u003eFor this outcome, the Columbia Suicide Risk Assessment Scale (C-SSRS), an instrument developed by Kelly Posner and collaborators in New York at Columbia University in 2007 to assess suicidal ideation, was used, Intensity of suicidal ideation and behavior, differentiating between behaviors with low probability of causing injury and those with higher probability of lethality (Posner et al., 2011).\u003c/p\u003e \u003cp\u003eThe instrument has an exclusive version to be used in research focusing on outcomes on suicidal behavior. Currently, the scale is available in 103 languages and is validated for Portuguese language and corresponds to one of the few tools that evaluates the entire spectrum of suicidal ideation, based on facts experienced by the individual and behavioral trends. (Posner et al., 2007). The Center for Disease Control and Prevention (CDC) and the Food and Drug Administration (Administra\u0026ccedil;\u0026atilde;o e Drogas - FDA) recommend the use of this scale (Posner et al., 2011). In this study, individuals who had a minimum score on any of the five subitems of the scale during the follow-up period were considered at risk of suicide.INSTRUMENTOS PARA AVALIA\u0026Ccedil;\u0026Atilde;O DAS MEDIDAS DE DESFECHO SECUND\u0026Aacute;RIO\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF THE SEVERITY OF DEPRESSIVE SYMPTOMS INTERVENTIONS\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eDRUG PROTOCOL FOR INSOMNIA\u003c/h2\u003e \u003cp\u003eBoth groups (group A and group B) received drug protocol for insomnia. Amitriptyline was chosen at 25 mg dosage because it is a medication indicated in the 2023 Brazilian Consensus on Insomnia for drug treatment and by the availability of the medication in the Unified Health System (SUS).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePROTOCOL OF TCCi for INSOMNIA\u003c/h2\u003e \u003cp\u003eOnly Group B received the TCCi protocol for insomnia. The Cognitive Behavioral Therapy for Insomnia (TCCi), was performed by a professional in the field of psychology with specific training in Cognitive Behavioral Therapy for Insomnia, master\u0026rsquo;s degree in the topic addressed, and extensive experience in the care of insomnia patients. Cognitive- behavioral therapy for insomnia (TCCi), in particular, has been shown to be effective in reducing insomnia, as well as mood and anxiety symptoms in several comorbid populations.\u003c/p\u003e \u003cp\u003eTCCi is an intervention usually performed in 6\u0026ndash;8 weekly face-to-face sessions lasting 30\u0026ndash;40 minutes. The treatment manuals describe that the TCCi consists of three main components (Sleep Restriction Therapy, Stimulus Control Therapy and Specific Cognitive Sleep Therapy), along with sleep psychoeducation and sleep hygiene.\u003c/p\u003e \u003cp\u003eIn this study, participants received eight weekly sessions of 60 to 90 minutes. The TCCi program considers the guidelines of experts in the area with session format and the application of treatment with focused structure (Sadler et al., 2018).\u003c/p\u003e \u003cp\u003eThe actions proposed in the TCCi protocol include, in the first four sessions, control stimuli (for example, going to bed only when sleepy), sleep restriction (for example, initially limiting time spent in bed to increase sleep efficiency), sleep hygiene (for example, remove stimulating sources from the room such as television / radio / clock) and relaxation (for example, diaphragmatic breathing, guided imagination). Cognitive restructuring of useless sleep beliefs (e.g., thought journals, behavioral experiments) and relapse prevention (e.g., summary of effective skills, maintenance of progress) were implemented in the second half of the program (Sadler et al., 2018).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe age of the 10 patients analyzed ranged from 22 to 62 years, had an average of 39.60 years, a standard deviation of11.15 years and a median of 36.50 years. In Table 1 are presented the results of the demographic profile of 10 patients and by group, being 4 from the Medication group and 6 from the Medication + Psychotherapy group; From this table it can be highlighted that: 6 patients were 36 to 62 years old and 4 had 22 to 35 , in the younger age group three were from the Medication group and one from the Medication + Psychotherapy group; 7 were female, three from the Medication group and 4 from the Medication + Psychotherapy group; most (7) had High School, three of the group of Medication and one of the group Medication + Psychotherapy, two who had elementary education were from the group Medication and one with higher education was from the group Medication; 4 had no children, two who had a child were from the Medication + Psychotherapy group and 4 had two children, two of each group; 6 had income equal to or higher than R$ 5,000.00 being 3 of each group and the others had income lower than R$ 5,000.00.\u003c/p\u003e\n\u003cp\u003eTable 1 - Evaluation of the demographic profile\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u0026nbsp;+ Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e22\u0026nbsp;a 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e4 (40,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e36\u0026nbsp;a 62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e5 (83,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e6 (60,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003eMasculine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e2 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e3 (30,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003eFeminine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e4 (66,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e7 (70,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003eEnsino fundamental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e2 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e2 (20,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003eEnsino m\u0026eacute;dio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e4 (66,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e7 (70,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003eEnsino superior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e1 (10,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKids\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e2 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e4 (40,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e2 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e2 (20,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e2 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e4 (40,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026lt; 5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e4 (40,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.5974%;\"\u003e\n \u003cp\u003e\u0026ge; 5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.7525%;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.8185%;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8317%;\"\u003e\n \u003cp\u003e6 (60,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTables 2 to 7 present the relative results of the scales of variables: index of severity of insomnia, depression and suicide risk (C-SSRS) in numerical form and categorized.\u003c/p\u003e\n\u003cp\u003eTable 2 shows the data of the groups according to the severity of insomnia and week of evaluation. From the results it is possible to verify that both groups presented a reduction in symptoms of insomnia. Additionally, the TCCi + Medication group (Group B) recorded better results with higher indices of reduction of insomnia symptoms throughout the intervention 15.17 (week 0) to 2.50 (week 8), although no significant differences were reported (p \u0026gt; 0.05) in the comparison between groups in none of the evaluations.\u003c/p\u003e\n\u003cp\u003eTable 2 - Statistics of the insomnia severity index by evaluation according to group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication + Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e14,50\u0026nbsp;\u0026plusmn; 3,32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e15,17 \u0026plusmn; 1,94 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,429\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e14,90 \u0026plusmn; 2,42 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e11,00\u0026nbsp;\u0026plusmn; 9,24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e9,83\u0026nbsp;\u0026plusmn; 6,01\u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e10,30 \u0026plusmn; 6,99 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e2,50\u0026nbsp;\u0026plusmn; 2,38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e5,33 \u0026plusmn; 3,98 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e4,20 \u0026plusmn; 3,58 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e2,50\u0026nbsp;\u0026plusmn; 1,73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e3,17 \u0026plusmn; 1,72 \u003csup\u003e(BC)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,524\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e2,90 \u0026plusmn; 1,66 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e5,00\u0026nbsp;\u0026plusmn; 6,16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e2,50 \u0026plusmn; 1,22 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e3,50 \u0026plusmn; 3,89 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12.987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8571%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e = 0,053\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.4545%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6364%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0195%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.0455%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(*)\u0026nbsp;Significant\u0026nbsp;difference\u0026nbsp;at 5.0%\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eMann-Whitney\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etest\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFriedman\u0026nbsp;test\u0026nbsp;with\u0026nbsp;comparisons\u0026nbsp;of\u0026nbsp;the\u0026nbsp;referred\u0026nbsp;test\u0026nbsp;(Conover)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eNote. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents the results of the analysis of the intensity of depressive symptoms, in which an important reduction was noticed in both groups since the beginning of the intervention, where significant differences were recorded between the assessments in each of the groups. Additionally, only a single significant difference between the groups stands out, observed in the first week of intervention.\u003c/p\u003e\n\u003cp\u003eTable 3 - Depression degree statistics by evaluation according to group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u0026nbsp;+ Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e31,50 \u0026plusmn; 9,15 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e18,50 \u0026plusmn; 8,57 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,043*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e23,70 \u0026plusmn; 10,67 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e19,00 \u0026plusmn; 14,94 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e11,67 \u0026plusmn; 7,84 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e14,60 \u0026plusmn; 11,09 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 1,41 \u003csup\u003e(CD)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e4,50 \u0026plusmn; 4,37 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e3,50 \u0026plusmn; 3,60 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e1,50 \u0026plusmn; 1,00 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e2,67 \u0026plusmn; 2,73 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e2,20 \u0026plusmn; 2,20 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e3,50 \u0026plusmn; 4,43 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 1,03 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e2,20 \u0026plusmn; 2,90 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.4566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e = 0,019*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.1866%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.9296%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.3486%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6939%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(*)\u0026nbsp;Significant\u0026nbsp;difference\u0026nbsp;at 5.0%\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eMann-Whitney\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etest\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFriedman\u0026nbsp;test\u0026nbsp;with\u0026nbsp;comparisons\u0026nbsp;of\u0026nbsp;the\u0026nbsp;referred\u0026nbsp;test\u0026nbsp;(Conover)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eNote. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 illustrates the averages of the scores related to suicide risk and from this analysis it is found that in both groups there was a reduction in the risk, however in the group Medication +TCCi (group B) the reduction was more expressive although no significant differences between groups were observed in any of the evaluations.\u003c/p\u003e\n\u003cp\u003eTable 4 - Suicide risk scale statistics (Columbia) by group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u0026nbsp;+ Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19,25 \u0026plusmn; 12,12 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17,00 \u0026plusmn; 14,62 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17,90 \u0026plusmn; 13,00 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e11,25 \u0026plusmn; 8,46 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e12,33 \u0026plusmn; 9,16 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e11,90 \u0026plusmn; 8,41 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e1097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e6,00 \u0026plusmn; 9,52 \u003csup\u003e(AB)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e3,20 \u0026plusmn; 6,20 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 2,31 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e1,60 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 2,31 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e1,60 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.8033%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.0656%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e = 0,029*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.5738%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.1311%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.8852%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.541%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(*)\u0026nbsp;Significant\u0026nbsp;difference\u0026nbsp;at 5.0%\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eMann-Whitney\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etest\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFriedman\u0026nbsp;test\u0026nbsp;with\u0026nbsp;comparisons\u0026nbsp;of\u0026nbsp;the\u0026nbsp;referred\u0026nbsp;test\u0026nbsp;(Conover)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eNote.\u0026nbsp;If\u0026nbsp;all\u0026nbsp;the\u0026nbsp;letters\u0026nbsp;in\u0026nbsp;brackets\u0026nbsp;are\u0026nbsp;distinct,\u0026nbsp;there\u0026nbsp;is\u0026nbsp;a\u0026nbsp;significant\u0026nbsp;difference\u0026nbsp;between\u0026nbsp;the\u0026nbsp;corresponding evaluations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom Table 5 it is emphasized that: the means of the depression scale in the Medication group reduced from W0 to W6 (from 31.50 to 1.50) and from this value increased to 3.50 in W8, while in the Medication + Psychotherapy group the averages reduced with the evaluation from 18.50 to 1.33; the only significant difference between the groups was verified in W0 and significant differences were recorded between the assessments in each of the groups, with differences between: in the Medication group, with the exception of 4 weeks (W4) which was not different from W6 and W8 in the In other pairs, the differences were significant; in the Medication + Psychotherapy group, except between W0 and W2 and between W6 and W8, the other pairs had significant differences; In the total group, with the exception of the pair W6 and W8, the other pairs showed significant differences.\u003c/p\u003e\n\u003cp\u003eTable 5 \u0026ndash; Statistics of the degree of depression by assessment according to group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication + Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e31,50 \u0026plusmn; 9,15 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e18,50 \u0026plusmn; 8,57 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,043*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e23,70 \u0026plusmn; 10,67 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e19,00\u0026nbsp;\u0026plusmn; 14,94\u003c/p\u003e\n \u003cp\u003e(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e11,67 \u0026plusmn; 7,84 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e14,60 \u0026plusmn; 11,09 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 1,41 \u003csup\u003e(CD)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e4,50 \u0026plusmn; 4,37 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e3,50 \u0026plusmn; 3,60 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1,50 \u0026plusmn; 1,00 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2,67 \u0026plusmn; 2,73 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2,20 \u0026plusmn; 2,20 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e3,50 \u0026plusmn; 4,43 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 1,03 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2,20 \u0026plusmn; 2,90 \u003csup\u003e(D)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e = 0,019*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(*)\u0026nbsp;Significant\u0026nbsp;difference\u0026nbsp;at 5.0%\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eMann-Whitney\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etest\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFriedman\u0026nbsp;test\u0026nbsp;with\u0026nbsp;comparisons\u0026nbsp;of\u0026nbsp;the\u0026nbsp;referred\u0026nbsp;test\u0026nbsp;(Conover)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eNote. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 shows that: in W0, 6 patients were classified as having mild depression, 5 in the Medication + Psychotherapy group and one in the Medication group, one with moderate depression was in the Medication group and three had severe depression, two in the Medication group and one in the Medication + Psychotherapy group; in the W2 assessment in the Medication group, the mild, moderate and severe categories had frequencies equal to two, one and one respectively, while in the Medication + Psychotherapy group 5 had mild depression and one moderate depression; In assessments W4, W6 and W8, all 10 patients in the study were classified as having mild depression.\u003c/p\u003e\n\u003cp\u003eTable 6 \u0026ndash; Degree of depression by assessment and group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 606px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication + Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0 week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e5 (83,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e6 (60,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (10,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (30,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e5 (83,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7 (70,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e1 (16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (20,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (10,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e4 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 175px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e10 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 7 highlights that: the average suicide risk scores in the Medication group reduced from assessment W0 to W6, from 19.25 to 2.00, they were the same between assessments W6 and W8; in the Medication + Psychotherapy group, the means reduced with the assessment from 17.00 to 1.33 from W0 to W4 and were equal to the aforementioned value in the assessments W4, W6 and W8; no significant differences were recorded between the groups in any of the assessments and significant differences were recorded between the assessments in each of the groups, with differences being observed: in the Medication W0 and W2 group different from W6 and W8; in the Medication + Psychotherapy group and in the total group, the W0 and W2 assessments were different from each other and different from the other three assessments.\u003c/p\u003e\n\u003cp\u003eTable 7 \u0026ndash; Suicide risk scale statistics (Columbia) by assessment according to group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication +\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePsychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003eAverage\u0026nbsp;\u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e19,25 \u0026plusmn; 12,12 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e17,00 \u0026plusmn; 14,62 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e17,90 \u0026plusmn; 13,00 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11,25 \u0026plusmn; 8,46 \u003csup\u003e(A)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e12,33 \u0026plusmn; 9,16 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,810\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e11,90 \u0026plusmn; 8,41 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e6,00 \u0026plusmn; 9,52 \u003csup\u003e(AB)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 0,690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e3,20 \u0026plusmn; 6,20 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 2,31 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1,60 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2,00 \u0026plusmn; 2,31 \u003csup\u003e(B)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e1,33 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep\u003csup\u003e(1)\u003c/sup\u003e = 1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1,60 \u0026plusmn; 2,07 \u003csup\u003e(C)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e = 0,029*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e(2)\u003c/sup\u003e \u0026lt; 0,001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e(*)\u0026nbsp;Significant\u0026nbsp;difference\u0026nbsp;at 5.0%\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003e\u003cstrong\u003eMann-Whitney\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003etest\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFriedman\u0026nbsp;test\u0026nbsp;with\u0026nbsp;comparisons\u0026nbsp;of\u0026nbsp;the\u0026nbsp;referred\u0026nbsp;test\u0026nbsp;(Conover)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eNote. If all the letters in brackets are distinct, there is a significant difference between the corresponding evaluations.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 8 shows that: in W0, 6 patients in the total group were classified as having a high suicide risk, 3 in each group and the rest having a low risk; in W2, half of the patients were at high risk, 2 in the Medication group and 3 in the Medication + Psychotherapy group and the rest were at low risk; in W4, with the exception of one patient in the Medication group with high risk, all others\u0026nbsp;had a mild\u0026nbsp;risk; in W6 and W8 all 8 patients were classified as mild risk.\u003c/p\u003e\n\u003cp\u003eTable 8 \u0026ndash; Columbia Scale that measures suicide by assessment and group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication\u0026nbsp;+ Psychotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (100,0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0 week\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e4 (40,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e6 (60,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e2 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e3 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5 (50,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e3 (75,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e9 (90,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSerious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e1 (25,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e1 (10,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e4 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e10 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e4 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e6 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e10 (100,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe ten patients allocated in this study showed significant improvements in the three outcomes analyzed after drug and psychotherapeutic interventions. Still in the socio-demographic evaluation we can observe that some patients had educational training of high school and higher education which allowed to work in a more permeable way cognitive interventions. The number of children was also another important factor and deserves to be highlighted, because we realize in the literature and clinical practice that it can be a limiting factor for the improvement and perpetuation of insomnia. (Geiger-Brown JM, Rogers VE, Liu W, Ludeman EM, Downton KD, Diaz-Abad M,2015).\u003c/p\u003e \u003cp\u003eIt is known in the psychiatric literature that females are associated with higher prevalence of depressive disorder and anxiety disorders (Cantilino et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Miguel; Gentil; Gattaz, 2011). These conditions, along with high levels of stress, also showed a higher prevalence of female depression in the vast majority of studies (Amr; Hady el Gilany; El-Hawary, 2008; Bassols et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Brenneisen Mayer et al., 2016; Coentre; Faravelli; Figueira, 2016; Saeed et al., 2016), but not all (Miller; Kemmelmeier; Dupey, 2013).\u003c/p\u003e \u003cp\u003eIn general, during the life context that presents itself today, there is little time available for other activities besides those related to work and family obligations. This usually generates a high burden of responsibility and collection. In this sense, receiving emotional family and/or professional support can raise life satisfaction and enable the population a source of decreased concern. That is, those who receive this support have a source of less stress. (Amr; Hady el Gilany; El-Hawary, 2008; Bassols et al., 2015; Bore; Kelly; Nair, 2016; Farzianpour et al., 2011; Morrison; Moffat, 2001; Wray; Mccall, 2007).\u003c/p\u003e \u003cp\u003eIn the general population, insomnia tends to increase with age with less total sleep time and impairment in its quality, because they are more associated, for example, with other sleep disorders such as obstructive sleep apnea and polydrugs. This statement in our study had a positive association with the presence of older patients and sleep impairment. Our sample, however, does not represent the general population. It is a small sample and we should carefully analyze these data.\u003c/p\u003e \u003cp\u003eIn the first outcome that was evaluated by the insomnia severity index, parameters such as whether the patient has difficulty staying or falling asleep, how much he is satisfied or dissatisfied with the current sleep pattern, and two important points how much the patient considers that poor sleep quality impairs his daily activities and how much he thinks other people perceive his problem, because, commonly, patients present cognitive distortions that end up impairing their perception of sleep. In the literature, we observed that TCCi is an effective method for managing sleep disorders in heterogeneous groups with insomnia and taxam ranging from 42 to 50% (Furukawa Y, Sakata M, Yamamoto R, Nakajima S, Kikuchi S, Inoue M, Ito M, Noma H, Takashina HN, Funada S, Ostinelli EG, Furukawa TA, Efthimiou O, Perlis M, 2023). These findings are also consistent with estimates that cognitive-behavioral therapy is effective in improving sleep patterns in about 70\u0026ndash;80% of patients with chronic insomnia (Haurin, 1991; Morin, Culbert and Schwartz, 1993), and that a third of the patients becomeif good sleepers at the end of treatment (Lacks \u0026amp; Powlishta, 1989).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThus we found in the present research the second outcome of evaluation that was in relation to the assessment through the MADRS scale instrument of the unipolar depression framework, It is important to note that the patients included in the research maintained the medications suggested by their psychiatrists, but were not performing any other form of psychotherapeutic intervention, besides Cognitive Behavioral Therapy for Insomnia. A range of previous studies in the population indicates an improvement in mood when associated with psychotherapeutic intervention, and evolution is considered faster in relation to determinant time. (Bray, I,1996, Geiger-Brown JM, Rogers VE, Liu W, Ludeman EM, Downton KD, Diaz-Abad M,2015).\u003c/p\u003e \u003cp\u003eWe observed in the question of the severity of insomnia here an improvement of the depressive framework in both groups, but without being able to create statistical differences. Sleep disturbances can trigger mental disorders, as well as psychiatric disorders can promote sleep problems (Kumar, 2016; Schnel; Albrech, Sandrelli, 2014). Poor quality of sleep also can lead to attention and functional performance losses. This may also be an explanatory factor of the association between poor sleep and worsening mood picture and suicidal behavior. Particularly in current life situations that society allows itself to function, sleep can be impaired and not compensated for by subsequent breaks, allow bring a greater sense of fatigue and sadness and consequent opening of mental disorders.\u003c/p\u003e \u003cp\u003eIn the third and final outcome that was to evaluate the risk of suicide through the Columbia scale instrument, we noticed from the analysis that both groups showed improvement in suicidal thoughts, but it is worth to emphasize and highlight that the group that underwent the psychopharmacological and psychotherapeutic interventions the improvement in negative and distorted thoughts was demonstrated earlier than the group with only medication. At this point, I allow during the writing of this passage to appreciate the positive feelings shown by patients and how much these positive responses remained in the course of the eight weeks and also beyond the follow-up after the observational period of the study.\u003c/p\u003e \u003cp\u003eIn any case, caution is needed in the interpretation of this study on iCCT and unipolar depression, insomnia and suicide risk, because it has some limitations. Our sample has a small representativeness, but it is a sample of patients treated in a reference service of a public hospital in a state of northeastern Brazil (Brazil is a continental country) and a single service. Thus, it may be difficult to extrapolate the results to a population with different characteristics, for example patients from other clinics, or patients with better purchasing power or from other Brazilian regions or other countries, or even younger.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe results of our study also lead to reflections on the very nature of mental disorders. The fact that the MADRS and C-SSRS scales show a reduced score in both groups, but without significant difference, leads us to think that psychiatric symptoms, and especially psychiatric diagnoses, are more complex conditions than the simple sum of symptoms and signs.\u003c/p\u003e \u003cp\u003eThus, acting in this dimension seems to be another window of opportunity for the establishment of psychotherapeutic and psychiatric efforts in the mental health network, not only for individuals with access to private services and who may benefit from other drug interventions, but also for other less favoured populations.\u003c/p\u003e \u003cp\u003eIt is true that one may question whether the effects demonstrated in this work will be maintained in the long term. Further investigations are necessary. However, it is possible to consider that, in the same way that the effect of psychotropic drugs on the treatment of mental disorders requires the continued use of medicines for relatively long periods, it is recommended, or at least desirable, that the techniques taught to participants continue being performed for the prolongation of effects. In fact, this happens with other psychotherapeutic techniques and was oriented to the patients at the end of the intervention.\u003c/p\u003e \u003cp\u003eAnyway, our study with the intervention has some limitations that should be considered. The patients were mostly women, which affects most individuals with insomnia and difficulty in adhering to medication and behavioral interventions. The group with the drug intervention was composed of only one man who presented an episode of post-traumatic stress disorder which made it difficult at certain stage of the follow-up to use the dose of the prescribed medication. The fact that some individuals are also patients with a slightly older age group hinders the improvement of sleep quality, because they have greater chances of clinical comorbidities, for example, nocturia and chronic pain that may make it difficult to treat dissonances such as insomnia.\u003c/p\u003e \u003cp\u003eThe fact that the same researcher evaluated the eight weeks of the medication group and the medication group plus psychotherapy could also have been other bias that contributes to not having as many differences in results in both groups at the end of the follow-up period. In the biweekly evaluations, patients reported that they felt comfortable being questioned by the same professional, i.e., the researcher trained in the psychiatric specialty.\u003c/p\u003e \u003cp\u003eThus, we can also think that what could have been a difficulty seems to have become a strength of the present study. If different investigators had been conducting the investigation in each group, differences in results could have been attributed to possible differences in the quality of the relationship with patients, a bias that would be potentially more difficult to be removed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn any case, despite the mental illness in the general population and sleep disorders such as insomnia being considered globally, there are still few proposals for pharmacological and psychotherapeutic intervention, especially in Latin America and with desirable statistical rigor.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe evaluated patients showed significant improvements in the three parameters of evaluation of the study. Performing leisure activity, associated with changes in behavior and thoughts with the use of a medication with sedative potential potentiates a good quality of sleep, besides worrying less about everyday situations, receive emotional support, being of a lower age, being male allows a favorable context for the non-appearance of symptoms of insomnia.\u003c/p\u003e \u003cp\u003eThese data signaled the need to create specialized care centers, for example, with access to the general population that has as its only access to mental health care the psychosocial care network, providing an increase in well-being andbe subjective (quality of life) and focusing on complaints related to poor sleep quality, allowing a decrease in symptoms that severely impair functionality. Thus, this research allowed to create a scientific support for other scientific studies in several population niches, promoting an evolution in the treatment of insomnia in the general population.\u003c/p\u003e \u003cp\u003eThe aforementioned intervention, proposed over eight weeks in patients with unipolar depression and based on a science network and the techniques of cognitive behavioral therapy for insomnia, was promising in increasing quality of life and sleep, although statistically not demonstrate pragmatic and concrete importance.\u003c/p\u003e \u003cp\u003eThese data indicate the possibility of expanding efforts by health professionals, mental health services and government agencies to build a context for promoting mental health resources. Future research may increase the sample of patients with unipolar depression, insomnia and suicidal behavior and verify the long-term effects of the intervention, analyze whether the intervention is more effective than the findings at this time, finally, extrapolate the findings to different populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL AND CONSENT TO PARTIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was carried out in accordance with the Declaration of Helsinki and received approval from the Ethics Committee for Research with Human Beings of the Federal University of Pernambuco (certificate number: 5.167.260 of 12/15/2021) and the Ethics Committee for Research with Human Beings of IMIP (certificate number: 5.307.597 of 03/23/2022). The study protocol was also retrospectively registered in the Brazilian registry of clinical trials (http://www.ensaiosclinicos.gov.br/rg/). Number: RBR-10b889rz/ UTN Number: U1111-1287- 9616 (February 13, 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll\u0026nbsp;participants\u0026nbsp;agreed\u0026nbsp;to\u0026nbsp;publish\u0026nbsp;the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETITIVE INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere\u0026nbsp;are\u0026nbsp;no\u0026nbsp;competing\u0026nbsp;financial\u0026nbsp;and\u0026nbsp;non-financial interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no external funding sources. The protocol and the study are being financed by the researcher with personal resources.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eARIST\u0026Oacute;TELES. \u003cstrong\u003e\u0026Eacute;tica \u0026agrave; Nic\u0026ocirc;maco\u003c/strong\u003e. 1. ed. S\u0026atilde;o Paulo: Atlas, 2009.\u003c/li\u003e\n\u003cli\u003eBASSOLS, A. M. et al. First- and last-year medical students: Is there a difference in the prevalence and intensity of anxiety and depressive symptoms? \u003cstrong\u003eRevista Brasileira de Psiquiatria\u003c/strong\u003e, v. 36, n. 3, p. 233\u0026ndash;240, 2014.\u003c/li\u003e\n\u003cli\u003eCANTILINO, A. et al. Transtornos psiqui\u0026aacute;tricos no p\u0026oacute;s-parto. \u003cstrong\u003eRevista de Psiquiatria Clinica\u003c/strong\u003e, v. 37, n. 6, p. 278\u0026ndash; 284, 2010.\u003c/li\u003e\n\u003cli\u003eCLARK, D. L.; BOUTROS, N. N.; MENDEZ, M. F. \u003cstrong\u003eThe brain and behavior\u003c/strong\u003e. 3. ed. 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PMID: 31623600; PMCID: PMC6798511.\u003c/li\u003e\n\u003cli\u003eWILKS CR, MORLAND LA, DILON KH, MACKINTOSH MA, BLAKEY SM, WAGNER HR, ELBOGEN\u003c/li\u003e\n\u003cli\u003eEB. Raiva, apoio social e risco de suic\u0026iacute;dio em veteranos militares dos EUA. J Psychiatr Res\u003cem\u003e. \u003c/em\u003e2019; 109 : 139\u0026ndash;144. doi: 10.1016 / j.jpsychires.2018.11.026.\u003c/li\u003e\n\u003cli\u003eWORLD HEALTH ORGANIZATION. \u003cstrong\u003eA User\u0026rsquo;s guide to the Self-ReportingQuestionnaire (SRQ)\u003c/strong\u003e. Geneva: WHO, 1994.\u003c/li\u003e\n\u003cli\u003eZHANG J, LIU X, FANG L. Efeitos combinados da depress\u0026atilde;o e ansiedade sobre o suic\u0026iacute;dio: Um estudo de aut\u0026oacute;psia psicol\u0026oacute;gica de caso-controle na China rural. Psychiatry Res. 2019; 271 (1872-7123): 370-373. doi: 10.1016 / j.psychres.2018.11.010\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Depression, Insomnia, Suicidal Behavior, Preventive Psychiatry, Cognitive Behavioral Therapy for Insomnia","lastPublishedDoi":"10.21203/rs.3.rs-5823715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5823715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eFAGUNDES, D. \u003c/strong\u003eEffect of Cognitive Behavioral Therapy for Insomnia in Depression and Suicide [Thesis]. Recife: Health Sciences Center, Federal University of Pernambuco; 2025.\u003c/p\u003e\n\u003cp\u003eINTRODUCTION: There is growing interest in understanding the relationship between sleep and suicide. Although insomnia is commonly cited as a critical risk factor for suicidal thoughts and behaviours, the evidence on the treatment and control of insomnia and its effects on reducing such behaviours is still unclear. OBJECTIVES: To evaluate the effect of CBTi , in patients diagnosed with Unipolar Depression with symptoms of insomnia, on suicidal behaviour.\u003c/p\u003e\n\u003cp\u003eMETHODS: This is an intervention, cross-sectional and analytical study. Data was collected using three validated and translated instruments. The study consisted of individuals aged 18 to 60 diagnosed with unipolar depression and who reported suicidal ideation with the intention of dying in the last week and/or attempted suicide in the last month. There were two randomised groups: Group A whose therapeutic protocol included a medication (Amitriptyline 25 mg) and Group B whose protocol included a pharmacological intervention with the medication (Amitriptyline 25 mg) and weekly CBT sessions with a protocol duration of 8 weeks. The primary outcomes included the assessment of insomnia severity (Insomnia Severity Index - ISI), suicide risk (Columbia Suicide Risk Rating Scale - C-SSRS) and the secondary outcomes included the severity of depressive symptoms (Montgomery Depression Scale - MDS). Primary and secondary outcome measures were collected at weeks 0, 2, 4, 6 and 8 of the interventions.\u003c/p\u003e\n\u003cp\u003eRESULTS: The study included 10 individuals selected from psychiatric outpatient care, with a higher prevalence of females and an average age of 30-50 years, who showed improvements in the symptoms mood and sleep, as well as changes in suicidal thoughts over the 8 weeks of observation and intervention.\u003c/p\u003e\n\u003cp\u003eCONCLUSION : The individuals assessed with the pharmacological and psychotherapeutic interventions showed a significant response, with an improvement in depressive symptoms, insomnia and suicidal behaviour in the first few weeks of the study. These data point to the need to take a broader look at patients with mood and sleep-related complaints in psychiatric clinical practice, allowing for a more focused intervention and faster progress in the psychopathological examination and psychiatric condition.\u003c/p\u003e","manuscriptTitle":"Effect of Cognitive Behavioral Therapy on symptoms of insomnia, depression and suicide risk","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 08:50:32","doi":"10.21203/rs.3.rs-5823715/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"97dd7ab7-7f84-4e88-891f-ff6645d351c2","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-30T08:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-21 08:50:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5823715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5823715","identity":"rs-5823715","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}