Comparing Engage with PST in Late-Life Major Depression: A Preliminary Report

Abstract

Objective The complexity of psychotherapies has been a barrier to community implementation. We used the Research Domain Criteria consensus as a guide to develop Engage, a streamlined, neurobiology-based psychotherapy for late-life depression that may match the skill set of practicing clinicians. This proof of concept study tested the hypotheses that Engage is bioequivalent to Problem Solving Therapy (PST) in reducing depressive symptoms, inducing remission, and ameliorating disability. Methods Engage assumes that abnormal function of the positive valence systems fuels depression and uses “reward exposure” (engagement in meaningful, rewarding activities) as its principal intervention. Negativity bias, apathy, and emotional dysregulation are expressions of abnormalities in the negative valence, arousal and regulatory, and cognitive control systems respectively. Engage targets each of them with simple interventions only if they interfere with reward exposure. We treated openly with 9 weekly sessions of Engage 39 older adults with unipolar major depression. We compared their course of depression (HAM-D), remission rate (HAM-D<10), and disability (WHODAS) with those of a historical comparison group (N=97) treated with 9 weekly sessions of PST. Results Community social workers and research therapists required one third as much training time in Engage as in PST. Engage was non-inferior to PST in reducing HAM-D and WHODAS. Remission rates for Engage at 6 and 9 weeks were 18.2%, and 41.1%. The corresponding figures for PST were 13.7% and 35.0%. Conclusion These initial observations suggest that Engage has comparable efficacy with PST in reducing depressive symptoms and disability and warrants a randomized controlled trial.

Six Years of Research on the National Institute of Mental Health’s Research Domain Criteria (RDoC) Initiative: A Systematic Review

“…“Engage”, first described in Alexopoulos and Arean (2014), is a psychological intervention designed to specifically target disturbances in RDoC-defined Positive and Negative Valence Systems through reward exposure , the facilitation of meaningful and rewarding activities. A sample of older adults with MDD received 9 weeks of Engage (Alexopoulos et al, 2015). Symptom improvements within this group were compared to a patient group from a previous study (Alexopoulos et al, 2011), in which participants received problem-solving therapy (PST).…”

Effects of Problem-Solving Therapy and Clinical Case Management on Disability in Low-Income Older Adults

“…Psychotherapies are often too difficult for front line workers to learn and sustain (62) and psychotherapies are rarely used with fidelity in social service settings (26). CM is an intervention that most social service workers are trained to provide.…”

“Engage” Therapy: Behavioral Activation and Improvement of Late-Life Major Depression

“…Thirty-nine of these subjects comprised the sample of the proof of concept study reported earlier (13) and 9 were subjects recruited later. They met DSM-IV criteria for major depression.…”

“…A proof of concept study comparing Engage with historical comparison group receiving problem solving therapy (PST), showed that Engage is non-inferior to PST in reducing depression in older adults. (13)…”