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Comparing the streamlined psychotherapy “Engage” with problem-solving therapy in late-life major depression. A randomized clinical trial

Abstract

Effective psychotherapies for late-life depression are underutilized, mainly because of their complexity. “Engage” is a novel, streamlined psychotherapy that relies on neurobiology to identify core behavioral pathology of late-life depression and targets it with simple interventions, co-designed with community therapists so that they can be delivered in community settings. Consecutively recruited adults (≥60 years) with major depression (n = 249) were randomly assigned to 9 weekly sessions of “Engage” or to the evidence-based Problem-Solving Therapy (PST) offered by 35 trained community social workers and assessed by blind raters. “Engage” therapists required an average of 30% less training time to achieve fidelity to treatment than PST therapists and had one-third of the PST therapists’ skill drift. Both treatments led to reduction of HAM-D scores over 9 weeks. The mixed effects model-estimated HAM-D ratings were not significantly different between the two treatments at any assessment point of the trial. The one-sided 95% CI for treatment-end difference was (−∞, 0.07) HAM-D points, indicating a non-inferiority margin of 1.3 HAM-D points or greater; this margin is lower than the pre-determined 2.2-point margin. The two treatment arms had similar response (HR = 1.08, 95% CI (0.76, 1.52), p = 0.67) and remission rates (HR = 0.89, 95% CI (0.57, 1.39), p = 0.61). We conclude that “Engage” is non-inferior to PST. If disseminated, “Engage” will increase the number of therapists who can reliably treat late-life depression and make effective psychotherapy available to large numbers of depressed older adults.

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Fig. 1: “Engage” vs. PST randomized clinical trial.
Fig. 2: Decline in severity of major depression in “Engage” and in PST-treated participants.
Fig. 3
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Funding

This study was supported by R01 MH102252 (GSA), R01 MH102304 (PAA), P50 MH113838 (GSA), T32 MH019132 (GSA), and P50 MH115837 (PAA).

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Correspondence to George S. Alexopoulos.

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GSA served on Advisory Board of Eisai and of Janssen Pharmaceuticals. He also served on the Speakers Bureaus of Allergan, Otsuka, and Takeda-Lundbeck. TDH is an employee of ‘Talkspace’. All other authors report no conflicts.

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Alexopoulos, G.S., Raue, P.J., Banerjee, S. et al. Comparing the streamlined psychotherapy “Engage” with problem-solving therapy in late-life major depression. A randomized clinical trial. Mol Psychiatry 26, 5180–5189 (2021). https://doi.org/10.1038/s41380-020-0832-3

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