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

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.

An Emotion Regulation Tablet App for Middle-Aged and Older Adults at High Suicide Risk: Feasibility, Acceptability, and Two Case Studies.

OBJECTIVE: The unique features of technological applications may improve the treatment of people at risk of suicide. In this article, we present feasibility and acceptability data as well as two case studies demonstrating the use of WellPATH, a tablet app that aims to help suicidal patients during emotionally-charged situations outside of therapy sessions. The WellPATH app was part of a 12-week psychotherapy intervention (CRISP - Cognitive Reappraisal Intervention for Suicide Prevention) for middle-aged and older adults after their discharge from a suicide-related hospitalization. DESIGN: The use of WellPATH includes three stages: preparation and practice, incorporation, and actual use. MEASUREMENTS: Feasibility was measured by the overall use of WellPATH during 12 weeks, and acceptability was measured with the three items of the Client Satisfaction Questionnaire. RESULTS: Twelve study participants were administered WellPATH as part of CRISP. The results provide preliminary evidence of feasibility and acceptability of WellPATH. Study participants and therapists reported high satisfaction with WellPATH and provided feedback for future research and development. The patients in the case studies reported a reduction in negative emotions and an increase in emotion regulation (i.e., cognitive reappraisal ability) after using techniques on the WellPATH app. CONCLUSION: Our preliminary findings suggest that use of technology applications such as the WellPATH app is feasible and accepted among middle-aged and older adults at high suicide risk. Further research with an adequately powered sample is needed to further evaluate WellPATH's feasibility and accessibility, and test its efficacy with this high-risk population.

Subjective, neuropsychological, and neural markers of memory in older adults.

OBJECTIVES: To investigate the relationship between the P300 event-related potential, neuropsychological measures of memory, subjective memory complaints (SMCs), and indicators of psychosocial functioning. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study of 79 community-based older adults, aged 60-75 years, participants completed online surveys and in-person neuropsychological and electroencephalogram (EEG) assessments. MEASUREMENTS: Measures included: the Change subscale of the Metamemory in Adulthood Questionnaire, NIH Toolbox Emotions battery (Perceived Stress and Psychological Well-Being), Geriatric Depression Scale, Geriatric Anxiety Scale, electrocortical measures (EEG), California Verbal Learning Test, 3rd Edition, and diagnostic ratings for mild and major neurocognitive disorders based on full neuropsychological battery, clinical interview, and two-clinician consensus. RESULTS: P300 amplitude was associated with long-delay verbal memory recall and diagnostic rating. SMCs were not associated with objective memory or diagnostic rating. SMCs were associated with higher perceived stress, anxiety, and depression symptoms and lower psychological well-being. CONCLUSIONS: Neural indicators such as the P300 may be useful for early detection of cognitive impairment. SMCs were not a reliable indicator of early memory impairment in relation to neuropsychological or neural indicators, but may be a useful indicator of unreported stress and mood symptoms in clinical settings.

Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression.

OBJECTIVE: To adapt and optimize problem adaptation therapy for depression in dementia by grounding it in the lives of people with dementia, caregivers and clinicians. METHODS: A person-centered qualitative approach was taken to elicit the unique cognitive, psychological and social needs of people with dementia relevant to the adaptation of the intervention. A two-stage design was used: the first involved interviews and focus groups to identify priorities and concerns surrounding depression in dementia, the second trialling of the adapted intervention. PARTICIPANTS: Ten people with dementia and nine caregivers participated in individual interviews, 35 healthcare practitioners and clinical academics with experience of working with dementia participated in focus groups. RESULTS: The findings highlight the importance of addressing key themes that typified the experience of depression among people with dementia including: a profound sense of isolation and role loss, the feeling of being both a burden and poorly understood, polarized thinking, interpersonal tensions, diverging views among carers and people with dementia about their capabilities, and changeability in cognitive ability and mood. These themes were used to inform adaptation of the intervention manual, ensuring that its content and delivery addressed the concerns of both people with depression and dementia and those who support them. CONCLUSION: Implications for PATH included a focus on facilitating open communication, supporting the continuation of valued roles, and improving confidence.

Depression, cognitive, and functional outcomes of Problem Adaptation Therapy (PATH) in older adults with major depression and mild cognitive deficits.

OBJECTIVES: Antidepressants have limited efficacy in older adults with depression and cognitive impairment, and psychosocial interventions for this population have been inadequately investigated. Problem Adaptation Therapy (PATH) is a psychosocial intervention for older adults with major depression, cognitive impairment, and disability. DESIGN: This study tests the efficacy of PATH versus Supportive Therapy for Cognitively Impaired Older Adults (ST-CI) in reducing depression (Montgamery Asberg Depression Rating Scale [MADRS]) and disability (World Health Organization Disability Assessments Schedule-II [WHODAS-II]) and improving cognitive outcomes (Mini Mental State Examination [MMSE]) over 24 weeks (12 weeks of treatment and 12-week post-treatment follow-up). SETTING: Participants were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry. Both interventions and all research assessments were conducted at home. PARTICIPANTS: Thirty-five older adults (age ≥ 65 years) with major depression and cognitive impairment no dementia (CIND). INTERVENTIONS: PATH aims to increase emotion regulation by incorporating a problem-solving approach, teaching compensatory strategies, and inviting caregiver participation. Supportive Therapy aims to facilitate the expression of affect, as well as promote empathy. MEASUREMENTS: Depression was measured using the MADRS, disability using the WHODAS-II, and cognition using the MMSE. RESULTS: PATH participants showed significantly greater reduction in MADRS total score (7.04 points at 24 weeks, treatment group by time interaction: F[1,24.4] = 7.61, p = 0.0108), greater improvement in MMSE total score (2.30 points at 24 weeks, treatment group by time interaction: F[1,39.8] = 13.31, p = 0.0008), and greater improvement in WHODAS-II total score (2.95 points at 24 weeks, treatment group by time interaction: F[1,89] = 4.93, p = 0.0290) than ST-CI participants over the 24-week period. CONCLUSIONS: PATH participants had better depression, cognitive, and disability outcomes than ST-CI participants over 6 months. PATH may provide relief to depressed older adults with CIND who currently have limited treatment options.

Negative Emotions and the Course of Depression During Psychotherapy in Suicidal Older Adults With Depression and Cognitive Impairment.

OBJECTIVE: The study examines the relationship of negative emotions with: 1) non-emotional symptoms (e.g., vegetative and physical symptoms) and 2) the course of depression in suicidal older adults with Major Depressive Disorder (MDD) and cognitive impairment treated with psychotherapy. DESIGN: The authors identified a subgroup of participants (N = 26) who expressed suicidal ideation at Baseline or Week 12 from a randomized controlled trial (RCT) of two psychosocial interventions, Problem Adaptation Therapy (PATH) and Supportive Therapy for Cognitively Impaired. The authors assessed negative emotions, non-emotional symptoms of depression, depression severity, and suicidal ideation at entry, week 4, week 8, and week 12. PARTICIPANTS: Participants were 65 years and older and had a diagnosis of unipolar depression, varying degrees of cognitive impairment (up to moderate dementia) and suicidal ideation. SETTING: The study was conducted in the Outpatient Department of New York Presbyterian/Weill Cornell Medicine in Westchester, NY. MEASUREMENTS: Negative emotions and non-emotional items were identified with the 24-item Hamilton Depression Rating Scale (Ham-D). RESULTS: Among participants with suicidal ideation, the reduction in negative emotions from baseline to week 4, week 4 to week 8, and week 8 to week 12 was significantly associated with the reduction in non-emotional symptoms of depression at weeks 4, 8, and 12 (F(1, 35) = 6.20, p = 0.02) and with the reduction in overall depression severity at weeks 4, 8, and 12 (F(1, 35) = 26.63, p <0.0001) after controlling for depression severity at baseline (HAM-D total score) and time trends. CONCLUSION: Our findings may guide the treatment of older patients with depression and suicidal ideation to help reduce depression and suicide risk.

Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) for Middle-Aged and Older Adults Hospitalized for Suicidality.

Middle-aged and older adults constitute a high suicide-risk group. Among adults aged 50 years old and older, suicide rates increased and suicide deaths almost doubled during the period from 2000 to 2015. Suicide rates are elevated for patients hospitalized for suicidality (i.e., active suicidal ideation or suicide attempt) and the 3 months post-hospitalization is the time of the highest suicide risk. Psychosocial interventions for middle-aged and older adults hospitalized for suicidality are sparse. In this article, we present the main aspects, stages, techniques and a clinical case study of Cognitive Reappraisal Intervention for Suicide Prevention (CRISP), a psychosocial intervention targeting cognitive reappraisal to reduce suicide risk in middle-aged and older adults who have been recently hospitalized for suicidal ideation or a suicide attempt. CRISP is based on the theory that hospitalization for suicidality is preceded by an emotional crisis ("perfect storm"); this emotional crisis is related to personalized (patient- and situation-specific) triggers; and identifying these personalized triggers and the associated negative emotions and providing strategies for an adaptive response to these triggers and negative emotions will reduce suicidal ideation and improve suicide prevention. CRISP therapists identify these triggers of negative emotions and use cognitive reappraisal techniques to reduce these negative emotions. The cognitive reappraisal techniques have been selected from different psychosocial interventions and the affective neuroscience literature and have been simplified for use with middle-aged and older adults. CRISP may fill a treatment need for the post-discharge high-risk period for middle-aged and older adults hospitalized for suicidality.

Two Interventions for Patients with Major Depression and Severe Chronic Obstructive Pulmonary Disease: Impact on Dyspnea-Related Disability.

OBJECTIVE: The Personalized Intervention for Depressed Patients with Chronic Obstructive Pulmonary Disease (PID-C) is an intervention aiming to help patients adhere to their rehabilitation and care. This study tested the hypothesis that the Problem-Solving Adherence (PSA) intervention, which integrates problem-solving into adherence enhancement procedures, reduces dyspnea-related disability more than PID-C. Exploratory analyses sought to identify patients with distinct dyspnea-related disability trajectories and to compare their clinical profiles. METHODS: In this randomized controlled trial in an acute inpatient rehabilitation and community, 101 participants diagnosed with chronic obstructive pulmonary disease (COPD) and major depression were included after screening 633 consecutive admissions for acute inpatient rehabilitation. Participants underwent 14 sessions of PID-C versus PSA over 26 weeks using the Pulmonary Functional Status and Dyspnea Questionnaire. RESULTS: The study hypothesis was not supported. Exploratory latent class growth modeling identified two distinct disability trajectories. Dyspnea-related disability improved in 39% of patients and remained unchanged in the rest. Patients whose dyspnea-related disability improved had more severe disability and less sense of control over their condition at baseline. CONCLUSION: Improvement or no worsening of disability was noted in both treatment groups. This is a favorable course for depressed patients with a severe, deteriorating medical illness. PID-C is compatible with the expertise of clinicians working in community-based rehabilitation programs, and after further testing in the community, it can be integrated in the care of depressed COPD patients.

Negative Emotions and Suicidal Ideation during Psychosocial Treatments in Older Adults with Major Depression and Cognitive Impairment.

OBJECTIVE: To examine the relationship of negative emotions with suicidal ideation during 12 weeks of Problem Adaptation Therapy (PATH) versus Supportive Therapy of Cognitively Impaired Older Adults (ST-CI), hypothesizing that improved negative emotions are associated with reduced suicidal ideation, PATH improves negative emotions more than ST-CI, and improved negative emotions, rather than other depression symptoms, predict reduction in suicidal ideation. METHODS: In a randomized controlled trial of two home-delivered psychosocial interventions, 74 older participants (65-95 years old) with major depressive disorder and cognitive impairment were recruited in collaboration with community agencies. The sample reported less intense feelings than suicidal intention. Interventions and assessments were conducted in participants' homes. PATH focuses on improving emotion regulation, whereas ST-CI focuses on nonspecific therapeutic factors, such as understanding and empathy. Improved negative emotions were measured as improvement in Montgomery Asberg's Depression Rating Scales' (MADRS) observer ratings of sadness, anxiety, guilt, hopelessness, and anhedonia. Suicidal ideation was assessed with the MADRS Suicide Item. RESULTS: MADRS Negative Emotions scores were significantly associated with suicidal ideation during the course of treatment (F[1,165] = 12.73, p = 0.0005). PATH participants had significantly greater improvement in MADRS emotions than ST-CI participants (treatment group by time: F[1,63.2] = 7.02, p = 0.0102). Finally, improved negative emotions, between lagged and follow-up interview, significantly predicted reduction in suicidal ideation at follow-up interview (F[1, 96] = 9.95, p = 0.0022). CONCLUSION: Findings thatimprovement in negative emotions mediates reduction in suicidal ideation may guide the development of psychosocial interventions for reduction of suicidal ideation (clinicaltrials.gov; NCT00368940).

Advances in Psychotherapy for Depressed Older Adults.

PURPOSE OF REVIEW: We review recent advances in psychotherapies for depressed older adults, in particular those developed for special populations characterized by chronic medical illness, acute medical illness, cognitive impairment, and suicide risk factors. We review adaptations for psychotherapy to overcome barriers to its accessibility in non-specialty settings such as primary care, homebound or hard-to-reach older adults, and social service settings. RECENT FINDINGS: Recent evidence supports the effectiveness of psychotherapies that target late-life depression in the context of specific comorbid conditions including COPD, heart failure, Parkinson's disease, stroke and other acute conditions, cognitive impairment, and suicide risk. Growing evidence supports the feasibility, acceptability, and effectiveness of psychotherapy modified for a variety of health care and social service settings. Research supports the benefits of selecting the type of psychotherapy based on a comprehensive assessment of the older adult's psychiatric, medical, functional, and cognitive status, and tailoring psychotherapy to the settings in which older depressed adults are most likely to present.

"Engage" Therapy: Behavioral Activation and Improvement of Late-Life Major Depression.

OBJECTIVE: Engage is a treatment for late-life depression developed to match the skills of community clinicians based on the theory that dysfunction in the Research Domain Criteria Project positive valence systems is a critical mechanism of late-life depression. Accordingly, it uses "reward exposure" (engagement in meaningful, rewarding activities) as its principal intervention. This study tests the hypothesis that change in behavioral activation, an index of positive valence systems function, during successive treatment periods with Engage and during follow-up predicts depression at the end of each period. METHODS: Forty-eight nondemented, older adults with unipolar major depression were treated openly with 9 weekly sessions of Engage and assessed 36 weeks after entry. Depression severity was assessed with the 24-item Hamilton Depression Rating Scale (HAM-D) and behavioral activation with the Behavioral Activation for Depression Scale (BADS) at baseline, 6 weeks (mid-treatment), 9 weeks (end of treatment), and 36 weeks. RESULTS: A mixed-effects model examined whether change in BADS in successive periods occurring during Engage treatment and during follow-up predicts depression at the end of each period. Both BADS change (F1,52 = 18.63, p < 0.0001) and time (F2,52 = 7.68, p = 0.0012) predicted HAM-D scores at the end of each observation period. Every point of increase in BADS change reduced the HAM-D by 0.105 points. HAM-D at each point did not predict subsequent change in BADS (F1,52 = 2.17, p = 0.146). CONCLUSION: During Engage treatment and follow-up, change in behavioral activation is followed by improvement of depressive symptoms and signs.

Clinical Case Management versus Case Management with Problem-Solving Therapy in Low-Income, Disabled Elders with Major Depression: A Randomized Clinical Trial.

OBJECTIVE: To test the hypotheses that (1) clinical case management integrated with problem-solving therapy (CM-PST) is more effective than clinical case management alone (CM) in reducing depressive symptoms of depressed, disabled, impoverished patients and that (2) development of problem-solving skills mediates improvement of depression. METHODS: This randomized clinical trial with a parallel design allocated participants to CM or CM-PST at 1:1 ratio. Raters were blind to patients' assignments. Two hundred seventy-one individuals were screened and 171 were randomized to 12 weekly sessions of either CM or CM-PST. Participants were at least 60 years old with major depression measured with the 24-item Hamilton Depression Rating Scale (HAM-D), had at least one disability, were eligible for home-based meals services, and had income no more than 30% of their counties' median. RESULTS: CM and CM-PST led to similar declines in HAM-D over 12 weeks (t = 0.37, df = 547, p = 0.71); CM was noninferior to CM-PST. The entire study group (CM plus CM-PST) had a 9.6-point decline in HAM-D (t = 18.7, df = 547, p <0.0001). The response (42.5% versus 33.3%) and remission (37.9% versus 31.0%) rates were similar (χ(2) = 1.5, df = 1, p = 0.22 and χ(2) = 0.9, df = 1, p = 0.34, respectively). Development of problem-solving skills did not mediate treatment outcomes. There was no significant increase in depression between the end of interventions and 12 weeks later (0.7 HAM-D point increase) (t = 1.36, df = 719, p = 0.17). CONCLUSION: Organizations offering CM are available across the nation. With training in CM, their social workers can serve the many depressed, disabled, low-income patients, most of whom have poor response to antidepressants even when combined with psychotherapy.

Two Behavioral Interventions for Patients with Major Depression and Severe COPD.

OBJECTIVE: Personalized Intervention for Depressed Patients with COPD (PID-C), a treatment mobilizing patients to participate in their care, was found more effective than usual care. To further improve its efficacy, we developed a Problem Solving-Adherence (PSA) intervention integrating problem solving into adherence enhancement procedures. We tested the hypothesis that PSA is more effective than PID-C in reducing depressive symptoms. Exploratory analyses sought to identify patients with distinct depressive symptom trajectories and compare their clinical profiles. DESIGN: Randomized controlled trial. SETTING: Acute inpatient rehabilitation and community. PARTICIPANTS: A total of 101 diagnosed with chronic obstructive pulmonary disease (COPD) and major depression after screening 633 consecutive admissions for acute inpatient rehabilitation. INTERVENTION: Fourteen sessions of PID-C versus PSA over 26 weeks. MEASUREMENTS: 24-item Hamilton Depression Rating Scale. RESULTS: PSA was not more efficacious than PID-C in reducing depressive symptoms. Exploratory latent class growth modeling identified two distinct depressive symptoms trajectories. Unlike patients with unfavorable course (28%) who remained symptomatic, patients with favorable course (72%) had a decline of symptoms during the hospitalization followed by a milder decline after discharge. Patients with unfavorable course were younger and had greater scores in disability, anxiety, neuroticism, and dyspnea related limitation in activities and lower self-efficacy scores. CONCLUSIONS: Both interventions led to sustained improvement depressive symptoms. PID-C matches the skills of clinicians employed by community rehabilitation programs and can be integrated in the care of depressed COPD patients. Patients with severe disability, anxiety, neuroticism, and low self-efficacy are at risk for poor outcomes and in need of close follow-up and targeted interventions. .

Comparing engage with PST in late-life major depression: a preliminary report.

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%, respectively. The corresponding figures for PST were 13.7% and 35.0%, respectively. CONCLUSION: These initial observations suggest that Engage has comparable efficacy with PST in reducing depressive symptoms and disability and warrants a randomized controlled trial.