Comparing Engage to PST for Late Life Depression

Policy reports document that evidence-based psychotherapies are rarely employed and sustained
in the community. Several causes of this science to service gap have been identified. One
cause, specific to behavioral interventions, is the complexity of interventions and the
competencies community clinicians must acquire and sustain over time in order to deliver
them. A realistic solution is to streamline behavioral interventions and tailor them to the
settings and therapist skill level available in the community. In response to this need, we
have developed Engage, which: 1) is streamlined on the basis of concepts and findings on the
neurobiology of depression; 2) consists of psychotherapeutic and ecosystem management
components of known efficacy; 3) has distilled and simplified these components so as they can
be accessible to most depressed older patients and taught to larger numbers of clinicians
than available therapies, e.g., Problem Solving Therapy (PST); and 4) is personalized through
a structured stepped approach focusing on "reward exposure". Problem Solving Therapy is an
evidenced-based intervention shown to be effective in treating late-life depression.

Three hundred (150 per site) patient participants will be randomly assigned to receive 9
sessions of either Engage or PST. Forty-two clinician participants will be randomly assigned
to receive training and certification in either Engage or PST. Once certified, clinicians
will be assigned a patient participant and administer their assigned intervention.

Inclusion Criteria (Patient participants):

- Age ≥ 60 years

- unipolar, non-psychotic major depression (by SCID, DSM-IV)

- MADRS ≥ 20

- MMSE ≥ 24

- off antidepressants or have been on a stable dose of an antidepressant for 12 weeks
and do not intend to change the dose in the next 10 weeks

- English speaking

- capacity to provide written consent

Exclusion Criteria (Patient participants):

- Presence of psychiatric diagnoses other than unipolar, non-psychotic major depression
or generalized anxiety disorder

- Newly started use of psychotropic drugs (<12wks) or cholinesterase inhibitors other
than mild doses of benzodiazepines

- Current active suicidal intent/plan

- Current substance abuse