Brain Changes During Social Reward Psychotherapy for Mid- and Late-Life Suicidality

Study Overview
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Brief Summary
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The investigators hypothesized that during the 9-week course of Engage & Connect treatment there will be an increase in brain functions of the Positive Valence System which in turn will lead to reduction in suicidality.

Detailed Description
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Social disconnection peaks in middle and late life and leads to an increased risk of suicide, persistent depression, and poor response to psychosocial interventions. There is a critical need to develop a mechanistic understanding of the link between social disconnection and suicidality, identify biological targets, and address targets with scalable interventions. The investigators developed a novel psychotherapy, Engage & Connect, aimed to improve functions of the Positive Valence System (PVS) that are impaired in suicidality through increased engagement in rewarding social activities. This study will use state-of-the-art precision imaging methods and clinical measures to evaluate brain- and behavioral changes in the PVS during psychotherapy. Participants will: Be randomly assigned to 9-weekly sessions of either Engage & Connect therapy or Symptom Review and Psychoeducation Complete 4 research assessments Complete 3 MRI scans

Official Title
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Brain Changes During Social Reward Psychotherapy for Mid- and Late-Life Suicidality: A Precision Imaging Trial

Conditions
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Depression, Suicidal Ideation, Major Depressive Disorder, Depressive Disorder

Intervention / Treatment
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* Behavioral: Engage & Connect Psychotherapy
* Behavioral: Symptom Review and Psychoeducation (SRP)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Ages aged 50-80 [stratified so that 50% are older than 65] Endorsement of Suicidal Ideation [Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders-5 (SCID-5) Suicide Item (Item 9) with a score of 2 Major Depressive Disorder as determined by the SCID-5 Depression Rating Scale [Montgomery-Åsberg Depression Rating Scale (MADRS)] score of 16 or greater. Mini Mental Status Exam (MMSE) equal or greater than 1 standard deviation below the mean score for patient's age and education Off antidepressants or on a stable dose of an antidepressant for 8 weeks and do not intend to change the dose in the next 10 weeks, without individual psychotherapy services during the study period. Capacity to provide consent for research assessment and treatment. Exclusion Criteria: Intent or plan to attempt suicide in the near future. History or presence of psychiatric diagnoses other than major depressive disorder without psychotic features, generalized anxiety disorder, or specific phobia. Use of psychotropic drugs or cholinesterase inhibitors other than use of 0.5 mg or less of lorazepam daily up to seven times per week. Neurological disorders (dementias, amnestic and multidomain Mild Cognitive Impairment, Parkinson's disease, epilepsy, etc.). Acute or severe medical illness in the past 3 months (metastatic cancer, multiple sclerosis, decompensated cardiac, liver or kidney failure, major surgery, stroke or myocardial infarction, cardiac, renal, or respiratory failure; severe chronic obstructive pulmonary disease, etc.) that may be the primary cause depressive symptoms, influence brain systems of interest, or impact ability to participate in the study. Contraindications to MRI scanning including cardiac pacemaker, heart valve replacement, vascular stent, insulin pump, cochlear implant, any other metallic biomedical implant contraindicating to MRI, and claustrophobia.

Ages Eligible for Study
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Minimum Age: 50 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Engage & Connect Psychotherapy<br>Engage & Connect is a remotely-delivered psychotherapy, aimed to increase engagement in rewarding social activities and in turn, reduce suicidality. In Engage & Connect, depressed middle-aged and older adults with suicidal ideation work with a therapist to develop action plans to pursue rewarding social activities of their choice. | Behavioral: Engage & Connect Psychotherapy<br>* 9-weeks of weekly psychotherapy sessions focused on social reward exposure<br>|
| Active Comparator: Symptom Review and Psychoeducation (SRP)<br>In this intervention, the therapist will review the participant's symptoms and provide literature-based clinical explanations and clarifications about the symptoms, the course, and the causes of depression and aging processes. In SRP, the therapist reviews the depressed individual's symptoms, and level of information on depression, identifies misconceptions, and guides selection of educational material which could benefit the patient. | Behavioral: Symptom Review and Psychoeducation (SRP)<br>* 9-weeks of weekly psychotherapy sessions focused on symptom review and psychoeducation about depression and aging<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in resting state functional connectivity of the Positive Valence System | Change in resting state fMRI connectivity of functional networks representing structures previously associated with the Positive Valence System (Dorsal anterior cingulate cortex [dACC], the Subgenual Anterior Cingulate Cortex [sgACC], and the basal forebrain/nucleus accumbens [NAcc]). The investigators will also test between-network connectivity between the positive valence system and the default mode-, salience-, and fronto-parietal networks. Functional connectivity within- and between-network will be measured with a correlational score of 0 to 1, with 0 being the lowest and 1 being the highest. | Baseline, midtreatment (week 6) and post treatment (week 9) | 
| Change in STAR task reaction time following social feedback | The Social Task for Assessment of Reward is a computerized task that measures response to social rewards. Reaction time will be measures in milliseconds. | Baseline, midtreatment (week 6), and post treatment (week 9) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Late Life Depression, Psychotherapy, Mechanisms of Action, Positive Valence System, Social Reward