Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial.
OBJECTIVE
Problem adaptation therapy (PATH) is a treatment for older adults with major depression, cognitive impairment (from mild cognitive deficits to moderate dementia), and disability. Antidepressants have limited efficacy in this population and psychosocial interventions are inadequately investigated.


OBJECTIVE
To test the efficacy of 12-week PATH vs supportive therapy for cognitively impaired patients (ST-CI) in reducing depression and disability in 74 older adults with major depression, cognitive impairment, and disability.


METHODS
A randomized clinical trial at the Weill Cornell Institute of Geriatric Psychiatry from April 1, 2006, to September 31, 2011. Interventions were administered at the participants' homes. Participants included 74 older individuals (age ≥ 65 years) with major depression and cognitive impairment to the level of moderate dementia. They were recruited through collaborating community agencies of Weill Cornell Institute of Geriatric Psychiatry and were randomly assigned to 12 weekly sessions of PATH or ST-CI (14.8% attrition rate).


METHODS
Home-delivered PATH vs home-delivered ST-CI. Problem adaptation therapy integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. Supportive therapy for cognitively impaired patients focuses on expression of affect, understanding, and empathy.


METHODS
Mixed-effects models for longitudinal data compared the efficacy of PATH with that of ST-CI in reducing depression (Montgomery-Asberg Depression Rating Scale) and disability (World Health Organization Disability Assessment Schedule II) during 12 weeks of treatment.


RESULTS
Participants in PATH had significantly greater reduction in depression (Cohen d, 0.60; 95% CI, 0.13-1.06; treatment × time, F(1,179) = 8.03; P = .005) and disability (Cohen d, 0.67; 95% CI, 0.20-1.14; treatment × time, F(1,169) = 14.86; P = .001) than ST-CI participants during the 12-week period (primary outcomes). Furthermore, PATH participants had significantly greater depression remission rates than ST-CI participants (37.84% vs 13.51%; χ(2) = 5.74; P = .02; number needed to treat = 4.11) (secondary outcome).


CONCLUSIONS
Problem adaptation therapy was more efficacious than ST-CI in reducing depression and disability. Problem adaptation therapy may provide relief to a large group of depressed and cognitively impaired older adults who have few treatment options.


BACKGROUND
Clinicaltrials.gov Identifier: NCT00368940.
Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York.
Dimitris N
DN
Kiosses
Department of Neurology, Weill Cornell Medical College, White Plains, New York.
Lisa D
LD
Ravdin
Stanford University, Stanford, California.
James J
JJ
Gross
Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York.
Patrick
P
Raue
Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York.
Nabil
N
Kotbi
Weill Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College, White Plains, New York.
George S
GS
Alexopoulos
D000223:Adaptation, Psychological; D000368:Aged; D000369:Aged, 80 and over; D001521:Behavior Therapy / Q000379:methods*; D003072:Cognition Disorders / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D003865:Major Depressive Disorder / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D005260:Female; D006699:Home Care Services; D006801:Humans; D008297:Male; D019989:Persons with Intellectual Disabilities / Q000523:psychology / Q000534:rehabilitation; D011340:Problem Solving; D011569:Psychiatric Status Rating Scales; D016896:Treatment Outcome