Problem adaptation therapy for older adults with major depression and cognitive impairment: a randomized clinical trial

Abstract

Importance: 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.

Design, setting, and participants: 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).

Interventions: 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.

Main outcomes and measures: 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 and relevance: 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.

Trials registration: Clinicaltrials.gov Identifier: NCT00368940.

Conflict of interest statement

The rest of the authors do not have any conflicts of interest or financial relationships with commercial interests.

Figures

Figure 1

Flow diagram of participant progress through the phases of the randomized trial.

Figure 2

Efficacy of PATH vs. ST-CI in Reducing Depression in 74 Older Adults with Major Depression, Advanced Cognitive Impairment and Disability. Depression scores over 12 weeks of PATH versus ST in 74 elders with major depression, advanced cognitive impairment, and disability based on the least squares means and standard error of the mixed effects model: time + time squared + treatment + treatment x time.

Figure 3

Efficacy of PATH vs. ST-CI in Reducing Disability in 74 Older Adults with Major Depression, Advanced Cognitive Impairment and Disability. Disability scores over 12 weeks of PATH versus ST in 74 elders with major depression, advanced cognitive impairment, and disability based on the least squares means and standard error of the mixed effects model: time + time squared + treatment+ treatment x time.