Late-life major depression, cognitive impairment and disability contribute to medical and psychiatric morbidity and mortality. Available antidepressants bring to remission fewer than 40% of depressed, cognitively impaired elders while psychosocial interventions for this population are underdeveloped and understudied. The proposed randomized clinical trial, the PI's first R01, will test the efficacy of Problem Adaptation Therapy (PATH), a new home-delivered psychosocial intervention for elders with major depression, cognitive impairment, and disability, compared to home-delivered Supportive Therapy (ST). PATH is innovative because it focuses on the patient's ecosystem (i.e. the patient, the caregiver, and the home-environment) and targets behavioral problems related to both depression and disability. This study builds on the PI's K23 award that supported the development of PATH, provided evidence for the feasibility of recruitment, randomization, retention, assessment procedures and implementation of PATH, and offered a signal that PATH is efficacious in reducing depression and disability in this population. Recruitment will be conducted through the Home Delivered Meals programs of 3 collaborating agencies of the Community Network Unit of the Cornell Advanced Center for Interventions and Services Research (ACISR). Participants will be 176 elders (>64 years) with unipolar major depression, cognitive impairment ranging from mild cognitive deficits up to the levels of mild to moderate dementia, and impairment in instrumental activities of daily living. All participants will have an available caregiver (family, significant other, or professional) and will be randomized to 12 weekly sessions of PATH or ST. Research assessments will be performed at study entry (baseline), and at 2, 4, 6, 8, 10, 12 and 24 weeks after randomization. The study is designed to test the hypotheses that home-delivered PATH is more effective than home-delivered ST a) in reducing patient's depression and disability and b) in increasing patient and caregiver's self- efficacy over the 12-week treatment period. After the completion of 12 weeks of treatment, participants will be followed for an additional 12 weeks to measure sustained effects of treatment. Therapists will be Master's level Social Workers (MSW) of the ACISR. We elected to train MSWs to pave the way towards future effectiveness and implementation projects. MSWs are available in many community-based social services across the country, often offer psychosocial interventions, and can be reimbursed through Medicare for these services. The proposal is consistent with NIMH strategic objectives as well as recommendations from the NIMH Geriatric Branch.
Depression, cognitive deficits and disability co-exist in older adults and contribute to detrimental consequences. Available antidepressant treatments do not meet the needs of the majority of depressed, cognitively impaired, disabled elders. If found to be effective, the proposed home- delivered intervention may provide relief to a large group of depressed elders and their families.
