Home-Based Therapy Helps Older Adults With Depression, MCI

Megan Brooks

November 13, 2014

A home-delivered problem-solving intervention reduces depression and mild cognitive impairment (MCI) in homebound older adults, who often have few treatment options.

In a randomized controlled trial, problem adaptation therapy (PATH) proved more efficacious than supportive therapy for the cognitively impaired (ST-CI) in reducing depression and disability.

"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," the authors, led by Dimitris N. Kiosses, PhD, of the Weill Cornell Institute of Geriatric Psychiatry in White Plains, New York, write.

The study was published online November 5 in JAMA Psychiatry.

Vulnerable Population

Older adults with major depression and cognitive impairment are a vulnerable group, at high risk for illness and premature death. Drug therapy has only limited efficacy, and psychotherapies are sparse, the investigators point out.

PATH integrates a problem-solving approach with compensatory strategies, environmental adaptations, and caregiver participation to improve patients' emotion regulation. ST-CI focuses on expression of affect, understanding, and empathy.

The investigators recruited 74 adults aged 65 years and older who had major depression, cognitive impairment to the level of moderate dementia, disability (at least one impairment in activities of daily living), and limited mobility.

They were randomly assigned to receive 12 weekly sessions of home-delivered PATH or home-delivered ST-CI. Three clinical psychologists, four clinical social workers, and one clinical doctoral candidate delivered both interventions.

The groups were well matched on demographic and baseline clinical variables. Most of the patients had primary caregivers, such as children, spouses, or other family members, and most of the caregivers had at least one session with the therapist.

PATH was clearly more efficacious than ST-CI, the researchers say.

In a mixed-effects model, PATH participants had a 43% greater decline in depression by week 12, as determined on the basis of the Montgomery-Åsberg Depression Rating Scale (MADRS), than participants who received ST-CI. PATH led to significantly lower depression scores at week 8 (P = .005) and week 12 (P = .001).

PATH participants also had a 93% greater decline in disability by week 12, as determined on the basis of the World Health Organization Disability Assessment Schedule II (WHODAS-II) total score. PATH led to significantly lower disability scores at week 8 (P = .04) and week 12 (P = .003).

Depression remission rates were also higher with PATH than with ST-CI (37.84% vs 13.51%).

In an exploratory analysis, PATH was effective in reducing depression even in those with drug-resistant depression, "but this observation needs to be confirmed in an adequately powered study," the researchers say.

The key innovations of PATH are its "personalized structured problem-solving approach, use of compensatory strategies and environmental adaptations, and caregiver participation to improve emotion regulation," they note. They think PATH reduces depression by improving emotion regulation through "situation selection, situation modification, attentional deployment, cognitive change, and response modification."

Despite its efficacy, Dr Kiosses and colleagues acknowledge that PATH faces "dissemination challenges." In this study, it was delivered in the home by trained clinicians. However, half of the therapists were social workers who are employed by home healthcare organizations, and costs of their services were reimbursed by Medicare.

Caregiver Involvement "Vital"

In a joint email to Medscape Medical News, James Long, PhD, and Mandy McCorkindale, PsyD, geriatric psychologists providing home-based mental health services in Arkansas, said they are "pleased to see that there is new research coming out for this population in a home setting."

The study "highlights a specific need for a growing section of our patient population; overall, the basic principles are largely consistent with effective approaches in the literature today," said Dr Long and Dr McCorkindale. They did not participate in the study.

In their experience, it is important to involve caregivers.

"In our clinical practice, we have found working with the caregivers to be a vital part of delivering effective interventions in the home. We have found that utilizing the caregivers as a source of reliable information, as well as an active participant in the therapeutic interventions, can be very beneficial and sometimes very necessary as the patient's level of cognitive impairment progresses. We are also very mindful of the caregivers' reported stress level as this can oftentimes be related to patient outcomes," they note.

In their view, 12 sessions delivered on consecutive weeks is a "significant commitment for patients, caregivers, and providers. We currently offer a structured caregiver support program that consists of 4 sessions, and even this can be difficult to manage at times."

It is noteworthy, they add, that significant improvement was achieved at the 8-week mark, with less improvement conveyed between weeks 8 and 12.

"This could be important if the researchers were to consider shortening the approach while at the same time trying to maximize the impact from the intervention. It would also be interesting to see if parts of the intervention outlined in the article could be used in a telephone-based format since this delivery method has also been used effectively with other interventions in home-based care programs," Dr Long and Dr McCorkindale said.

The study was supported by the National Institute of Mental Health. A complete list of author disclosures is provided in the original article.

JAMA Psychiatry. Published online November 5, 2014. Abstract

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