Home-delivered Intervention for Depressed, Cognitively Impaired Elders

Depression, cognitive impairment and disability often coexist in older adults and contribute
to medical and psychiatric morbidity and mortality. We developed and propose to test the
efficacy of a new psychosocial intervention, Problem Adaptation Therapy (PATH), for patients
with major depression, cognitive impairment (up to the level of mild to moderate dementia)
and disability. The proposed R01 study meets a critical need of this population, i.e. a
treatment alternative for patients in whom antidepressants may have limited efficacy and for
whom psychosocial interventions are underdeveloped and understudied.

The principal innovation of PATH is its personalized approach focusing on the patient's
ecosystem (i.e. the patient, the caregiver, and the home-environment) and targeting
behavioral problems related to both depression and disability. PATH is delivered at the
patients' home, teaches the patient-caregiver dyad problem-solving skills, and incorporates
environmental adaptations (including notes, signs, reminders, calendars, voice alarms) to
improve the patient's functioning.

Inclusion Criteria

1. Age: >64 (65 years and older).

2. Diagnosis: Major depression, unipolar as determined by the Structured Clinical
Interview for the Diagnostic and Statistical Manual for Mental Disorders (SCID), using
Diagnostic and Statistical Manual for Mental Disorders (DSM)IV criteria.

3. Severity of depression: Montgomery Asberg Depression Rating Scale (MADRS) >=18.

4. Disability, i.e. impairment in at least 1 Instrumental Activity of Daily Living as
measured by Philadelphia Multilevel Assessment Instrument - Instrumental Activities of
Daily Living subscale (MAI-IADL).

5. Evidence of at least mild cognitive impairment but not severe impairment (Dementia
Rating Scale (DRS) total score between 90 and 133 inclusive).

6. Caregiver (family member or professional) able and willing to participate in
treatment.

7. Off antidepressants, cholinesterase inhibitors, or memantine or on a stable dosage for
12 weeks and no medical recommendation for change of these agents in the near future.

8. Command of English sufficient to participate in therapy and research assessments.

Exclusion Criteria

1. High suicide risk, i.e. intent or plan to attempt suicide in near future.

2. Axis I psychiatric disorder or substance abuse other than unipolar major depression,
non-psychotic depression.

3. Axis II diagnosis of antisocial personality as determined by the SCID personality
disorder section (using DSM-IV criteria).

4. Moderate to Severe Dementia: We will exclude participants with DRS Total Score
corresponding to moderate or more severe dementia (DRS Total <=90).

5. Acute or severe medical illness (i.e., delirium, metastatic cancer, decompensated
cardiac, liver or kidney failure, major surgery, stroke or myocardial infarction
during the three months prior to entry); drugs known to cause depression (e.g.,
reserpine, alpha-methyl-dopa, steroids); or chronic addictive drug use.

6. Current involvement in psychotherapy.

7. Aphasia.