Problem Adaptation Therapy (PATH): Origins, Current Status, and Future Directions

Evidence-based psychosocial interventions for older adults with clinically significant depression and cognitive impairment are scarce. In 2011, based on evidence that a problem-solving approach had been beneficial with older adults with depression and mild executive dysfunction, we developed Problem Adaptation Therapy (PATH), an intervention designed to help reduce depression and disability in older adults with major depression and cognitive impairment, ranging from mild cognitive deficits to moderate dementia.¹ To meet the specific needs of depressed, cognitively-impaired older adults, the original PATH required significant modifications. Specifically, PATH: a) was home-delivered; b) used a problem-solving approach that had been found effective in patients with mild executive dysfunction and depression;^2,3 c) incorporated environmental adaptations/compensatory strategies to bypass the cognitive and functional limitations of this population; and d) selectively involved an available and willing caregiver/family member. PATH was designed to promote the patient’s independence while on the other hand it utilized the limited participation of an overwhelmed caregiver.

In the early stages of PATH development, we observed three limitations: A) Patients did not need to follow every stage of problem-solving therapy, for example, the patient and the therapist may skip the “brainstorm of solutions” and may quickly identify the best possible solution. B) A problem-solving approach was not adequate to help cognitively impaired older adults reduce depression and disability. For example, some patients may continue to be depressed even when their problems are solved, or some patients may be remitted from depression without a resolution of their problem. And C) Cognitively impaired older adults were not able to find the solutions of the problems by themselves; they needed significant help from their therapist and family member or significant other.

To address the first limitation, we simplified the problem-solving approach so that stages can be skipped if they are not necessary. To address the second limitation, we broadened the problem-solving therapy approach by adding emotion regulation techniques. So, the focus of the intervention is not on the solution of the problem per se, but the reduction of the negative emotions associated with the problem. PATH therapist utilizes simplified emotion regulation techniques to reduce the negative emotions, even though the patient’s problem cannot be solved. Along these lines, PATH follows the process model of emotion regulation of James Gross. Based on this model, PATH therapist utilizes five ways to regulate emotions: a) situation selection (i.e., select the situation one is exposed to); b) situation modification (i.e., modify the situation one is exposed to); c) attentional deployment (i.e., shift attention); d) cognitive reappraisal (i.e., change how one thinks about the situation); and e) response modulation (i.e., use direct efforts to change one’s emotional responses).⁴

To address the patients’ difficulty to generate and select solutions, we developed a model of an active therapist and we simplified the techniques so the therapist and the patient may have a tool box of easy-to-use techniques to select from and implement. Even though the patient ultimately decides if and how to use PATH’s techniques, the therapist guides the generation of techniques, simplifies them, and facilitates and monitors their implementation. The patient, with the help of the PATH therapist, evaluates and incorporates the involvement of a caregiver/family member/significant other. The approach of an active therapist is a deviation from the Cognitive Behavioral Therapy model, also used in Problem Solving Therapy, which focuses on the socratic questioning during which the patient will eventually generate the solution to their problems or will identify and confront inaccurate negative thoughts. In contrast, PATH focused on a model that the therapist will actively participate in the process. In fact, through the PATH approach, the therapist and the patient’s ecosystem (i.e., caregiver/significant other, home environment) compensate for the patient’s cognitive deficits.

Even though the theory and creation of PATH appear to be complicated, PATH is easy-to-use and acceptable to patients and the caregivers.⁴ As a result, PATH has been used in different settings, including home, primary-care, and in-office.^4-6 In the current issue of the American Journal of Geriatric Psychiatry, Ceide et al. describe the application of PATH in frail and underrepresented groups of elderly as part of the Montefiore Health System (PATH-MHS). Specifically, 105 participants completed the PATH-MHS intervention throughout three programs: Montefiore-Einstein Center for Aging Brain (CAB), Montefiore Memory Disorders Center (MDC), and Montefiore Home Care (MHC). Furthermore, PATH was administered in English and Spanish. The study demonstrated feasibility of PATH-MHS and significant within-group improvements in reducing depression and disability. Ceide et al. also observed a reduction in caregiver burden in the whole group but not in a subgroup of frail elders. Importantly, the PATH treatment effects on depression and disability were comparable to the treatment effects of the original PATH study.

Ceide et al.’s results highlight an exciting development for 3 reasons. First, PATH was delivered in underrepresented groups and patients with low education level. Specifically, in our original home-delivered PATH study, PATH participants had an average of 13 years of education compared to an average of 10 years of education in the Ceide et al.’s study. Also, there were about 85% versus 22% non-Caucasian or Hispanic participants in Ceide et al’s study versus our original PATH study, respectively. Second, PATH was delivered as part of a clinical geriatric program. Even though the original PATH was a home-delivered intervention and the therapists were clinical social workers, the therapists were part of our research program. Third, 55% of PATH participants in the current study were primary Spanish speakers, which demonstrate preliminary evidence of feasibility and acceptability of PATH in Spanish.

Despite the encouraging results, the Ceide et al. study has limitations that need to be addressed in future research. The most critical limitation is that the study did not have a control group. As a result, it is unclear whether PATH would have significant improvement in depression and disability if it was compared to another treatment or to usual care. Even though the original PATH study demonstrated that home-delivered PATH is efficacious in reducing depression and disability compared to home-delivered Supportive Therapy, future effectiveness randomized clinical trials may examine the effects of PATH in different clinical and community settings.

Future directions for PATH can focus on two critical areas: a) understanding PATH’s mechanism of action and exploring moderators of treatment; and b) incorporating technology into the treatment. Understanding the mechanism(s) of action of PATH in reducing depression and disability will help us to better explain “how PATH works.” PATH focuses on utilizing emotion regulation techniques to reduce negative emotions and to increase positive emotions. Based on unpublished and published preliminary data from our lab in different studies and populations groups, PATH appears to reduce negative emotions and improve two aspects of emotion regulation, i.e., cognitive reappraisal (in older adults with depression and cognitive impairment) and expressive suppression (in older adults with chronic pain). Furthermore, we have observed that in psychotherapy, reduction of negative emotions precedes and predicts the reduction in non-emotional symptoms of depression, which may help us understand how PATH may reduce depression.⁷ Additional adequately-powered studies may focus on PATH’s mechanism of action (i.e., reduction of negative emotions, aspects of emotion regulation) and may help us better understand the therapeutic elements of PATH. Similarly, examining moderators of treatment may help us understand in which groups PATH works best and in which groups PATH is not effective. Future studies need to focus on identifying baseline demographic, clinical, or other characteristics that may influence therapy outcomes.

The consequences of the Covid-19 pandemic underscore the need for the remote administration of psychosocial interventions. This is particularly important for older adults who lived in underserved communities. In addition, many patients may have difficulty attending in-person therapy sessions due to other challenges, for example, residing far from academic centers, or experiencing transportation challenges. Therefore, developing interventions delivered remotely is critical, especially given the increased reliance on telehealth as a medium for health care delivery. Initial evidence of remote phone or video administration of PATH demonstrates feasibility and acceptability in depressed, cognitively impaired, older adults. Nevertheless, depressed, cognitively impaired, older adults may have difficulty navigate through technology because of their cognitive deficits. Future research may focus on creating easy-to-use technology while at the same time keeping intact the therapeutic elements of the intervention.

In sum, we developed PATH to help reduce depression and disability in depressed, cognitively impaired, older adults. Ceide et al.’s article provides further evidence that PATH may be helpful in patient with low education level and patients in underrepresented groups. This significant development paves the road for future adequately-powered studies that can examine the application of PATH to diverse underrepresented groups, understand how PATH works, and develop technologically-advanced tools that may help this vulnerable group of older adults.

DATA STATEMENT

The data has not been previously presented orally or by poster at scientific meetings.