THE EFFECTIVENESS OF PROBLEM ADAPTATION THERAPY (PATH) IN A CULTURE AND LANGUAGE RICH COMMUNITY

Abstract

Introduction About 40% of homebound older adults have an unrecognized psychiatric disorder such as dementia, depression and substance abuse. Behavioral health programs have systematically excluded older adults with significant disability and/or cognitive impairment as they have difficulty engaging in various types of psychotherapy including Problem Solving Therapy (PST). Problem Adaptation Therapy (PATH) is a treatment developed at Weill Cornell's Westchester Division by Dimitri Kiosses, PhD for older adults with depression, cognitive impairment, and disability. PATH utilizes a problem-solving approach along with caregiver participation, compensatory mechanisms, and environmental adaptations. In 2016, Montefiore Medical Center collaborated with Cornell to pilot PATH in a diverse and bilingual patient population funded by the Fan Fox & Leslie R. Samuels Foundation. While most of the patients and caregivers enrolled have reported their satisfaction with the program, it is unclear if there are aspects of PATH that vary in effectiveness based on cultural and language factors. In this study, our objective was to assess if PATH worked equally well in English and Spanish speakers. Variables of interest include presence of suicidal ideation, caregiver stress, coping strategies employed and treatment response. Methods We reviewed the EPIC Electronic Health Records of 70 Montefiore Home Care and Geriatric Neurology Center patients (≥60 years old) seen between January 2017 and April 2018. Patients who did not complete PATH treatment were excluded; therefore 57 patients were included in the analysis. Important variables identified by chart review included primary language (English or Spanish), initial and final PHQ9 scores(Patient Health Questionnaire), presence of suicidality at initial and final PATH visits, the presence of moderate anxiety using BAI (Beck Anxiety Inventory) or GAD7 (Generalized Anxiety Disorder), caregiver stress measured by AMA caregiver stress scores, and coping strategies employed. Coping strategies employed in PATH fall into 4 categories: acoustic (timers), visual (notes), planning (step-by-step plan), and attentional (shaping procedure to sustain attention). Descriptive and bivariate analyses were conducted using SPSS 25 (Statistical Package for the Social Sciences). Chi-squared test was completed for categorical variables. Fisher's exact test was used when greater than 20% of cells had less than 5 expected observations. Independent sample t-test was utilized to compare mean differences of continuous variables. Results The mean age was 79.6 (±9.0) years; 85% were female; and 37% were Spanish-speaking. Spanish speakers had significantly higher initial PHQ9 scores than English speakers [PHQ9 Mean Score 11.7 (±3.1) vs. 8.9 (±5.1), p-value= 0.03]. Furthermore, Spanish speakers were significantly more likely to have moderate anxiety than English speakers (42.9% vs. 9.7%, χ2= 6.6, p-value= 0.02). Initial caregiver stress scores did not differ significantly based on language status. Also, the types of coping strategies employed during treatment did not differ significantly in Spanish and English speakers. In terms of treatment response for the entire cohort, the mean difference in PHQ9 score from initial to final visit was a 3.0 (±1.9) (p-value= 0.01), which was a significant decrease in scores. 37% of participants achieved remission (defined by 50% decrease in PHQ9 score) by the end of treatment. Remission rates were not significantly different by language status. Conclusions This study found that overall PATH (an innovative psychosocial intervention for depressed, cognitively impaired older adults) achieved 37% remission in this clinically and culturally complex population. Spanish speakers presented with higher depression and anxiety than English speaking counterparts. This could be due to either: reporting differences or late presentation due to stigma around seeking mental health treatment. The reasons behind these associations warrant further investigation in a larger cohort and more complex regression models, adjusting for important confounders. Based on similar treatment strategies and response to treatment, we can conclude that PATH was equally effective in both English and Spanish speakers. This similar response was present despite more severe presentations amongst Spanish speakers at baseline. The results of the proposed study will be used to inform implementation of this psychosocial intervention for depressed cognitively impaired older adults in a culturally diverse, urban community. This research was funded by Fan Fox & Leslie R. Samuels Foundation