Problem Adaptation Therapy (PATH): An Approach to Depression with Cognitive Impairment

This article unpacks PATH’s theoretical foundations, core components and mechanisms of action, and then drills down into its clinical applications.

Related article: Using Cognitive Behavioural Therapy (CBTp) to Treat Psychosis, Assessing and Treating Depression.

Introduction

Late-life depression often co-exists with mild cognitive impairment (MCI), dementia, chronic physical illness and functional disability. Up to one-third of community-dwelling older adults with major depressive disorder (MDD) also meet criteria for MCI, and the presence of cognitive deficits predicts poorer response to antidepressant medication and higher relapse rates.

Against this backdrop, Problem Adaptation Therapy (PATH) emerged from the Weill Cornell Institute of Geriatric Psychiatry as a manualised, home-delivered psychotherapy that weaves together problem-solving therapy (PST), emotion‑regulation principles, environmental adaptation tools, and caregiver participation (Kiosses, 2022).

This article unpacks PATH’s theoretical foundations, core components and mechanisms of action, and then drills down into its clinical applications across dementia, frailty, chronic pain and post‑stroke rehabilitation. Practical case vignettes, implementation tips and learning points are provided to help mental health professionals translate the model into routine care.

Foundations and rationale of PATH

Problem Adaptation Therapy (PATH) was designed to address a persistent treatment gap: late-life depression complicated by cognitive impairment and functional disability, where standard psychotherapies often falter. Its rationale is pragmatic and ecological—reduce the cognitive load of therapy, build compensatory routines, and enlist the patient’s immediate environment and caregivers as active ingredients in change.

Drawing from problem-solving therapy, behavioural activation, emotion-regulation science, and rehabilitation principles, PATH reframes “non‑adherence” as a solvable design problem rather than a patient deficit. Here we outline how the model evolved, why it is needed, and the theoretical scaffolding that supports its use in complex geriatric presentations.

Origins

PATH was developed by Dimitris Kiosses, George S. Alexopoulos and colleagues to bridge a critical treatment gap: late-life depression complicated by cognitive deficits that undermine standard problem‑solving therapy (PST) (Kiosses et al., 2015). Building on early PST studies showing that executive dysfunction blunts treatment response, the authors grafted compensatory strategies and environmental supports onto the traditional seven‑step PST framework, thereby lowering the cognitive load on patients while preserving an active, skill‑building stance.

Conceptual model

PATH targets three interlocking domains:

1. Emotion regulation – depressive affect is conceptualised as a failure to down‑regulate negative emotion in the face of everyday problems. Structured problem‑solving, pleasurable activity scheduling and caregiver‑mediated prompts cultivate adaptive emotion‑regulation strategies (Kanellopoulos et al., 2020).
2. Cognitive compensation – explicit use of external memory aids (calendars, labels, colour‑coded folders), checklists and task simplification offsets impairments in working memory, initiation/perseveration, and planning.
3. Ecosystem enhancement – by embedding therapy in the home, PATH therapists can remove environmental “friction points” (e.g., poor lighting, clutter) and coach caregivers to provide cueing or partial task completion, thereby maximising real‑world generalisation (Kiosses Lab, 2025).

Structure and delivery

The standard protocol comprises twelve weekly 60‑minute sessions delivered in the patient’s home (or via telehealth). Each session follows a consistent rhythm:

1. Mood check‑in and review of between‑session tasks
2. Problem identification & definition
3. Generation of alternative solutions (therapist scaffolds brainstorming if executive function is limited)
4. Decision‑making and action planning
5. Environmental adaptation selection (e.g., placing a pill‑organiser on the breakfast table)
6. Caregiver rehearsal of cueing or support strategies

A booster phone call is offered at week 13, and follow‑up reviews at 24 weeks are recommended to consolidate gains (Kiosses, 2022).

Core components and mechanisms

This section moves from what PATH is to how PATH works. It unpacks the therapy’s building blocks—structured problem‑solving, environmental adaptation tools, caregiver participation, and emotion‑regulation exercises—and explains how these elements interact to produce clinical change. You will see how PATH deliberately transfers demands from fragile executive systems to reliable external supports, while cultivating small wins that restore agency. We also highlight the proposed mediators (e.g., improved problem‑solving ability, reduced disability) that link session‑level techniques to symptom relief.

The following table summarises key components, offering practical illustrations and hypothesised mechanisms of change.

Component	Practical Illustration	Mechanism of Change
Problem‑solving steps	Mr A struggles to remember GP appointments. Therapist helps him list the problem, brainstorm reminders (SMS alerts, wall calendar), choose the SMS option and test it for two weeks.	Enhances self‑efficacy; reduces helplessness.
Environmental adaptation tools	Large‑font medication schedule taped to the fridge; colour‑coded pillboxes.	Bypasses working‑memory deficits; reduces task complexity.
Caregiver participation	Daughter practises “guided step” prompting for shower routine, then fades assistance.	Extends therapy into daily life; prevents skill erosion.

Quantitative mediation analyses indicate that improvement in problem‑solving skills accounts for roughly one‑third of the variance in depressive symptom change, while reduction in disability explains an additional quarter (Kiosses et al., 2015).

Clinical applications of PATH

PATH is versatile across settings and diagnoses that commonly co‑occur with cognitive deficits, from mild cognitive impairment and dementia to chronic pain and post‑stroke syndromes. Here we translate principles into practice: who benefits most, how to tailor techniques to different levels of impairment, and what outcomes to expect. Brief case vignettes illustrate common decision points—selecting the right environmental aid, calibrating caregiver involvement, and pacing problem‑solving steps. The aim is to help you, the clinician, recognise real‑world opportunities to deploy PATH within multidisciplinary care.

Major depression with mild cognitive impairment

The landmark JAMA (Journal of the American Medical Association) Psychiatry randomised controlled trial (n = 74) demonstrated that PATH was superior to Supportive Therapy for Cognitively Impaired (ST‑CI) on both depression remission (38% vs 14%) and disability reduction at 12 weeks, with a number‑needed‑to‑treat of 4 (Kiosses et al., 2015). A 24‑week extension confirmed maintenance of gains (Kanellopoulos et al., 2020).

Case vignette – Mrs B, 79 years: Mrs B presented with pessimistic rumination, apathy and  Mini-Mental State Exam (MMSE) = 25 (the lowest score not considered to show cognitive impairment). Antidepressant therapy produced partial response. Over twelve PATH sessions her therapist introduced a weekly pill organiser (visual adaptation) and coached her nephew to send daily telephone reminders (caregiver cueing). Scores on the Montgomery-Asberg Depression Rating Scale (MADRS) dropped from 30 (indicating moderate depression) to 10 (indicating mild depression), and she resumed weekly church attendance.

Depression in dementia (PATHFINDER adaptation)

The multicentre PATHFINDER RCT (n = 336) compared adapted PATH with treatment‑as‑usual in mild‑to‑moderate Alzheimer’s disease. PATH produced greater Cornell Scale for Depression in Dementia reductions (−4.3 points) and an incremental cost‑effectiveness ratio of £8,940 per QALY (Quality-Adjusted-Life-Year, an economic measurement), well below NICE (National Institute for health and Care Excellence) thresholds (McCombie et al., 2021; Panca et al., 2024). Caregiver strain also fell by 17%.

Clinical pearl: In moderate dementia, therapists use more visual prompts and rely heavily on caregiver‑led task breakdown; verbal brainstorming is minimised.

Frailty and multicultural populations

A Montefiore Health System pilot (n = 145) embedded PATH into a public‑hospital home‑care service. Despite high comorbidity and language diversity, 78% completed ≥10 sessions and achieved clinically significant MADRS improvement (Ceide et al., 2020). Spanish‑language manuals and pictorial worksheets facilitated engagement.

Chronic pain comorbidity

Preliminary data from PATH‑Pain (n = 48) suggest meaningful reductions in pain‑related disability and depressive symptoms compared with wait‑list controls (Kiosses et al., 2025). The protocol incorporates pacing charts and co-ordinated breathing exercises to address physical de‑conditioning.

Post‑stroke cognitive impairment

Recognising that one‑third of stroke survivors develop depression and executive dysfunction, UK investigators have launched a £1.26 m National Institute of Health Research (NIHR) trial of PATH for post‑stroke cognitive impairment (NIHR, 2024). Integration with existing NICE stroke‑rehabilitation guidance underscores the therapy’s ecosystem focus (NICE, 2023).

Case vignette – Mr L, 68 years, post‑right‑MCA (middle cerebral artery) stroke: Executive deficits hampered his adherence to physiotherapy. The therapist and spouse created a laminated step‑by‑step exercise chart and set smartphone alarms. After eight sessions Mr L completed daily exercises independently and his scores on the Patient Health Questionnaire-9 (PHQ‑9) fell from 18 (indicating moderately severe depression) to 8 (indicating mild depression).

Implementation guide for clinicians

Turning evidence into routine care requires clear workflows, role clarity, and fidelity support. Here we present a brief, step‑by‑step roadmap for integrating PATH into your service: assessment and case selection, session structure, documentation, caregiver engagement, measurement, and coordination with pharmacotherapy and rehabilitation teams. We offer practical tips to avoid common pitfalls (e.g., over‑verbal instruction with executive dysfunction) and suggest training and supervision approaches that maintain quality without overburdening staff. Use this guide to pilot, evaluate, and scale PATH within your local context.

1. Assessment – Combine mood scales (MADRS or PHQ‑9) with cognitive screens (Montreal Cognitive Assessment, or MoCA/MMSE) and functional ratings (World Health Organization Disability Assessment Schedule, or WHODAS 2.0). Cornell Scale for Depression in Dementia is recommended in moderate cognitive impairment.
2. Selecting PATH candidates – Suitable for adults ≥55 years with current Major Depressive Disorder (MDD) or clinically significant depressive symptoms plus demonstrable cognitive or functional limitations. Severe behavioural disturbance or active psychosis are relative contraindications.
3. Therapist training – A two‑day skills workshop plus ongoing weekly supervision has been shown to ensure fidelity (Kiosses, 2022). Competency checklists cover problem definition, scaffolded brainstorming, and environmental adaptation prescription.
4. Session logistics – Conduct sessions in the patient’s home where possible; this allows direct observation of environmental triggers (e.g., confusing medication shelf) and immediate implementation of aids. TelePATH is feasible when caregivers can camera‑tour the environment.
5. Caregiver engagement – Invite a family member to attend the first session, define specific cueing roles and provide written instructions (large‑font, step‑wise). Emphasise positive reinforcement rather than criticism.
6. Measuring progress – Track depression, disability, and a personalised goal‑attainment scale. A plateau in symptom reduction after session 6 often signals the need for additional environmental aids or a second caregiver to share tasks.
7. Integration with pharmacotherapy – PATH complements the two classes of anti-depressants known as SSRIs and SNRIs; inform prescribers of functional improvements that may guide medication tapering.

Conclusion

Problem Adaptation Therapy (PATH) represents a paradigm shift from purely intrapsychic interventions toward a pragmatic, ecosystem‑based psychotherapy tailored to the cognitive realities of late life. By dovetailing problem‑solving skills with environmental and caregiver scaffolding, PATH reliably reduces depression and disability across diverse clinical contexts—from early MCI to moderate dementia, chronic pain and post‑stroke adaptation.

Emerging digital and group formats hold promise for scaling the model, though future work must clarify long‑term maintenance mechanisms and culturally nuanced adaptations. For mental health professionals treating complex geriatric depression, PATH offers a robust, evidence‑based addition to the therapeutic toolbox.

Key takeaways

• PATH merges problem‑solving, environmental adaptation and caregiver involvement to offset cognitive deficits.
• Multiple RCTs and a 2024 systematic review support its superiority over supportive therapy in reducing depression and disability.
• Conducting sessions in the patient’s ecosystem allows real‑time modification of environmental triggers.
• Training carers to cue and reinforce new routines is central to sustaining gains.
• Variants exist for dementia (PATHFINDER), chronic pain and multilingual settings.
• Economic analyses show favourable cost‑utility ratios within accepted health‑service thresholds.
• Improvements in problem‑solving capability and reduction in functional disability mediate mood change.
• PATH can be delivered alongside pharmacotherapy and often enhances adherence.
• Brief workshops plus supervision achieve therapist competency across disciplines.
• Digital TelePATH and group formats are under evaluation, alongside trials in stroke rehabilitation and primary care.

Questions therapists often ask

Q: How do I know when PATH is a better fit than standard CBT for an older adult with depression?

A: When cognitive impairment is getting in the way of CBT—clients forgetting homework, struggling with abstract reasoning, or getting overwhelmed by multi-step tasks—PATH tends to land better. It leans on environmental scaffolding, behavioural activation, and caregiver involvement rather than heavy cognitive restructuring. If you find yourself repeatedly simplifying CBT to the point that it barely resembles CBT, you’re already in PATH territory.

Q: What does “problem-solving with supports” actually look like in session?

A: It’s more concrete and more collaborative than classic problem-solving therapy. You break tasks into small, achievable steps, build visual cues or environmental prompts, and identify a supporter who can help the client follow through. The therapist becomes more of a guide structuring the environment around the client’s abilities, not simply coaching them to “think differently.”

Q: How do I integrate caregivers without making the client feel sidelined?

A: PATH frames caregivers as part of the toolkit rather than the decision-makers. The client chooses where support is welcome, and you emphasise that the aim is to reduce burden, not remove autonomy. In practice, that means asking the client which tasks feel hardest and then inviting the caregiver to help with only those steps—always with the client’s permission.

Q: What should I do when a client’s executive dysfunction makes even simple behavioural activation plans collapse?

A: You shrink the plan further and embed cues directly into their environment. Instead of “walk daily,” it becomes “walk for three minutes after breakfast,” paired with a visual reminder near the table. PATH is built on the assumption that impaired initiation is a symptom, not a lack of motivation—so the intervention compensates rather than pushes harder.

Q: What outcomes can I realistically expect with PATH in clients who have moderate cognitive impairment?

A: The article makes clear that you’re not aiming for a cognitive reboot. The realistic gains are improved mood, better daily functioning, and reduced stress for both client and caregiver. PATH’s strength is that it works with cognitive limitations rather than against them, which often leads to steadier, more sustainable progress than traditional talk-heavy approaches.

References

• Ceide, M.E.; Glasgow, A.; Weiss, E.F.; Stark, A.; Kiosses, D. N.; & Zwerling, J.L. (2022). Feasibility of Problem Adaptation Therapy in a diverse, frail older adult population (PATH-MHS). American Journal of Geriatric Psychiatry, 30(8), 917-921.
• Collyer S, Dorstyn D. Problem Adaptation Therapy (PATH) to Treat Depression in Older Adults With Cognitive Impairment: A Systematic Review of Treatment Effects. International Journal of Geriatric Psychiatry. 2024 Aug;39(8):e6130. doi: 10.1002/gps.6130. PMID: 39160658.
• Kanellopoulos, D.; Rosenberg, P.; Ravdin, L.D.; Maldonado, D.; Jamil, N.; Quinn, C.; Kiosses, D.N.. (2020). Depression, cognitive, and functional outcomes of Problem Adaptation Therapy (PATH) in older adults with major depression and mild cognitive deficits. International Psychogeriatrics, 32(4), 2020, pp 485-493. ISSN 1041-6102. https://doi.org/10.1017/S1041610219001716
• Kiosses, D. N. (2022). Problem Adaptation Therapy (PATH): Origins, current status, and future directions. American Journal of Geriatric Psychiatry, 30(8), 922-924.
• Kiosses DN, Ravdin LD, Banerjee S, Wu Y, Henderson CR Jr, Pantelides J, Petti E, Maisano J, Meador L, Kim P, Vaamonde D, Reid MC. Problem Adaptation Therapy for Older Adults with Chronic Pain and Negative Emotions in Primary Care (PATH-Pain): A Randomized Clinical Trial. American Journal of Geriatric Psychiatry. 2025 Apr;33(4):345-357. doi: 10.1016/j.jagp.2024.12.008. Epub 2025 Jan 6. PMID: 39875212; PMCID: PMC12001379.
• Kiosses, D. N., Ravdin, L. D., Gross, J. J., Raue, P., Kotbi, N., & Alexopoulos, G. S. (2015). Problem Adaptation Therapy for older adults with major depression and cognitive impairment: A randomised clinical trial. 2015 Jan; 72(1):22–30. doi: 10.1001/jamapsychiatry.2014.1305.
• Kiosses Lab. (2025). Emotion, cognition, and psychotherapy research. Author. Retrieved on 4 August 2025 from: https://kiosseslab.weill.cornell.edu/           
• McCombie, C.; Cort, E.; Gould, R.L.; Kiosses, D.N.; Alexopoulos, G.S.; Howard, R.; Lawrence, V.C. (2021). Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression, The American Journal of Geriatric Psychiatry, 29(2), 2021, pp192-203. ISSN 1064-7481 https://doi.org/10.1016/j.jagp.2020.05.025
• National Institute for Health and Care Excellence. (2023). Stroke rehabilitation in adults NICE Clinical Guidelines 236. London: NICE. ISBN-13: 978-1-4731-5481-0
• National Institute for Health Research. (2024). Trial to address disabling cognitive condition affecting stroke survivors to begin. NIHR. Retrieved on 4 August 2025 from: https://www.nihr.ac.uk/news/trial-address-disabling-cognitive-condition-affecting-stroke-survivors-begin                        
• Panca, M., Howard, R., Cort, E., Rawlinson, C., Gould, R. L., Wiegand, M., Downey, A. M., Banerjee, S., Fox, C., Harwood, R., Livingston, G., Moniz-Cook, E., Russell, G., Thomas, A., Wilkinson, P., Freemantle, N., & Hunter, R. M. (2024). Cost-utility analysis of adapted problem adaptation therapy for depression in mild-to-moderate dementia caused by Alzheimer’s disease: PATHFINDER randomised controlled trial. British Journal of Psychiatry open, 10(6), e189. https://doi.org/10.1192/bjo.2024.775