Depressive disorders

The most thorough evaluation of problem-solving treatment has been for depressive disorders. Depressive disorders are known to be linked with stressful life events, and patients with depression may be less likely to cope with these stresses in a clear problem-focused way. An early small study of group problem-solving therapy (eight 90-minute sessions) for students with depression, recruited by newspaper advertisement, indicated that problem-solving therapy was more effective than a waiting-list control (Nezu, 1986).

Two studies have evaluated the effectiveness of problem-solving treatment for major depression in primary care. In the first study (Mynors-Wallis et al, 1995), 91 primary care patients with major depression were randomly allocated to either problem-solving treatment, amitriptyline or a placebo treatment involving both drug and psychological placebos. All treatments were given in six sessions over 12 weeks. At 6 and 12 weeks after treatment, problem-solving treatment was as effective in treating depression as amitriptyline, and significantly more effective than the placebo treatment. Problem-solving was associated with a low drop-out rate (only 7% of the sample compared with 19% for the amitriptyline sample) and was rated as helpful or very helpful by 100% of the patients receiving it (compared with 83% of the amitriptyline sample).

A second study evaluating problem-solving treatment for major depression in primary care (Mynors-Wallis et al, 2000) sought to answer two further questions. First, is the combination of problem-solving treatment and antidepressant medication more effective than either treatment alone? Second, can the problem-solving treatment be delivered as effectively by suitably trained practice nurses as by general practitioners (GPs)? One-hundred-and-fifty-one patients were randomly allocated to receive problem-solving treatment from a GP, problem-solving treatment from a practice nurse, antidepressant medication alone from a GP, or the combination of problem-solving treatment and antidepressant medication. The antidepressant medication used was a selective serotonin reuptake inhibitor (SSRI). The results from this study at 6, 12 and 52 weeks indicated that there were no significant differences between any of the four treatment groups, providing further support for problem-solving treatment as an effective treatment for depressive disorders in primary care.

In common with other psychological and drug treatments for depressive disorders, predictors as to which patients might benefit from drug treatment and which might benefit from problem-solving treatment remain elusive (Mynors-Wallis & Gath, 1997). Clinical experience suggests that patients who readily accept the link between their problems and symptoms and those who wish to work within the collaborative framework of problem-solving treatment do well. Patients who wish to take a more passive role and be ‘made better’ by the doctor or nurse are harder to motivate to take part in the treatment.

There is some evidence that problem-solving treatment may be effective for older adults (aged over 55 years) with a depressive disorder (Arean et al, 1993). A four-centre study in the USA compared paroxetine, problem-solving treatment and placebo for the treatment of minor depression and dysthymia (Barrett et al, 1999). A five-centre European study evaluated problem-solving treatment and a group educational programme for depressive disorders identified by community sampling (Dowrick et al, 1998).

Emotional disorders

In primary care, psychological disorders do not necessarily fit into simple ICD–10 categories (World Health Organization, 1992). Many patients present with a range of depressive and anxious symptoms – emotional disorders. Although many of these disorders resolve quickly, a significant proportion of patients develop chronic conditions with significant clinical and social morbidity. Two studies have evaluated problem-solving treatment for such patients. The first selected patients identified at high risk of poor outcome. These patients were randomly allocated to receive either four sessions of problem-solving from a research psychiatrist or treatment as usual from their GP. At the end of treatment and at 6-month follow-up, patients treated with problem-solving showed significantly greater improvement on all standardised measures; they also reported greater satisfaction with treatment (Catalan et al, 1991).

A second study evaluating problem-solving treatment for emotional disorders in primary care sought to evaluate the treatment as given by community nurses (Mynors-Wallis et al, 1997). Community nurses were first trained in the techniques of problem-solving, and were then used as therapists in a trial treating patients with emotional disorders. Patients with emotional disorders of at least 1 month's duration were referred by their GP. These patients were randomly allocated to either problem-solving treatment given by a trained nurse therapist or to treatment as usual from their GP. Although there was no difference in symptom scores between the two groups at 8 or 26 weeks, patients who had received problem-solving treatment took significantly less disability days and days off work. One of the problems faced in this naturalistic study was the wide variability in the illness severity and chronicity of patients referred. A lesson from the study was that guidance is needed as to the type of patients who might benefit from problem-solving treatment, as opposed to watchful waiting alone or more intensive and specialist interventions.

Deliberate self-harm

Acts of deliberate self-harm are often committed in the context of psychosocial problems. Intuitively, therefore, problem-solving treatment would seem to be an appropriate and valid treatment. Two studies have evaluated problem-solving treatment for patients following an episode of deliberate self-harm. Hawton et al (1987) evaluated problem-solving treatment as a part of a counselling intervention, by comparison with treatment as usual by the GP, for patients following an episode of deliberate self-harm. There were no major differences in outcome between the two groups. Two subgroups, however, did show some benefit from problem-solving – women and individuals with problems in their relationship with their partner.

In a second study (Salkovskis et al, 1990), problem-solving treatment given by a community psychiatric nurse was effective in reducing the distress experienced by overdose patients, selected as having a high risk of repetition. Short-term effectiveness was also demonstrated in preventing further overdose attempts. As with the treatment of emotional disorders, the key to the effectiveness of problem-solving treatment following deliberate self-harm is to target the appropriate patients. Further research is needed to fully answer this particular question.

Schizophrenia

Falloon et al (1984) have described the use of problem-solving techniques within the context of family therapy for patients with schizophrenia. Problem-solving is used to clarify the particular problems each family faces and to enhance the family's coping skills.

Stage 1 – explanation of treatment and its rationale

There are three steps:

1. Recognition of emotional symptoms

   Obtain a full account of the patient's symptoms; emotional, cognitive and physical. A full knowledge of the patients' symptoms helps the patient to feel understood but is also needed to link problems with symptoms.

2. Recognition of problems

   List the patient's problems. This list can be compiled by enquiring about potential problem areas such as relationships, work, money, housing, health and leisure activities.

3. Making the link between emotional symptoms and problems

   A link should be made between the patient's symptoms and problems. The patient should understand that his or her symptoms are an emotional response to his or her problems. The therapist then explains that the patient can tackle his or her problems during treatment, and that if successful, resolution of the problems will lead to resolution of the symptoms. Although unrealistic expectations should not be fostered, some optimism should be encouraged in order to motivate the patient. At this point, it is important to emphasise that the patient will play an active part in the treatment.

Stage 2 – clarification and definition of problems

A list of problems should already have been drawn up. The next step is to choose one particular problem that is important to the patient, and which the therapist considers feasible for problem-solving. This problem should be defined as clearly as possible. In specifying the problem, it may help if the patient considers four questions:

1. What is the problem?

2. When does the problem occur?

3. Where does the problem occur?

4. (d)Who is involved in the problem?

Large problems should be broken down into smaller and more manageable parts. Usually, the patient presents several related problems. The therapist and patient should review these problems carefully, and then select one or two problems to tackle initially. The choice of a particular problem should be guided by (a) what is seen as relevant to the patient and (b) problems for which achievable goals can be set.

See Box 5⇓ for a patient-based problem list.

Stage 3 – setting achievable goals

Once the problems have been clarified and defined, the next stage is to set one or more achievable goals. In making this choice, it is important to take into account the balance between the patient's resources and obstacles. The patient's resources may include:

1. personal strengths and assets;

2. education, leisure activities and social and financial resources;

3. support from other people, such as spouse or other relative, friend, or professional person such as a social worker or clergyman; and

4. self-help groups: direct advice about the availability of self-help groups may be appropriate.

Achievable goals should be SMART goals; Specific, Measurable, Achievable, Relevant and Timed.

It is important that the patient develops a sense of achievement early in treatment; for this purpose, goals should be identified that can be achieved quickly, for example, before the next session. Medium-term goals can be attained in stages over the course of treatment. Goals are often more achievable if they can be achieved by the patient alone rather than relying on someone else (see Box 6⇓).

Stage 4 – generating solutions

Once an achievable goal has been set, the patient is asked to brainstorm as many solutions as he or she can generate. Potential solutions should not be discarded or pre-judged, even if initially they seem to be silly or unworkable.

Stage 5 – choice of preferred solution

The therapist encourages the patient to draw up a list of the pros and cons for each potential solution. It may be useful to ask the patient to prepare this list as a homework task. The patient should select a preferred solution, that is a solution that best achieves the stated goals with the least personal and social disadvantages. Some patients find this stage of problem-solving the most difficult to achieve alone; such patients may ruminate about possible solutions without being able to choose one (see Box 7⇓).

Stage 6 – implementation of the preferred solution

It is important not to rush this stage because the patient may lack the confidence to implement the preferred solution. The steps needed to achieve the solution may have to be broken down into simple sub-steps. There should be clear specifications of the sub-steps and when they should be carried out.

The patient should have a clear set of tasks that need to be completed between therapy sessions (see Box 8⇓). These tasks are referred to as homework.

Stage 7 – evaluation

It is importance that in second and subsequent problem-solving sessions a detailed evaluation of progress made since the previous session is undertaken (see Boxes 9⇓, ⇓, ⇓, ⇓ and ⇓). Failure to complete tasks successfully may be because of a poor understanding of the treatment process and in particular the homework. Unforeseen obstacles may arise or patients may simply lack the motivation to fulfil tasks outside the treatment sessions. Achievable goals need to be redrawn in the light of experience.

The patient and therapist should review the original problems, consider progress and always be prepared to add new problems to the problem list. The patient may work through a series of short- and mid-term goals to reach a long-term goal. For example, if the final goal is to secure a new job, the short-term and intermediate goals might be to:

1. obtain information about the qualifications required;

2. send for application forms;

3. apply for a job; and

4. attend for an interview if asked.