problem solving therapy in primary care

• CLASSIFIEDS
• Advanced search

American Board of Family Medicine

Advanced Search

The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis

• Find this author on Google Scholar
• Find this author on PubMed
• Search for this author on this site
• Figures & Data
• Info & Metrics

Background: There is increasing demand for managing depressive and/or anxiety disorders among primary care patients. Problem-solving therapy (PST) is a brief evidence- and strength-based psychotherapy that has received increasing support for its effectiveness in managing depression and anxiety among primary care patients.

Methods: We conducted a systematic review and meta-analysis of clinical trials examining PST for patients with depression and/or anxiety in primary care as identified by searches for published literature across 6 databases and manual searching. A weighted average of treatment effect size estimates per study was used for meta-analysis and moderator analysis.

Results: From an initial pool of 153 primary studies, 11 studies (with 2072 participants) met inclusion criteria for synthesis. PST reported an overall significant treatment effect for primary care depression and/or anxiety ( d = 0.673; P < .001). Participants' age and sex moderated treatment effects. Physician-involved PST in primary care, despite a significantly smaller treatment effect size than mental health provider only PST, reported an overall statistically significant effect ( d = 0.35; P = .029).

Conclusions: Results from the study supported PST's effectiveness for primary care depression and/or anxiety. Our preliminary results also indicated that physician-involved PST offers meaningful improvements for primary care patients' depression and/or anxiety.

• Anxiety Disorders
• Depressive Disorder
• Mental Health
• Primary Health Care
• Problem Solving
• Psychotherapy

Depressive and anxiety disorders are the 2 leading global causes of all nonfatal burden of disease 1 and the most prevalent mental disorders in the US primary care system. 2 ⇓ – 4 The proportion of primary care patients with a probable depressive and/or anxiety disorder ranges from 33% to 80% 2 , 5 , 6 ; primary care patients also have alarmingly high levels of co-/multi-morbidity of depressive, anxiety, and physical disorders. 7 Depression and anxiety among primary care patients contribute to: poor compliance with medical advice and treatment 8 ; deficits in patient–provider communication 9 ; reduced patient engagement in healthy behaviors 10 ; and decreased physical wellbeing. 11 , 12 Given the high prevalence of primary care depression and anxiety, and their detrimental effects on the qualities of primary care treatments and patients' wellbeing, it is important to identify effective interventions suitable to address primary care depression and anxiety.

Primary care patients with depression and/or anxiety are often referred out to specialty mental health care. 13 , 14 However, outcomes from these referrals are usually poor due to patients' poor adherence and their resistance to mental health treatment 15 , 16 . Therefore, it is critical to identify effective mental health interventions that can be delivered in primary care for patients' depression and/or anxiety. 17 , 18 During the past decade, a plethora of clinical trials have investigated different mental health interventions for depression and anxiety delivered in primary care. One of the most promising interventions that has received increasing support for managing depression and anxiety in primary care is Problem-Solving Therapy (PST).

Holding that difficulties with problem solving make people more susceptible to depression, PST is a nonpharmacological, competence-based intervention that involves a step-by-step approach to constructive problem solving. 19 , 20 Developed from cognitive-behavioral-therapy, PST is a short-term psychotherapy approach delivered individually or in group settings. The generic PST manual 19 contains 14 training modules that guides PST providers working with patients from establishing a therapeutic relationship to identifying and understanding patient-prioritized problems; from building problem-solving skills to eventually solving the problems. Focused on patient problems in the here-and-now, a typical PST treatment course ranges from 7 to 14 sessions and can be delivered by various health care professionals such as physicians, clinical social workers or nurse practitioners. Because the generic PST manual outlines the treatment formula in detail, providers may deliver PST after receiving 1 month of training. For example, 1 feasibility study on training residents in PST found that residents can provide fidelious PST after 7 weeks' training and reach moderate to high competence after 3 years of practicing PST. 21 PST also has a self-help manual available to clients when needed.

PST is a well-established, evidence-based intervention for depression in specialty mental health care and is receiving greater recognition for its effectiveness in treating depression and anxiety in primary care. Systematic and meta-analytic reviews of PST for depression consistently reported moderate to large treatment effects, ranging from d = 0.4 to d = 1.15. 22 ⇓ – 24 Several clinical trials indicated PST's clinical effectiveness in alleviating anxiety as well. 25 , 26 Most importantly, PST has been adapted for primary care settings (PST-PC) and can be delivered by a variety of health care providers with fewer number of sessions and shorter session length. These unique features make PST(-PC) an ideal psychotherapy for depressive and/or anxiety disorders in primary care.

Previous reviews of PST focused on its effectiveness for depression care, but with little attention to PST's effect on anxiety or comorbid depression anxiety. In addition, to our knowledge, no previous reviews of PST have focused on managing depressive and/or anxiety disorders in primary care. Although research demonstrates that PST has a strong evidence base for treating depression and/or anxiety in specialty mental health care settings, more research is needed to determine whether PST remains effective for treating depressive and/or anxiety disorders when delivered in primary care. To address this gap, we conducted a systematic review and meta-analysis on the effectiveness of PST for treating depressive and/or anxiety disorders with primary care patients.

Search Strategies

This review included searches in 6 electronic databases (Academic Search Complete, CINAHL, Medline, PsychINFO, PUBMED, and the Cochrane Library/Database) and 3 professional Web sites (Academy of Cognitive Therapy, IMPACT, Anxiety and Depression Association of America) for primary care depression and anxiety studies published between January 1900 and September 2016. We also E-mailed major authors of PST studies for feedback and input. Search terms of title and/or abstract searches included: [“PST” or “Problem-Solving Therapy” or “Problem Solving Therapy” or “Problem Solving”] AND [“Depression” or “Depressive” or “Anxiety” or “Panic” or “Phobia”] AND [“primarycare” or “primary care” or “PCP” or “Family Medicine” or “Family Doctor”]. We supplemented the procedure described above with a manual search of study references.

Eligibility Criteria

For inclusion in analyses, a study needed to be 1) a randomized-controlled-trial of 2) PST for 3) primary care patients' 4) depressive and/or anxiety disorders. For studies that examined face-to-face, in-person PST, the intervention must be delivered in primary care for inclusion. If studies examined tele-PST (eg, telephone delivery, video conferencing, computer-based), the intervention must be connected to patients' primary care services for a study to be included. For example, when a primary care physician prescribed computer-based PST at home for their patients, the study met inclusion criteria (as it was still considered managing depression “in primary care” in the present review). However, studies would be excluded if a primary care physician referred patients to an external mental health intervention. Finally, studies must document and report sufficient statistical information for calculating effect size for inclusion in the final analysis.

Data Abstraction and Coding

Two authors (AZ and JES) reviewed an initial pool of 153 studies and agreed to remove 65 studies based on title and 68 studies based on abstract, resulting in 20 studies for full-text review. To develop the final list, we excluded 6 studies after closer review of full-text and consultation with a third reviewer who is an established PST researcher. Lastly, we excluded 2 studies due to 1) a study with a design that blurred the effect of PST with other treatments and 2) unsuccessful contact with a study author to request data needed for calculating effect size. We used a final sample of 11 studies for meta-analysis. The PRISMA chart is presented in Figure 1 .

• Download figure
• Open in new tab

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart of literature search for Problem-solving therapy (PST) studies for treating primary care patients' depression and/or anxiety.

Statistical Analysis

This study conducted meta-analysis with the following procedures: 1) calculated a weighted average of effect size estimates per study for depression and anxiety separately (to ensure independence) 27 ; 2) synthesized an overall treatment effect estimate using fixed- or random-effects model based on a heterogeneity statistic (Q-statistic) 28 ; and 3) performed univariate meta-regression with a mixed-effects model for moderator analysis. 29 Although other more advanced statistical approaches allow inclusion of multiple treatment effect size estimates per study for data synthesis, like the Generalized Least Squares method 30 or the Robust Variance Estimation method 31 , this study employed a typical approach because of the relatively small sample and absence of study information required to conduct more advanced methods. Following procedures outlined by Cooper and colleagues 32 , we conducted all analyses with R software. 33 We chose to conduct analyses in R, rather than software specific to meta-analysis (eg, RevMan), because R allowed for more flexibility in statistical modeling (eg, small sample size correction). 34 Sensitivity analysis using Robust Variance Estimation did not significantly alter results estimated with the typical approach. And so this study presents results from only the typical approach for purposes of parsimony and clarity.

Publication Bias, Risk of Bias and Quality of Studies

To detect publication bias, we used a funnel plot of effect size estimates graphed against their standard errors for visual investigation. To evaluate risk of bias, we used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials 35 and the Quality Assessment of Controlled Intervention Studies to evaluate study quality. 36

Primary Studies

Eleven PST studies for primary care depression and/or anxiety reported a total sample size of 2072 participants. Participants' age averaged 50.1 and ranged from 24.5 to 71.8 years old. Ten studies reported participants' sex with an average of 35.6% male participants across all studies. Seven studies (63.6%) reported participants' racial background with most identified as non-Hispanic white (83.6%). Other racial/ethnic groups were poorly reported for meaningful summary. Five studies used active medication as a comparison, including 3 studies that used both active medication and placebo medication. The rest compared PST with treatment-as-usual while 2 studies used active control group (eg, video education material). Four studies involved physicians in some component of intervention delivery. PCPs provided PST in 2 studies; supervised and collaborated with depression care manager in 1 study, and collaborated with a primary care nurse in another. Ten studies reported an average of 6 PST sessions ( M = 6.1) ranging from 3 to 12 sessions. All but 1 study (n = 10) used individual PST and 2 studies used tele-health modalities to provide PST. All studies used standardized measures of depression and anxiety. Examples of the most common measures included: PHQ-9, CES-D, HAM-D, and BDI-II. Table 1 presents a detailed description of study characteristics.

• View inline

Study Characteristics for Problem-Solving Therapy as Intervention for Treating Depression and/or Anxiety Among Primary Care Patients ( n = 11)

Publication Bias, Risk of Bias, and Quality of Studies

The funnel plot ( Figure 2 ) did not indicate any clear sign of publication bias. Risk of bias ( Table 4 ) indicated an overall acceptable risk across studies included for review with blinding of participants and personnel, blinding of outcome assessment and incomplete outcome data most vulnerable to risk of bias. Quality of study assessment ( Table 5 ) indicated an overall satisfactory study quality with over half of studies (n = 6) achieving ratings of “Good” study quality.

Funnel Plot for Publication Bias in Problem-solving therapy (PST) Studies for Treating Primary Care Patients' Depression an/or Anxiety.

Meta-analysis and moderator analysis

Figure 3 presents a forest plot of treatment effects per study, including depression and anxiety measures. Table 3 presents subgroup analysis of overall treatment effect by moderator and Table 2 presents the results of meta-analysis and moderator analysis. Meta-analysis revealed an overall significant treatment effect of PST for primary care depression and/or anxiety ( d = 0.67; P < .001). Further investigation revealed no significant difference between the mean treatment effect of PST for depression versus anxiety in primary care ( d ( diff .) = −0.25; P = .317) while subgroup analysis revealed the overall treatment effect for anxiety was not significant ( d = 0.35; P = .226). Age was found to be a significant moderator (β 1 = 0.02; P = .012) for treatment outcomes, indicating that for each unit increase in participants' age, the overall treatment effect for primary are depression and/or anxiety are expected to increase by 0.02 (standard deviations). Neither participants' ethnic or racial backgrounds nor marital status significantly moderated the overall treatment outcome.

Forest Plot of PST Treatment Effect Size Estimates for Treating Primary Care Patients' Depression and/or Anxiety per Study.

PST for Treating Primary Care Patients' Depression and/or Anxiety; Results of Univariate Meta-regression

Results of Subgroup Analysis of Overall Treatment Effect (by Moderator) of PST for Treating Primary Care Patients' Depression and/or Anxiety

PST for Treating Primary Care Patients' Depression and/or Anxiety; Results of the Cochrane Collaboration's Tool for Assessing Risk of Bias *

Quality Assessment of Controlled PST Intervention Studies for Primary Care Patients' Depression and/or Anxiety ( n =11)

The overall treatment effect was not moderated by any treatment characteristics including: treatment modality (individual vs group PST), delivery methods (face-to-face vs tele-health PST), number of PST sessions and length of individual PST sessions. Subgroup analysis indicated an overall significant treatment effect of in-person PST ( d = 0.72; P < .001) but not of tele-PST ( d = 0.53; P = .097). However, the difference between the 2 was not statistically significant.

PST providers background and primary care physician's involvement significantly moderated the overall treatment effect size. Master's-level providers reported an overall treatment effect ( d = 1.57; P < .001) significantly higher than doctoral-level providers ( d = −1.33; P = .007). Both physician-involved and nonphysician involved PST reported significant overall treatment effect of PST for depression and/or anxiety in primary care ( d = 1.06; P < .001 and d = 0.35; P = .029, respectively). Moderator analysis further revealed that PST without physician involvement reported significantly greater treatment effects compared with physician-involved PST in primary care ( d = −0.71; P = .005). Results of subgroup and moderator analyses indicated that while the difference (in treatment effect) between physician and nonphysician involved PST in primary care were statistically significant, physician-involved PST was also statistically significant, thus practically meaningful.

Results of the study demonstrated a statistically significant overall treatment effect in outcomes of depression and/or anxiety for primary care patients receiving PST compared with patients in control groups. The outcome type—depression versus anxiety—failed to moderate treatment effect; only PST for depression reported a significant overall effect size. This could indicate that many studies primarily targeted depression and included anxiety measures as secondary outcomes. For this reason, we expect to find a greater treatment effect for primary care depression. It was unsurprising that treatment characteristics failed to moderate treatment effect size because most primary studies used PST-PC or its modified version; there was insufficient variation between studies (and moderators), yielding insignificant moderating coefficients.

Although delivery method did not moderate treatment effect reported in studies included in this review, significant effect was only reported by studies using face-to-face in-person PST but not by those with tele-PST modalities (n = 2). Although evidence for the effectiveness of tele-PST is established or increasing in a variety of settings 37 ⇓ – 39 most PST studies for primary care patients have used face-to-face, in-person PST. Our study further supported the use of face-to-face in-person PST for treating depression and anxiety among primary care patients. We recognize, however, that current and projected shortages in specialty mental health care provision, felt acutely in subspecialties such as geriatric mental health, necessitate more trials with PST tele-health modalities. 40

It is salient to note that, while nonphysician-involved PST studies reported significantly greater treatment effect than those involving physicians, PCP-involved studies also reported an overall significant effect size. Closer examination indicated that studies with physician-involved PST were either delivered by physicians or other nonmental health professionals (eg, registered nurses or depression care managers). Lack of sufficient PST training might explain the difference in treatment effect sizes being statistically significant. Yet, the fact that physician-involved PST studies reported an overall statistically significant effect size for primary care depression and/or anxiety suggested a meaningful treatment effect for clinical practice. When faced with a shortage of mental health professionals (eg, psychologists, clinical social workers, licensed professional counselors), our findings suggest physician-led or -supervised PST interventions could still improve primary care patients' depression and/or anxiety. Researchers are encouraged to further examine the treatment effect of PST delivered by mental health professionals in collaboration with primary care physicians.

This study has several weaknesses that are inherent to meta-analyses. There is no way to assure we included all studies despite adopting a comprehensive search and coding strategy (ie, file drawer problem). Second, while all studies in this meta-analysis seemed to have satisfactory methodological rigor, it is possible that internal biases within some studies may influence results. This study takes a quantitative meta-analysis approach which inherently neglects other study designs and methodologies that also provide valuable information about the effectiveness, feasibility, and acceptability of PST for treating primary care patients with depression. To ensure independence of data, this study used a weighted average of effect size estimates per study in synthesizing an overall treatment effect and conducting moderator analysis. While sensitivity analysis did not reveal significant differences from the reported results, we will not know for sure how our choice of statistical method might affect the results.

• Acknowledgments

The authors are grateful to Dr. Namkee Choi, Professor and the Louis and Ann Wolens Centennial Chair in Gerontology at the University of Texas at Austin Steve Hicks School of Social Work, for her mentorship and insightful comments during preparation of the manuscript.

This article was externally peer reviewed.

Funding: none.

Conflict of interest: none declared.

Ethics Review: This is a systematic review and meta-analysis based on de-identified aggregate study data. No human participants or animals were involved in this study. No ethics review was required.

To see this article online, please go to: http://jabfm.org/content/31/1/139.full .

• Received for publication July 5, 2017.
• Revision received September 14, 2017.
• Accepted for publication September 27, 2017.
• Whiteford HA ,
• Degenhardt L ,
• Kroenke K ,
• Spitzer RL ,
• Williams JB ,
• Monahan PO ,
• Verhaak PF ,
• Hilbink-Smolders M ,
• Mitchell AJ ,
• Sherbourne CD ,
• Mussell M ,
• Schellberg D ,
• Clarke DM ,
• Schenker Y ,
• Stewart A ,
• Vander Weg MW
• Salovey P ,
• Rothman AJ ,
• Detweiler JB ,
• Williams JW
• Hunkeler EM ,
• Pincus HA ,
• Thielke S ,
• Richards D ,
• Gilbody S ,
• Grimshaw J ,
• Maguth Nezu C ,
• D'Zurilla TJ
• D'Zurilla TJ ,
• Dietrich AJ ,
• Seville JL ,
• Cuijpers P ,
• van Straten A ,
• Warmerdam L
• Kirkham JG ,
• Kleiboer A ,
• Seekles W ,
• Higgins JP ,
• Thompson SG
• Raudenbush SW
• Hedges LV ,
• Valentine JC
• Gleser LJ ,
• Harris LV ,
• Valentine ,
• 33. ↵ R Development Core Team . R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria . Vienna, Austria : R Foundation for Statistical Computing 2015 .
• Pustejovsky JE
• Altman DG ,
• Gøtzsche PC ,
• 36. ↵ National Heart, Lung, and Blood Institute . Quality assessment of controlled intervention studies . Systematic evidence reviews and clinical practice guideline . Available from: https://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/tools/rct .
• Marinucci ML ,
• Sirrianni L ,
• Wilson NL ,
• Cartreine JA ,
• Buckey JC ,
• Sandoval L ,
• Yarborough BJ
• Barret JE ,
• Williams JW ,
• Chibanda D ,
• Shetty AK ,
• Tshimanga M ,
• Stranix-Chibanda L ,
• Rusakaniko S
• Von Korff M ,
• Tamburrino M ,
• McCusker J ,
• Mynors-Wallis LM ,
• Dietrich AJ
• Reynolds CF III . ,
• Thomas SB ,
• Schmaling KB ,
• Dimidjian S ,
• Williams JW Jr . ,
• Barrett J ,
• Sullivan M ,
• Cornell J ,

In this issue

• Table of Contents
• Table of Contents (PDF)
• Cover (PDF)
• Index by author

Thank you for your interest in spreading the word on American Board of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Citation Manager Formats

• EndNote (tagged)
• EndNote 8 (xml)
• RefWorks Tagged
• Ref Manager

• Tweet Widget
• Facebook Like
• Google Plus One

Jump to section

Related articles.

• No related articles found.
• Google Scholar

Cited By...

• Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt
• Psychologic Treatment of Depression Compared With Pharmacotherapy and Combined Treatment in Primary Care: A Network Meta-Analysis
• Brief behaviour change strategies for distressed patients in primary care
• Interventions Must Be Realistic to Be Useful and Completed in Family Medicine

More in this TOC Section

• Management of Chronic Heart Failure with Reduced Ejection Fraction
• GLP-1 RAs and SGLT2-Is to Lower Glucose and Reduce the Risk of Cardiovascular and Diabetic Kidney Disease
• Perinatal Depression: A Guide to Detection and Management in Primary Care

Similar Articles

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Sweepstakes
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Evidence-Based Behavioral Interventions in Primary Care

Although there is growing sentiment that strengthening behavioral health care services in primary care is critically needed, the majority of existing behavioral interventions were developed for settings very different from the fast paced environment of primary care.

Current strategies require extensive clinical training and an unrealistic time commitment from both the patient and the provider. Although many psychotherapies require six to twelve sessions to be effective, in reality, most people only go to one or two. Less than 10% of primary care patients with depression receive a minimally adequate level of evidence-based psychotherapy, in part because many of the psychotherapies being used were developed for weekly, one-hour visits with a specialty mental health provider.

“As integrated care becomes commonplace, the challenge is to transform effective behavioral interventions to meet the competing demands and limited resources of primary care clinics,” explains Pat Areán, director of the University of Washington’s new Targeted Treatment Development Program and affiliate faculty investigator at the AIMS Center. “Most patients prefer behavioral interventions like psychotherapy, counseling, or cognitive training to medication. The lack of evidence-based behavioral interventions that are tailored to primary care poses a major barrier to their treatment.”

Integrated care provides patients with on-site mental health care to prevent fragmented treatment and decrease the number of patients who slip through the cracks. Effective integrated care models such as collaborative care use medications, behavioral interventions, or both, changing the treatment plan as necessary until the patient gets better. To be effective in primary care, a behavioral intervention should:

• Include a patient engagement component. Skipping right to treatment doesn’t work.
• Be time efficient, running no more than 20-30 minutes a visit.
• Follow a structure-based approach. A modularized treatment with clear steps keeps the provider and patient on track despite the distractions in primary care.
• Minimize required clinical training. The treatment should be able to be administered by non-specialists who work in a health care team.
• Be relevant and applicable to the diverse patient populations found in primary care.
• Have a substantial research evidence-base.

Of the multiple behavioral interventions in existence, only a few have been proven to work in primary care including Problem Solving Therapy-Primary Care, Cognitive Behavioral Therapy, Interpersonal Counseling, and Behavioral Activation.

Problem Solving Therapy-Primary Care (PST-PC) is the most widely-used intervention to treat depression and anxiety in the primary care environment. PST-PC is a brief therapy that uses six to ten, 30-minute sessions to help patients solve the “here and now” problems contributing to their depression. PST-PC has been found to significantly improve mental health treatment in a wide range of settings, including diverse provider and patient populations.

An adaptation of Cognitive Behavioral Therapy (CBT) has also been found to be beneficial for both depression and anxiety in primary care. CBT uses short-term, goal-oriented therapy to interrupt patterns of thinking that prevent patients from feeling better. Brief Cognitive Therapy makes the intervention more accessible in primary care by using shorter and fewer sessions.

Interpersonal Counseling (IPC), an outgrowth of Interpersonal Therapy, may further reduce the time required to treat depression in primary care. The model was found to be more effective than normal care after six or fewer, 30-minute sessions with some patients improving markedly after only one or two. Designed to be implemented by nurse practitioners in primary care, IPC focuses on current functioning, recent life changes, sources of stress and difficulties in interpersonal relationships.

A fourth behavioral intervention proven to work in primary care is Behavioral Activation (BA), an evidence-based psychotherapy that identifies work, social, health, or family activities patients have stopped engaging in because of their mood. BA takes concrete steps to re-introduce these activities into the patient’s life and decrease avoidance behaviors and any other behaviors that contribute to a depressed mood. The patient and provider create an action plan, including any obstacles, triggers, and consequences.

While the above behavioral interventions have been proven to work in primary care, they all have constraints that make them difficult to implement, such as the amount of training and on-going supervision clinicians need, not to mention the time demands needed from patients.

“We need to create new interventions from the ground up,” said Areán. “We need interventions that are personalized, easy to learn and easy to deliver in the settings they are needed most.”

The UW’s Targeted Treatment Development Program is currently focused on developing behavioral interventions in low-income, ethnic minority, and older populations implemented in non-specialty settings such as primary care, assisted living, senior services, and day treatment. These new interventions will be based on advances in cognitive neuroscience, using input from patients and clinicians to inform the design of the intervention.

“Primary care has the potential to significantly reduce the global burden of mental health conditions if we can create nimble, adaptable, innovative solutions that any clinician can provide and that are acceptable to a broad array of patients,” said Areán.

Issues by year

Advertising

Volume 41, Issue 9, September 2012

Problem solving therapy Use and effectiveness in general practice

Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings. 1 It has been described as well suited to general practice and may be undertaken during 15–30 minute consultations. 2

Problem solving therapy takes its theoretical base from social problem solving theory which identifies three distinct sequential phases for addressing problems: 3

• discovery (finding a solution)
• performance (implementing the solution)
• verification (assessing the outcome).

Initially, the techniques of social problem solving emerged in response to empirical observations including that people experiencing depression exhibit a reduced capacity to resolve personal and social problems. 4,5 Problem solving therapy specifically for use in primary care was then developed. 6

Problem solving therapy has been shown to be effective for many common mental health conditions seen by GPs, including depression 7–9 and anxiety. 10,11 Most research has focused on depression. In randomised controlled trials, when delivered by appropriately trained GPs to patients experiencing major depression, PST has been shown to be more effective than placebo and equally as effective as antidepressant medication (both tricyclics and selective serotonin reuptake inhibitors [SSRIs]). 7,8 A recent meta-analysis of 22 studies reported that for depression, PST was as effective as medication and other psychosocial therapies, and more effective than no treatment. 9 For patients experiencing anxiety, benefit from PST is less well established. It has been suggested it is most effective with selected patients experiencing more severe symptoms who have not benefited from usual GP care. 10 Problem solving therapy may also assist a group of patients often seen by GPs: those who feel overwhelmed by multiple problems but who have not yet developed a specific diagnosis.

Although PST has been shown to be beneficial for many patients experiencing depression, debate continues about the mechanism(s) through which the observed positive impact of PST on patient affect is achieved. Two mechanisms have been proposed: the patient improves because they achieve problem resolution, or they improve because of a sense of empowerment gained from PST skill development. 12 Perhaps both factors play a part in achieving the benefits of PST as a therapeutic intervention. The observed benefit of PST for patients experiencing anxiety may be due to problem resolution and consequent reduction in distress from anticipatory concern about the identified but unsolved problem.

It is important to note that, while in the clinical setting we may find ourselves attempting to solve problems for patients and to advise them on what we think they should do, 13 this is not PST. Essential to PST, as an evidence based therapeutic approach, is that the clinician helps the patient to become empowered to learn to solve problems for themselves. The GP's role is to work through the stages of PST in a structured, sequential way to determine and to implement the solution selected by the patient. These stages have been described previously. 14 Key features of PST are summarised in Table 1 .

Using PST in general practice

Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, which are seen by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. To this end, a number of worksheets have been developed. A simple, single page worksheet is shown in Figure 1 . A typical case study in which PST may be useful is presented in Table 2 . By contrast, patients whose thinking is typically characterised by unhelpful negative thought patterns about themself or their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]). 15 Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients.

Problem solving therapy may be used with patients experiencing depression who are also on antidepressant medication. It may be initiated with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes.8 In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised.

The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously been discussed by the author 14 and are summarised in Table 3 . Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems. 12 of action includes empowerment of patients to address symptom causing life problems. Social and cultural context should be considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions.

General practitioners may be concerned that consultations that include PST will take too much time. 13 However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes. 15 Therefore, the concern over consultation duration may be more linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration.

Figure 1. Problem solving therapy patient worksheet

PST skill development for GPs

Many experienced GPs have intuitively developed valuable problem solving skills. Learning about PST for such GPs often involves refining and focusing those skills rather than learning a new skill from scratch. 13 A number of practical journal articles 16 and textbooks 10 that focus on developing PST skills in primary care are available. In addition, PST has been included in some interactive mental health continuing medical education for GPs. 17 This form of learning has the advantage of developing skills alongside other GPs.

Problem solving therapy is one of the Medicare supported FPS available to GPs. It is an approach that has developed from a firm theoretical basis and includes principles that will be familiar to many GPs. It can be used within the constraints of routine general practice and has been shown, when provided by appropriately skilled GPs, to be as effective as antidepressant medication for major depression. It offers an additional therapeutic option to patients experiencing a number of the common mental health conditions seen in general practice, including depression 7–9 and anxiety. 10,11

Conflict of interest: none declared.

• Gask L. Problem-solving treatment for anxiety and depression: a practical guide. Br J Psychiatry 2006;189:287–8. Search PubMed
• Hickie I. An approach to managing depression in general practice. Med J Aust 2000;173:106–10. Search PubMed
• D'Zurilla T, Goldfried M. Problem solving and behaviour modification. J Abnorm Psychol 1971;78:107–26. Search PubMed
• Gotlib I, Asarnow R. Interpersonal and impersonal problem solving skills in mildly and clinically depressed university students. J Consult Clin Psychol 1979;47:86–95. Search PubMed
• D'Zurilla T, Nezu A. Social problem solving in adults. In: Kendall P, editor. Advances in cognitive-behavioural research and therapy. New York: Academic Press, 1982. p. 201–74. Search PubMed
• Hegel M, Barrett J, Oxman T. Training therapists in problem-solving treatment of depressive disorders in primary care: lessons learned from the: "Treatment Effectiveness Project". Fam Syst Health 2000;18:423–35. Search PubMed
• Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised control trial comparing problem solving treatment with Amitryptyline and placebo for major depression in primary care. BMJ 1995;310:441–5. Search PubMed
• Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26–30. Search PubMed
• Bell A, D'Zurilla. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. Search PubMed
• Mynors-Wallis L Problem solving treatment for anxiety and depression. Oxford: OUP, 2005. Search PubMed
• Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res 2011;187:113–20. Search PubMed
• Mynors- Wallis L. Does problem-solving treatment work through resolving problems? Psychol Med 2002;32:1315–9. Search PubMed
• Pierce D, Gunn J. GPs' use of problem solving therapy for depression: a qualitative study of barriers to and enablers of evidence based care. BMC Fam Pract 2007;8:24. Search PubMed
• Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam Physician 2007;36:230–3. Search PubMed
• Pierce D, Gunn J. Depression in general practice, consultation duration and problem solving therapy. Aust Fam Physician 2011;40:334–6. Search PubMed
• Blashki G, Morgan H, Hickie I, Sumich H, Davenport T. Structured problem solving in general practice. Aust Fam Physician 2003;32:836–42. Search PubMed
• SPHERE a national mental health project. Available at www.spheregp.com.au [Accessed 17 April 2012]. Search PubMed

Also in this issue: Psychological strategies

Professional

Printed from Australian Family Physician - https://www.racgp.org.au/afp/2012/september/problem-solving-therapy © The Australian College of General Practitioners www.racgp.org.au

Evidence-Based Psychotherapy in Primary Care

Information & authors, metrics & citations, view options, box 1. questions to help increase the likelihood that patients are receiving evidence-based psychological interventions.

Anxiety Disorders

Primary care cbt, key evidence-based treatment principles.

Information

Published in.

• Psychotherapy
• Primary care

Competing Interests

Export citations.

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

To download the citation to this article, select your reference manager software.

There are no citations for this item

View options

Login options.

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Purchase Options

Purchase this article to access the full text.

PPV Articles - Focus

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

PREVIOUS ARTICLE

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

The Effectiveness of Problem-Solving Therapy for Primary Care Patients' Depressive and/or Anxiety Disorders: A Systematic Review and Meta-Analysis

• January 2018
• The Journal of the American Board of Family Medicine 31(1):139-150
• 31(1):139-150

• University of Michigan

• California Lutheran University
• This person is not on ResearchGate, or hasn't claimed this research yet.

• East China University of Political Science and Law

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

No full-text available

To read the full-text of this research, you can request a copy directly from the authors.

• Tyrone B. Pretorius

• Kristina Metz
• Jade Mitchell

• MohammedE Helmy
• LamiaaG Elhamrawy

• KhaledH Afifi
• CLIN PSYCHOL REV

• Anouk L Grubaugh
• Kenta Honma
• Hiroki Annaka
• Tomonori Nomura

• Prof Crick Lund
• J AM MED DIR ASSOC

• J AM ACAD CHILD PSY
• Benjamin Chan

• BMC PSYCHIATRY
• Benjamin W C Chan

• Charisse V. Ahmed
• Amelia E. Van Pelt
• Alison M. Buttenheim
• Merrian Brooks

• Physiother Theor Pract

• Andrea Battimelli
• Giovanni Di Cara

• María José Sanchez-Roman

• Anne Soejbjerg
• Stinne Eika Rasmussen

• CURR PSYCHOL

• J ADOLESCENT HEALTH

• Chung Ming Leung
• Yau Sum Wan

• Kevin Fiscella

• Teck Kuan Lim
• Ernest Tsun Fung Yeung

• BMC HEALTH SERV RES

• Charmaine Chitiyo
• Sandra Mboweni

• Chuanqi Ding

• Jingfen Jin

• Charisse Victoria Ahmed
• DEPRESS ANXIETY
• Antonella Sociali

• Ailin Shahabi
• Abbas Rahmati
• Noshirvan Khezri Moghadam
• Traumatology
• Sayedhabibollah Ahmadi Forooshani
• Kate Murray

• Nigar Khawaja

• Jessica A. Walker
• Julie Loebach Wetherell

• Munif Ishad Mujib

• Alexis Colley

• Veronica Yank
• Victoria L Tang

• Asal Pishyar

• Ahmad Abedi
• Gholamali Afroz

• Austin Y Su
• Brandon A. Kohrt
• CURR NEUROPHARMACOL

• Eamon J. McCrory
• Sarah Young
• Christina M. Temes
• TURK PSIKIYATR DERG

• Hozan Saatçioğlu

• BRAIN BEHAV IMMUN

• Christopher M Callahan
• Mohammad Hadi Zeinolabedini

• J PSYCHOSOM RES

• PSYCHOL REP
• Victoria J Dunsmore

• Norrina B Allen
• Mercedes R Carnethon
• Zahra Zafari
• Ghodsi Ahghar
• Mohammad Sahebalzamani
• J PSYCHIATR RES

• Paul Duberstein

• Peter Franks
• Daniel Michelson

• CURR MOL MED
• Shivani Bagga
• Manish Kumar
• ARIANNE JENNINGS

• J NEUROPSYCH CLIN N
• Katsunaka Mikami

• David J Moser
• Robert G. Robinson
• Marijn A Prins

• M. Hilbink-Smolders

• Avinash K. Shetty

• Anjana Sengupta

• Mark T Hegel

• Kay C Currie
• J GEN INTERN MED

• Anita Stewart

• Thomas E. Oxman

• Allen J Dietrich

• Alexander J. Rothman
• Jerusha B. Detweiler
• Wayne T Steward

• J Am Med Assoc

• Paula Whitty

• Ruth Thomas
• ARCH GEN PSYCHIAT

• Michael Lane

• Wayne Katon

• Caren B Jordan

• Thomas J. D'Zurilla
• R Development Core Team

• AM J GERIAT PSYCHIAT

• L.J. Gleser
• Stephen W. Raudenbush

• Peter C Gøtzsche
• J.P.T. Higgins
• James E. Pustejovsky

• S.G. Thompson
• Can J Community Ment Health

• Wike Seekles

• Kurt Kroenke
• ADDICT BEHAV

• Mark W. Vander Weg
• Marjorie Baler
• Carine Luxama
• Deborah Dreyfus
• GERONTOLOGIST

• C. Nathan Marti
• Martha L Bruce
• Matthew C. Johnson
• Paul D. Ellis
• L Mynors-Wallis
• Dennis Gath
• Frances Baker
• INT J GERIATR PSYCH

• Yvonne Y C Lo
• Alissa C. Bell
• Arch Fam Med

• Cathy D Sherbourne
• Kenneth B. Wells
• Karen B. Schmaling
• Sona Dimidjian

• Rollin Nagel
• Mary Kay Smith
• PRIMARY CARE

• GEN HOSP PSYCHIAT

• Robert L. Spitzer

• J HEALTH SOC BEHAV
• National Heart
• Ja Cartreine
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

• Search Menu

Sign in through your institution

• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Numismatics
• Classical Literature
• Classical Reception
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Papyrology
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Archaeology
• Late Antiquity
• Religion in the Ancient World
• Social History
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Emotions
• History of Agriculture
• History of Education
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Evolution
• Language Reference
• Language Acquisition
• Language Variation
• Language Families
• Lexicography
• Linguistic Anthropology
• Linguistic Theories
• Linguistic Typology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Modernism)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Media
• Music and Religion
• Music and Culture
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Science
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Politics
• Law and Society
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Legal System - Costs and Funding
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Restitution
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Clinical Neuroscience
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Toxicology
• Medical Oncology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Medical Ethics
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Security
• Computer Games
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Psychology
• Cognitive Neuroscience
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business Ethics
• Business Strategy
• Business History
• Business and Technology
• Business and Government
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Social Issues in Business and Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic History
• Economic Systems
• Economic Methodology
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Management of Land and Natural Resources (Social Science)
• Natural Disasters (Environment)
• Pollution and Threats to the Environment (Social Science)
• Social Impact of Environmental Issues (Social Science)
• Sustainability
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• Ethnic Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Behaviour
• Political Economy
• Political Institutions
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Theory
• Politics and Law
• Politics of Development
• Public Policy
• Public Administration
• Qualitative Political Methodology
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Disability Studies
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter

17 Problem-solving treatment in primary care

• Published: September 1996
• Cite Icon Cite
• Permissions Icon Permissions

Chapter 17 discusses problem-solving treatment in primary care and outlines a series of studies into the treatment of emotional disorders in primary care, including the effects of not prescribing anxiolytic medication for emotional disorders, the feasibility and efficacy of problem-solving for emotional disorders and poor prognosis treatment, problem-solving treatment for major depression in general practice, further evaluation of problem-solving treatment for major depression in primary care.

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code
• Add your ORCID iD

Institutional access

Sign in with a library card.

• Sign in with username/password
• Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Research article
• Open access
• Published: 26 October 2011

Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV

• Dixon Chibanda 1 ,
• Petra Mesu 2 ,
• Lazarus Kajawu 1 , 2 ,
• Frances Cowan 3 , 4 ,
• Ricardo Araya 5 &
• Melanie A Abas 6  

BMC Public Health volume  11 , Article number:  828 ( 2011 ) Cite this article

28k Accesses

206 Citations

173 Altmetric

Metrics details

There is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale.

We trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention.

Of 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention.

We have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial.

Trial registration

ISRCTN: ISRCTN25476759

Peer Review reports

Mental disorders cause considerable suffering, disability and social exclusion in Africa, and are poorly recognised and undertreated [ 1 , 2 ]. In Zimbabwe, common mental disorders, such as depression mixed with anxiety, are found in over 25% of those attending primary health care services or maternal services, and in up to 30% of females in the community [ 3 – 5 ]. In the Zimbabwean Shona language, thinking too much ( kufungisisa ), along with deep sadness ( kusuwisisa ), and painful heart (moyo unorwadza) are terms in common use for emotional distress being close to European and American categories of common forms of depression and anxiety [ 3 , 6 ]

There is increasing evidence, mainly from other world regions but also rapidly growing evidence from within low income countries, that improving mental health is a low cost approach to improve quality of life and reduce disability [ 7 , 8 ]. Very little of this evidence, however, is from Africa. In Chile, low intensity low-cost treatments for depression have been integrated into primary health care [ 9 ]. These include, for example, psycho education, problem-solving therapy and self-help approaches [ 10 , 11 ]. Problem-solving therapy has been shown to be effective for depression and common mental health problems [ 12 , 13 ]. Previous attempts to deliver care for common mental disorders through primary care clinics in Zimbabwe although promising in the short-term had shown little long-term success due to reliance on overstretched nursing staff and lack of supervision [ 14 ]. In 2005, a government operation in Mbare , a township in Harare, resulted in many people becoming homeless or losing their livelihoods [ 15 ] and was perceived by the Mbare community to lead to high rate of emotional distress. Local stakeholders identified the need for a community mental health intervention. This had to be at no extra cost to the primary health care clinic, to utilise space outside the overcrowded clinic rooms, and to use methods already tested locally. A pilot intervention based on a problem-solving approach was identified [ 16 ]. It was suggested this be delivered by lay health workers via a 'Friendship Bench' ( Chigaro Chekupanamazano ) placed in the clinic grounds, and that a system of supervision and stepped care be part of the package. A team comprising psychologists, a primary care nurse and a psychiatrist adapted existing training materials on problem solving therapy [ 16 , 17 ] in the light of experience working with lay workers and general nurses in primary care. Adaptations included at least one home visit by the lay workers early in the therapy given it is normal practice for lay workers to visit clients in their homes, and encouraging clients to schedule some positive activities that really mattered to them to make life more rewarding. The training and the intervention were pre-tested in 5 lay workers and 143 primary care clients and found to be acceptable to them and to the lay workers. The aim of this pilot was to gather preliminary data on the effectiveness of this intervention and to see if the intervention would be feasible, and if so to gather ideas about how best to implement it on a larger scale.

Mbare is a high density suburb or township in the south of Harare. It is characterized by ethnic diversity and high unemployment with most residents relying on informal trading. The literacy rate is estimated to be over 90%. There are three government run Primary Health Care (PHC) clinics, staffed almost exclusively by general nurses, for a population of approximately 200 000. The study took place in all three clinics.

Twenty lay workers, locally termed health promoters, support the nurses at these three clinics. The lay workers are a respected group of primary health care providers, commonly referred to as ambuya utano (grandmother health provider) (Figure 1 ). In Mbare , all lay workers are female, literate, have at least primary school education, and have lived locally for at least 15 years. Their mean age is 58 years. Their main role is in community health outreach, which includes supporting people living with HIV/AIDS and Tuberculosis by providing individual and family support (practical, psychological and spiritual) and encouraging medication adherence. They also deliver community health education and promotion e.g. through encouraging immunisation and methods to control disease outbreaks. Lay workers report weekly to the environmental health officer and a nurse-manager. The lay workers cover geographical patches, which are sections of the community demarcated by the City of Harare according to street grids. Each geographical patch has approximately 3000 inhabitants. Ten lay workers were selected at random for this pilot: three from two of the clinics and four from the largest clinic.

Some of the lay health workers involved in the Friendship Bench project, sitting in front of one of the Benches .

Participants

Inclusion criteria: aged 18 and over; residents of geographical patches in Mbare , Harare, covered by the ten selected lay workers; score > 7 on Shona Symptom Questionnaire screen for common mental disorders. Exclusion criteria: requiring acute medical attention such that they cannot participate; severe psychiatric symptoms and/or risk to self or others requiring specialist referral as assessed by primary care research nurse

Ethical approval was obtained from the Medical Research Council of Zimbabwe and written informed consent was sought from all participants. The study was registered as a non-controlled trial http://www.controlled-trials.com/ISRCTN25476759

Recruitment

We aimed to recruit from the clinic staff, from the community, and from the lay workers themselves. The psychiatrist (DC) and psychologists (PM, KJ) presented to the clinic nursing staff and to all 20 lay workers the rationale for the project and referral methods to the friendship Bench. Notices written in the local vernacular language explaining the location and uses of the benches were placed at six different points within the entrance hall and waiting area of each clinic.

The lay workers introduced and publicised the Friendship Bench to the community through community stakeholders' meetings and during visits to people's homes, churches, schools and police stations. They introduced it as an adjunct to their normal daily community health outreach activity. They described the Friendship Bench approach as aimed at addressing common mental health issues such as kufungisisa (thinking too much) as a result of, among other things, HIV infection, AIDS, domestic violence, family sickness and poverty.

Clients were either referred or could self refer to the Friendship Bench, which was available Mon-Friday 9.00 am to 12.00 pm at each clinic. Those referred or who self-referred were directed by nursing or reception staff to sit on the Friendship Bench which in each clinic was a large wooden bench located under a tree within sight of the lay workers' office. One duty lay worker was responsible for the Bench each day on rotation and would approach the Bench after a potential client sat on it. The duty lay worker was responsible for collecting data on inclusion criteria including residential and basic demographic information and on psychological symptoms using the Shona Symptom Questionnaire (SSQ) [ 4 ]. She also gathered information on recent stressors using a brief life events screen based on one used previously in Harare [ 18 ]. Everyone was offered some education, advice and often sign-posted to support services. Those meeting inclusion criteria were referred to a research nurse for assessment of risk to self or to others (e.g. suicidal ideation, history of deliberate self harm, very severe symptoms). She referred those excluded on these grounds to the visiting psychiatrist (DC). She invited those meeting eligibility criteria to participate in the pilot and took written informed consent. She then referred them back to the lay worker who made arrangements for their first Friendship Bench session within 2-5 days with a lay worker that covered their geographical patch.

Outcome measure

The main outcome measure was the Shona Symptom Questionnaire (SSQ). The SSQ is a 14-item screening tool for common mental disorders, integrating local idioms and internationally recognised items for emotional distress. It was developed and validated in Zimbabwe using exemplary cross-cultural methods [ 4 ]. It is self-administered and has a reliable internal consistency (r = 0.85) and satisfactory sensitivity and specificity, with a score of > = 8 being the cut-point. It is based on a yes/no response and asks about symptoms such as thinking too much, failing to concentrate, work lagging behind, insomnia, suicidal ideation, unhappiness and so on, over a 1 week period. All participants were approached six to eight weeks after their first treatment session to complete a self-administered SSQ which was collected by the research nurse in the absence of the attending lay worker.

The Intervention

The intervention consisted of brief individual talking therapy based on problem-solving therapy delivered by a lay worker. Most sessions took place sitting on a bench termed "The Friendship Bench" ( Chigaro Chekupanamazano ). The Friendship Benches were made for the project by local craftsmen (see Figure 1 ). They are located within the grounds of each of the three participating clinics in a discrete area under the trees in the clinic gardens.

Table 1 shows the activities involved in the delivery of the Friendship Bench. The lay worker would initially explain to all participants how to self-administer the screening tool, the Shona Symptom Questionnaire. Problem-solving therapy (PST) included identification and exploration of problems, and identification and implementation of solutions, based on prior principles [ 19 ]. Our PST was a locally developed seven-step plan previously used in partnership with government, lay and traditional care providers [ 16 ]. Up to a maximum of 6 sessions on the Bench were offered with the second session taking place at the client's home and sometimes also one of the later sessions. Those most in financial need were referred to two local income-generating projects (peanut butter making; recycling). The problem solving therapy was enhanced with a component of activity scheduling in that clients were also encouraged to carry out activities that really mattered to them to make life more rewarding. Home visits included prayer. Prayer was already a well recognised part of the support provided by LW in their community health outreach role in Mbare , which has a 98% Christian population with more than 70 Christian faith groups. On average each prayer lasts 15-30 minutes and is delivered by one lay worker together with the family. The aim of the prayer is to comfort the sick and the family. The use of prayer in formal gatherings related to health is a common practice in Zimbabwe. The existing prayer format used prior to the introduction of the Friendship Bench was incorporated in the six sessions without any alterations.

Training, selection and supervision of facilitators

All 20 lay workers were trained.

We provided an 8-day training run by two clinical psychologists (PM and LK), a general nurse trained in systemic counselling (ST) and a psychiatrist (DC). This covered didactic lectures on common mental disorders (CMD), including kufungisisa (thinking too much) but particularly focussed on skills to identify CMD using the Shona Symptoms Questionnaire [ 4 ], and to manage CMD using simple psycho-education and problem-solving therapy [ 16 – 19 ]. Lay workers then took part in two days of pre-testing including screening, identification, and referral processes within the clinic, and referral of 'red flags' (critical case-situations such as suicidal risk). We made use of practise with clients on the Friendship Bench and in clients' homes'. We developed a client referral manual, which included a list of NGO's, private and public institutions, and church organizations to be used by lay workers or patients.

Ten lay workers were selected at random for the pilot: three from two of the clinics and four from the largest clinic.

A daily peer-support group for lay workers was introduced. The peer group meetings were facilitated by one of the lay workers who would then present during weekly group supervision where all lay workers participated. A clinic staff nurse trained in counseling provided weekly group supervision at the largest clinic. The clinical psychologist and the psychiatrist provided further supervision every fortnightly and monthly, respectively.

We developed a brief 6-item questionnaire with a 4-point Likert scale for the lay workers to evaluate the PST intervention. For instance, we asked them to rate the ease with which they had learned the problem-solving therapy approach, the ease with which they delivered the intervention and the proportion of clients who appeared to benefit from the PST approach. We asked the lay workers to complete this once 6 weeks after the study has begun. We also carried out one focus group with 6 of the 10 workers and asked them to describe their experiences of delivering the intervention. Their responses were recorded in writing and analysed for content and themes by two of the authors.

Data analysis

Descriptive statistics (means and standard deviations and proportions) were estimated for those who participated, who declines, who were lost to follow, and who were excluded due to psychiatric risk. We used t-tests and regression models to test changes in SSQ scores before and after completion of the treatment, adjusting for SSQ scores at baseline. Data were entered and analysed using EpiInfo 2002 and STATA 10.0 (Release 10, College Station, TX: Stata Corporation. 2003) after range checks and double entry of all questionnaires.

Recruitment and attrition at follow-up

Between July and November 2007, 948 persons visited the Bench. Of these 948 persons who visited the Bench, 395 (42%) scored above the cut-point of the Shona Symptom Questionnaire (SSQ). Among these, 33 (8%) with a mean SSQ score of 11.8 (sd 1.2) were excluded from the pilot study due to being severely depressed and/or suicidal and were referred to the psychologist or psychiatrist (see Figure 2 ). Of the 362 invited to take part, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (320 participants). Of the 395, 188 (48%) presented with an HIV-related problem of whom 166 (88%) participated.

Flow diagram of recruitment into the study .

Table 2 shows the characteristics of the 395 who scored above the cut-point of the SSQ, according to whether or not they entered the study. Participants were more likely to be female. More of those who participated were female and married (70% female, 57% married) compared to those who declined (42% female, 43% married) or who were those lost to follow-up (40% female, 41% married). Those with less than eight years of education were more likely to be lost to follow-up than to participate. The primary reasons presented for visiting the Bench among those who participated were HIV-related, somatic complaints and domestic violence.

Most of those who participated were referred to the Friendship Bench by clinic staff (35%) and lay workers (24%). Other common forms of referral were: friend/relative (13%), self-referral (12%) or police (9%).

Psychological symptoms scores before and after the six-week intervention period

All participants completed a minimum of 3 sessions over a six week period with 20%, 30%, 21% and 30% completing 3, 4, 5 or 6 sessions respectively.

The mean SSQ score for the 320 cases was 11.3 (sd 1.4) before treatment. After receiving between 3 to 6 sessions the mean score dropped by 4.8 points to 6.5 (sd 2.4) [t = 13.6 (p = 0.0087)]. For those completing 3 or more sessions, 66% recovered to below case level on the SSQ at 6-8 weeks

Table 3 shows the drop in SSQ scores according to the number of sessions attended, adjusting for baseline SSQ score. The more sessions attended the larger the drop in SSQ scores with a drop of more than 3 points observed among those who attended all six sessions.

Lay workers evaluation

Nine of the ten lay workers rated themselves as very able to deliver the PST intervention. All of them rated at least half of their clients as benefiting from PST with 7/10 rating 'more than half' of their clients benefiting from the intervention. Themes emerging from the focus group suggested that the lay workers viewed effective ingredients of the Friendship Bench to include:

Their position of trust in the community-clients viewed them as wise and confidential. The clients viewed them as 'persons who would not gossip' which was 'reassuring in a small community'

Being able to visit clients in their homes which they felt instilled hope

Minimising stigma associated with having a mental health problem. The lay workers heard from their clients that as they were already connected with public health work (rather than psychiatry) and carried out home visits routinely as part of their work on public health promotion and that it was not stigmatising for clients with kufungisisa (thinking too much) to be visited.

The structured 'talk therapy' helped them to monitor the progress and challenges that clients were facing.

Breaking down the problems into specific and manageable steps

Giving feedback to clients.

In the focus group, the lay workers reported several case histories of their clients. These included the following:

A female client who had been to the bench with a score of 12/14 on the SSQ at baseline and subsequently received 2 home visits described the lay health workers as 'bringing peace' in her home, and 'less agitation' from her partner. Her score dropped to 7/14 after six sessions.

ii) A female client with an SSQ of 11/14 dropped to 6/14 after five sessions which included a home visit after she presented with being unable to come to terms with her HIV status.

iii) A female senior member of the local protestant church described the home visits as 'hope for those of us who are unable to open up in a church congregation about our HIV status'. Her score went down to 5/14 from 10/14 after 6 sessions.

This is the first example of lay health workers in Africa delivering a low intensity mental health intervention, using locally adapted tools, for common mental disorders in primary care. We have shown that it is feasible for lay workers to deliver this intervention for depression and common mental disorders, and that recruitment to the intervention from primary care, community agencies and self-referral was also feasible (Figure 2 ). The treatment appeared acceptable to the community and the lay workers were able to integrate the intervention into their routine work. Preliminary findings also show that the intervention is efficacious in reducing psychological morbidity, with a drop in score of nearly 5 points on the 14-item psychological outcome scale after 3-6 sessions, and efficacy proportional to the number of sessions attended. Over half of those who participated had presented with a problem related to HIV.

Chance does not seem a likely explanation for our finding as the significance value for the drop in score after 3-6 sessions was at p < 0.01 level. Bias may explain some of the results in that women and married participants were more likely to participate than to decline or to be lost to follow-up and those with lower education were more likely to be lost to follow-up than to participate. However, overall, the response rate of 88% was extremely high so it appears unlikely that bias is playing a major role in explaining the results. Measurement error is also unlikely to explain the findings. The Shona Symptom Questionnaire was developed using optimal cross-cultural methods and has been validated against an international diagnostic interview with most of those scoring at or above the recommended cut-off having mixed depression and anxiety or pure depression using ICD criteria [ 4 ].

We do not have a comparison group from the same study who did not receive the intervention. However, a prospective study in primary care in Harare showed that a mean drop in score of 4.7 (sd 6.3) on the SSQ was associated with recovery from 'case' to 'non-case' and with significantly less disability [ 20 ] (see Table 3 of the Patel paper). These authors further report that those who experienced a drop in score of 4 or more points on the SSQ were more likely to self-report an improvement in health than those who remained at case-level on the SSQ. Our crude mean drop in score of 4.8 points thus appears to represent a meaningful drop in score indicating efficacy of the Friendship Bench intervention. Furthermore, our finding that drop in score was significantly correlated with the number of sessions attended, even after adjusting for baseline SSQ score, adds weight to our assertion that the intervention appears to be efficacious. In our pilot, 34% remained cases at 6-8 weeks follow-up after the intervention, whereas in the Patel et al study [ 20 ], where there was no specific intervention, 48% of primary health care attenders remained cases.

The quantitative findings are supported by the lay workers evaluation. All of them rated at least half of their clients as benefiting from problem-solving therapy with 7/10 rating 'more than half' of their clients benefiting from the intervention. Themes that emerged from qualitative work support the argument that implementing this intervention through an existing public health intervention and by mature women with a position of trust in the community, helps explain its apparent efficacy. The lay workers-or 'grandmother health providers' are viewed as wise, confidential, authoritative and not prone to gossip. As the lay workers were already respected for their public health work, participants said they did not find it not stigmatising to be visited.

The intervention is theoretically closely linked to problem-solving therapy, which has been shown to be effective for depression and common mental health problems [ 12 , 13 ], together with an activity scheduling component [ 21 ]. It incorporates local adaptations that are integral to the routine work of the therapists who are culturally sanctioned lay health workers, known and respected as 'grandmother health providers'. For instance, the inclusion of Christian prayer for 15 minutes during 1 or 2 of the 6 sessions was part of the existing practice of the lay workers and it would have been inappropriate to remove that normal practice. While there is no evidence from randomised controlled trials that prayer is an effective treatment for depression in Christians, there is some suggestion from non-randomised studies with small samples that religious activities may benefit depression [ 22 ].

In 1994 we showed that major barriers to up-scaling mental health care in this setting include lack of supervision, and lack of recording systems for common mental disorders. We provided evidence that problems in improving primary mental health care may be less with the attitudes (or even the training) of primary care staff and more with bureaucratic limitations such as the inadequacy of the diagnostic codes, absence of mental health supervision, lack of protocol for following-up CMD patients, lack of medicines, and lack of incentives to see patients with CMD [ 23 ]. The Friendship Bench has managed to address some of these challenges, especially through making use of lay workers and providing a system for them of peer and nurse-led supervision, with an available step up to specialist care which has been used in less than 10% of cases screening positive for CMD. An emphasis on local concepts and terms helped to reduce stigma of mental disorders. The local knowledge of the lay workers facilitated linkage with two local income-generating projects (peanut butter making; recycling) for those in most financial need.

Our decision to use problem-solving therapy was anchored in earlier evidence that kufungisisa and common mental disorders were associated with everyday social and health problems [ 16 , 24 ], and that the community trusted the lay health workers to aid them in resolving these problems using culturally accepted methods, which sometimes included prayer. This is consistent with the traditionally accepted rationale for using problem-solving therapy [ 19 ]. We found that those who used a greater number of sessions benefited more. Thus in future work it will be important to optimise adherence to the intervention and to follow-up clients. Given the value found in Western settings of written materials for clients in low-intensity psychological treatments, we wish to develop these for clients in Zimbabwe, with the aim of increasing the efficacy of the therapy. We will also add training in more collaborative structured approaches to activity scheduling for clients who remain depressed despite problem-solving therapy.

Of the 320 participants in this pilot, just over half had presented with an HIV-related problem. There is need to evaluate whether treatment for depression might improve physical health outcomes such as medication adherence in those who have depression co-morbid with physical illness [ 25 ].

With the large treatment gap that currently exists in low and middle income countries for mental health care, lay workers may be able to play a pivotal role [ 26 ]. In Zimbabwe, earlier work has shown the feasibility of using lay workers to prevent mother to child transmission of HIV, and to screen for psychological morbidity [ 5 , 27 , 28 ]. While there is evidence supporting the effectiveness of task-shifting in HIV [ 29 ], immunization, malaria prevention, and management of upper respiratory infections [ 30 ], ours is an important study given the dearth of evidence on lay workers addressing depression and common mental health problems in Africa.

Limitations of the study include the short follow-up period of 6 weeks. Also, the observed drop in SSQ score after six sessions of problem-solving therapy was not controlled for potential confounding factors such as socio-economic position [ 31 ]. The fundamental limitation to this study is the absence of a comparison group receiving 'usual care' or a placebo intervention, if one could be found. Furthermore, the lay workers were not observed during the course of their work and what they did in practice could have differed from their training. The low level of attrition among the participants is unusual; however, this could be attributed to the short follow up period, the close proximity of participants to the local study area, and the ability of the lay workers and research nurse to physically follow up participants in the community, and is consistent with high follow-up rates found in previous research in Harare [ 20 ]. The City of Harare Health Department continued the Friendship Bench after the pilot. In the 14 months from January 2008 to February 2009, 2348 clients had visited the Friendship Bench with 973 having received the problem-solving intervention. In view of this it is imperative to rigorously test this intervention.

We have found preliminary evidence that lay primary health care workers can deliver locally adapted problem-solving therapy in Harare, Zimbabwe and that this can be associated with a meaningful reduction in symptoms of depression and common mental disorders. The problem solving therapy was integrated into the routine work load of the community based lay workers whose roles include supporting people living with HIV and carrying out health promotion activities. There is need to carry out appropriately powered randomised controlled trials to test if this task-shifting mental health intervention is effective compared to usual care in reducing psychological symptoms and also in improving physical health outcomes in those who have depression co-morbid with physical illness.

No external funding

Bolton P, et al: Group Interpersonal Psychotherapy for Depression in Rural Uganda: A Randomized Controlled Trial. Journal of the American Medical Association. 2003, 289 (23): 3117-10.1001/jama.289.23.3117.

Article   PubMed   Google Scholar  

Saxena S, et al: Resources for mental health: scarcity, inequity, and inefficiency. Lancet. 2007, 370 (9590): 878-89. 10.1016/S0140-6736(07)61239-2.

Abas MA, Broadhead JC: Depression and anxiety among women in an urban setting in Zimbabwe. Psychological Medicine. 1997, 27: 59-10.1017/S0033291796004163.

Article   CAS   PubMed   Google Scholar  

Patel V, et al: The Shona Symptom Questionnaire: the development of an indigenous measure of common mental disorders in Harare. Acta Psychiatrica Scandinavica. 1997, 95 (6): 469-10.1111/j.1600-0447.1997.tb10134.x.

Stranix-Chibanda L, et al: Screening for psychological morbidity in HIV-infected and HIV-uninfected pregnant women using community counselors in Zimbabwe. Journal of the International Association of Physicians in AIDS Care. 2005, 4 (4): 83-8. 10.1177/1545109706286555.

Patel V, et al: The explanatory models and phenomenology of common mental disorders in primary care in Harare. Psychological Medicine. 1995, 25: 1191-10.1017/S003329170003316X.

Lancet Global Mental Health Group, et al: Scale up services for mental disorders: a call for action. Lancet. 2007, 370 (9594): 1241-52.

Article   Google Scholar  

Hyman S, et al: Mental Disorders. Disease control priorities in Developing Countries). 2006, New York: Oxford University Press, 605-626.

Google Scholar  

Araya R, et al: Treating depression in primary care in low-income women in Santiago, Chile: a randomised controlled trial. Lancet. 2003, 361 (9362): 995-1000. 10.1016/S0140-6736(03)12825-5.

Araya R, et al: Cost-effectiveness of a primary care treatment program for depression in low-income women in Santiago, Chile. American Journal of Psychiatry. 2006, 163 (8): 1379-87. 10.1176/appi.ajp.163.8.1379.

Richards DA, et al: Improving access to psychological therapies: phase IV prospective cohort study. British Journal of Clinical Psychology. 2009, 48 (Pt 4): 377-96.

Cuijpers P, et al: Problem Solving Therapies For Depression: A meta-analysis. European Psychiatry. 2007, 22 (1): 9-15. 10.1016/j.eurpsy.2006.11.001.

Malouff JM, et al: The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review. 2007, 27 (1): 46-57. 10.1016/j.cpr.2005.12.005.

Abas M, et al: Primary care services for depression in Harare, Zimbabwe. Harvard Review of Psychiatry. 2003, 11 (3): 157-10.1080/10673220303952.

Tibaijuka AK: Report of the Fact-Finding Mission to Zimbabwe to assess the Scope and Impact of Operation Murambatsvina by the UN Special Envoy on Human Settlements Issues In Zimbabwe. UN Habitat. 2005

Abas M, et al: Defeating depression in the developing world: a Zimbabwean model. British Journal of Psychiatry. 1994, 164 (3): 293-10.1192/bjp.164.3.293.

Amani Trust: The Chiweshe Nurse-Counsellor Programme: Trainer's Manual (revised). Harare. 1994

Broadhead J, Abas M: Life events, difficulties and depression among women in an urban setting in Zimbabwe. Psychological Medicine. 1998, 28: 29-10.1017/S0033291797005618.

Mynors-Wallis L: Problem-solving treatment in general psychiatric practice. Advances in psychiatric treatment. 2001, 417-425.

Patel V, et al: Outcome of common mental disorders in Harare, Zimbabwe. British Journal of Psychiatry. 1998, 157: 53-57.

Mazzucchelli T, et al: Behavioral Activation Treatments for Depression in Adults: A Meta-analysis and Review. Clinical Psychology: Science and Practice. 16 (4): 383-411.

Townsend M, et al: Systematic Review of Clinical Trials Examining the Effects of Religion on Health. Southern Medical Journal. 2002, 95 (12): 142929-

Abas M, et al: Common mental disorders and primary health care: Current practice in low-income countries. Harvard Review of Psychiatry. 2003, 11 (3): 166-10.1080/10673220303954.

Patel V, et al: Women, poverty and common mental disorders in four restructuring societies. Social Science & Medicine. 1999, 49 (11): 1461-10.1016/S0277-9536(99)00208-7.

Article   CAS   Google Scholar  

Sikkema K, et al: Mental Health Treatment to Reduce HIV transmission Risk Behaviour: A Positive Prevention Model. Aids and Behaviour. 2010, 14 (2): 252-10.1007/s10461-009-9650-y.

Patel V, et al: Improving the outcomes of primary care attenders with common mental disorders in developing countries: a cluster randomized controlled trial of a collaborative stepped care intervention in Goa, India. Trials. 2008, 9 (1): 4-10.1186/1745-6215-9-4.

Article   PubMed   PubMed Central   Google Scholar  

Shetty A, et al: The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe. AIDS Research and Therapy. 2008, 5 (1): 17-10.1186/1742-6405-5-17.

Chibanda D, et al: Validation of the Edinburgh Postnatal Depression Scale among women in a high HIV prevalence area in urban Zimbabwe. Archives of Women's Mental Health. 2009

Zachariah N, et al: Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa Royal Society of Tropical Medicine and Hygiene. 2009, 103: 549-558.

Lewin S, et al: Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews. 2009, 3

Abas MA, et al: Socioeconomic Deprivation and Extended hospitalization in severe mental disorder; A two year follow-up study. Psychiatric Services. 2008, 59 (3): 322-325. 10.1176/appi.ps.59.3.322.

Pre-publication history

The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/828/prepub

Download references

Acknowledgements

We thank Dr. F Lovemore Director of the Counselling Services Unit (CSU), and Dr. P Chonzi and Dr S Mungofa, Directors of The City of Harare Health Department, Harare hospital psychiatric unit and the Mbare community; Shirly Tshimanga (ST), nursing staff at the three clinics, Church groups, Local police, Schools, NGO's and the health promoters for their continued support of the Friendship Bench. Written consent was provided by the lay health workers for the photograph shown in Figure 1 .

Author information

Authors and affiliations.

Department of Psychiatry, University of Zimbabwe, Harare, Zimbabwe

Dixon Chibanda & Lazarus Kajawu

Counselling Services Unit, Harare, Zimbabwe

Petra Mesu & Lazarus Kajawu

Centre for Sexual Health and HIV Research, University College London, London, UK

Frances Cowan

Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe

School of Social and Community Medicine, Bristol, UK

Ricardo Araya

King's College London, Institute of Psychiatry, London, UK

Melanie A Abas

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Dixon Chibanda .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors' contributions

DC was responsible for study design, data collection, writing manuscript and analysis of the data. PM and LK responsible for study design and review of second draft. FC reviewed second draft. RA assisted with analysing data and editing manuscripts.

MA developed Multiple Symptoms Card, made comments on first draft of manuscript, responsible for second draft of manuscript, contributed to revisions following referees comments and to writing of final draft. All authors read and approved the manuscript.

Authors’ original submitted files for images

Below are the links to the authors’ original submitted files for images.

Authors’ original file for figure 1

Authors’ original file for figure 2, authors’ original file for figure 3, authors’ original file for figure 4, authors’ original file for figure 5, rights and permissions.

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Reprints and permissions

About this article

Cite this article.

Chibanda, D., Mesu, P., Kajawu, L. et al. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health 11 , 828 (2011). https://doi.org/10.1186/1471-2458-11-828

Download citation

Received : 06 June 2010

Accepted : 26 October 2011

Published : 26 October 2011

DOI : https://doi.org/10.1186/1471-2458-11-828

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Primary Health Care
• Common Mental Disorder
• Common Mental Health Problem
• Primary Mental Health Care

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Problem-solving treatment: evidence for effectiveness and feasibility in primary care

Affiliation.

• 1 Warneford Hospital, Oxford.
• PMID: 8976466
• DOI: 10.2190/0HVY-CD2F-0KC7-FVTB

Objective: There is a need for psychological treatments for psychiatric disorders in primary care. The purpose of this article is to review studies of problem-solving treatment (PST). PST is a brief psychological treatment for emotional symptoms in primary care patients.

Method: A series of different studies of primary care patients in Oxford are reviewed.

Results: In primary care, PST is effective for patients with major depression and for patients with more broadly defined emotional disorders. PST can be effectively delivered in primary care settings by psychiatrists, general practitioners, or nurses. PST may be more expensive than primary care practitioners' usual treatment in terms of direct costs. However, PST might result in greater savings if indirect costs are also considered.

Conclusions: PST is a feasible, brief, effective treatment for mental disorders of mild to moderate severity in primary care. Replication studies and further research on combination treatments, long-term outcomes, and indirect costs are indicated.

PubMed Disclaimer

Similar articles

• Cost-effectiveness of problem-solving treatment in comparison with usual care for primary care patients with mental health problems: a randomized trial. Bosmans JE, Schreuders B, van Marwijk HW, Smit JH, van Oppen P, van Tulder MW. Bosmans JE, et al. BMC Fam Pract. 2012 Oct 10;13:98. doi: 10.1186/1471-2296-13-98. BMC Fam Pract. 2012. PMID: 23052105 Free PMC article. Clinical Trial.
• Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial. Kendrick T, Simons L, Mynors-Wallis L, Gray A, Lathlean J, Pickering R, Harris S, Rivero-Arias O, Gerard K, Thompson C. Kendrick T, et al. Br J Psychiatry. 2006 Jul;189:50-9. doi: 10.1192/bjp.bp.105.012435. Br J Psychiatry. 2006. PMID: 16816306 Clinical Trial.
• Can we address depression in vision rehabilitation settings? Professionals' perspectives on the barriers to integrating problem-solving treatment. Holloway E, Sturrock B, Lamoureux E, Keeffe J, Hegel M, Casten R, Mellor D, Rees G. Holloway E, et al. Disabil Rehabil. 2018 Feb;40(3):287-295. doi: 10.1080/09638288.2016.1250172. Epub 2016 Nov 20. Disabil Rehabil. 2018. PMID: 27868437
• Are psychological treatments for depression in primary care cost-effective? Bosmans JE, van Schaik DJ, de Bruijne MC, van Hout HP, van Marwijk HW, van Tulder MW, Stalman WA. Bosmans JE, et al. J Ment Health Policy Econ. 2008 Mar;11(1):3-15. J Ment Health Policy Econ. 2008. PMID: 18424872 Review.
• Does shared care help in the treatment of depression? Agius M, Murphy CL, Zaman R. Agius M, et al. Psychiatr Danub. 2010 Nov;22 Suppl 1:S18-22. Psychiatr Danub. 2010. PMID: 21057395 Review.
• Visual Impairment and Mental Health: Unmet Needs and Treatment Options. Demmin DL, Silverstein SM. Demmin DL, et al. Clin Ophthalmol. 2020 Dec 3;14:4229-4251. doi: 10.2147/OPTH.S258783. eCollection 2020. Clin Ophthalmol. 2020. PMID: 33299297 Free PMC article. Review.
• A Task-Shifting Problem-Solving Therapy Intervention for Depression and Barriers to Antiretroviral Therapy Adherence for People Living With HIV in Zimbabwe: Case Series. Nyamayaro P, Bere T, Magidson JF, Simms V, O'Cleirigh C, Chibanda D, Abas M. Nyamayaro P, et al. Cogn Behav Pract. 2020 Feb;27(1):84-92. doi: 10.1016/j.cbpra.2018.10.003. Epub 2019 Jan 4. Cogn Behav Pract. 2020. PMID: 32153343 Free PMC article.
• Integrated Care for Depression in Older Primary Care Patients. Bruce ML, Sirey JA. Bruce ML, et al. Can J Psychiatry. 2018 Jul;63(7):439-446. doi: 10.1177/0706743718760292. Epub 2018 Mar 1. Can J Psychiatry. 2018. PMID: 29495883 Free PMC article. Review.
• Measurement, Education and Tracking in Integrated Care (METRIC): use of a culturally adapted education tool versus standard education to increase engagement in depression treatment among Hispanic patients: study protocol for a randomized control trial. Sanchez K, Eghaneyan BH, Killian MO, Cabassa L, Trivedi MH. Sanchez K, et al. Trials. 2017 Aug 3;18(1):363. doi: 10.1186/s13063-017-2109-y. Trials. 2017. PMID: 28774339 Free PMC article. Clinical Trial.
• Randomized Controlled Trial of a Computerized Interactive Media-Based Problem Solving Treatment for Depression. Sandoval LR, Buckey JC, Ainslie R, Tombari M, Stone W, Hegel MT. Sandoval LR, et al. Behav Ther. 2017 May;48(3):413-425. doi: 10.1016/j.beth.2016.04.001. Epub 2016 May 3. Behav Ther. 2017. PMID: 28390503 Free PMC article. Clinical Trial.

Publication types

• Search in MeSH

Related information

• Cited in Books
• PubChem Compound (MeSH Keyword)

LinkOut - more resources

Full text sources.

• MedlinePlus Health Information

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• HHS Author Manuscripts

Problem-Solving Therapy in the Elderly

Dimitris n. kiosses.

Weill-Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College

George S. Alexopoulos

Opinion statement.

We systematically reviewed randomized clinical trials of problem-solving therapy (PST) in older adults. Our results indicate that PST led to greater reduction in depressive symptoms of late-life major depression than supportive therapy (ST) and reminiscence therapy. PST resulted in reductions in depression comparable with those of paroxetine and placebo in patients with minor depression and dysthymia, although paroxetine led to greater reductions than placebo. In home health care, PST was more effective than usual care in reducing symptoms of depression in undiagnosed patients. PST reduced disability more than ST in patients with major depression and executive dysfunction. Preliminary data suggest that a home-delivered adaptation of PST that includes environmental adaptations and caregiver involvement is efficacious in reducing disability in depressed patients with advanced cognitive impairment or early dementia. In patients with macular degeneration, PST led to improvement in vision-related disability comparable to that of ST, but PST led to greater improvement in measures of vision-related quality of life. Among stroke patients, PST participants were less likely to develop a major or minor depressive episode than those receiving placebo treatment, although the results were not sustained in a more conservative statistical analysis. Among patients with macular degeneration, PST participants had significantly lower 2-month incidence rates of major depression than usual care participants and were less likely to suffer persistent depression at 6 months. Finally, among stroke patients, PST participants were less likely to develop apathy than those receiving placebo treatment. PST also has been delivered via phone, Internet, and videophone, and there is evidence of feasibility and acceptability. Further, preliminary data indicate that PST delivered through the Internet resulted in a reduction in depression comparable with that of in-person PST in home-care patients. PST delivered via videophone results in an improvement in hospice caregivers' quality of life and a reduction in anxiety comparable to those of in-person PST. PST-treated patients with cognitive impairment may require additional compensatory strategies, such as written notes, memory devices, environmental adaptations, and caregiver involvement.

Introduction

Late-life depression worsens the outcomes of medical illnesses, promotes disability, increases expense, and complicates care by clouding the clinical picture and undermining treatment adherence, yet responds only modestly to pharmacotherapy [ 1 ]. Problem-solving therapy (PST) is a psychotherapy that has been used widely in psychiatry. Meta-analyses have highlighted the use of PST in a variety of conditions, including depressive disorders, conduct disorders, obesity, and substance abuse, across different populations (including children and young and older adults) and settings (including outpatient, home care, and primary care), and with different outcomes (including mental and physical health and quality of life) [ 2 , 3 ].

PST has two premises: 1) Finding the best possible solution to current everyday problems may reduce the experience of stress and improve peoples' lives, and 2) teaching people problem-solving skills will help them solve future problems. Because older adults experience many stressors in everyday life as a result of medical illnesses, losses, disability, and cognitive impairment, a hands-on approach using discrete and easily taught steps to solve problems is appealing and practical. PST includes the following steps: problem orientation, problem definition, generation of solutions (brainstorming), evaluations of solutions, selection of the best possible solution, and solution implementation and evaluation [ 4 , 5 ]. PST adaptations have been created for different groups of older adults (e.g., PST-ED for depressed patients with executive dysfunction and PATH for homebound depressed patients with advanced cognitive impairment) and settings (PST-PC [PST for primary care] and PST-HC [PST for home health care]).

In the past 5 years, an increasing number of articles utilizing PST for older adults has been reported ( Table 1 ). Our systematic review focuses on randomized clinical trials (RCTs) of PST in older adults, because RCTs are the state of the art for evidence-based practice and can provide class I and II levels of evidence. PST treatment studies focus on reducing depression and improving functioning and quality of life, whereas PST prevention studies concentrate on delaying the onset of major or minor depression.

CHS-PCF, Cardiovascular Health Study–Phenotypic Classification of Frailty; EN, exercise and nutrition program; MDD, major depressive disorder; NR, ; PATH, problem adaptation therapy; PBO, placebo; PST, problem-solving therapy; PST-HC, problem-solving therapy–home care; PST-PC, problem-solving therapy–primary care; RT, reminiscence therapy; ST, supportive therapy; ST-CI, supportive therapy for cognitively impaired older adults; TS, telephone support calls; UC, usual care; UC+E, usual care plus education; WLC, waiting-list condition.

Finally, ongoing clinical trials, not included in the current review, focus on using PST or adaptations of PST to a) reduce depression in low-income, homebound [ 6 ], medically ill older adults [ 7 , 8 ] and opiate abusers [ 9 ] or b) prevent the onset of depressive episodes in high-risk elders [ 10 ].

We searched PubMed (1966–2013), PsycNET (1840–2013), and Cochrane databases, emphasizing studies from the past 5 years. The searches were conducted using the following keywords: “problem solving therapy,” “PST,” “old*,” and “eld*” (the asterisk denotes any combination of the word). In addition, we selected appropriate studies from previously published meta-analyses and reviews. Inclusion criteria of studies were a) an RCT using problem-solving therapy [ 4 , 5 ], b) published in English, and c) with the average participant 60 years old or older. This review does not include interventions that included PST as only one aspect or step of the treatment (e.g., IMPACT, PEARL, or other stepped-cared programs), because PST was given in combination with other depression interventions and the relative effect of PST could not be determined. We identified 734 abstracts and potential articles through our searches, 15 of which were original RCTs that met our criteria; of those, 12 were published in the past 5 years (see Table 1 for the characteristics of the 15 RCTs). Two of 15 were prevention studies in patients with macular degeneration and stroke. The following treatment options are based mainly on results from the analyses of primary outcomes.

Diagnosed major depression

The results are based on four studies of PST [ 11• class I study, 12 – 14 ]. Two multisite studies [ 11• , 12 , 15 ] used a PST adaptation for depressed patients with executive dysfunction (PST-ED) and another study used a PST adaptation (PATH) for depressed patients with advanced cognitive impairment including dementia [ 14 ]. All studies used depression treatment as a control condition (reminiscence therapy [RT] [ 13 ]; supportive therapy [ST] [ 11• class I study, 12 , 14 ].

Despite the strong control condition, PST showed significantly greater reduction in depression post treatment. In one study [ 13 ], the benefits of group PST vs. group RT were maintained at 24 weeks.

Standard procedure

• PST-ED [ 11• class I study, 12 ]: 12 sessions in 12 weeks delivered by doctoral-level clinical psychologists and licensed social workers.
• Home-delivered PATH (problem adaptation therapy) [ 14 ]: 12 sessions in 12 weeks delivered by doctoral-level clinical psychologists and licensed social workers.
• PST [ 13 ]: 12 weekly group sessions delivered by advanced graduate students in clinical psychology.

Special points

• Depressed older adults with executive dysfunction: Participants in PST-ED had a significantly greater reduction in depression than participants in ST over 12 weeks in two multisite studies. Cohen's d ranged from 1.08 [ 12 ] to 0.48 [ 11• class I study]. However, Cohen's d for the 2003 study by Alexopoulos et al. [ 12 ] must be interpreted with caution because of the small sample size.
• Depressed older adults with advanced cognitive impairment: Participants in home-delivered PATH had a significantly greater reduction in depression than participants in home-delivered ST. Cohen's d was 0.77, but it also must be interpreted with caution considering the small sample size (N = 30) [ 14 ].
• Participants in group PST show a greater reduction in depression at 3 months (post treatment) than participants in group RT and those in the wait-list control condition. Estimated Cohen's d between PST vs. RT was 1.08.

Minor depression, dysthymia, or depression symptoms

The results are based on three studies of PST-PC [ 16• class I study] in minor depression or dysthymia and PST-HC [ 17 , 18 ] in depression in home-care patients. Compared with usual care, PST had a greater reduction in depression in home-care patients; however, compared with paroxetine or placebo, PST had a reduction in depression similar to that of paroxetine and placebo in patients with dysthymia and minor depression.

• PST-PC: Six sessions in 11 weeks delivered by doctoral-level psychologists, social workers, and counselors with master's degrees.
• PST-HC: Six sessions in 6 [ 18 ] or 8 weeks [ 17 ] delivered by master's-level social workers.
• PST-PC participants had a reduction in depression comparable to that of participants in the placebo or paroxetine group among patients with dysthymia or minor depression.
• Among home-care patients with subthreshold depression and cardiovascular disease, participants in PST-HC had a significantly greater reduction in depression than usual-care participants.
• Among home-care patients with significant depressive symptoms, participants in PST-HC had a greater reduction in depression and greater improvement in quality of life over the course of 6 months than usual-care participants.

Prevention of depression and apathy

The results are based on two studies of prevention in patients with macular degeneration ([ 19• ] and [ 20 ] used the same sample) and stroke patients ([ 21• ] and [ 22 ] used the same sample). In one study, the outcome was prevention of a major depressive episode [ 19• class I study, 20 ], whereas in the other, the outcome was prevention of a major or minor episode of depression [ 21• class I study] or prevention of onset of apathy [ 22 ].

Stroke patients participating in PST were less likely to develop a major or minor depressive episode than those in the placebo group. This difference became nonsignificant in a more conservative analysis, which assumed that baseline patients who did not continue the study would have developed depression. Among patients with macular degeneration, PST participants had significantly lower 2-month incidence rates of major depression than usual-care participants and were less likely to suffer persistent depression at 6 months. In a recent analysis of the study sample of Robinson et al. [ 21• ] of the subjects who did not exhibit apathy at baseline, escitalopram or PST was significantly more effective in preventing new onset of apathy following stroke compared with placebo [ 22 ].

• Patients with macular degeneration [ 19• class I study, 20 ]: six sessions in 8 weeks delivered by nurses and master's-level counselors.
• Stroke patients [ 21• class I study, 22 ]: six sessions in the first 12 weeks and six reinforcement sessions in the following 9 months.
• Stroke study [ 21• class I study]: placebo participants were 2.2 times more likely than PST participants and 4.5 times more likely than escitalopram participants to develop depression.
• Stroke study [ 22 ] (outcome: onset of apathy): placebo participants were 3.47 times more likely than escitalopram patients and 1.84 times more likely than PST patients to develop apathy.

Functioning, frailty, and quality of life

The results are based on three studies of PST [ 12 , 15 , 14 ]. Two multisite studies [ 12 , 15 ] used PST-ED; the other study used PATH for depressed patients with advanced cognitive impairment including dementia [ 14 ]. All studies used depression treatment as a control condition (ST) [ 12 , 14 , 15 ].

PST participants had significantly greater reduction in disability at 12 weeks than ST participants in all three studies. In one study [ 15 ], the benefits of PST vs. ST were sustained between 12 and 36 weeks.

• PST-ED [ 12 , 15 ]: 12 sessions in 12 weeks delivered by doctoral-level clinical psychologists and licensed social workers.
• Home-delivered PATH (problem adaptation therapy) [ 14 ]: 12 sessions in 12 weeks delivered by a doctoral-level clinical psychologist and licensed social worker.

Exploratory analyses revealed that disability mediated the effects of depression at the end of treatment (12 weeks).

Targeted vision function

The results are based on only one study of patients with age-related macular degeneration [ 23 ]. PST participants did not have greater improvement in vision function than ST participants in the primary outcome measure at 3 months (end of treatment) or 6 months but had greater improvement in the secondary outcome of vision-related quality of life [ 23 ].

• Six sessions in 12 weeks delivered by therapists with a bachelor's or master's degree.
• PST targeting functional problems of vision loss and reducing the difficulty of vision-dependent tasks did not show significant improvement over ST at 3 and 6 months after baseline [ 23 ].
• PST showed greater improvement in the secondary outcome of vision-related quality of life compared with ST.

The results are based on only one study of frail community older adults [ 24 ]. Participants receiving PST did not have significant improvement in any of the frailty measures: weight loss, exhaustion, low activity level, slowness, and weakness.

• Six sessions in 3 months delivered by trained case managers.

Quality of life

The results are based on one study [ 25 ] focusing on a group of outpatients who screened positive for psychological problems by the Chinese version of the Hospital Anxiety and Depression Scale. PST-PC participants had improvement in health-related quality of life comparable with that of placebo participants who watched health education videos.

• PST-PC: three sessions in 6 weeks delivered by primary care doctors.

Although participants in PST-PC had significant improvement in the role-emotional and mental components of the SF-36 Health-Related Quality of Life assessment at week 6, whereas the placebo group did not, a mixed-effects analysis accounting for potential covariates and baseline measures did not show any difference between the two groups in any outcome.

Alternative deliveries

• Older adults who are homebound or live in rural areas may need alternative ways to deliver PST, such as phone, videophone, or Internet.
• Special considerations are required for patients with hearing and vision problems as well as patients with cognitive impairment.

The results are based on three studies of PST delivered through telephone [ 26 ], videophone [ 27 ], or Skype [ 28 ]. The subjects for each study were cancer patients [ 26 ], hospice caregivers [ 27 ], and home-care patients with depression [ 28 ].

• Telephone: varied number of sessions (based on negotiation with the patient) in 3 months delivered by nurse counselors.
• Videophone: three sessions in 20 days.
• Skype: six weekly sessions.

Special Points

• Delivering PST through phone, videophone, and Internet is feasible and acceptable to vulnerable older adults.
• PST counseling delivered over the phone to cancer patients showed greater improvement in certain coping areas than usual care, but there were no significant differences in reduction of depression or improvement in psychosocial adjustment.
• Videophone-delivered PST showed improvement in caregiver quality of life and reduction in anxiety compared with in-person PST.
• PST delivered through Skype demonstrated results comparable with those of in-person PST in homebound older adults, and both PST conditions showed a greater reduction in depression compared with a condition of support calls [ 28 ]. Among patients in the sample, 67% had major depressive disorder, 29% had minor depression, and 4% had dysthymia.

Considerations

Length of treatment.

• Ten of 15 studies had between 6 and 12 PST sessions in 12 weeks.
• The two prevention studies had six sessions in 8 or 12 weeks, and one of them [ 21• , 22 ] had six additional sessions in the following 9 months.

Therapists and treatment fidelity

• Therapists included those with a bachelor's or master's degree in social science, master's-level social workers, nurse counselors, advanced graduate students in clinical psychology, and doctoral-level clinical psychologists.
• Reviews of recorded sessions and notes were performed in 9 of 15 studies.

Race, education, and socioeconomic status

• The majority of participants in most studies were older Caucasian adults with at least 12 years of education. Two studies were conducted in Hong Kong [ 25 ] and in Taiwan [ 24 ]. Future research will focus on racially diverse participants, as well as those with limited education and low socioeconomic status.

Cognitive impairment and dementia

• Older adults with cognitive impairment also may need compensatory strategies, including written session notes, memory devices, environmental adaptations, and caregiver participation, to help them with their cognitive deficits.

Acknowledgments

This paper was supported in part by grants from the National Institute of Mental Health (R01 MH075897, R01 MH076829, and P30 MH085943 [to George S. Alexopoulos] and R01 MH091045 [to Dimitris N. Kiosses]) and an Alzheimer's Association Investigator Initiated Research Grant (to Dimitris N. Kiosses).

George S. Alexopoulos has served as a consultant for Pfizer and Otsuka, has received grants from Forest Laboratories, and has received payment for lectures, including service on speakers bureaus, from AstraZeneca, Avanir Pharmaceuticals, Novartis, and Sunovion.

Compliance with Ethics Guidelines: Conflict of Interest : Dimitris N. Kiosses declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent : This article does not contain any studies with human or animal subjects performed by any of the authors.

Contributor Information

Dimitris N. Kiosses, Weill-Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.

George S. Alexopoulos, Weill-Cornell Institute of Geriatric Psychiatry, Weill Cornell Medical College.

Papers of particular interest have been highlighted as:

• Of importance