problem solving therapy primary care (pst pc)

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The Use of Problem-Solving Therapy for Primary Care to Enhance Complex Decision-Making in Healthy Community-Dwelling Older Adults

Christopher m nguyen, kuan-hua chen, natalie l denburg.

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Edited by: Federica Scarpina, Istituto Auxologico Italiano (IRCCS), Italy

Reviewed by: Tiago Bento, Instituto Universitário da Maia, Portugal; Guido Edoardo D’Aniello, Istituto Auxologico Italiano (IRCCS), Italy

*Correspondence: Christopher M. Nguyen, [email protected]

This article was submitted to Clinical and Health Psychology, a section of the journal Frontiers in Psychology

Received 2017 Oct 24; Accepted 2018 May 14; Collection date 2018.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Some older adults who are cognitively healthy have been found to make poor decisions. The vulnerability of such older adults has been postulated to be the result of disproportionate aging of the frontal lobes that contributes to a decline in executive functioning abilities among some older adults. The purpose of this study was to investigate whether decision-making performance in older adults can be enhanced by a psychoeducational intervention. Twenty cognitively and emotionally intact persons aged 65 years and older were recruited and randomized into two conditions: psychoeducational condition [Problem-Solving Therapy for Primary Care (PST-PC)] and no-treatment Control group. Participants in the psychoeducational condition each received four 45-min sessions of PST-PC across a 2-week period. The Iowa Gambling Task (IGT) was administered as the outcome measure to the treatment group, while participants in the Control group completed the IGT without intervention. A significant interaction effect was observed between group status and the trajectory of score differences across trials on the IGT. Particularly, as the task progressed to the last 20% of trials, participants in the PST-PC group significantly outperformed participants in the Control group in terms of making more advantageous decisions. These findings demonstrated that a four-session problem-solving therapy can reinforce aspects of executive functioning (that may have declined as a part of healthy aging), thereby enhancing complex decision-making in healthy older adults.

Keywords: aging, decision making, executive functioning, Iowa Gambling Task, Problem-Solving Therapy for Primary Care

Introduction

The ability of older adults to make sound decisions regarding retirement, allocation of resources, living arrangements, health insurance, and medical procedures has a profound effect on the well-being of the individual as well as society, cumulatively. Even older adults who are cognitively healthy, without a neurodegenerative disease or mild cognitive impairment, have been found to make poor decisions ( Denburg et al., 2007 ). Specifically, some older adults fail to make advantageous decisions and become susceptible to scams, make poor financial decisions, or experience abuse of trust and get taken advantage of by others. These forms of financial exploitation have been reported to increase dramatically among older adults ( Lichtenberg et al., 2015 ).

The weaknesses in decision-making capacity among older adults have been postulated to be triggered by a distinct neurological change: disproportionate age-related decline of the frontal lobes of the brain ( West, 1996 ). In particular, the frontal lobe hypothesis of cognitive aging posits that cognitive abilities dependent on the frontal regions of the brain would experience a disproportionate age-related decline, whereas other functioning independent of the frontal lobes will remain relatively intact ( West, 1996 ). This theory has gained support from multiple neuroscience disciplines, including neuropsychology, neuroanatomy, and functional neuroimaging (see review by, Reuter-Lorenz et al., 2016 ). The reasons why some older adults are vulnerable and susceptible to making poor decisions have been examined thoroughly through neurobiological and behavioral mechanisms, and research on applied contexts has been important to understanding day-to-day decisions ( Hess et al., 2015 ). Much of the current research on aging and decision making in applied domains has focused on the implication of decisions in various contexts such as medical decision-making ( Leventhal et al., 2015 ), health-related decisions ( Liu et al., 2015 ), and consumer decision-making ( Carpenter and Yoon, 2015 ). Yet, research efforts examining interventions to enhance older adults decision-making abilities are lacking.

Deficits in decision-making may be a function of weaknesses in executive functioning. Specifically, executive functions involve abilities such as planning, organization, goal setting, initiation, and utilization of feedback and attention shifting – all essential skills necessary in the process of decision-making. A review of the treatment modalities revealed that Problem-Solving Therapy for Primary Care (PST-PC; Hegel and Arean, 2003 ) is one treatment modality to have demonstrated efficacy in managing such executive dysfunction ( Alexopoulous et al., 2003 ).

Problem-Solving Therapy for Primary Care was developed as an efficient modality to treat patients in busy primary care settings over the course of 4–8 sessions. It has been found that as few as three sessions of PST-PC could be beneficial ( Mynors-Wallis et al., 2000 ; Hegel et al., 2004 ; Arean et al., 2008 ). Trained specialists can deliver PST-PC after undergoing a brief training module ( Hegel et al., 2004 ; Arean et al., 2008 ). Furthermore, PST-PC has been demonstrated to be as effective when implemented by nurses and primary care physicians as compared to implementation by mental health professionals ( Mynors-Wallis et al., 2000 ; Unutzer et al., 2002 ). When comparing PST-PC with antidepressants among depressed patients, PST-PC has been shown to be just as efficacious in improving psychological symptoms and social functioning ( Mynors-Wallis et al., 1995 ). Furthermore, the effectiveness of PST-PC has been evaluated in several randomized-controlled trials to treat various psychological problems including depression, anxiety, and insomnia ( Dowrick et al., 2000 ; Mynors-Wallis et al., 2000 ).

Problem-Solving Therapy for Primary Care has been demonstrated as an efficacious intervention to improve mood and cognitive functioning in elderly depressed patients ( Alexopoulous et al., 2003 ; Arean et al., 2008 , 2010 ). When compared with other treatment modalities such as cognitive-behavioral therapy and psychodynamic approaches, depressed older adults who were treated with PST-PC reported fewer depressive symptoms and improved functioning at 12 months and up to 24 months follow-up ( Arean et al., 2008 ). Elderly depressed patients receiving PST-PC treatments have exhibited reduction of symptoms, endorsed higher response rate to treatment, and greater remission rate when compared with those receiving a person-centered psychotherapy treatment approach ( Arean et al., 2010 ). Among depressed elderly patients with impairments in aspects of executive functioning, those receiving PST-PC treatments (versus supportive counseling) demonstrated greater improvement in generating alternative solutions and decision-making skills, in addition to reduced depressive symptoms and improved functioning ( Alexopoulous et al., 2003 ).

The purpose of this study was to investigate whether decision-making performance among healthy community-dwelling older adults can be improved by a brief four-session (approximately 2 weeks) problem-solving therapy modality. To our knowledge, this is one of the first studies to introduce a psychosocial intervention to enhance complex decision-making among healthy community-dwelling older adults in an outpatient context. PST-PC was specifically chosen due to its: 1) efficacy among older adults; 2) efficient protocol that can be delivered in four sessions (or in our case, about 2 weeks); and 3) effectiveness when implemented by trained individuals not in the field of mental health ( Arean, 2009 ). Morever, the cognitive changes associated with aging have demonstrated age-related effects in prefrontal brain structures contributing to weaknesses in aspects of executive functioning (e.g., planning, initiation, decision-making, and problem-solving), and thus the utilization of PST-PC as a possible compensatory strategy to address these deficits can be a valuable form of intervention. It was hypothesized that decision-making performance among healthy community-dwelling older adults would improve for those in the PST-PC condition when compared to participants in the no-treatment Control condition.

Materials and Methods

Participants.

Participants were included in the study if they were heathy, community-dwelling, aged 65 years and older, and cognitively and emotionally intact, and were excluded from the study if they had any major underlying medical conditions (e.g., cancer, cardiovascular disease, and movement disorder). Participants were recruited from a pool of participants involved in an ongoing project investigating the neural correlates of decision-making. These participants were evaluated extensively, with both clinical interview and comprehensive neuropsychological assessment, and thus were deemed cognitively and emotionally intact (after Tranel et al., 1997 ). Participants completed an informed consent process approved by an Institutional Review Board, and were financially compensated for their involvement. Twenty participants were randomly assigned to two groups: psychoeducational condition (PST-PC) and no-treatment Control group. The PST-PC group ( n = 10) had a mean age of 80.5 years [standard deviation (SD) = 3.5] and 50% males. The Control group ( n = 10) had a mean age of 80.0 years ( SD = 4.3) and 50% males.

All participants completed a 2-h comprehensive battery of neuropsychological tests to assess a broad range of cognitive abilities. A research assistant with training in neuropsychological assessment administered the test battery under the supervision of a neuropsychologist (NLD). Ten domains were assessed with the following administered instruments: general mental status (Folstein Mini-Mental State Examination; Folstein et al., 1975 ); estimated premorbid IQ (Wide Range Achievement Test-3; Wilkinson, 1993 ); verbal and non-verbal intellectual functioning (Wechsler Abbreviated Scale of Intelligence; Wechsler, 1999 ); attention and working memory (Wechsler Adult Intelligence Scale-III Working Memory Index; Wechsler, 1997 ); processing speed (Trail Making Test Part A; Spreen and Strauss, 1998 ); language (Controlled Oral Word Association Test; Benton and Hamsher, 1989 ); learning and memory [Rey Auditory Verbal Learning Test ( Rey, 1941 ) and Rey–Osterrieth Complex Figure Test ( Rey, 1964 )]; visuoperception (Benton Facial Discrimination Test; Benton et al., 1994 ); mental flexibility and set-shifting (Trail Making Test Part B; Spreen and Strauss, 1998 ); and mood (Beck Depression Inventory-II; Beck et al., 1996 ).

Participants randomized into the psychoeducational condition each completed four 45-min sessions of the PST-PC protocol during a 2-week period. A doctoral candidate in psychology (CMN) with training in cognitive-behavioral therapy delivered the PST-PC sessions following a manualized protocol to all participants under the supervision of a licensed clinical psychologist (NLD). Through a seven-step model of PST-PC ( Hegel and Arean, 2003 ), participants identified problems to be solved; discussed and evaluated different resolutions to reach desired goals; created action plans to accomplish determined goals; and evaluated their effectiveness in resolving designated problems. In the first session, the structure of the treatment process was outlined, and the seven stages of the problem-solving process were thoroughly discussed. In the second session, the participant selected one problem from the list generated in the first session to be resolved. The seven stages of PST-PC were integrated during the process of identifying the problem to be resolved and formation of the action plan. During the third session, participants evaluated the outcomes of their action plans. This session consisted of a discussion on how well they have integrated the seven stages of PST-PC toward the resolution of a designated problem to be resolved. If a participant successfully resolved the problem, a new problem was selected, and the process was discussed in the last session. If a participant was not successful in resolving a designated problem, the next session was used to further discuss progress or setbacks. The final session was used to review the participants’ progress and reinforce continued efforts in resolution of future problems ( Hegel and Arean, 2003 ).

All but one participant completed the PST-PC protocol at our clinic. For this one individual, the sessions were completed at their home due to limited mobility secondary to a recent orthopedic surgery. There was a 3- to 4-day interval between each of the four sessions. Participants were scheduled to complete the outcome measure within 3 days of completing the final PST-PC session. The participants from the Control group were recruited and scheduled to complete the outcome measure.

Manipulation Check

A manipulation check was applied to confirm that the seven stages of the PST-PC protocol was successfully implemented. At baseline and post-PST-PC sessions, participants were asked to respond to one open-ended essay-format question, as follows: “Please describe the process of problem-solving in detail, including all steps and the criteria for successfully completing each one.” All essays were scored using criteria designated in the 20-item Problem-Solving Treatment Knowledge Assessment (PST-KA; Cartreine et al., 2012 ), based on how well each essay discussed the stages of Problem-Solving Treatment (e.g., Identifying the Problem, Setting a Goal, Brainstorming Solutions, Selecting Solutions for Implementation, and Action Planning). Each item on the PST-KA was rated on a six-point scale (0–5; very poor to very good). The possible range of scores was 0–100, with higher scores indicating greater baseline knowledge/knowledge obtained (hereafter refered to as closure knowledge). Two research assistants who were blind to the time point of the completed essays completed the ratings. An average score was calculated across scores from the research assistants.

Decision-Making Outcome Measure

The Iowa Gambling Task (IGT; Bechara, 2007 ) is a measure of complex decision-making under ambiguity that features real-world aspects of reward, punishment, and unpredictability. The IGT is a computer-administered test comprised of 100 card selections from four decks of cards. On each trial, choosing a card gives an immediate monetary reward. At random points, the selection of some cards results in losing a sum of money. Two decks of cards are predetermined to offer a lower immediate gain and even lower long-term loss, yielding an overall net gain of money (i.e., referred to as “the good decks”). Alternatively, the other two decks are predetermined to offer a higher immediate gain but even higher long-term loss, yielding an overall net loss of money (i.e., referred to as “the bad decks”). Participants are not informed of the number of trials or the gain/loss patterns.

Performance on the IGT is often quantified by dividing the 100 trials into five distinct blocks of 20 trials each to examine participant’s learning curve ( Bechara, 2007 ). A score for each block is calculated by subtracting the number of selection from the good decks from the number of selections from the bad decks, while a total score for the IGT is calculated by subtracting the total number of selections from the bad decks from the total number of selections from the good deck. A positive total score indicates advantageous decision-making, whereas a negative total score indicates disadvantageous decision-making ( Bechara, 2007 ).

Statistical Analysis

Preliminary analysis examined the data for the presence of outliers. Independent samples t -tests were employed to examine differences between the participant groups on demographic variables, cognitive performance, and mood. Next, a paired-samples t -test was conducted to examine whether a mean difference existed in baseline and/or closure knowledge after four sessions of PST-PC. Finally, to explore the effects of PST-PC on the decision-making outcome measure, a 2x5 repeated measures analysis of variance (ANOVA) using group status (PST-PC versus Control) as the between-subjects factor and trial block (1–5) as the within-subjects factor was employed to evaluate performance on the IGT outcome measure by trial block.

The two participant groups did not significantly differ in terms of education, general mental status, estimated premorbid IQ, verbal and non-verbal intellectual functioning, attention and working memory, processing speed, language, learning and memory, visuoperception, mental flexibility and set-shifting, and mood. Demographic and cognitive characteristics are presented in Table 1 . A paired-samples t -test comparing pre- and post-intervention PST-KA scores of participants from the PST-PC group revealed a significant difference in the baseline knowledge assessment scores ( M = 22.0; SD = 13.3) as compared to the closure knowledge scores ( M = 38.8, SD = 19.6); t (9) = -2.3, p = 0.047. This implied that the seven stages of the PST-PC protocol was successfully implemented. A repeated measures ANOVA revealed a non-significant main effect for group on IGT scores, F (4,15) = 2.04, p = 0.097. Although there were no significant group differences with the overall IGT index, descriptive statistics revealed that four (of 10) participants in the Control group achieved an overall index in IGT scores that were below zero (range: -16 to -44), as compared to none from the PST group. Of note, IGT scores that were significantly below zero have been classified as an “Impaired” performance in past studies ( Denburg et al., 2005 ). A significant interaction effect was indicated between group status and the trajectory of score differences across the five trial blocks on the IGT, F (4,15) = 3.24, p = 0.017, which is indicative that group status had different effects on participant’s learning curve on the IGT trials, as presented in Figure 1 . To explore this interaction, contrasts were performed for individual trial blocks, revealing a statistically significant difference between the two groups in advantages versus disadvantageous selections on the last block of the IGT, t (18) = -3.02, p = 0.007, d = 1.35, 95% CI [-22, -4]. Particularly, as the task progressed to the end, participants in the PST-PC group significantly outperformed participants in the Control group in terms of making more advantageous decisions in the last 20% of trials (or card selections 81–100).

Demographic and cognitive characteristics.

Shown are Folstein Mini-Mental State Examination (MMSE); Wide Range Achievement Test-3 (WRAT-3) Reading subtest (in Standard Scores); Wechsler Abbreviated Scale of Intelligence (WASI) Verbal Comprehension Index (VCI) and Performance Reasoning Index (PRI) (in Standard Scores); Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) Working Memory Index (WMI) (in Standard Scores); Controlled Oral Word Association Test (COWAT); Rey Auditory Verbal Learning Test (RAVLT), Rey–Osterrieth Complex Figure (Rey-O); and Beck Depression Inventory-II (BDI-II).

Iowa Gambling Task scores by trail block for PST-PC and Control groups. Decision-making performance on the IGT in PST-PC and Control participants, graphed as a function of trial block [±SEM (standard error of the mean)]. A significant interaction effect was indicated between group status and the trajectory of score differences across the five trial blocks on the IGT, revealing a statistically significant difference between the two groups in advantageous versus disadvantageous selections on the last block of the IGT, or during the last 20% of selections.

The purpose of this study was to investigate whether decision-making performance among healthy community-dwelling older adults could be improved as a result of a well-validated psychoeducational intervention. Twenty participants were recruited and randomized into two conditions: PST-PC and a no-treatment Control group. The theoretical framework of this study is based on a body of literature suggesting that a disproportionate deterioration of the frontal lobes during aging contributes to a decline in executive functioning abilities among some older adults ( West, 1996 ). Previous work from our laboratory have supported this “frontal lobe hypothesis,” revealing that seemingly healthy older adults often make disadvantageous decisions ( Denburg et al., 2005 , 2006 , 2007 ). Specifically, we have found that some older adults may experience a greater decline in non-memory-related cognitive functioning, such as problem-solving and mental flexibility, contributing to weaknesses in their decision-making abilities ( Denburg and Hedgcock, 2015 ). The findings from the current study demonstrated that a four-session (approximately 2 weeks) problem-solving therapy can reinforce aspects of executive functioning (that may have declined as a part of healthy aging), thereby enhancing decision-making abilities.

With regard to decision-making outcomes, the proportion of our participants with “impaired” and “unimpaired” performance on the IGT from the Control group is comparable to findings from previous studies using this classification. Specifically, Denburg et al. (2005 , 2006 ) defined “impaired” performance on the IGT as being significantly worse than performance at chance level, and found that approximately 25–35% of their older adult sample performed in the “impaired” range. Additionally, this finding is consistent with another study suggesting that a subset of older adults make less advantageous decisions when compared to younger adults ( Fein et al., 2007 ).

Interestingly, earlier findings by Bechara et al. (1997) have indicated that by the 80th card selection (out of 100), normal healthy young adults would reach a “conceptual period” during which they exhibited knowledge regarding optimal choices based on prior feedback and typically avoid the disadvantage selections. Notably, as the task progressed to the latter 20% of the task, participants in the PST-PC group significantly outperformed participants in the Control group in terms of making more advantageous decisions. Group differences emerged as the IGT progressed such that those in the PST-PC group learned to adapt to feedback that led to making more advantageous decisions. Alternatively, participants without the benefit of the PST-PC psychoeducation treatment (i.e., the Control group) shifted between decks and were inefficient in developing a strategy over time which may have contributed to the overall less advantageous choices than participants in the PST-PC group.

It has been postulated that individuals exhibiting difficulty in developing an advantageous and stable strategy over time on the IGT is likely to be related to weaknesses in aspects of executive functioning ( Okdie et al., 2016 ). Furthermore, an inflexibility in responding to negative feedback after a disadvantageous decision has been postulated to be related to poor executive functioning, which results in an individual being less likely to adapt to the feedback to choose more advantageous options ( Zamarian et al., 2008 ). The findings from this study suggests that PST-PC may be effective in generating an efficient learning process that contributes to advantageous decision-making outcomes.

The components taught during the various PST-PC sessions provide an opportunity for the individual to broadly strengthen executive skills referenced by Lezak et al. (2012) , such as emotional regulation, behavioral initiation, planning, organization, cognitive flexibility, and problem-solving. A person with weaknesses in executive dysfunction can be overwhelmed with complex tasks and situations, which can be remediated during the initial stages of PST-PC through a structured approach to problem solving (e.g., breaking down complex problems into small and manageable parts). Cognitive flexibility is facilitated during the brainstorming stages of PST-PC, where individuals are encouraged to generate multiple solutions toward a satisfactory resolution of a problem. Aspects of executive functioning such as planning and organization are facilitated during the middle phases of PST-PC, where individuals evaluate and compare solutions generated during the brainstorming step to determine the best selection to be implemented. Behavioral initiation is fostered through the development of an action plan during the later steps of PST-PC. Overall, the process of implementing the stages of PST-PC requires abstract problem-solving with inductive reasoning and flexible adjustment of responses based on feedback, and may have contributed to improved decision-making outcomes.

A psychoeducational approach such as PST-PC can contribute to increased self-efficacy among older adults and improve decision-making abilities. To illustrate, it has been suggested that interventions can be more efficacious when integrating older adults’ strengths, such as their life experiences, to increase self-efficacy (e.g., positivity, confidence, and motivation) ( Strough et al., 2015 ). Furthermore, to improve their sense of self-efficacy, individuals must be engaged in an activation process that facilitates the examination of his/her knowledge, skills, and confidence with respect to the relevant topic requiring a decision to be made, and then formulating a concrete action plan to be implemented ( Hibbard and Mahoney, 2010 ). The latter stages of PST-PC evoked this process, when participants were asked to evaluate and compare solutions generated through brainstorming, and to determine the best selection to be implemented as an action plan. Furthermore, solicited feedback from the participants revealed that the psychoeducational component of PST-PC provided during the initial sessions solidified and enhanced preexisting knowledge and approaches to problem-solving (i.e., promoting self-efficacy from life experiences), in addition to providing a structured approach to facilitate a more efficient process for resolving practical everyday challenges.

This is one of the first studies to adapt PST-PC for use as an intervention to enhance decision-making in healthy community-dwelling older adults. By contrast, much of the extant literature in facilitation of advantageous decision-making outcomes relies extensively on the use of decision aids, or interventions designed to assist in the deliberation between treatment options by provided content-related information (e.g., health-related information when choosing between medical treatment options) ( Stacey et al., 2014 ). While these decision aids have been found to be effective in increasing knowledge and risk perception as well as contributing to a more well-informed decision-making process, few studies have explicitly examined its effectiveness among older adults ( van Weert et al., 2016 ). Incidentally, a majority of participants in this study readily identified a common health-related theme (e.g., weight loss, managing high cholesterol, improving sleep hygiene, and managing chronic pain) when asked to identify a problem to be applied during the PST-PC protocol. Perhaps this is suggestive that PST-PC can be utilize as a modality to facilitate more active participation (as compared to decision aids) among older adults in enhancing aspects of complex decision-making processes in the healthcare arena.

This study is not without its limitations. Participants in our study were highly educated (e.g., 70% with 16 years of education and above) for an older adult sample and performed in the high average range on measures of general intellectual functioning. By contrast, the 2015 Census data reported that only 27% of the population 65 years of age and older had earned a bachelor’s degree or more ( He et al., 2005 ). Finally, the present study had a relatively small sample size and was homogenous in terms of race (i.e., all participants were non-Hispanic, white). These issues may limit the generalizability of our findings. Another limitation of the study is the utilization of a single laboratory measure of decision making. While the IGT has been a well-validated measure to detect decision-making deficits ( Bechara, 2007 ), decision-making is complex and multifaceted, and undoubtedly difficult to measure fully with any laboratory task. Future studies should validate the efficacy of PST-PC in enhancing decision-making outcomes among older adults in other applied tasks such as the Multiple Errands test ( Tranel et al., 2007 ) or the Financial Decision-Making test ( Shivapour et al., 2012 ).

Ethics Statement

This study was carried out in accordance with the approval of University of Iowa Institutional Review Board with written informed consent from all subjects.

Author Contributions

CMN and NLD: study concept, design, analysis, data interpretation, manuscript writing, data verification, and analysis. K-HC: study design.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer GD and handling Editor declared their shared affiliation.

Funding. This study was funded by American Psychological Association Science Directorate’s Dissertation Research Award to CMN.

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Problem-Solving Treatment and Coping Styles in Primary Care Minor Depression

Thomas e oxman, mark t hegel, allen j dietrich.

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Correspondence concerning this article should be addressed to Thomas Oxman, Department of Psychiatry, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756. E-mail: [email protected]

Research was undertaken to compare Problem-Solving Treatment for Primary Care (PST-PC) to usual care (UC) for minor depression and examine whether treatment effectiveness was moderated by coping style. PST-PC is a six-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in two academic, primary care clinics. A total of 141 subjects were eligible and randomized, and 107 completed treatment (57 PST-PC, 50 UC) and a 35-week follow-up. Analysis using linear mixed modeling revealed significant effects of treatment and coping such that those in PST-PC improved at a faster rate, and those initially high in avoidant coping were significantly more likely to have sustained benefit from PST-PC.

Keywords: depression, psychotherapy, counseling, primary care, coping

INTRODUCTION

Minor depression, defined as relatively sustained depressed mood without the full syndrome that characterizes major depressive disorder, is one of the most common types of depressive disorders ( Beekman et al., 1995 ; Blazer, Hughes, & George, 1987 ). This is particularly true in primary care with rates of minor depression as much as four times greater than major depression ( Barrett, Barrett, Oxman, & Gerber, 1988 ; Broadhead, Blazer, George, & Tse, 1990 ; Jaffe, Froom, & Galambos, 1994 ; Williams, Kerber, Mulrow, Medina, & Aguilar, 1995 ). If persons are to be treated for minor depression, it is most likely to occur in the primary care setting ( Barrett et al., 1988 ; Garrard et al., 1998 ; Regier et al., 1993 ).

Despite the high prevalence and associated functional impairment, there is limited evidence that antidepressants are of clinically significant benefit to persons with minor depression ( Goldberg, Privett, Ustun, Simon, & Linden, 1998 ; Guy, Ban, & Schaffer, 1983 ; Linden et al., 1999 ; Paykel, Freeling, & Hollyman, 1988 ) (but see ( Judd et al., 2004 ). Similarly, for people with minor depression, there is limited evidence for the effectiveness of manual driven, structured psychotherapies such as cognitive-behavioral therapy (CBT) ( Cuijpers, van Straten, & Warmerdam, 2007 ; Oxman & Sengupta, 2002 ) or the most widely used psychosocial treatment in primary care, nonspecific “counseling” ( Orleans, George, Houpt, & Brodie, 1985 ; Robinson et al., 1995 ; Spitzer et al., 1995 ).

Problem Solving Treatment for Primary Care

Because minor depression is often a reaction to the multiple stresses and strains of life, coping interventions such as problem solving therapies would seem to be an ideal treatment. In recent meta-analyses, problem solving therapy, was superior to no treatment, treatment as usual, and attention placebo for treating major depressive disorder ( Cuijpers, van Straten et al., 2007 ; Malouff, Thorsteinsson, & Schutte, 2007 ). The problem solving treatment tested in the current study for minor depression is a brief variant of social problem solving therapy ( D’Zurilla & Nezu, 1999 ). It is a psychosocial skills training intervention originally designed and tested in the United Kingdom as a treatment for emotional distress in primary care ( Catalan, Gath, Bond, Day, & Hall, 1991 ). It has since been shown to be effective in treating major depression in primary care ( Mynors-Wallis, 2002 ; Mynors-Wallis, Gath, Lloyd-Thomas, & Tomlinson, 1995 ). During the past ten years the intervention has been adapted and elaborated for investigation in the United States ( Barrett et al., 2001 ; Unutzer et al., 2002 ; Williams et al., 2000 ). It has been coined Problem Solving Treatment for Primary Care or PST-PC. PST-PC consists of six sessions lasting 30 minutes each. PST-PC can be delivered by non-mental health professionals, such as nurses and social workers. In PST-PC the entire problem solving skill set is introduced in the first session and the skills are reinforced at each of the subsequent sessions.

Coping Styles and Depression

Given that PST-PC focuses on coping skills, it is reasonable to expect that its effectiveness may be moderated by individual differences in coping styles. Researchers have long noted an association between individual differences in coping styles and depressive symptomatology (e.g., ( Billings & Moos, 1984 ; Folkman & Lazarus, 1986 ). A recent comprehensive review of the literature identifies the three most frequent categories of coping style as problem-solving, avoidance, and seeking social support ( Skinner, Edge, Alman, & Sherwood, 2003 ). A meta-analysis of studies on the association of coping styles with physical and psychological health found that the largest effect size involved the negative association between avoidance and psychological health ( Penley, Tomaka, & Wiebe, 2002 ). With respect to depression, an avoidant coping style has regularly been shown to be associated with increased depression among adolescents ( Gomez & McLaren, 2006 ), young adults (e.g., ( Penland, Masten, Zelhart, Fournet, & Callahan, 2000 ), new mothers (e.g., ( Terry, Mayocchi, & Hynes, 1996 ), late middle-aged adults (e.g., ( Holahan, Moos, Holahan, Brennan, & Schutte, 2005 ) and the elderly (e.g., ( Mausbach et al., 2006 ). In addition, avoidant coping appears to interfere with spontaneous improvement in minor depression ( Hegel, Oxman, Hull, Swain, & Swick, 2006 ).

Given that PST-PC is focused on decreasing behavioral avoidance of problems ( Moorey, Holting, Hughes, Knynenberg, & Michael, 2001 ) by problem-focused engagement, the differential effectiveness of treatment may be qualified by individual differences in coping style. Specifically, PST-PC may train individuals to compensate for characteristics that they lack. In such a compensatory model, PST-PC should have the greatest effectiveness among individuals low in problem-focused coping and use of social support and/or high in avoidance. The purpose of the present research was to test the therapeutic effect of PST-PC compared to usual care for persistent minor depression in primary care and examine the extent to which its effectiveness is moderated by individual differences in coping styles.

Participants and Procedures

Participants came from two academic primary care clinics. The first was a general internal medicine clinic with 20 board-certified staff internists and over 16,000 patients age 18 or older. Patients in this clinic have a mean age of 53 and are 57% female. The second was a family medicine clinic with nine board-certified family physicians and over 5,500 patients. Patients in this clinic had a mean age of 42 and are 67% female. Patients were mailed or received in the primary care clinic waiting room a depression screen, the PHQ-9 ( Spitzer, Kroenke, & Williams, 1999 ), prior to an appointment with their primary care clinician (PCC). Patients could also be referred by their PCC based on the PCC’s clinical assessment of depression. For the period January 1, 2003 through May 31, 2006, 12,486 screens were administered. Of these 8,215 screens were returned (66%). Of these 2202 (27%) were positive (i.e., endorsed depressed mood or anhedonia as being present for at least some of the days in the past two weeks, ( Whooley, Avins, Miranda, & Browner, 1997 ). Among these 2,202, 402 (18%) provided their name and phone number consenting to be contacted about the study. During this same period 110 patients were referred directly by their PCC. Of the 512 patients referred in either manner, 283 (55%) were successfully contacted and agreed to be scheduled for a study evaluation and 227 completed the evaluation, 132 (58%) of whom were from screening and 95 (42%) from PCC referral (see Figure 1 ). The medical school’s Committee for the Protection of Human Subjects approved the study. A complete description of the study was provided to the patient, and written informed consent was obtained.

Figure 1. CONSORT flowchart.

PST-PC = problem-solving treatment for primary care; UC = usual care.

*Attending 4 or more sessions of PST-PC is considered adequate treatment ( Williams et al., 2000 ).

At their referral intake, subjects were evaluated by a research mental health clinician using a semi-structured interview to assess eligibility, a modified PRIME-MD ( Spitzer et al., 1994 ). Inclusion criteria were as follows: diagnosis of minor depression consisting of 2 to 4 DSM-IV symptoms of depression, one of which was depressed mood or anhedonia; presence of symptoms for at least two weeks but less than two years; impaired daily function; score ≥ 10 on the 17-item Hamilton Rating Scale for Depression (HAMD, Hamilton, 1967 ); age 18 or older. Exclusion criteria were as follows: major depressive disorder within previous six months; dysthymia; current antidepressant drug use; current treatment with a psychotherapist; major psychiatric co-morbidity (psychosis, bipolar affective disorder, PTSD, substance abuse within past six months; acute suicidal risk). 180 subjects met eligibility criteria and were entered into a four-week watchful waiting period.

The purpose of the watchful waiting phase was to identify patients with persistent minor depression. After four weeks, subjects were re-evaluated to see if they still met eligibility criteria, and if so were randomized. Randomization was stratified by gender and age group (18 to 59 and 60 and older). A randomization list for each strata was independently prepared by a statistician in blocks of four, consecutively assigned by a research assistant who kept the assessors blind to assignment. Subjects were re-evaluated for depressive symptoms at four, nine, and 35 weeks after randomization.

Interventions

PST-PC is a six-session intervention, which took place over a nine week period. The first PST-PC treatment session was one hour in length and included an assessment of the patient’s problems, an explanation of the rationale of treatment, establishing a positive problem orientation, and a complete problem solving treatment session. This initial problem solving treatment session consisted of taking the patient through six problem solving steps. First, a problem was clarified, evaluated for barriers to its resolution, and an objective problem definition was developed. Second, an achievable goal was developed that could be accomplished prior to the next treatment session. Importance was placed on the goal addressing the barriers identified in the previous step. Third, multiple solution alternatives were identified via brainstorming. Fourth, each solution was evaluated for its unique advantages (pros) as well as obstacles to its implementation (cons) and one or more solutions were chosen for implementation. Fifth, a specific plan of action was designed for implementing the solution prior to the subsequent visit. The second through sixth sessions were approximately 30 minutes in length. These sessions were entirely dedicated to implementing the PST-PC strategy for at least one problem area. Each of these sessions began by completing the sixth step of PST-PC that was to evaluate the implementation of the solution from the previous session. In keeping with the prototype for PST-PC developed in the UK, time was also spent discussing and planning regular pleasant activities (e.g., leisure, social, and recreational activities) to be completed between sessions.

Two masters level counselors were trained to provide PST-PC in a program consisting of a one-day workshop with demonstrations and role play, a comprehensive treatment manual ( Hegel & Arean, 2003 ), and five supervised training cases consisting of six sessions each. Each therapist was determined to have met basic competency criteria as defined by at least a “satisfactory” performance for each session of their last two training cases.

Patients randomized to UC had a visit scheduled with their PCC within four weeks. Patients were urged to discuss treatment options with their PCC. While the provision of a diagnosis to both patient and PCC and the scheduling of a follow-up appointment were a deviation from UC (necessitated by ethical and practical considerations), the intervention in other respects was to approximate routine physician practice in non-research circumstances. PCCs had the option of suggesting additional watchful waiting, prescribing antidepressants, and/or providing brief supportive counseling or external referral to specialty mental health.

Assessments took place at five time points: recruitment (“- 4 weeks”), end of watchful waiting / randomization (“week 0”), mid-treatment (“week 4”), end of treatment (“week 9”), and six-month follow-up (“week 35”). The following measures were used.

The Hamilton Rating Scale for Depression (HAM-D)

The 17-item HAM-D ( Hamilton, 1967 ) was used as an eligibility criterion for entry into watchful waiting and subsequently into the treatment study (HAM-D ≥ 10) ( Barrett et al., 2001 ; Williams et al., 2000 ). The items are rated during a clinical interview with a score range from 0 to 53. The HAM-D was administered at weeks -4, 0, 4, 9, 35.

Montgomery-Asberg Depression Rating Scale (MADRS)

The 10-item, observer-rated MADRS was used as the principle measure of improvement for these analyses. MADRS items are rated on a 0-to-6 severity scale, resulting in a total score range of 0 to 60. The MADRS is sensitive to treatment change ( Davidson, Turnbull, & Strickland, 1986 ; Montgomery & Asberg, 1979 ). The MADRS focuses primarily on psychic symptoms of depression. In medical patients this helps in distinguishing treatment effects on depression from comorbid medical symptoms ( McDowell, 1996 ). Also, the MADRS was not subject to being potentially confounded and limited in range by use as an eligibility criterion for entry into the RCT, as was the HAM-D. The MADRS was administered at weeks -4, 0, 4, 9, 35. A standardized coefficient alpha of .75 to .89 was observed over the course of the study.

Hopkins Symptom Checklist 20-item Depression Scale (HSCL-d-20)

The HSCL-d-20 was a secondary, self-report measure of depressive symptoms. This 20-item depression scale ( Katon et al., 1995 ) is derived from the 90-item HSCL ( Lipman, Covi, & Shapiro, 1979 ). Items are rated on a 5-point scale (0 to 4) according to how much the symptom has been experienced during the past week. Scale scores are determined by dividing the sum of the items by the total number of items, yielding a range of 0-4. The HSCL-d-20 was administered at weeks -4, 0, 4, 9, 35. A standardized coefficient alpha of .86 to .92 was observed over the course of the study.

The Brief COPE ( Carver, 1997 ), a shortened version of the original COPE ( Carver, Scheier, & Weintraub, 1989 ), has 28 self-report items that combine to form 14 subscales of coping reactions. Based on previous confirmatory factor analyses of the original COPE ( Tedlie, 1993 ), we were particularly interested in three subcomponents: problem focused coping (e.g., “I’ve been taking action to try to make the situation better”), using social support, and avoidant coping (e.g., “I’ve been giving up the attempt to cope”). A principal components analysis applied to earlier data provided additional support for this factor structure ( Hegel et al., 2006 ). Subscales were created for each of the theorized coping factors (Problem-focused Coping, six items, alpha = .79; Social Coping, four items, alpha = .82; Avoidant Coping, four items, alpha = .68). Items are rated on a 4-point scale (0-3) according to how much they pertain to the person. The Brief COPE was administered at weeks -4 and 35.

Medical Outcomes Short Form-36 (SF-36)

The SF-36 is a multidimensional measure of function developed by the RAND Corporation from the Health Insurance Experiment ( Wells et al., 1989 ). We selected the role emotional scale as the most specific descriptor of functional impairment from depression and one of the two standardized component summary measures (physical component score, PCS) of the SF-36 to measure functional impairment from medical conditions to control for this influence on depression outcomes. We did not use the mental health component summary measure because it includes depressive symptoms and, thus, is not an independent measure of function. The SF-36 was administered at weeks -4, 0, 9, and 35.

Problem Solving Treatment for Primary Care Adherence and Competence Scale (PST-PAC)

The PST-PAC was used as the measure of therapist fidelity to the PST-PC protocol. The PST-PAC was completed by the PST-PC trainer/supervisor based on audiotape review of treatment sessions. The PST-PAC is comprised of seven items scored on a 0 to 5 scale (0=very poor, 5=very good). Six items assess fidelity to technical skills, completing the six specific problem solving stages, with an internal consistency alpha from .83 to .89 and an average inter-rater agreement per item (defined as agreement on the rating plus or minus 1 point) of 86%. The seventh item is a global rating of the overall performance of the therapist taking into account patient and problem complexity ( Hegel, Dietrich, Seville, & Jordan, 2004 ).

Care as Usual Treatment (CUT)

The CUT is a 47-item self-report we constructed to collect information on the use of pharmacologic and psychotherapeutic interventions for depression during the treatment trial. The CUT was administered at weeks 0, 9, and 35. Because very few patients in PST-PC used outside treatment, the primary analytic purpose of the CUT was to assess the use of antidepressants or outside psychotherapy in usual care over the treatment trial. One dichotomous variable was the use or non-use of such therapies. A second variable was a four-point Likert scale, by blind rating, for the adequacy of the treatment based on additional questions in the CUT.

Statistical Analyses

We conducted bivariate analyses to compare demographic and clinical characteristics of PST-PC and UC patients at baseline and primary hypotheses regarding treatment and coping styles were tested by intention to treat analysis using a linear mixed model with five time periods. Because we assumed non-linearity over time, time was treated as a repeated factor. Treatment (PST-PC versus UC) was treated as a time-invariant factor and the three coping styles (Avoidant Coping, Problem-focused Coping, and Social Coping) were treated as time-invariant, continuous covariates. We assessed fixed effects for these variables and their interactions in a fully factorial design using SPSS Mixed with restricted maximum likelihood estimation. A variety of initial models that varied solely in their specification of the error variance-covariance matrix were compared using Schwarz’s Bayesian Information Criterion (BIC) as a parsimonious index of model fit in order to identify the most appropriate error structure to assume when testing our hypotheses. Following tests of our primary hypotheses regarding the effects of Time, Treatment, and Coping Styles, analyses were conducted that controlled for background variables (gender, age group, education, recruitment site, and marital status) as well as use of treatment (CUT) and physical functioning (SF-36 PCS). For recruitment purposes, a power analysis was based on an effect size from earlier work ( Williams et al., 2000 ). We estimated that a sample size of 136 and a clinically significant difference (e.g. a 25% difference in depression remission) would result in a power of 80% with alpha set at 0.05. Finally, a series of analyses were conducted to assess the clinical significance of observed change.

Sample Characteristics

A total of 167 subjects completed watchful waiting. Of these, 141 were still eligible and randomized, 72 to PST-PC and 69 to UC (see Figure 1 ). Baseline sociodemographic and clinical characteristics of both groups appear in Table 1 . The randomized group included a wide variation in duration of minor depression with a mean of almost one year, (50.84 ± 37.12 weeks) and a relatively high level of impairment (SF-36 role emotional = 41.37 ± 39.01). Consistent with the sociodemographics of the population served by the clinics, 54% had a college education, 68% had an income > $40,000, and there was little impairment from medical comorbidity (mean SF-36 PCS of 74.18 ± 23.70). There was a significant difference between the two treatment groups only in employment, with 10% more persons in the UC group employed and a trend for more comorbid panic disorder in the UC group.

Table 1. Baseline Sociodemographic and Clinical Characteristics.

Therapy characteristics.

Less than 30% of UC subjects received or accepted a prescription for antidepressants. No patients in PST-PC reported taking a prescription drug for antidepressants. Similarly, only 4 (5.8%) of subjects in UC and three (4.2%) of PST-PC subjects reported having one or more appointments with an outside mental health professional. Fifty-six of 69 (81.2%) UC subjects had at least one depression-related visit with their PCC.

Therapists were not unique to site. They alternated assignment of subjects randomized to PST-PC unless scheduling prevented a patient being seen initially within two weeks. Because of scheduling availability of the therapists and patients, therapist 1 had 10 subjects at the family medicine site and therapist 2 only had 3 subjects at the family medicine site. The therapists had equal numbers of patients at the general internal medicine site.

The independent evaluators were asked to guess randomization assignment. They correctly guessed for 48% of PST-PC assigned subjects and for 62% of UC assigned subjects (χ 2 =1.56, p=0.21, Kappa = 0.10). There was no difference in correct guessing between the two evaluators.

PST-PC sessions were audio recorded and a random selection of one-third of sessions (n=59) were analyzed for adherence. The therapists achieved an adequate mean (SD) score or better (≥ 3) on the technical skills of treatment: defining the problem 4.31 (±1.25), establishing realistic goals 4.39 (±1.31), generating solutions 4.20 (±1.34), choosing solutions 3.69 (±1.43), implementing solutions 4.25 (±1.55), and evaluating outcome 4.25 (±0.98). On the global measure of treatment quality a mean rating of 3.92 (±0.97) (good to very good) was achieved. Therapist 1 was rated significantly higher than therapist 2 on 5 of the 7 scales. However, There were no significant differences in MADRS or HSCL scores at any time point between therapists (p values ranging from a low of 0.237 for MADRS before randomization to 0.925 at week 9).

Of the 141 participants randomized to receive either PST-PC or UC, 107 completed treatment (PST-PC = 57/72; UC = 50/69; χ 2 = .86, n.s.). Completers were compared to noncompleters on all baseline and clinical characteristics that appear in Table 1 . Completers were younger, t(139) = -3.099, p = .002, had better physical functioning as measured by the SF-36 PCS, t(139) = 2.295, p = .023, and were less likely to be suffering from a panic disorder, χ 2 (1) = 12.01, p = .003, Fischer’s Exact Test.

For the primary analyses, the MADRS measure of depression was treated as a continuous variable assessed at five time points, with Time treated as a repeated factor, Treatment as a fixed factor, and each coping style as continuous covariates in a fully factorial linear mixed model. This analysis revealed a main effect of Time, F(4,166.279) = 101.367, p < .001, such that participants showed decreases in depression over the course of the study. In addition, there was a significant effect of Treatment, F(1,107.597) = 8.352, p < .01, such that patients receiving PST generally had lower levels of depression than those receiving UC (although this was not the case at Week 0). The Time by Treatment interaction approached conventional levels of significance, F(4,166.279) = 2.33, p = .058, such that individuals in the PST-PC group appeared to improve at a faster rate over the course of treatment and follow-up compared to those in UC. With respect to coping styles, there was a significant main effect of Avoidant Coping, F(1,105.464) = 9.163, p = .003, and a Time by Treatment by Avoidant Coping interaction, F(4,157.945) = 3.626, p = .007. The latter interaction is depicted in Figure 2 . 1 It can be seen in this figure that those high in Avoidance assigned to UC improved less than (a) those high in Avoidance assigned to PST and (b) those low in Avoidant Coping in either treatment group.

Figure 2. Depression as a function of Time, Treatment, and Avoidance Coping as assessed by Observer-Rating (MADRS).

Note. Avoidance coping is treated as a continuous measure. As a consequence, the plotted values do not represent means. Rather they represent constructed values for individuals one standard deviation above and below the mean in Avoidance. 1

In addition to these effects, there was a significant main effect of Problem-focused Coping, F(1,123.857) = 4.850, p = .029, and a Problem-focused Coping by Time interaction, F(4,164.840) = 2.580, p = .039. Although those high in Problem-focused Coping began treatment at a slightly lower level of depression, they improved at a slower rate over the course of the study. In addition, there was a three-way interaction of Problem-focused Coping, Social Coping, and Treatment, F(1,98.676) = 7.801, p = .006. High Problem-focused, high Social Coping individuals randomly assigned to Usual Care, and low Problem-focused, low Social Coping individuals randomly assigned to PST, started at Week 0 with lower levels of depression. Because this interaction involved Treatment but existed prior to treatment initiation (Week 0), and because it was non-significant at Weeks 4, 9, and 35 when Week 0 MADRS levels were covaried, it was attributed to the vagaries of random assignment.

These analyses were also conducted using the following covariates entered as a block: Marital status, Education level, Age, Gender, Physical functioning, Recruitment site, Use of other treatments, and Use of treatments by Time. This had the effect of rendering the interaction of Treatment and Time significant at conventional levels, F(4,164.369) = 3.354, p = .011. All seven of the other effects remained statistically significant. Of the demographic covariates in the final model, only Education, F(1,135.461) = 5.073, p = .026, achieved significance such that those with higher education were less depressed. A final covariance analysis conducted within the PST-PC treatment condition revealed that when Therapist was included as a covariate it was not statistically significant and did not alter the level of significance of any of the remaining effects.

A follow-up set of analyses were conducted in order to provide support for the interpretation of the Time by Treatment by Avoidant Coping interaction in terms of the ineffectiveness of UC among those high in Avoidant Coping. Given that both depression and Avoidant Coping were assessed as continuous variables, this interaction can be viewed in terms of variation in their intercorrelation as a function of the discrete variables of Time and Treatment. This variation is depicted in Figure 3 . Avoidant Coping (as measured four weeks prior to treatment onset) becomes more strongly associated with depression over the watchful waiting period (Week -4 to Week 0). This association then becomes weaker over the course of treatment (Week 0 to Week 9), particularly among those in PST-PC. Most strikingly, Avoidant Coping (again, as measured four weeks prior to treatment onset) is once again related to depression at the 35 week follow-up among those who had been assigned to UC, r(N=50) = .34, p = .016, but is unrelated to depression among those who had PST-PC, r(N=58) = -.05, p > .50. The size of the difference between the latter two correlations is statistically significant, z = 2.03, p = .042. This pattern supports an interpretation of the Time by Treatment by Avoidant Coping interaction in terms of the effectiveness of PST-PC relative to UC to break the association of dispositional Avoidant Coping and depression. Similar effects were not observed for Problem-Focused or Social Coping, whose correlations with depression did not achieve conventional levels of significance at any time-point.

Figure 3. Correlation of Avoidant Coping as measured at Week Minus 4 with Depression as a function of Time and Treatment.

*p < .05

As a secondary analysis, the HSCL-d-20 measure of depression was also treated as a continuous variable assessed at five time points, with Time treated as a repeated factor, Treatment as a fixed factor, and each coping style as continuous covariates in a fully factorial linear mixed model. These self-report results essentially replicated the observerrated MADRS results. There were main effects of Time, F(4,187.246) = 50.741, p < .001, Treatment, F(1,98.730) = 7.137, p < . 01, and Avoidant Coping, F(1,97.291) = 25.662, p < .001, although the main effect of Problem-focused Coping only approached conventional levels of significance, F(1,110.129) = 3.493, p = .064. Unlike the MADRS, the predicted Time by Treatment interaction achieved conventional levels of significance, F(4,187.246) = 3.903, p = .005, such that individuals in the PST-PC group improved at a faster rate over the course of treatment and follow-up compared to those in UC. In addition, although there was a significant Treatment by Avoidant Coping interaction, F(1,97.291) = 7.458, p = .007, with individuals high in Avoidance showing less improvement in UC than in PST-PC, this interaction was not qualified by Time. At the same time, univariate analyses conducted at each time period revealed that the two-way interaction of Treatment by Avoidance was only a significant interaction at the 4 week measurement period, F(1,96) = 6.548, p = .012. Although the three way interaction of Treatment, Social Coping, and Problem-focused Coping previously attributed to random assignment differences also appeared for the HSCL-d-20, F(1,93.127) = 9.327, p = .003, pre-random assignment differences diminished over the course of the study, thus yielding a four-way interaction with Time, F(4,176.823) = 3.532, p = .008. Finally, the Problem-focused Coping by Time interaction was not significant, F(4,183.487) < 1.00, n.s.

Clinical Significance

The clinical significance of treatment effects was assessed following the recommendations of Jacobson ( Jacobson, Roberts, Berns, & McGlinche, 1999 ; Jacobson & Truax, 1991 ). The results of a meta-analysis of control participants from ten studies was used to define the mean and standard deviation of the MADRS in the normal population ( Zimmerman, Chelminski, & Posternak, 2004 ). Given that our initial sample distribution overlapped the normal comparison group, clinically significant change in functioning subsequent to therapy was defined as an outcome MADRS score closer to the mean of the control group than the mean of the initial sample ( Jacobson & Truax, 1991 ). As a consequence, the criterion for clinically significant change was a MADRS score of 11.35. Of the four groups depicted in Figure 2 , only the high and low Avoidance individuals in the PST-PC group fell below this value (11.35) after 4 weeks of treatment. By the end of 9 weeks of treatment, low Avoidance individuals in the UC group also fell below this value. High Avoidance individuals in the UC group never achieved clinically significant improvement according to this criterion.

Jacobson and Truax ( Jacobson & Truax, 1991 ) also recommend using the Reliable Change Index to assess clinically significant change. Within the present sample, a reduction on the MADRS of 10.78 units would constitute clinically significant change according to this index. Relative to initial baselines, high Avoidance individuals in the UC group never achieve this criterion, whereas individuals in the other three groups achieve it after 9 weeks of treatment and maintain it through follow-up.

Although useful as a criterion to assess the clinical significance of change observed in the linear mixed model, the Reliable Change Index can also be used to define each individual as having achieved or not achieved clinically significant change relative to their own pretreatment baseline at each of the three measurement periods following treatment onset (Weeks 4, 9, and 35). These longitudinal, dichotomous data were analyzed using General Estimating Equations in a fully factorial design. Consistent with the previous analyses, this analysis yielded an interaction of Treatment and Avoidant Coping, Wald χ 2 (1) = 8.716, p = .003, such that participants high in avoidance were more likely to improve in PST than UC whereas this was not true for those low in avoidance. Predicted proportions for high and low avoidant individuals appear in Table 2 . There was also a main effect of Time, Wald χ 2 (2) = 17.808, p < .001, such that participants improved over time and a main effect of Problem-Focused Coping, Wald χ 2 (1) = 6.815, p < .01, such that those low in Problem-Focused Coping were more likely to improve than those high in Problem-Focused Coping. Finally, there was an interaction of social coping and time, Wald χ 2 (2) = 6.279, p = .04. Those high in Social Coping were more likely to improve early in treatment compared to those low in Social Coping.

Table 2. Predicted Proportion of Individuals with High and Low Avoidant Coping showing Clinically Significant Change.

Note. Avoidant coping is treated as a continuous measure. The table values represent recreated proportions for individuals one standard deviation above and below the mean in Avoidance. 1

Completer Analyses

All of the above intent-to-treat analyses were also conducted using repeated measures ANOVA. Because of its treatment of missing data, such an approach limits participants to those with complete data and hence all of those who completed treatment. These analyses replicated all of the essential findings of the intent-to-treat linear mixed model approach and provided stronger support for two previously observed near significant patterns. Thus, for the MADRS, the Time by Treatment interaction was significant, averaged F(3.49,61.09) = 2.522, p = .041, and for the HSCL-d-20, the Time by Treatment by Avoidance interaction was F(4,79) = 2.464, p = .052. 2

The duration of illness and associated impairment of this patient sample supports previous assertions that minor depression should be treated ( Cuijpers, Smit et al., 2007 ). This treatment trial suggests that a significant majority of primary care patients with persistent and relatively severe minor depression do not spontaneously improve during watchful waiting, but do improve once engaged in some form of active treatment. This treatment trial also found two significant and specific benefits for PST-PC.

First, those receiving PST-PC improved more quickly than those in UC. This effect approached significance for the uncorrected analyses of the MADRS (p = .058) and achieved significance for the covariate corrected intent-to-treat analyses and completer analyses of the MADRS and all three analyses of the HSCL-d-20. These findings are consistent with earlier work. In previous work comparing PST-PC with a placebo for minor depression in primary care, PST-PC also showed a more rapid improvement in symptoms, but not overall outcome, for adults age 60 and older ( Williams et al., 2000 ). In a smaller study of adults age 18 to 59 with minor depression, symptom improvement with PST-PC was slower than placebo or antidepressant during the first two weeks of treatment, but faster during the next nine weeks of treatment ( Barrett et al., 2001 ). At the end of treatment, overall symptom reduction was not significantly different. In these two earlier studies, patients in the medication or placebo interventions had more treatment visits than in the present study, yet PST-PC still showed faster symptom improvement over the course of the treatment trial. Together, these results suggest that there is something about PST-PC that improves symptoms at a faster rate and that it is not just due to the number of treatment contacts.

Second, patients relying on an avoidant coping style showed greater improvement with PST-PC than Usual Care. These differences persisted for at least six months following treatment. Similar results were observed when patients were categorized on clinically significant change in depression. These results support the hypothesized compensatory model for PST-PC. As in previous research, avoidant coping in general was more strongly related to depression than other coping styles. Taken together, these findings support the notion that PST-PC for minor depression may counteract a dispositional tendency to avoid dealing with problems, supporting the argument for matching treatment with individual characteristics ( Dussseldorp, Spinhoven, Bakker, van Dyck, & van Balkom, 2007 ; Karno & Longabaugh, 2007 ; Thieme, Turk, & Flor, 2007 ).

A meta-analysis of PST studies found a high level of heterogeneity for unclear reasons ( Cuijpers, van Straten et al., 2007 ). In earlier multisite trials ( Barrett et al., 2001 ; JW Williams et al., 2000 ) there were indications that there may have been site differences, either in patients or therapists. These studies did not assess and control for coping styles and therefore were not designed to detect their influence. The present trial was able to address the issue of patient differences and suggests that these differences are important.

Limitations

To some extent the results of this study are limited in their generalizability given the type of patients who chose to participate. Knowing this was a study of counseling, the sample was probably self-selected for desiring non-pharmacologic treatment. Also, the sample was primarily Caucasian, with higher income and education, potentially further limiting generalizability. A large number of patients with possible minor depression did not agree to further evaluation or participation. However, we suppose that those who did participate probably were motivated by more persistent and impairing minor depression and comorbidity and thus are the ones most likely in need of some form of active treatment.

In addition, it is possible that the differential effectiveness of treatment was to some degree a function of the imbalance in the number of PST-PC vs. UC treatment contacts. However, earlier work controlling for the number of sessions resulted in similar findings ( Williams et al., 2000 ). At the same time, it is hard to conceptualize how variation in the number of contacts would systematically affect only those with an avoidant coping style. Finally, it was observed that at alpha=.68, the reliability of the Avoidant Coping scale fell just short of the traditional .70 definition of an acceptable level of reliability. It should be kept in mind that alpha constitutes an estimated lower bound of scale reliability and that a lower alpha increases error and diminishes effect sizes rather than increasing them.

Conclusions

We feel that there are three important findings in the present study. First, all patients improved over time. The fact that marked improvement was not observed until the watchful waiting period was completed and treatment initiated, even for participants assigned to usual care, suggests that usual care interactions are relatively good at improving minor depression ( Carney, Dietrich, Eliassen, Owen, & Badger, 1999 ). Additional research needs to be conducted to identify factors responsible for such effects. Second, relative to Usual Care, PST-PC led to greater improvement over time, but third this effect was qualified by individual differences in avoidant coping style. Patients high in avoidance assigned to Usual Care showed the least improvement over time and this was generally true regardless of measure (MADRS or HSCL-d-20), analysis (linear mixed modeling of depression as a continuous variable vs. GEE analysis of dichotomous clinically significant change), and design (intent-to-treat analyses vs. completer analyses).

On the basis of these findings it is suggested that more careful diagnosis and treatment matching may be necessary in primary care. When a primary care patient with minor depression is interested in treatment, a PCC might consider asking questions about avoidant coping. For those patients who employ avoidant coping strategies such as denial or behavioral disengagement ( Carver, 1997 ; Carver et al., 1989 ), referral for a problem focused treatment may be more beneficial than standard primary care treatment.

Acknowledgments

This work was supported by grant R01 MH62322 from the National Institute of Mental Health.

We thank Cynthia Hewitt for her tireless efforts in coordinating most aspects of the study, Brady Cole, MA, and Dyan Patton, MSW, for their efforts as PST-PC therapists, Janette Seville, PhD, for her assistance as an independent evaluator, Angelica Barrett for help with recruitment and retention, and Jessica Magidson for assistance with preliminary data analyses.

Readers not familiar with the importance of adopting this approach to testing and depicting the effects of continuous predictors are referred to MacCallum, Shaobo, Preacher & Rucker (2002) and Aiken and West (1991) respectively.

Although there are no generally accepted estimates of effect sizes in linear mixed model analyses, corresponding adjusted η 2 values for the repeated measures analysis of variance conducted on the MADRS for completers were Time, η 2 = .76, Treatment, η 2 = .03, Time by Treatment, η 2 = .09, Avoidant coping, η 2 = .07, Time by Treatment by Avoidant coping, η 2 = .14, Problem-focused coping, η 2 = .02, Time by Problem-focused coping, η 2 = .11, and Problem-focused Coping by Social Coping by Treatment, η 2 = .07. Similar effect sizes were observed for the HSCL-d-20.

Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at http://www.apa.org/journals/ccp/

Contributor Information

Thomas E. Oxman, Departments of Psychiatry and of Community and Family Medicine, Dartmouth Medical School

Mark T. Hegel, Department of Psychiatry, Dartmouth Medical School

Jay G. Hull, Department of Psychological and Brain Sciences, Dartmouth College

Allen J. Dietrich, Departments of Community and Family Medicine and of Medicine, Dartmouth Medical School

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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.

Effectiveness of problem-solving therapy for older, primary care patients with depression: results from the IMPACT project

Affiliation.

• 1 University of California San Francisco, Department of Psychiatry, San Francisco, CA 94143, USA. [email protected]
• PMID: 18591356
• DOI: 10.1093/geront/48.3.311

Purpose: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia.

Design and methods: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in the treatment of 1,801 primary care patients, 60 years of age or older, with major depression or dysthymia. This study is a secondary data analysis (n = 433) of participants who received either PST-PC (by means of collaborative care) or community-based psychotherapy (by means of usual care).

Results: Older adults who received PST-PC had more depression-free days at both 12 and between 12 and 24 months (beta = 47.5, p <.001; beta = 47.0, p <.001), and they had fewer depressive symptoms and better functioning at 12 months (beta(dep) = -0.36, p <.001; beta(func) = -0.94, p <.001), than those who received community-based psychotherapy. We found no differences at 24 months.

Implications: Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression.

Publication types

• Comparative Study
• Multicenter Study
• Research Support, Non-U.S. Gov't
• Depression / psychology
• Depression / therapy*
• Educational Status
• Family Practice / methods*
• Follow-Up Studies
• Personal Satisfaction
• Problem Solving*
• Psychiatric Status Rating Scales
• Psychotherapy / methods*
• Time Factors
• Treatment Outcome