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

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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 .

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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.

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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.
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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.

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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.

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Training residents in problem-solving treatment of depression: a pilot feasibility and impact study

Affiliation.

• 1 Department of Psychiatry, Dartmouth Medical School, Hanover, NH 03755, USA. [email protected]
• PMID: 14999578

Background and objectives: Primary care patients with depression may prefer or require a non-pharmacological treatment such as counseling. We investigated the feasibility of teaching family medicine residents an evidence-based brief counseling intervention for depression (Problem-solving Treatment of Depression for Primary Care [PST-PC]).

Methods: Eleven residents over 3 consecutive years were provided a brief training program in PST-PC. Residents were evaluated for skill acquisition, changes in self efficacy, intentions to improve their care for depression, and post-residency integration of PST-PC into their daily practice.

Results: Trainees met established criteria for competency to administer PST-PC. They improved to moderate-to-high levels of self efficacy for treating depression, including for their counseling skills, and in their intentions to improve their depression management. At up to 3 years post residency, 90% indicated they were using PST-PC, often in a modified form, and also for illnesses other than depression. They indicated they would recommend the training to new residents.

Conclusions: The PST-PC training program evaluated in this study is feasible in residency training and appears to influence practice post residency. These findings warrant continued investigation of this training program with a larger sample of residents and evaluation of outcomes with depressed patients treated with PST-PC in real-world practice settings.

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Wechsler individual achievement test.

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The Wechsler Individual Achievement Test-Third Edition (WIAT-III) is an individually administered clinical instrument developed by Pearson and designed to assess academic achievement. Academic achievement is defined as the ability to apply cognitive skills and learned knowledge to grade-level expectations. The results obtained from the administration of the WIAT-III can be utilized to identify academic achievement strengths and weaknesses, inform educational decisions, diagnose a learning disability, and design interventions.

According to the technical manual, the WIAT-III is designed to be administered to individuals aged 4–19 years (or prekindergarten through grade 12).

The WIAT-III consists of 16 subtests designed to evaluate reading, writing, mathematic, listening, and speaking skills. Specific subtests related to reading include early reading skills, word reading, pseudoword decoding, reading comprehension, and oral reading fluency. Specific subtests...

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Hill, A.K., Johnson, K.L. (2017). Wechsler Individual Achievement Test. In: Kreutzer, J., DeLuca, J., Caplan, B. (eds) Encyclopedia of Clinical Neuropsychology. Springer, Cham. https://doi.org/10.1007/978-3-319-56782-2_1499-2

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Wechsler Individual Achievement Test - 3rd (WIAT-III A&NZ)

The WIAT-III is an individual assessment of academic achievement for students from the age of 4 till 50 years 11 months. The WIAT-III encompasses a broad range of academic skills such as Reading, Writing, Mathematics and Oral Language. It evaluates these various aspects of academic achievement by having the child engage in a variety of tasks.  These tasks are divided into three scales, the Reading Scale, Mathematics Scale and Written Language Scale. Results are reported as Percentile Ranks (PR) and broad descriptors. PR represents where a child scored in comparison to children of the same age group, eg, a PR=50 means a child performed better than 50 of 100 students of the same age. Percentile ranks between 25 and 75 are in the average range.

Subtests of WIAT-III include:

Basic reading word reading, pseudoword decoding, maths problem solving, numerical operations, maths fluency, listening comprehension, oral expression, reading comprehension & fluency reading comprehension, oral reading fluency, early reading skills, alphabet writing fluency, essay composition subtest, sentence composition subtest.

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Step 4: Score Paragraphs. Score Paragraphs using the following rules: Count the number of paragraphs in the essay. Each paragraph = 1 point (max = 5 points). If there is only one block of text, it can be counted as 1 paragraph as long as it contains at least. 2 punctuation marks, each following a different statement.

If a WIAT-III assessment already exists for this examinee, while opening an existing assessment, the previously entered values are displayed. ... Word Count Raw Score (WC) 3-12. 0-9999. Essay Composition Theme Development and Text Organization (TDTO) Introduction. 3-12. 0-2. Conclusion. 3-12. 0-2. Paragraphs. 3-12. 0-5. Transitions. 3-12. 0-5.

Presented by: Gloria Maccow, PhDThis webinar focuses on one component of the WIAT-III: the Essay Composition. During the hour-and-a-half long webinar, the pr...

If correct ending punctuation follows the last word of a sentence, always mark a CWS after the word. IWS: An Incorrect Word Sequence is two adjacent words that do not qualify as a CWS. A dot ( ) is used to mark each IWS. CIWS = CWS - IWS: To calculate the CIWS score, sum CWS and IWS separately, and subtract IWS from CWS.

The Scoring Assistant is provided in every WIAT-III Canadian kit and is a fast and reliable tool for examiners using the WIAT-III. There are various reporting options available and a number of step-by-step tips for scoring written expression subtests right in the software. Scoring the WIAT-III by hand is possible however.

Word Count in Essay Composition. •Word Count is a measure of productivity, and has been shown to be a sensitive indicator of writing disorders. •The Word Count score was optional on the WIAT-II; however, it contributes to the subtest score on the WIAT-III. Assessing College Students for SLD Classification: Using WAIS-IV and WIAT-III ...

Additional Guidance on the use of the WIAT-III-UK (update Sept 2018) 1 Additional Guidance on use of the Wechsler Individual Achievement Test 3rd Ed UK ... • Word Count on Essay Composition may be calculated differently than on other tests (e.g. crossed-out words not counted) • Written Expression measures (e.g. Essay Composition, Sentence ...

Essay Composition Word Count 48 96 39 44 4 Average Theme Development and Text Organisation 5 97 42 46 5 Average Oral Expression ... Area of Achievement Weakness WIAT-III Oral Language: 78 Area of Processing Weakness WISC-V QRI: 88 Area of Processing Strength WISC-V VCI: 111 Comparison Relative Strength Score

WIAT-III Age Based Scores Subtest Score Summary Subtest Raw Score Standard Score 95% Confidence Interval Percentile Rank Normal Curve Equiv. Stanine Grade Equiv. Age Equiv. ... Essay Composition Word Count 79 111 77 65 7 Average Theme Development and Text Organization 4 95 37 43 4 Average Oral Expression

This webinar will focus on one component of the WIAT-III: the Essay Composition. During the hour-and-a-half long webinar, the presenter will describe and demonstrate the criteria used to score the essay. Participants will view sample essays to evaluate content and organization. Most of the session will be devoted to scoring criteria for theme ...

The WIAT-III may be scored via the scoring workbook or WIAT-III Scoring Assistant. The WIAT-III Scoring Assistant includes an interactive scoring guide for the essay composition subtest, performs all basic scoring conversions, provides a clinician score report, performs in-depth analysis of skills, provides a parent report, provides a pattern ...

WIAT®-IIIA&NZEssay Composition: "Quick Score" for Theme Development and Text Organisation. The following steps can be used to score most essays quickly and reliably. To ensure accurate scores, however, you must familiarise yourself with the Scoring Guide (in the online scoring platform or in appendix B.6 of the Examiner's Manual) prior ...

Essay Composition. Subtest component standard scores allow practitioners to evaluate differences in performance between components and to identify relative strengths and weaknesses. Reliability Coefficients. Tables 1-3 include the reliability coefficients of the subtest component scores for the fall, spring, and age samples, respectively.

The WIAT-III provides seven composite scores that may be considered independently or all together for a Total Achievement Score: The Composites, with their required grade specific subtests, are listed below: WIAT-III Composites and the Required Subtests to get Each According to Grade: 1. Oral Language Composite: Grade Pre-K- 12+

WIAT®-IIIUK Score Report ID: 54321 15/05/2017, Page 2 Susan Sample SAMPLE. 70 60 55 50 45 40 MFS AWF Note. SAMPLE 80 65 ... Essay Composition Word Count 48 106 66 58 6 Average Theme Development and Text Organisation 5 109 73 63 6 Average Oral Expression Expressive Vocabulary 7 95 37 43 4 Average

Misspelled Words (except names of people) or Word Endings • Item 1: Cats and doggs are pets. (1 error) • Item 2: The green frog jumpes. (1 error) Texting Language • Item 1: Btw cats and dogs are pets. (1 error) Word Boundary • Item 3: Mark has a sixyearold sister named Ann. (1 error) • Item 3: Mark has a six year old sis ter named Ann.

WIAT-III Q-global Word Card (Digital) A103000232440 Qualification Level B. Once ordered, the digital asset is accessible by logging into Q-global and visiting the Q-global Resource Library. ... Quick Score Guide for WIAT-III Essay Composition; Patterns of Strengths & Weaknesses Models for Identifying SLD (NASP 2010) WIAT-III Enhanced Content ...

The WIAT-III is an individual assessment of academic achievement for students from the age of 4 till 50 years 11 months. The WIAT-III encompasses a broad range of academic skills such as Reading, Writing, Mathematics and Oral Language. ... Essay Composition Subtest. Students in years AU 3-12+ / NZ 4-13+ are given 10 minutes to write an essay on ...

Supplemental Subtest Score Summary. * Indicates a raw score that is converted to a weighted raw score (not shown). The score is the same as or higher than the scores obtained by 50% of students in the normative sample; 50% of students in the normative sample scored higher than this score.

Composite scores from the WIAT-III A&NZ can also be compared to the WISC-V . The WIAT-IIIA&NZ is linked to the WISC-VA&NZ, not to the WISC-IV Australian. The composite score from the WIAT-II Australian Abbreviated does not exist in the current WIAT-IIIA&NZ. Q: Do parallel forms exist? A: No, there are no parallel forms for the WIAT-IIIA&NZ. Q ...

WIAT-III Subtests. Term. 1 / 14. Early Reading Skills. Click the card to flip 👆. Definition. 1 / 14. (for Prek-3rd grade) Measures basic skills necessary for reading, including sound awareness, naming of letters, letter-sound correspondence, and comprehension of words. Click the card to flip 👆.

SAMPLE REPORT. This student was recently administered theWechsler Individual Achievement Test-Fourth Edition(WIAT®-4). This test includes 20 subtests to measure listening, speaking, reading, writing, and mathematics skills. The following is a description of each subtest that was administered to this student.

Annual Goal. Given a list of ___ words containing (circle: initial/medial/final) position consonant digraphs, the student will identify the digraphs and read the list aloud with no more than ___ consonant digraph errors. Consonant digraphs will include the following (circle/enter): ch, sh, th, wh, ng, dg, gh, ____.

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