An important finding from this study is the lack of any significant difference between the four treatment groups. From this we drew two conclusions. Firstly, the combination of problem solving treatment and antidepressant medication is no more effective than either treatment alone. Secondly, there is no difference in outcome if the problem solving treatment is given by a suitably trained general practitioner or by a suitably trained practice nurse.
A second important finding is that patients in all groups showed a notable improvement over the 12 week treatment period. This improvement was maintained in all groups at the 52 week follow up. In the absence of a placebo group it is necessary to compare the proportion of patients recovered in this study with those in other studies. Detailed meta-analyses of the efficacy of treatments for depression in primary care were published by the depression guideline panel in the United States.14
In these analyses the percentage of patients with major depression who have recovered after 12 weeks of treatment are as follows: selective serotonin reuptake inhibitors 47%, behavioural therapy 55%, cognitive psychotherapy 47%, and combination therapies 35%-54%. In a previous study that evaluated the use of problem solving treatment for major depression in primary care, 27% of patients recovered in the placebo group.4
This study provides follow up data at 52 weeks, which is longer than most follow up periods for depressive disorder in primary care. The follow up was naturalistic, and general practitioners were free to provide whatever treatment was appropriate for their patients.Only about two thirds of patients overall were fully recovered at a year whatever treatment had been given. These results provide evidence that depressive disorders in primary care may be of lengthy duration even with appropriate treatment.
The nurses in this study were experienced problem solving therapists who had participated in a previous study that evaluated problem solving treatment. The general practitioners received theoretical training in problem solving treatment from an experienced therapist and then treated five patients under supervision before starting the trial. It may be that the results achieved by such a research team would be better than those in routine general practice.
When should problem solving treatment be given?
The results of this study provide further evidence that problem solving treatment is effective for the treatment of depressive disorders in primary care. An important clinical question needs to be answered: what is the place for problem solving treatment among other treatments for depressive disorders in primary care? How should the general practitioner choose between problem solving treatment and antidepressant medication or between problem solving treatment and alternative psychological treatments?
The provision of any psychological treatment depends on the availability of suitably trained therapists. Although problem solving is a simple treatment, therapists need both theoretical and practical training before they can be deemed competent in its delivery. At present most general practitioners do not have time to offer problem solving treatment themselves nor do they have access to a suitably trained therapist. If general practitioners are to have a meaningful alternative to antidepressant medication in the treatment of depressive disorders there will need to be an investment in the training of problem solving therapists. A training package for use by practice nurses has been evaluated.5
Patient preference is important; they should be willing to participate actively in a collaborative treatment process.
The severity of the depression is probably also important. In our experience, although some patients with quite severe depressive disorders can be successfully treated with problem solving treatment,15
it is more difficult to treat patients in whom poor concentration and lack of motivation are important components of their illness. Thus problem solving is probably more suitable for moderate depressive disorders than for the more severe illnesses.
Problem solving treatment is a goal orientated, collaborative, and active process and focuses on the here and now. Patients gain a clear sense of involvement in the process of recovery. Problem solving treatment is suitable for primary care because it is relatively brief and can be delivered by primary care nurses. The first challenge for the future is to provide training for interested practice nurses in delivering the treatment as evaluated. Secondly, a briefer adaptation of problem solving techniques that can be used by the general practitioners in their regular consultations needs to be evaluated.