Depression is a common problem in primary care, with a prevalence of approximately 5 percent. Antidepressive medications and psychologic therapies are effective. In Britain, a problem-solving, therapeutic approach has been developed for use in the primary care setting. This technique includes six structured psychologic sessions conducted by physicians or nurses who have received training in this area. Mynors-Wallis and colleagues compared the efficacy of pharmacologic and problem-solving approaches in a randomized, controlled trial of the treatment of major depression in primary care.
Patients who were 18 to 65 years of age who presented to family physicians (between 1994 and 1996) with a depressive disorder that required treatment were included in the study. Inclusion criteria included scoring 13 or above on the 17-item Hamilton rating scale for depression, meeting the definition of probable or definite major depression on the research diagnostic criteria and having a duration of illness of at least four weeks. Exclusion criteria included taking antidepressants or undergoing psychologic therapy, drug or alcohol abuse, psychotic features, suicide risk or an additional psychiatric disorder before onset of depression. The patients were randomized to one of four treatment groups and stratified so that each group contained patients with an equivalent severity of symptoms. Of the 80 patients assigned to the two problem-solving groups, 39 patients were allocated to problem solving with a family physician and 41 patients were allocated to problem solving with a nurse. Of the 71 patients assigned to the antidepressant treatment groups, 36 were allocated to a medicine-only group and 35 were allocated to combination treatment with an antidepressant and problem-solving therapy. Patients in the combination therapy group attended six sessions for antidepressant treatment and six sessions for problem-solving therapy. Patients in the other three treatment groups attended six sessions (at weeks 1, 2, 3, 5, 7 and 11), but additional sessions could be offered if clinically indicated. Patients were referred back to their family physicians after 12 weeks. In the drug treatment groups, patients received an initial dosage of 100 mg of fluvoxamine or 20 mg of paroxetine. Fluvoxamine was the initial drug of choice for this study, but a change was made to paroxetine because of its more widespread use in primary care. Pill counts were used to monitor compliance. At weeks 6, 12 and 52, patients were assessed by independent reviewers using four standardized scales to measure aspects of depression and social functioning.
More than 70 percent (116) of the study participants completed the full course of treatment. Patients received medication for a mean duration of 10.7 weeks. Patients who were assigned to problem-solving treatment alone attended a mean number of 4.6 treatment sessions, and those assigned to the combination-therapy group attended a mean number of 5.2 treatment sessions. In all four treatment groups, recovery rates ranged from 51 to 67 percent of patients, with a partial recovery rate of 11 to 15 percent at week 12 of treatment. No statistically significant differences in outcome were demonstrated between the treatment groups. At week 52, recovery rates ranged from 56 to 66 percent and partial recovery rates ranged from 15 to 25 percent. No statistically significant differences were found between the treatment groups.
The authors conclude that problem-solving therapy is effective in the treatment of patients with depressive disorders. However, the study revealed no significant differences in efficacy between any of the four treatment modalities, both therapeutic approaches were effective and patients in all four groups sustained improvements at one year. A combination of antidepressant therapy and problem-solving instruction did not appear to be more effective than the antidepressant therapy alone. In the two problem-solving groups, no differences were evident between the physician-conducted sessions and the nurse-conducted sessions. The authors stress the importance of training primary care personnel in problem-solving techniques and advocate the continued development of briefer interventions for use in primary care.