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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

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

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

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

At a Glance

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

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

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

Key Components

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

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

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

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

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

Planful Problem-Solving

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

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

Other Techniques

Other techniques your therapist may go over include:

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

What Problem-Solving Therapy Can Help With

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

Mental Health Issues

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

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

Specific Life Challenges

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

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

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

Benefits of Problem-Solving Therapy

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

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

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

Other Types of Therapy

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

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

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

• Older adults
• People coping with serious illnesses like cancer

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

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

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

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

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

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

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

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

Keep In Mind

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

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

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

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

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

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

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

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

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

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

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

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

Problem Solving Treatment (PST)

Problem-Solving Treatment (PST) is a brief form of evidence-based treatment that was originally developed in Great Britain for use by medical professionals in primary care. It is also known as Problem-Solving Treatment – Primary Care (PST-PC). PST has been studied extensively in a wide range of settings and with a variety of providers and patient populations.

PST teaches and empowers patients to solve the here-and-now problems contributing to their depression and helps increase self-efficacy. It typically involves six to ten sessions, depending on the patient’s needs. The first appointment is approximately one hour long because, in addition to the first PST session, it includes an introduction to PST techniques. Subsequent appointments are 30 minutes long.

PST is not indicated as a primary treatment for: substance abuse/dependence, acute primary post-traumatic stress disorder, panic disorder, new onset bipolar disorder, new onset psychosis.

Learn more about how to get trained in PST on this page .

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Problem-Solving Therapy: How It Works & What to Expect

Author: Lydia Antonatos, LMHC

Lydia Angelica Antonatos LMHC

Lydia has over 16 years of experience and specializes in mood disorders, anxiety, and more. She offers personalized, solution-focused therapy to empower clients on their journey to well-being.

Problem-solving therapy (PST) is an intervention with cognitive and behavioral influences used to assist individuals in managing life problems. Therapists help clients learn effective skills to address their issues directly and make positive changes. PST is used in various settings to address mental health concerns such as depression, anxiety, and more.

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What Is Problem-Solving Therapy?

Problem-solving therapy (PST) is based on a model that the body, mind, and environment all interact with each other and that life stress can interact with a person’s predisposition for developing a mental condition. 2 Within this context, PST contends that mental, emotional, and behavioral struggles stem from an ongoing inability to solve problems or deal with everyday stressors. Therefore, the key to preventing health consequences and improving quality of life is to become a better problem-solver. 3 , 4

The problem-solving model has undergone several revisions but upholds the value of teaching people to become better problem-solvers. Overall, the goal of PST is to provide individuals with a set of rational problem-solving tools to reduce the impact of stress on their well-being.

The two main components of problem-solving therapy include: 3 , 4

• Problem-solving orientation: This focuses on helping individuals adopt an optimistic outlook and see problems as opportunities to learn from, allowing them to believe they can solve problems.
• Problem-solving style: This component aims to provide people with constructive problem-solving tools to deal with different life stressors by identifying the problem, generating/brainstorming solution ideas, choosing a specific option, and implementing and reviewing it.

Techniques Used in Problem-Solving Therapy

PST emphasizes the client, and the techniques used are merely conduits that facilitate the problem-solving learning process. Generally, the individual, in collaboration and support from the clinician, leads the problem-solving work. Thus, a strong therapeutic alliance sets the foundation for encouraging clients to apply these skills outside therapy sessions. 4

Here are some of the most relevant guidelines and techniques used in problem-solving therapy:

Creating Collaboration

As with other psychotherapies, creating a collaborative environment and a healthy therapist-client relationship is essential in PST. The role of a therapist is to cultivate this bond by conveying a genuine sense of commitment to the client while displaying kindness, using active listening skills, and providing support. The purpose is to build a meaningful balance between being an active and directive clinician while delivering a feeling of optimism to encourage the client’s participation.

This tool is used in all psychotherapies and is just as essential in PST. Assessment seeks to gather facts and information about current problems and contributing stressors and evaluates a client’s appropriateness for PST. The problem-solving therapy assessment also examines a person’s immediate issues, problem-solving attitudes, and abilities, including their strengths and limitations. This sets the groundwork for developing an individualized problem-solving plan.

Psychoeducation

Psychoeducation is an integral component of problem-solving therapy and is used throughout treatment. The purpose of psychoeducation is to provide a client with the rationale for problem-solving therapy, including an explanation for each step involved in the treatment plan. Moreover, the individual is educated about mental health symptoms and taught solution-oriented strategies and communication skills.

This technique involves verbal prompting, like asking leading questions, giving suggestions, and providing guidance. For example, the therapist may prompt a client to brainstorm or consider alternatives, or they may ask about times when a certain skill was used to solve a problem during a difficult situation. Coaching can be beneficial when clients struggle with eliciting solutions on their own.

Shaping intervention refers to teaching new skills and building on them as the person gradually improves the quality of each skill. Shaping works by reinforcing the desired problem-solving behavior and adding perspective as the individual gets closer to their intended goal.

In problem-solving therapy, modeling is a method in which a person learns by observing. It can include written/verbal problem-solving illustrations or demonstrations performed by the clinician in hypothetical or real-life situations. A client can learn effective problem-solving skills via role-play exercises, live demonstrations, or short-film presentations. This allows individuals to imitate observed problem-solving skills in their own lives and apply them to specific problems.

Rehearsal & Practice

These techniques provide opportunities to practice problem-solving exercises and engage in homework assignments. This may involve role-playing during therapy sessions, practicing with real-life issues, or imaginary rehearsal where individuals visualize themselves carrying out a solution. Furthermore, homework exercises are an important aspect when learning a new skill. Ongoing practice is strongly encouraged throughout treatment so a client can effectively use these techniques when faced with a problem.

Positive Reinforcement & Feedback

The therapist’s task in this intervention is to provide support and encouragement for efforts to apply various problem-solving skills. The goal is for the client to continue using more adaptive behaviors, even if they do not get it right the first time. Then, the therapist provides feedback so the client can explore barriers encountered and generate alternate solutions by weighing the pros and cons to continue working toward a specific goal.

Use of Analogies & Metaphors

When appropriate, analogies and metaphors can be useful in providing the client with a clearer vision or a better understanding of specific concepts. For example, the therapist may use diverse skills or points of reference (e.g., cooking, driving, sports) to explain the problem-solving process and find solutions to convey that time and practice are required before mastering a particular skill.

What Can Problem-Solving Therapy Help With?

Although problem-solving therapy was initially developed to treat depression among primary care patients, PST has expanded to address or rehabilitate other psychological problems, including anxiety , post-traumatic stress disorder , personality disorders , and more.

PST theory asserts that vulnerable populations can benefit from receiving constructive problem-solving tools in a therapeutic relationship to increase resiliency and prevent emotional setbacks or behaviors with destructive results like suicide. It is worth noting that in severe psychiatric cases, PST can be effectively used when integrated with other mental health interventions. 3 , 4

PST can help individuals challenged with specific issues who have difficulty finding solutions or ways to cope. These issues can involve a wide range of incidents, such as the death of a loved one, divorce, stress related to a chronic medical diagnosis, financial stress , marital difficulties, or tension at work.

Through the problem-solving approach, mental and emotional distress can be reduced by helping individuals break down problems into smaller pieces that are easier to manage and cope with. However, this can only occur as long the person being treated is open to learning and able to value the therapeutic process. 3 , 4

Lastly, a large body of evidence has indicated that PST can positively impact mental health, quality of life, and problem-solving skills in older adults. PST is an approach that can be implemented by different types of practitioners and settings (in-home care services, telemedicine, etc.), making mental health treatment accessible to the elderly population who often face age-related barriers and comorbid health issues. 1 , 5, 6

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Problem-Solving Therapy Examples

Due to the versatility of problem-solving therapy, PST can be used in different forms, settings, and formats. Following are some examples where the problem-solving therapeutic approach can be used effectively. 4

People who suffer from depression often evade or even attempt to ignore their problems because of their state of mind and symptoms. PST incorporates techniques that encourage individuals to adopt a positive outlook on issues and motivate individuals to tap into their coping resources and apply healthy problem-solving skills. Through psychoeducation, individuals can learn to identify and understand their emotions influence problems. Employing rehearsal exercises, someone can practice adaptive responses to problematic situations. Once the depressed person begins to solve problems, symptoms are reduced, and mood is improved.

The Veterans Health Administration presently employs problem-solving therapy as a preventive approach in numerous medical centers across the United States. These programs aim to help veterans adjust to civilian life by teaching them how to apply different problem-solving strategies to difficult situations. The ultimate objective is that such individuals are at a lower risk of experiencing mental health issues and consequently need less medical and/or psychiatric care.

Psychiatric Patients

PST is considered highly effective and strongly recommended for individuals with psychiatric conditions. These individuals often struggle with problems of daily living and stressors they feel unable to overcome. These unsolved problems are both the triggering and sustaining reasons for their mental health-related troubles. Therefore, a problem-solving approach can be vital for the treatment of people with psychological issues.

Adherence to Other Treatments

Problem-solving therapy can also be applied to clients undergoing another mental or physical health treatment. In such cases, PST strategies can be used to motivate individuals to stay committed to their treatment plan by discussing the benefits of doing so. PST interventions can also be utilized to assist patients in overcoming emotional distress and other barriers that can interfere with successful compliance and treatment participation.

Benefits of Problem-Solving Therapy

PST is versatile, treating a wide range of problems and conditions, and can be effectively delivered to various populations in different forms and settings—self-help manuals, individual or group therapy, online materials, home-based or primary care settings, as well as inpatient or outpatient treatment.

Here are some of the benefits you can gain from problem-solving therapy:

• Gain a sense of control over your life
• Move toward action-oriented behaviors instead of avoiding your problems
• Gain self-confidence as you improve the ability to make better decisions
• Develop patience by learning that successful problem-solving is a process that requires time and effort
• Feel a sense of empowerment as you solve your problems independently
• Increase your ability to recognize and manage stressful emotions and situations
• Learn to focus on the problems that have a solution and let go of the ones that don’t
• Identify barriers that may hinder your progress

How to Find a Therapist Who Practices Problem-Solving Therapy

Finding a therapist skilled in problem-solving therapy is not any different from finding any qualified mental health professional. This is because many clinicians often have knowledge in cognitive-behavioral interventions that hold similar concepts as PST.

As a general recommendation, check your health insurance provider lists, use an online therapist directory , or ask trusted friends and family if they can recommend a provider. Contact any of these providers and ask questions to determine who is more compatible with your needs. 3 , 4

Are There Special Certifications to Provide PST?

Therapists do not need special certifications to practice problem-solving therapy, but some organizations can provide special training. Problem-solving therapy can be delivered by various healthcare professionals such as psychologists, psychiatrists, physicians, mental health counselors, social workers, and nurses.

Most of these clinicians have naturally acquired valuable problem-solving abilities throughout their career and continuing education. Thus, all that may be required is fine-tuning their skills and familiarity with the current and relevant PST literature. A reasonable amount of understanding and planning will transmit competence and help clients gain insight into the causes that led them to their current situation. 3 , 4

Questions to Ask a Therapist When Considering Problem-Solving Therapy

Psychotherapy is most successful when you feel comfortable and have a collaborative relationship with your therapist. Asking specific questions can simplify choosing a clinician who is right for you. Consider making a list of questions to help you with this task.

Here are some key questions to ask before starting PST:

• Is problem-solving therapy suitable for the struggles I am dealing with?
• Can you tell me about your professional experience with providing problem-solving therapy?
• Have you dealt with other clients who present with similar issues as mine?
• Have you worked with individuals of similar cultural backgrounds as me?
• How do you structure your PST sessions and treatment timeline?
• How long do PST sessions last?
• How many sessions will I need?
• What expectations should I have in working with you from a problem-solving therapeutic stance?
• What expectations are required from me throughout treatment?
• Does my insurance cover PST? If not, what are your fees?
• What is your cancellation policy?

How Much Does Problem-Solving Therapy Cost?

The cost of problem-solving therapy can range from $25 to $150 depending on the number of sessions required, severity of symptoms, type of practice, geographic location, and provider’s experience level. However, if your insurance provider covers behavioral health, the out-of-pocket costs per session may be much lower. Medicare supports PST through professionally trained general health practitioners. 1

What to Expect at Your First PST Session

During the first session, the therapist will strive to build a connection and become familiar with you. You will be assessed through a clinical interview and/or questionnaires. During this process, the therapist will gather your background information, inquire about how you approach life problems, how you typically resolve them, and if problem-solving therapy is a suitable treatment for you. 3 , 4

Additionally, you will be provided psychoeducation relating to your symptoms, the problem-solving method and its effectiveness, and your treatment goals. The clinician will likely guide you through generating a list of the current problems you are experiencing, selecting one to focus on, and identifying concrete steps necessary for effective problem-solving. Lastly, you will be informed about the content, duration, costs, and number of therapy sessions the therapist suggests. 3 , 4

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Is Problem-Solving Therapy Effective?

Extensive research and studies have shown the efficacy of problem-solving therapy. PST can yield significant improvements within a short amount of time. PST is also useful for addressing numerous problems and psychological issues. Lastly, PST has shown its efficacy with different populations and age groups.

One meta-analysis of PST for depression concluded that problem-solving therapy was as efficient for reducing symptoms of depression as other types of psychotherapies and antidepressant medication. Furthermore, PST was significantly more effective than not receiving any treatment. 7 However, more investigation may be necessary about PST’s long-term efficacy in comparison to other treatments. 5,6

How Is PST Different From CBT & SFT?

Problem-solving, cognitive-behavioral, and solution-focused therapy belong to the cognitive-behavioral framework, sharing a common goal to modify thoughts, aptitudes, and behaviors to improve mental health and quality of life.

Problem-Solving Therapy Vs. Cognitive-Behavioral Therapy

Cognitive behavioral therapy (CBT) is a short-term psychosocial treatment developed under the premise that how we think affects how we feel and behave. CBT addresses problems arising from maladaptive thought patterns and seeks to challenge and modify these to improve behavioral responses and overall well-being. CBT is the most researched approach and preferred treatment in psychotherapy due to its effectiveness in addressing various problems like anxiety, sleep disorders, substance abuse, and more.

Like CBT, PST addresses mental, emotional, and behavioral issues. However, PST may provide a better balance of cognitive and behavioral elements.

Another difference between these two approaches is that PST mostly focuses on faulty thoughts about problem-solving orientation and modifying maladaptive behaviors that specifically interfere with effective problem-solving. Usually, PST is used as an integrated approach and applied as one of several other interventions in CBT psychotherapy sessions.

Problem-Solving Therapy Vs. Solution-Focused Therapy

Solution-focused therapy (SFT) , like PST, is a goal-directed, evidence-based brief therapeutic approach that encourages optimism, options, and self-efficacy. Similarly, it is also grounded on cognitive behavioral principles. However, it differs from problem-solving therapy because SFT is a semi-structured approach that does not follow a step-by-step sequential format. 8

SFT mainly focuses on solution-building rather than problem-solving, specifically looking at a person’s strengths and previous successes. SFT helps people recognize how their lives would differ without problems by exploring their current coping skills. Community mental health, inpatient settings, and educational environments are increasing the use of SFT due to its demonstrated efficacy. 8

Final Thoughts

Problem-solving therapy can be an effective treatment for various mental health concerns. If you are considering treatment, ask your doctor for recommendations or conduct your own research to learn more about this approach and other options available.

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For Further Reading

• 12 Strategies to Stop Using Unhealthy Coping Mechanisms
• Depression Therapy: 4 Effective Options to Consider
• CBT for Depression: How It Works, Examples, & Effectiveness

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Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy .

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Mehmet Eskin. (2013). Problem solving therapy in the clinical practice . Elsevier.

Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-Solving Therapy A Treatment Manual . Springer Publishing Company.

Cuijpers, P., et al. (2018). Problem-solving therapy for adult depression: An updated meta-analysis. European Psychiatry   48 , 27–37. https://doi.org/10.1016/j.eurpsy.2017.11.006

Kirkham, J. G., Choi, N., & Seitz, D. P. (2015). Meta-analysis of problem-solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry , 31 (5), 526–535. https://doi.org/10.1002/gps.4358

Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review , 29 (4), 348–353. https://doi.org/10.1016/j.cpr.2009.02.003

Proudlock, S. (2017). The Solution Focused Way Incorporating Solution Focused Therapy Tools and Techniques into Your Everyday Work . Routledge.

Nezu, A. M., Nezu, C. M., & Gerber, H. R. (2019). (Emotion‐centered) problem‐solving therapy: An update. Australian Psychologist , 54 (5), 361–371. https://doi.org/10.1111/ap.12418

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10 Best Problem-Solving Therapy Worksheets & Activities

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

• Social problem-solving
• The problem
• The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

• Stressful life events
• Emotional distress and wellbeing
• Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

• Enhance positive problem orientation
• Decrease negative orientation
• Foster ability to apply rational problem-solving skills
• Reduce the tendency to avoid problem-solving
• Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

• Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
• Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
• Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
• Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
• Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
• Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
• Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
• Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
• Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
• Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
• Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
• Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
• Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
• Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

• Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
• Is PST acceptable to the client?
• Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

• Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
• Define Obtain all required facts and details of potential obstacles to define the problem.
• Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
• Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
• Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

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Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

• I can solve this problem; I’ve tackled similar ones before.
• I can cope with this.
• I just need to take a breath and relax.
• Once I start, it will be easier.
• It’s okay to look out for myself.
• I can get help if needed.
• Other people feel the same way I do.
• I’ll take one piece of the problem at a time.
• I can keep my fears in check.
• I don’t need to please everyone.

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PST practitioners have many different techniques available to support clients as they learn to tackle day-to-day or one-off trauma.

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Ask the client to complete the following:

• Describe the problem you are facing.
• What is your goal?
• What have you tried so far to solve the problem?
• What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

• Who is involved?
• What did or did not happen, and how did it bother you?
• Where did it happen?
• When did it happen?
• Why did it happen?
• How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.

Visualization

Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

• Clarifying the problem by looking at it from multiple perspectives
• Rehearsing a solution in the mind to improve and get more practice
• Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

• Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
• Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
• Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.

If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

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While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry ,  48 (1), 27–37.
• Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
• Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies  (4th ed.). Guilford Press.
• Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
• Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
• Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
• Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

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What is Problem-Solving Therapy? (The Pros and Cons)

When you’re navigating a difficult situation, it can feel like problems keep piling up. It’s easy to feel overwhelmed and discouraged when you can’t seem to find a solution to any of them.

Fortunately, problem-solving therapy can be a short-term, effective way to find the answers you need.

Here at KMA Therapy, we know that choosing a type of therapy should be the least of your problems. We’re passionate about educating our clients and community about the different types of therapy available, and how to know which ones could be a great choice for them.

After reading this article, you’ll know what problem-solving therapy is, what happens during problem-solving therapy, and its pros and cons.

What is Problem-Solving Therapy?

Problem-solving therapy is a short-form treatment that usually lasts between four and twelve sessions.

It is most frequently used to treat depression, with a primary focus on helping you build the tools needed to identify and solve problems.

The main goal of problem-solving therapy is to improve your overall quality of life by helping you reduce the impact of stressors and problems you’re facing.

Problem-solving therapy is used to treat:

• Suicidal ideation
• Self-harm behaviours

If you’re experiencing suicidal ideation or are having thoughts of harming yourself, you can connect with Talk Suicide Canada for immediate support.

What Happens During Problem-Solving Therapy?

During problem-solving therapy, your therapist will focus on two main components.

1. Positive problem-solving framework

Positive problem-solving involves creating a framework that allows you to view things in a positive way by allowing yourself to feel confident and capable when handling your problems.

This means figuring out how to accept that you’ll still face problems in your life, while feeling more sure about your ability to face, address, and overcome them.

2. Planful problem-solving

Planful problem-solving involves four steps that help you learn how to solve problems in a healthy way:

• Defining the problem that you need to solve in a way where potential solutions can be created
• Exploring alternative solutions to the problem you’re facing by listing as many creative solutions to your problem as you can
• Discussing decision-making strategies to help you know which solution to choose and how to adapt to overcome obstacles
• Implementing your solution for your problem and assessing whether it was the right choice

What are the Pros of Problem-Solving Therapy?

Problem-solving therapy is an effective and helpful form of therapy that can help you see meaningful changes in your life in a short amount of time.

Problem-solving therapy may be a great choice for you if:

• You want a short-term form of therapy
• You’re facing specific issues that you want to build solutions for
• You’re looking for clear solutions to problems without unpacking the cause

In general, problem-solving therapy is a great choice if there’s something specific in your life that’s causing additional problems.

For example, if you’re struggling with depression that makes you unable to keep in touch with loved ones or stay on top of your bills, problem-solving therapy can be a great choice to help you find solutions that work for these specific issues.

However, if you’re struggling to find the motivation to get out of bed in the morning because you want a deeper sense of purpose in your life, another form of therapy might be a better choice.

What are the Cons of Problem-Solving Therapy?

While problem-solving therapy can be quick, effective, and empowering, it’s not always the best choice if you’re interested in more in-depth conversations in therapy.

Problem-solving therapy may not be the right fit if you:

• Are looking to unpack or reprocess past experiences
• Want to explore complex or existential questions in therapy
• Are interested in changing general behavioural patterns (rather than specific problems)

Alternatives to Problem-Solving Therapy

After learning about the pros and cons of problem-solving therapy, you may be interested in some alternative forms of therapy to explore.

Alternatives to problem-solving therapy include:

• Existential therapy , which allows you to explore your sense of purpose and meaning in life
• Cognitive behavioural therapy , which focuses on helping you restructure your thought and behaviour patterns
• Dialectical behaviour therapy, which helps you build skills to change and solve problems, with an additional focus on mindfulness and relationships

Next Steps for Beginning Therapy

After reading this article, you know what problem-solving therapy is and how to know if it’s the right choice for you.

Here at KMA Therapy, our passionate team of therapists has been supporting our clients with tailored therapy plans for over 15 years.

You don’t have to know exactly what type of therapy you want to pursue when you meet a therapist for the first time, so don’t worry if you’re feeling overwhelmed.

It’s helpful to have a sense of what you like and dislike, and what types of therapy sound interesting to you - but your therapist will help you choose what will work best and create a treatment plan customized to you.

Register online for more information or download our free Therapy 101 Guide to learn more.

If you’d prefer to keep reading, explore these articles we’ve chosen for you:

• What is Psychodynamic Therapy? (The Pros and Cons)
• Therapy 101: The Ultimate Guide to Beginning Therapy
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Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

• What Is Cognitive Behavioral Therapy?
• Take our Your Mental Health Today Test
• Find a therapist who practices CBT
• Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
• The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
• The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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Problem-Solving Therapy

• Reference work entry
• First Online: 01 January 2017
• pp 1874–1883
• Cite this reference work entry

• Sherry A. Beaudreau 2 , 3 , 4 ,
• Christine E. Gould 2 , 5 ,
• Erin Sakai 6 &
• J. W. Terri Huh 6 , 7  

104 Accesses

Behavioral intervention; Skills-based therapy; Treatment

Problem-solving therapy (PST), developed by Nezu and colleagues, is a non-pharmacological, empirically supported cognitive-behavioral treatment (D’Zurilla and Nezu 2006 ; Nezu et al. 1989 ). The problem-solving framework draws from a stress-diathesis model, namely, that life stress interacts with an individual’s predisposition toward developing a psychiatric disorder. The driving model behind PST posits that individuals who experience difficulty solving life’s problems or coping with stressors of everyday living struggle with psychiatric symptoms more often than individuals considered as good problem solvers. This psychological treatment teaches a step-by-step approach to the process of identifying and implementing adaptive solutions for daily problems. By teaching individuals to solve their problems more effectively and efficiently, this model assumes that their stress and related psychiatric symptoms will...

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Alexopoulos, G. S., Kiosses, D. N., Heo, M., Murphy, C. F., Shanmugham, B., & Gunning-Dixon, F. (2005). Executive dysfunction and the course of geriatric depression. Biological Psychiatry, 58 (3), 204–210.

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Beaudreau, S.A., Gould, C.E., Sakai, E., Huh, J.W.T. (2017). Problem-Solving Therapy. In: Pachana, N.A. (eds) Encyclopedia of Geropsychology. Springer, Singapore. https://doi.org/10.1007/978-981-287-082-7_90

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Volume 41, Issue 9, September 2012

Problem solving therapy Use and effectiveness in general practice

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

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

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

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

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

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

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

Using PST in general practice

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

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

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

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

Figure 1. Problem solving therapy patient worksheet

PST skill development for GPs

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

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

Conflict of interest: none declared.

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Also in this issue: Psychological strategies

Professional

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

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.

CBT is based on several core principles, including:

• Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
• Psychological problems are based, in part, on learned patterns of unhelpful behavior.
• People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

• Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
• Gaining a better understanding of the behavior and motivation of others.
• Using problem-solving skills to cope with difficult situations.
• Learning to develop a greater sense of confidence in one’s own abilities.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:

• Facing one’s fears instead of avoiding them.
• Using role playing to prepare for potentially problematic interactions with others.
• Learning to calm one’s mind and relax one’s body.

Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy.

CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behavior.

CBT therapists emphasize what is going on in the person’s current life, rather than what has led up to their difficulties. A certain amount of information about one’s history is needed, but the focus is primarily on moving forward in time to develop more effective ways of coping with life.

Source: APA Div. 12 (Society of Clinical Psychology)

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Problem-solving treatment in general psychiatric practice.

Published online by Cambridge University Press:  02 January 2018

The role of the general adult psychiatrist has changed significantly over the past decade. There is a focus (almost exclusively in some cases) on the management of patients with severe mental illness. Within the multi-disciplinary team, the key role of the psychiatrist is often perceived as the management of medication, making decisions about clinical risk and acting as gatekeeper to often restricted in-patient beds. Psychological and social interventions are commonly seen as the remit of other members of the team. Although psychiatric training should equip psychiatrists to have at least a reasonable understanding and practical knowledge of psychological treatments, many consultants in their day-to-day practice do not have sufficient time to utilise such treatments. These factors brought together result in a situation where the practice of many general adult psychiatrists is almost exclusively the treatment of patients with severe illness and within the treatment of such patients, psychiatric practice is much more about medication and risk management than the personal implementation of psychological interventions.

If busy general psychiatrists are to utilise psychological treatments in their day-to-day work, such treatments must be brief, focused and effective. The treatments must be feasible within a busy out-patient clinic. Behavioural treatments are a good model for such a treatment, and are often satisfying interventions with good outcomes.

Problem-solving treatment is a brief psychological intervention that has been shown to be effective in the treatment of major depression and for patients with a broad range of emotional disorders that have not resolved with simple measures. The treatment derives from cognitive–behavioural principles. The rationale of problem-solving treatment is given in Box 1 .

Box 1. Rationale of problem-solving treatment

Problem-solving treatment can also have an educational role in general psychiatry: it can be taught to trainee psychiatrists as an introduction to brief psychological treatments.

What is problem-solving treatment?

Problem-solving treatment is a brief, structured psychological intervention. The treatment shares with other cognitive–behavioural treatments a focus on the here and now, rather than a dwelling on past experiences and regrets. The treatment involves an active collaboration between patient and therapist, with the patient taking an increasingly active role in the planning of treatment and the implementing of activities between treatment sessions. The treatment has been evaluated as an intervention lasting approximately four to six sessions.

During treatment, the therapist and patient attempt to achieve four main goals (see Box 2 ). The first goal is to increase patients' understanding of the link between their current symptoms and their current everyday problems. Included in this goal is an understanding that problems are an expected part of everyday living, and that effective resolution of the problems will result in a reduction of symptoms.

Box 2. Goals of problem-solving treatment

The second goal of treatment is to increase the patients' ability to clearly define their current problems. The importance of setting concrete, specific and realistic goals for problem resolution is emphasised.

The third goal of problem-solving treatment is to teach the patient a specific problem-solving procedure in an attempt to solve his or her problems in a structured way. Specific problem-solving skills are introduced and practised using the real-life problems the patient is currently attempting to solve.

The final goal is to produce more positive experiences regarding the patients' ability to solve problems. Patients often feel beset and overwhelmed by the difficulties they face. Problem-solving treatment helps provide a sense of mastery and self-control.

Evidence supporting use of problem-solving

Depressive disorders.

The most thorough evaluation of problem-solving treatment has been for depressive disorders. Depressive disorders are known to be linked with stressful life events, and patients with depression may be less likely to cope with these stresses in a clear problem-focused way. An early small study of group problem-solving therapy (eight 90-minute sessions) for students with depression, recruited by newspaper advertisement, indicated that problem-solving therapy was more effective than a waiting-list control ( Reference Nezu Nezu, 1986 ).

Two studies have evaluated the effectiveness of problem-solving treatment for major depression in primary care. In the first study ( Reference Mynors-Wallis, Gath and Lloyd-Thomas Mynors-Wallis et al , 1995 ), 91 primary care patients with major depression were randomly allocated to either problem-solving treatment, amitriptyline or a placebo treatment involving both drug and psychological placebos. All treatments were given in six sessions over 12 weeks. At 6 and 12 weeks after treatment, problem-solving treatment was as effective in treating depression as amitriptyline, and significantly more effective than the placebo treatment. Problem-solving was associated with a low drop-out rate (only 7% of the sample compared with 19% for the amitriptyline sample) and was rated as helpful or very helpful by 100% of the patients receiving it (compared with 83% of the amitriptyline sample).

A second study evaluating problem-solving treatment for major depression in primary care ( Reference Mynors-Wallis, Gath and Day Mynors-Wallis et al , 2000 ) sought to answer two further questions. First, is the combination of problem-solving treatment and antidepressant medication more effective than either treatment alone? Second, can the problem-solving treatment be delivered as effectively by suitably trained practice nurses as by general practitioners (GPs)? One-hundred-and-fifty-one patients were randomly allocated to receive problem-solving treatment from a GP, problem-solving treatment from a practice nurse, antidepressant medication alone from a GP, or the combination of problem-solving treatment and antidepressant medication. The antidepressant medication used was a selective serotonin reuptake inhibitor (SSRI). The results from this study at 6, 12 and 52 weeks indicated that there were no significant differences between any of the four treatment groups, providing further support for problem-solving treatment as an effective treatment for depressive disorders in primary care.

In common with other psychological and drug treatments for depressive disorders, predictors as to which patients might benefit from drug treatment and which might benefit from problem-solving treatment remain elusive ( Reference Mynors-Wallis and Gath Mynors-Wallis & Gath, 1997 ). Clinical experience suggests that patients who readily accept the link between their problems and symptoms and those who wish to work within the collaborative framework of problem-solving treatment do well. Patients who wish to take a more passive role and be ‘made better’ by the doctor or nurse are harder to motivate to take part in the treatment.

There is some evidence that problem-solving treatment may be effective for older adults (aged over 55 years) with a depressive disorder ( Reference Arean, Perri and Nezu Arean et al , 1993 ). A four-centre study in the USA compared paroxetine, problem-solving treatment and placebo for the treatment of minor depression and dysthymia ( Reference Barrett, Williams and Oxman Barrett et al , 1999 ). A five-centre European study evaluated problem-solving treatment and a group educational programme for depressive disorders identified by community sampling ( Reference Dowrick, Casey and Dalgard Dowrick et al , 1998 ).

Emotional disorders

In primary care, psychological disorders do not necessarily fit into simple ICD–10 categories ( World Health Organization, 1992 ). Many patients present with a range of depressive and anxious symptoms – emotional disorders. Although many of these disorders resolve quickly, a significant proportion of patients develop chronic conditions with significant clinical and social morbidity. Two studies have evaluated problem-solving treatment for such patients. The first selected patients identified at high risk of poor outcome. These patients were randomly allocated to receive either four sessions of problem-solving from a research psychiatrist or treatment as usual from their GP. At the end of treatment and at 6-month follow-up, patients treated with problem-solving showed significantly greater improvement on all standardised measures; they also reported greater satisfaction with treatment ( Reference Catalan, Gath and Bonday Catalan et al , 1991 ).

A second study evaluating problem-solving treatment for emotional disorders in primary care sought to evaluate the treatment as given by community nurses ( Reference Mynors-Wallis, Davies and Gray Mynors-Wallis et al , 1997 ). Community nurses were first trained in the techniques of problem-solving, and were then used as therapists in a trial treating patients with emotional disorders. Patients with emotional disorders of at least 1 month's duration were referred by their GP. These patients were randomly allocated to either problem-solving treatment given by a trained nurse therapist or to treatment as usual from their GP. Although there was no difference in symptom scores between the two groups at 8 or 26 weeks, patients who had received problem-solving treatment took significantly less disability days and days off work. One of the problems faced in this naturalistic study was the wide variability in the illness severity and chronicity of patients referred. A lesson from the study was that guidance is needed as to the type of patients who might benefit from problem-solving treatment, as opposed to watchful waiting alone or more intensive and specialist interventions.

Deliberate self-harm

Acts of deliberate self-harm are often committed in the context of psychosocial problems. Intuitively, therefore, problem-solving treatment would seem to be an appropriate and valid treatment. Two studies have evaluated problem-solving treatment for patients following an episode of deliberate self-harm. Hawton et al (1987) evaluated problem-solving treatment as a part of a counselling intervention, by comparison with treatment as usual by the GP, for patients following an episode of deliberate self-harm. There were no major differences in outcome between the two groups. Two subgroups, however, did show some benefit from problem-solving – women and individuals with problems in their relationship with their partner.

In a second study ( Reference Salkovskis, Atha and Storer Salkovskis et al , 1990 ), problem-solving treatment given by a community psychiatric nurse was effective in reducing the distress experienced by overdose patients, selected as having a high risk of repetition. Short-term effectiveness was also demonstrated in preventing further overdose attempts. As with the treatment of emotional disorders, the key to the effectiveness of problem-solving treatment following deliberate self-harm is to target the appropriate patients. Further research is needed to fully answer this particular question.

Schizophrenia

Falloon et al (1984) have described the use of problem-solving techniques within the context of family therapy for patients with schizophrenia. Problem-solving is used to clarify the particular problems each family faces and to enhance the family's coping skills.

How to provide problem-solving treatment

Problem-solving can be given over 4–6 sessions. The first session will need to last about an hour. Subsequent sessions can be of about 30 minutes.

In the first session, the most important task is to motivate the patient to comply with treatment (see Box 3 ). This motivation can be achieved if the patient recognises that the therapist has listened to and understood the patient's difficulties, and has used this understanding to explain the principles of problem-solving clearly and simply. Problem-solving treatment can be considered as a series of stages (see Box 4 ).

Box 3. Aims of first session

Box 4. Stages of problem-solving treatment

Stage 1 – explanation of treatment and its rationale

There are three steps:

Stage 2 – clarification and definition of problems

A list of problems should already have been drawn up. The next step is to choose one particular problem that is important to the patient, and which the therapist considers feasible for problem-solving. This problem should be defined as clearly as possible. In specifying the problem, it may help if the patient considers four questions:

Large problems should be broken down into smaller and more manageable parts. Usually, the patient presents several related problems. The therapist and patient should review these problems carefully, and then select one or two problems to tackle initially. The choice of a particular problem should be guided by (a) what is seen as relevant to the patient and (b) problems for which achievable goals can be set.

See Box 5 for a patient-based problem list.

Box 5. A problem list

Mrs W was a 43-year-old office administrator for a light engineering company. She had been married for 16 years and her husband had severe arthritis, which resulted in him being wheelchair-bound and unable to work. They had no children. Mrs W was referred into the study following a 9-month history of worsening depression. Her main complaint was of poor memory and concentration

Mrs W was still not completely convinced that her symptoms were due to a depressive disorder, and some time was spent at the beginning of this session explaining the nature of depressive illness, and the physiological and cognitive effects that might occur. A problem list was then drawn up:

an unsupportive boss

difficult and possibly dishonest subordinates

previous attempts to resolve difficulties had failed

Husband – although Mr and Mrs W were spending a lot of time together, Mrs W felt that her main role was as a nurse and that they were doing few ‘normal’ things that they could both enjoy

Housework – Mrs W felt that the house was becoming increasingly untidy and dirty, and was in need of a spring clean, but she did not have the energy to do this

Mrs W decided she wanted to work on problems 1 and 2 first – both seemed problems that could be further defined and for which achievable goals could be set

Stage 3 – setting achievable goals

Once the problems have been clarified and defined, the next stage is to set one or more achievable goals. In making this choice, it is important to take into account the balance between the patient's resources and obstacles. The patient's resources may include:

(a) personal strengths and assets;

(b) education, leisure activities and social and financial resources;

(c) support from other people, such as spouse or other relative, friend, or professional person such as a social worker or clergyman; and

(d) self-help groups: direct advice about the availability of self-help groups may be appropriate.

Achievable goals should be SMART goals; Specific, Measurable, Achievable, Relevant and Timed.

It is important that the patient develops a sense of achievement early in treatment; for this purpose, goals should be identified that can be achieved quickly, for example, before the next session. Medium-term goals can be attained in stages over the course of treatment. Goals are often more achievable if they can be achieved by the patient alone rather than relying on someone else (see Box 6 ).

Box 6. Achievable goals

First, Mrs W decided that she needed a break from work in order to assess the difficulties that she was facing. She decided that she needed 2 weeks off work. The second goal was to go out with her husband on at least two occasions in the week

Stage 4 – generating solutions

Once an achievable goal has been set, the patient is asked to brainstorm as many solutions as he or she can generate. Potential solutions should not be discarded or pre-judged, even if initially they seem to be silly or unworkable.

Stage 5 – choice of preferred solution

The therapist encourages the patient to draw up a list of the pros and cons for each potential solution. It may be useful to ask the patient to prepare this list as a homework task. The patient should select a preferred solution, that is a solution that best achieves the stated goals with the least personal and social disadvantages. Some patients find this stage of problem-solving the most difficult to achieve alone; such patients may ruminate about possible solutions without being able to choose one (see Box 7 ).

Box 7. Generation and choice of solutions

In the clinical example of Mrs W, the solutions considered for obtaining 2 weeks off from work included taking annual leave, taking sick leave and resigning from the job. She chose taking sick leave and thought she should consult her GP to ask for a sick certificate. The possible solutions for going out with her husband included a cinema trip, a meal in a pub, a visit to a local beauty spot, a trip to Bournemouth and a visit to friends. Mrs W decided not to choose the solution immediately but to discuss it with her husband.

Stage 6 – implementation of the preferred solution

It is important not to rush this stage because the patient may lack the confidence to implement the preferred solution. The steps needed to achieve the solution may have to be broken down into simple sub-steps. There should be clear specifications of the sub-steps and when they should be carried out.

The patient should have a clear set of tasks that need to be completed between therapy sessions (see Box 8 ). These tasks are referred to as homework.

Box 8. Implementation plan

• Sick note from GP

• Ring work to tell them she is not coming in

• Ring for appointment with GP

• Explain to GP that she is not coping at work and needs time off from work for treatment to be a success

• Discuss with husband plans for time together

• Ring cinema for a timetable – ask about disabled seating

• Explain to husband about treatment plan after supper

• Plan two trips out before next week

Stage 7 – evaluation

It is importance that in second and subsequent problem-solving sessions a detailed evaluation of progress made since the previous session is undertaken (see Boxes 9 , 10 , 11 , 12 and 13 ). Failure to complete tasks successfully may be because of a poor understanding of the treatment process and in particular the homework. Unforeseen obstacles may arise or patients may simply lack the motivation to fulfil tasks outside the treatment sessions. Achievable goals need to be redrawn in the light of experience.

Box 9. Aims of session two and subsequent sessions

• Review the patient's progress and reinforce success and continued effort

• If problem resolution not successful, explore changes to strategy and develop new implementation plans

• Address problems from the problem list and new problems as they emerge

• Gradually increase the patient's independence in conducting problem-solving and facilitate a positive problem-solving attitude

Box 10. Mrs W – session two

• Mrs W was given 2 weeks' sick leave by her GP. She had telephoned her immediate boss at work to explain why. She had made it clear that the stresses and difficulties at work were the cause of her illness. She had been very successful in planning sessions out with her husband, had been to the cinema and to visit a local beauty spot. She was also planning a weekend trip to Bournemouth for 2 weeks' time.

• to receive no telephone calls from work after 7.00p.m.

• to make an appointment to see one of the company directors in order to sort out her workload.

Box 11. Mrs W – session three

• Mrs W had decided that her husband would answer all her evening telephone calls. He was very pleased to do this as it gave him a useful role. She and her husband continued to go out, in fact, three or four times a week because she had been off work. Both felt that this was very beneficial. Mrs W was going to see the director the day she returned to work.

• The remainder of this third session was spent discussing in detail what Mrs W would say to the company director. She believed that he would be sympathetic to her difficulties, but would like her to come up with potential solutions. Mrs W decided that she would ask for a further reduction in her hours so that she would be working only 3 days, which would allow a colleague at work who wanted to work full-time to take over some of her jobs. Mrs W earmarked two areas of her work that she felt could be supervised by this colleague.

• Mrs W also resolved to talk to her immediate boss, in order to explain to him in more detail how intolerable the work situation had become, and also to air her concerns about one of her subordinate's possible dishonesty.

Box 12. Mrs W – session four

Mrs W was now back at work and said that her colleagues had been very sympathetic. She was, however, finding it difficult to free up enough of her time in order to achieve the goal of only working 3 days. She set herself the goal of having 1 day per week of not doing any work-related activity. Ways of achieving this were discussed and Mrs W decided to draw up a timetable for herself. Her husband had begun answering the telephone in the evening and had been successful in delaying calls until the next morning. However, Mrs W was finding it difficult to cope with the anxiety of not knowing what the calls had been about.

Box 13. Mrs W – session five

• Mrs W had managed to restructure her work so that she was working only 4 days. She saw this as a great achievement, and did not feel that it was realistic, or even desirable, to reduce her workload to 3 days, although in fact that was all she was being paid for. She was able to not work each Wednesday. It was agreed that she would not be telephoned on this day. She and her husband planned to use Wednesdays as an opportunity to go out together. Evening telephone calls had almost ceased, and Mrs W had starting taking them herself, but agreed that if they became more frequent, she would ask her husband to answer them again.

• Mrs W picked up another problem from her problem list, which was housework. She still believed that the house needed a spring clean. She looked at different options as to how this might be done. She decided that she would contact ‘Maids’, a local cleaning service, to find out how much it would cost her for them to come and spring clean the house.

• At the end of this session she did not believe that she needed any more help.

The patient and therapist should review the original problems, consider progress and always be prepared to add new problems to the problem list. The patient may work through a series of short- and mid-term goals to reach a long-term goal. For example, if the final goal is to secure a new job, the short-term and intermediate goals might be to:

(a) obtain information about the qualifications required;

(b) send for application forms;

(c) apply for a job; and

(d) attend for an interview if asked.

Combining problem-solving treatment with antidepressant medication

The rationale for using problem-solving treatment for patients with major depression has been described above. Although the evidence suggests that problem-solving treatment and antidepressant medication in combination are no more effective than either treatment alone, problem-solving treatment can be used as an adjunct to the prescription of medication. There are two reasons for this. First, there is evidence that poor compliance with medication reflects, at least in part, the view of patients that their symptoms are caused by problems within their environment and that these are not likely to be helped by medication alone. Second, problem-solving provides a structured way of assisting patients with their social difficulties, and the antidepressant medication can be seen as part of this process in that physical symptoms are resolved, enabling patients to implement problem-solving interventions.

Patients with anxiety disorders referred into general psychiatric practice are by definition of poor prognosis and hence may be a group for whom problem-solving treatment may be of benefit. Generalised anxiety disorder in particular is a chronic relapsing and remitting condition with few well-evaluated therapies. For such patients, the use of problem-solving helps to provide an understandable explanation for their symptoms and also a practical approach to dealing with the everyday stresses. Problem-solving strategies can be implemented alongside other anxiety management techniques. Problem-solving treatment is not appropriate for agoraphobia or specific phobias.

Personality disorders

General psychiatry remains beset by how to manage patients with a personality disorder. Problem-solving techniques may be a helpful treatment for some of these patients. The emphasis is on the patient identifying and then resolving his or her problems. Patients have to set goals for treatment and the therapist assists with this. The offer of such a treatment may not be welcomed by patients who want their problems to be solved for them. However, the offer of a course of problem-solving treatment not only avoids getting caught up in the rather sterile discussion that there is nothing that can be done, but also provides a very clear, time-limited, here and now treatment focusing on what the patient identifies as his or her goals. Responsibility for goal-setting and implementation remains firmly with the patient.

Conclusions

Problem-solving treatment is a brief effective intervention for a range of non-psychotic anxious and depressive disorders. The structure of the treatment fits well into the standard out-patient clinic. Problem-solving treatment provides a model for a psychological intervention that is easily understood by patients (for treatment) and by colleagues (for training).

Multiple choice questions

(a) setting a problem list

(b) reviewing past successes and failures

(c) examining the patient/therapist relationship

(d) setting achievable goals

(e) defining problems precisely.

(a) chosen by the therapist

(b) achieved before the next treatment session

(c) achieved within a defined time span

(d) related to problems chosen

(e) linked to relationship difficulties.

(a) depressive disorders

(b) simple phobias

(d) adolescent depression

(e) anxiety disorders in primary care.

(a) combined with antidepressant medication

(b) when delivered by community nurses

(c) when delivered over ten sessions

(d) patients have many psychosocial problems

(e) patients have a chronic illness.

(c) achievable

(d) resisted

MCQ answers

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• Volume 7, Issue 6
• Laurence Mynors-Wallis
• DOI: https://doi.org/10.1192/apt.7.6.417

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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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Problem solving therapy - use and effectiveness in general practice

Affiliation.

• 1 Department of Rural Health, Rural Health Academic Centre, the University of Melbourne, Ballarat, Victoria, Australia. [email protected]
• PMID: 22962642

Background: Problem solving therapy (PST) is one of the focused psychological strategies supported by Medicare for use by appropriately trained general practitioners.

Objective: This article reviews the evidence base for PST and its use in the general practice setting.

Discussion: Problem solving therapy involves patients learning or reactivating problem solving skills. These skills can then be applied to specific life problems associated with psychological and somatic symptoms. Problem solving therapy is suitable for use in general practice for patients experiencing common mental health conditions and has been shown to be as effective in the treatment of depression as antidepressants. Problem solving therapy involves a series of sequential stages. The clinician assists the patient to develop new empowering skills, and then supports them to work through the stages of therapy to determine and implement the solution selected by the patient. Many experienced GPs will identify their own existing problem solving skills. Learning about PST may involve refining and focusing these skills.

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What Types of Therapy Are Helpful for Depression?

What is psychotherapy, psychotherapy for depression.

• Therapy Approaches
• How Long Does It Take to Work?
• Choosing a Therapist

Depression is more than feeling sad or unmotivated for a few days; it’s an ongoing and persistent feeling of extreme sadness or despair affecting every aspect of a person’s life. Data from 2020 shows 18.4% of U.S. adults have received a diagnosis of depression.

Fortunately, treatment options like psychotherapy can be effective. The key is finding out what type of psychotherapy is right for you, depending on the severity of your symptoms, personal preferences, and therapy goals. 

This article covers the most effective evidence-based psychotherapy treatments for depression.

The Good Brigade / Getty Images

Psychotherapy is talk therapy . It takes place in outpatient settings (i.e., therapy offices) and inpatient settings (i.e., hospitals). Its purpose is to help relieve symptoms and prevent them from returning.

Each form of psychotherapy is unique, but typical sessions help a person identify the thought patterns, learned behaviors, or personal circumstances that may be contributing to their depression. The focus then shifts to building healthy coping strategies for managing negative thoughts, unwanted behaviors, and difficult emotions or experiences.

The following are the most common types of psychotherapy for depression.

Cognitive Therapy

Cognitive therapy (also called cognitive processing therapy) is a type of cognitive behavioral therapy shown to be effective in helping people challenge and change unhelpful or unwanted beliefs or attitudes that result from traumatic experiences such as sexual assault or natural disaster.

Cognitive therapy involves learning about symptoms like intrusive thoughts resulting from traumatic experiences and working on processing the experience and questioning and reframing negative self-thinking.  

Behavioral Therapy

Behavioral therapy (also called behavioral activation) focuses on how certain behaviors influence or trigger symptoms of depression. It works by helping a person identify and understand specific behavioral triggers and then providing behavioral activation exercises that encourage behavioral modifications or changes where possible, resulting in more positive mood outcomes.

Cognitive Behavioral Therapy (CBT)

CBT is considered the best-researched technique and the "gold standard" of psychotherapy. It's been shown effective in reducing depression symptoms and helping patients build skills to change thought patterns and behaviors to break them out of depression. It also encourages greater adherence to medications and other treatments.

CBT when combined with medication for depression has been shown more effective in treating symptoms and preventing relapse than pharmacology alone.

Dialectical Behavior Therapy (DBT)

DBT is a skilled-focused technique centered on acceptance and change. It involves acceptance-oriented skills, such as mindfulness and increasing tolerance to distress. It also uses change-oriented skills, emotional regulation (keeping emotions in check), and interpersonal development (i.e., saying no, asking for what you want, and establishing interpersonal boundaries).

Research suggests DBT is particularly beneficial for people experiencing chronic suicidal thinking .

Suicide Prevention Hotline

If you or someone you know is having suicidal thoughts, dial  988  to contact the  988 Suicide & Crisis Lifeline  and connect with a trained counselor. For more mental health resources, see our  National Helpline Database.

Psychodynamic Therapy

Psychodynamic therapy is based on the theory that moods and behaviors are directly but unconsciously related to childhood and past experiences. It involves building self-awareness of these experiences and their influence on a person while empowering them to change unwanted patterns.

Treatment with psychodynamic therapy has been shown to be as effective as other treatments in reducing depressive symptoms in depressive disorders.

Interpersonal Therapy (IPT)

IPT focuses on how relationships impact mental health. It helps people manage and strengthen current relationships, as well as looking at how different environments influence thinking and behavior. Numerous studies support the effectiveness of ITP for depression treatment and symptom relapse prevention.

Problem-Solving Therapy (PST)

PST is about strengthening a person’s ability to cope with stressful events by enhancing problem-solving skills. Several studies support the effectiveness of problem-solving therapy for people with depression, depressive disorders, and other mental health conditions.

Approaches to Therapy for Depression

Therapy is not one-size-fits-all. The best approach will depend on severity of symptoms and overall therapy goals, and may include a combination of individual therapy, group therapy , family therapy , or couples therapy . Someone experiencing ongoing depression may benefit from the one-on-one support of individual therapy, but also from a family-based approach and peer support groups .

How Long Does Therapy for Depression Take?

The length of time therapy takes to experience results will vary depending on factors such as:

• Depression type: Acute depression (i.e. depression that does not persist over a long period of time) will typically take fewer sessions to show results than chronic depression.
• Symptom severity: More severe symptoms like suicidal thinking may require longer or more intensive treatment.
• Therapy goals: Focused goals are reached more quickly than broader-based goals.
• Session frequency: People are typically advised to attend as often as they feel comfortable, but more frequent sessions typically result in quicker results.
• Technique: Some types of therapy like cognitive behavioral therapy are more goal-focused and generally quicker than other types.
• Trust: Higher levels of trust between client and therapist often yield quicker results.
• Personal circumstances: A new or ongoing traumatic life experience or other health condition like substance use disorder may prolong how long treatment takes.

General Timeline

Psychotherapy can be short-term and last a few weeks to months (for situational acute depression) or long-term and last a few months to years (for persistent or chronic depression).

How to Choose a Technique and Therapist

Consider which types of therapy best align with your goals and seek a therapist who offers that type of therapy. Bear in mind that therapists may offer more than one technique and can help you determine which techniques may be most suitable.

When choosing a therapist, you may consider their credentials, such as if they have a medical degree and can prescribe medication for depression , as a psychiatrist can. It's crucial to choose a therapist whom you feel comfortable working with. It’s OK to attend a few sessions before deciding if they're the right therapist for you. 

A Word From Verywell

Making sure you feel comfortable and have rapport with your therapist is one of the most important determinants for effective therapy. Set up short introductions or consultations with a few therapists so you can pick one you feel you can build the most rapport with.

There are many types of evidence-based therapy that are suitable for treating depression. Some involve working one-on-one with a therapist, and others may include family members, spouses, or peer groups experiencing depression. Making the correct choice includes determining your therapy goals and finding a therapist you feel comfortable working with.

Centers for Disease Control and Prevention. National, state-level, and county-level prevalence estimates of adults aged ≥18 years self-reporting a lifetime diagnosis of depression — United States, 2020 .

Informed Health. Depression: How effective is psychological treatment?

American Psychological Association. Cognitive processing therapy (CPT) .

University of Michigan. Behavioral activation for depression .  

Gautam M, Tripathi A, Deshmukh D, Gaur M. Cognitive behavioral therapy for depression . Indian J Psychiatry . 2020;62( 2):S223-S229. doi:10.4103/psychiatry.IndianJPsychiatry_772_19

Wersen AD, Meiser-Stedman R, Laidlaw K. A meta-analysis of CBT efficacy for depression comparing adults and older adults . Journal of Affective Disorders . 2022;319:189-20. doi:10.1016/j.jad.2022.09.020

University of Washington. Dialectical behavioral therapy . 

American Psychiatric Association. What is psychotherapy?

Steinert C, Munder T, Rabung S, Hoyer J, Leichsenring F. Psychodynamic therapy: as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes . AJP . 2017;174(10):943-953. doi:10.1176/appi.ajp.2017.17010057

American Psychological Association. APA dictionary of psychology: interpersonal psychotherapy (ITP) .

Cuijpers P, Donker T, Weissman MM, Ravitz P, Cristea IA. Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis. Am J Psychiatry . 2016;173(7):680-687. doi:10.1176/appi.ajp.2015.15091141 

Zhang A, Park S, Sullivan JE, Jing S. The effectiveness of problem-solving therapy for primary care patients' depressive and/or anxiety disorders: A systematic review and meta-analysis . J Am Board Fam Med . 2018;31(1):139-150. doi:10.3122/jabfm.2018.01.170270

American Psychological Association. How long will it take for treatment to work?

By Michelle Pugle Michelle Pugle, MA is a freelance writer and reporter focusing on mental health and chronic conditions. As seen in Verywell, Healthline, Psych Central, Everyday Health, and Health.com, among others.

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5 Problem-Solving Therapy: Theory and Practice

• Published: May 2017
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Problem-solving therapy (PST) is a psychosocial intervention that teaches clients to cope with the stress of “here-and-now” problems in order to reduce negative health and mental health outcomes. In this chapter, the six stages of PST—problem orientation, problem definition, solution generation, decision-making, solution implementation, and outcome evaluation—are explained and exemplified via vignettes. Areas for which problem-solving therapy has been found useful are summarized, including depression, anxiety, relationship difficulties, and distress related to medical problems such as cancer and diabetes. The chapter describes contexts for practice, including primary care and home care, as well as adaptations for the use of PST with older adults. Finally, a case example of a problem-solving intervention with an unemployed depressed older man is presented to illustrate this approach.

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PROBLEM-SOLVING THERAPY FOR OLDER ADULTS

S. cummings.

1 University of Tennessee, Knoxville, Tennessee

Problem solving therapy (PST) is an effective intervention for treating older adults who struggle with stress related health and mental health issues (D’Zurilla & Nezu, 1999; Nezu, Nezu & D’Zurilla 2013). Clients are trained to overcome major obstacles that inhibit effective coping and heighten stress by means of problem identification, generation of solutions, solution implementation, and post-implementation evaluation. Effective problem solving involves the ability to adaptively develop and match helpful solutions to life problems while taking into account internal and external factors that impact the problem (Nezu, 2013). Research documents the effectiveness of PST for use with older adults experiencing a variety of issues ranging depression, anxiety and mild cognitive impairment to cancer, arthritis and post-stoke functioning (Kirkham, Seitz, & Choi, 2015). PST treatment principles and strategies will be presented and the research base reviewed. A case study will highlight the PST treatment approach with older adults.

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Solving the side effect problem of siRNA drugs for genetic disease treatment

by Nagoya University

Small interfering RNA (siRNA) drugs are a class of therapeutic agents that silence specific genes associated with inherited diseases. However, siRNA drugs have challenges because siRNAs often silence genes other than the target ones, causing side effects.

Using formamide, a group from Nagoya University in Japan has succeeded in chemically altering siRNA to reduce the risks of these off-target effects, improving the safety of siRNA drugs for genetic therapy. The results were published in Nucleic Acids Research .

siRNAs are short, double-stranded RNAs. siRNAs interact with the target's messenger RNA (mRNA), the blueprint of proteins, hindering their expression. By silencing the products of harmful genes, such as disease-causing proteins, siRNAs are a potential treatment for a range of genetic diseases.

However, siRNA's therapeutic potential is limited by off-target effects, which occur when the siRNAs interact with non-target mRNA strands. These unintended interactions can lead to harmful alterations in essential genes, disrupting cellular processes and impairing the immune response.

A significant cause of these off-target effects is a seven-nucleotide region known as the seed region, located within the guide strand of the siRNA, which is critical for target recognition. Off-target effects frequently occur because the seed region sequence forms base pairs with non-target mRNA strands.

"The off-target effect likely occurs when non-target mRNAs exist that form base pairs with the seed region of siRNA," Professor Hiroshi Abe explained. "We realized that the off-target effect could be suppressed by reducing the base pairing ability or double-strand stability in this seed region using chemical modification , ensuring that a stable complex is formed only when the entire guide strand binds to the target mRNA."

The group led by Professor Abe and his student Kohei Nomura used a formamide modification to modify the siRNA in this important region. Formamide groups can inhibit the formation of hydrogen bonds .

In mRNA, hydrogen bonds between complementary bases are essential for the stability of the double helix. Formamide interferes with these hydrogen bonds, leading to destabilization of the helical structure of the mRNA, causing denaturation or separation of the strands. Without strand formation, the binding to the seed region of siRNA is difficult, reducing the risk of off-target effects.

"This modification achieved suppression of off-target effects with higher efficiency than existing chemical modifications," said Abe. "Introduction of the modification at a single location achieved the desired effect, enabling a highly flexible sequence design of siRNA."

Chemically modified siRNAs using this modification are expected to be applied as siRNA drugs with fewer side effects. Nomura believes the research has potential applications as siRNA drugs for diseases such as hereditary transthyretin amyloidosis, acute hepatic porphyria, primary hyperoxaluria type 1, primary hypercholesterolemia, and mixed dyslipidemia.

Journal information: Nucleic Acids Research

Provided by Nagoya University

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• Published: 14 September 2024

Reduction of intracortical inhibition (ICI) correlates with cognitive performance and psychopathology symptoms in schizophrenia

• Minghuan Zhu 1   na1 ,
• Yifan Xu 2   na1 ,
• Qi Zhang 1 ,
• Xiaoyan Cheng 1 ,
• Lei Zhang 1 ,
• Fengzhi Tao 1 ,
• Jiali Shi 1 ,
• Xingjia Zhu 1 ,
• Zhihui Wang 1 ,
• Xudong Zhao 1 &
• Weiqing Liu   ORCID: orcid.org/0000-0002-5808-1785 1  

Schizophrenia volume  10 , Article number:  78 ( 2024 ) Cite this article

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Schizophrenia

Cognitive impairment is a core symptom of schizophrenia (SZ), with GABAergic dysfunction in the brain potentially serving as a critical pathological mechanism underlying this condition. Intracortical inhibition (ICI), which includes short-interval intracortical inhibition (SICI) and long-interval intracortical inhibition (LICI), can be used to assess the inhibitory function of cortical GABAergic neurons. The aim of this study was to investigate the relationship between ICI and cognitive function, as well as psychopathological symptoms, in SZ patients. We recruited 130 SZ patients and 105 healthy controls (HCs). All subjects underwent paired-pulse transcranial magnetic stimulation (ppTMS) measurements, which included resting motor threshold (RMT), SICI and LICI. The cognitive function of all subjects was assessed using the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB). The psychopathological symptoms of the SZ group were assessed using the Positive and Negative Syndrome Scale (PANSS). We examined group differences in MCCB scores, RMT, SICI, and LICI. Within the SZ group, we assessed the relationship between ICI and cognitive function, as well as psychopathological symptoms. Two-way ANOVA, Mann–Whitney U test, Receiver operating characteristic (ROC) curves, and partial Spearman correlation analysis were performed. The SZ group showed a worse cognitive score in all 6 cognitive dimensions of the MCCB compared to the HC group (all p  < 0.05). The SZ group had lower degree of SICI and LICI compared to the HC group (both p  < 0.05). ROC curves analysis showed that SICI and LICI all displayed good performance in differentiating SZ patients and HCs (both p  < 0.05), and SICI exhibited a better performance, yielding an area under the curve (AUC) of 0.856 (95% CI 0.807–0.904). Furthermore, in the SZ group, SICI demonstrated a significant negative correlation with PANSS positive score, negative score, general psychopathology score, and total score (all p Bonferroni  < 0.05), and LICI demonstrated a significant negative correlation with PANSS positive score, general psychopathology score and total score (all p Bonferroni  < 0.05). Additionally, in the SZ group, SICI demonstrated a significant positive correlation with speed of processing score, working memory score, verbal learning score, visual learning score, and reasoning and problem-solving score of the MCCB (all p Bonferroni  < 0.05), while LICI was only weakly positive correlated with speed of processing score of the MCCB ( r  = 0.247, p  = 0.005, p Bonferroni  = 0.03). Our results demonstrate that the reduction of ICI could serve as a trait-dependent in-vivo biomarker of GABAergic deficits for SZ and related cognitive impairments.

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Introduction.

Schizophrenia (SZ), a chronic and debilitating disorder, affects approximately 1% of the world’s population, imposing significant burdens on patients and their families. The primary symptoms of SZ are categorized into positive symptoms, negative symptoms, and cognitive deficits 1 . Current research suggests that cognitive deficits may constitute the core symptom of SZ 2 , 3 , often present in the prodromal stage before the full manifestation of positive and negative symptoms 4 , 5 . Deficits in cognition exert serious adverse effects on the functional outcomes and long-term prognosis of patients with SZ 6 , 7 . However, the pathophysiological mechanisms underlying cognitive deficits in SZ remain unclear.

Emerging evidence indicates that central GABAergic inhibitory interneuron (GI) dysfunction in the brain may be a critical pathological mechanism in the onset of SZ 8 , 9 . Postmortem brain studies have demonstrated a reduction in the number and density of parvalbumin-positive (PV+) GIs in the prefrontal cortex of individuals with SZ 10 , 11 , 12 . The most consistent finding is the functional impairment of PV+ GIs in layer 3 of the prefrontal cortex. Gamma (γ) oscillations, which are ubiquitous neuroelectric activities in the brain, are closely linked to cognitive processes 13 , 14 , 15 , 16 , 17 . Studies have shown that GABAergic inhibitory function is crucial for the generation of γ oscillations, with PV+ GIs playing a prominent role 18 .

Intracortical inhibition (ICI) is a paired-pulse transcranial magnetic stimulation (ppTMS)-based measure that can serve as an indicator of the inhibitory function of the cerebral cortex. Research has indicated that ICI can reflect the function of GIs in the cortex 19 , 20 . By adjusting the stimulation interval to 1–4 ms or 50–200 ms, short-interval intracortical inhibition (SICI) or long-interval intracortical inhibition (LICI) can be induced, respectively. Studies have found that SICI may reflect the effects of GABAA receptors, which induce rapid inhibitory postsynaptic potentials (IPSPs) 21 , while LICI may reflect the effects of GABAB receptors, which induce slow IPSPs 22 .

Studies have indicated an association between SZ and altered ICI. However, conclusions have been varied 23 , 24 . A recent meta-analysis conducted by Lányi et al. 25 has reported a robust inhibitory deficit in SICI among individuals diagnosed with SZ. However, the association between SZ and LICI, the effects of medication on ICI, and the association between ICI and cognitive function and other psychopathologies of SZ has not been thoroughly investigated. Preliminary studies have suggested that SICI may correlate with cognitive function in patients with SZ 26 , 27 . For instance, Takahashi et al. 26 reported that SICI was negatively correlated with raw scores of the working memory component of the Brief Assessment of Cognition in Schizophrenia (BACS). Similarly, Mehta et al. 27 found that SICI was negatively correlated with emotion processing and a global social cognition score. However, these studies involved small sample sizes and did not cover a more comprehensive range of cognitive dimensions as measured by the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) 28 , which is a widely used cognitive assessment tool for SZ.

Based on the aforementioned research background, we hypothesize that ppTMS-based ICI may serve as a psychopathological marker of cognitive deficits in SZ. Our study has two primary aims: (1) to compare ICI and cognitive function between SZ patients and healthy controls (HCs), and (2) to explore the relationship between ICI, cognitive function, and psychopathological symptoms in SZ patients.

Materials and methods

Patients were recruited from the Shanghai Pudong New Area Mental Health Center and the First Affiliated Hospital of Kunming Medical University. This study received approval from the Institutional Review Board of Shanghai Pudong New Area Mental Health Center (No. PDJWLL2021028), and all participants provided informed consent.

Participants met the following inclusion criteria: (1) a diagnosis of SZ according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), confirmed using the Structured Clinical Interview for DSM-IV (SCID-I/P) 29 ; (2) aged between 18 and 60 years; (3) Han ethnicity; (4) right-handed; (5) had not taken benzodiazepines within the past 3 months; and (6) had not received transcranial magnetic stimulation (TMS) or electroconvulsive therapy within the past 3 months. The exclusion criteria included: (1) pregnancy; (2) severe physical diseases; (3) any other major Axis I disorder; and (4) substance abuse or dependence. HCs were selected based on the absence of any major Axis I disorder diagnosis and no family history of mental disorders.

We recruited 130 SZ patients (male/female: 49/81; average age: 30.92 ± 9.56 years), with 70 from the Shanghai Pudong New Area Mental Health Center and 60 from the First Affiliated Hospital of Kunming Medical University. Among the SZ patients we enrolled, 46 were first-episode drug-naïve (FEDN), 84 were receiving stable dose of antipsychotic treatment, and the antipsychotics taken by the patients were all converted to chlorpromazine equivalent doses 30 . Additionally, we recruited 105 sex- and age-matched HCs (male/female: 48/57; average age: 30.39 ± 12.68 years), with 49 from Shanghai and 56 from Kunming.

Clinical assessments

Demographic and clinical data were collected using a self-designed questionnaire. Psychopathological symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) 31 , 32 , while cognitive functioning was evaluated using 6 cognitive dimensions of the MCCB. These dimensions included speed of processing, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition. Both assessors underwent thorough training on these scales, achieving an inter-rater concordance of over 0.8.

Measurement of ICI

We used the same model of TMS machine (NS5000, YIRUIDE Group, CN) and set the same parameters in both Shanghai and Kunming sites. Subjects were seated in a comfortable chair with a headrest to stabilize their head position throughout the procedure, with their arms passively supported. An electrode was placed on the right first flexor pollicis brevis muscle to record electromyograms. Single and paired-pulse stimulation was administered using a 60-mm figure-of-eight coil, with the maximum magnetic field strength at the center being 3.5T. The coil was held tangentially to the hand area of the left motor cortex, with the handle oriented backward and away from the midline at a 45° lateral angle.

Electromyography (EMG) recordings were acquired using the YIRUIDE system. The stimulation site that produced the largest Motor Evoked Potential (MEP) in the right first flexor pollicis brevis muscle was marked to ensure a consistent coil position throughout the experiment. The resting motor threshold (RMT) was defined as the lowest intensity that produced MEPs with a peak-to-peak amplitude of greater than 50 μV in at least five out of ten trials.

Measurement of target MEP: the target MEP was obtained with a stimulus intensity set to 120% of RMT, recording 5 stimulations and calculating the average value.

Measurement of SICI: a pre-stimulus (80% of RMT) was administered 2 milliseconds before the target stimulus (120% of RMT) 33 , recording 5 stimulations and calculating the average value as MEP1. SICI was calculated using the formula: [1 − (MEP1/target MEP)] * 100%.

Measurement of LICI: a pre-stimulus (120% of RMT) was administered 150 milliseconds before the target stimulus (120% of RMT) 34 , recording 5 stimulations and calculating the average value as MEP2. LICI was calculated using the formula: [1 − (MEP2/ target MEP)] * 100%.

Statistical analysis

Statistical analyses were performed using IBM SPSS, version 25.0. Continuous variables were initially assessed for normality using the Kolmogorov-Smirnov one-sample test. The normally distributed demographic data were compared using the analysis of variance (ANOVA) and described as mean ± standard deviation, whereas non-normally distributed data were compared using the Mann–Whitney U test. The categorical variables between groups were compared using the Chi-square test/Fisher exact test. Receiver operating characteristic (ROC) curves were utilized to explore the potential of using ICI factors as biomarkers to differentiate between SZ patients and HCs. Correlations between PANSS scores, MCCB scores, and ICI were evaluated using partial Spearman correlation analysis. p  < 0.05 was considered statistically significant (two-tailed).

Demographic, ICI, and clinical characteristics between patients and HCs

The proportion of SZ patients recruited in Shanghai is not significantly different from that of the subjects recruited in Kunming ( χ 2  = 1.20, p  = 0.296). The demographic data of the subjects are summarized in Table 1 . No significant differences in age, education, or sex distribution were observed between the SZ patient group and the healthy control group (all p  > 0.05). SZ patients displayed worse cognitive scores of the MCCB compared to HCs, including lower scores in speed of processing, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition (all p  < 0.05). Additionally, SZ patients exhibited a lower degree of both SICI and LICI compared to HCs (both p  < 0.05). There was no significant difference in the RMT between SZ patients and HCs ( p  > 0.05). Aside from significant differences in age and illness duration, no other demographic information or clinical characteristics showed statistical differences between the FEDN SZ group and the medicated SZ group.

SICI performs better than LICI in discriminating SZ patients from HCs as a biomarker

ROC curves were analyzed to evaluate the diagnostic value of SICI and LICI for distinguishing SZ patients from HCs. As depicted in Fig. 1 , both SICI and LICI demonstrated acceptable area under the curve (AUC) for classifying SZ patients and HCs (both p  < 0.05). The cutoff for SICI was 22.00 (AUC: 0.856, 95% CI: 0.807–0.904) with 68.6% sensitivity and 89.2% specificity ( p  < 0.001). The cutoff for LICI was 19.60 (AUC: 0.730, 95% CI: 0.665–0.795) with 68.6% sensitivity and 73.8% specificity ( p  < 0.001).

SICI and LICI provided an acceptable AUC for discriminating patients from HCs (both p  < 0.05). Among them, SICI exhibited a better performance.

Relationship between ICI and psychopathological symptoms in SZ patients

As shown in Fig. 2 , controlling the age as covariate, partial Spearman correlation analysis showed that SICI was negative associated with PANSS positive score, negative score, general psychopathology score and total score in SZ patients ( r  = −0.226, p  = 0.002, p Bonferroni  = 0.008; r  = −0.278, p  = 0.001; p Bonferroni  = 0.004; r  = −0.311, p  < 0.001, p Bonferroni  < 0.05; r  = −0.316, p  < 0.001, p Bonferroni  < 0.05, respectively). As shown in Fig. 3 , controlling the age as covariate, partial Spearman correlation analysis showed that LICI was negative associated with PANSS positive score, general psychopathology score and total score in SZ patients ( r  = −0.222, p  = 0.011, p Bonferroni  = 0.044; r  = −0.289, p  = 0.001, p Bonferroni  = 0.004; r  = −0.257, p  = 0.003, p Bonferroni  = 0.012, respectively). While, LICI was not associated with PANSS negative score in SZ patients after Bonferroni correction ( r  = −0.180, p  = 0.041, p Bonferroni  = 0.164).

a There were significant negative association between SICI and PANSS positive score ( r  = −0.266, p  = 0.002, p Bonferroni  = 0.008). b There were significant negative association between SICI and PANSS negative score ( r  = −0.278, p  = 0.001, p Bonferroni  = 0.004). c There were significant negative association between SICI and PANSS general psychopathology score ( r  = −0.311, p  < 0.001, p Bonferroni  < 0.05). d There were significant negative association between SICI and PANSS total score ( r  = −0.316, p  < 0.001, p Bonferroni  < 0.05).

a There were significant negative association between LICI and PANSS positive score ( r  = −0.222, p  = 0.011, p Bonferroni  = 0.044). b There were no significant negative association between LICI and PANSS negative score ( r  = -0.180, p  = 0.041, p Bonferroni  > 0.05). c There were significant negative association between LICI and PANSS general psychopathology score ( r  = −0.289, p  = 0.001, p Bonferroni  = 0.004). d There were significant negative association between LICI and PANSS total score ( r  = −0.257, p  = 0.003, p Bonferroni  = 0.012).

Relationship between ICI and cognitive function in SZ patients

Controlling for age as a covariate, partial Spearman correlation analysis revealed no significant relationship between SICI and MCCB social cognition score in SZ patients ( r  = 0.147, p  = 0.095). Similarly, controlling for age as a covariate, partial Spearman correlation analysis showed no significant relationship between LICI and working memory score, verbal learning score, visual learning score, reasoning and problem-solving score, or social cognition score of the MCCB in SZ patients (all p  > 0.05). As illustrated in Fig. 4 , controlling for age as a covariate, partial Spearman correlation analysis indicated a positive association between SICI and speed of processing score, working memory score, verbal learning score, visual learning score, and reasoning and problem-solving score of the MCCB in SZ patients ( r  = 0.552, p  < 0.001, p Bonferroni  < 0.05; r  = 0.418, p  < 0.001, p Bonferroni  < 0.05; r  = 0.325, p  < 0.001, p Bonferroni  < 0.05; r  = 0.304, p  < 0.001, p Bonferroni  < 0.05; r  = 0.337, p  < 0.001, p Bonferroni  < 0.05, respectively), while, LICI was positively associated with MCCB speed of processing score ( r  = 0.247, p  = 0.005, p Bonferroni  = 0.03), only.

a There were significant positive association between SICI and MCCB speed of processing score ( r  = 0.552, p  < 0.001, p Bonferroni  < 0.05). b There were significant positive association between SICI and MCCB working memory score ( r  = 0.418, p  < 0.001, p Bonferroni  < 0.05). c There were significant positive association between SICI and MCCB verbal learning score ( r  = 0.325, p  < 0.001, p Bonferroni  < 0.05). d There were significant positive association between SICI and MCCB visual learning score ( r  = 0.304, p  < 0.001, p Bonferroni  < 0.05). e There were significant positive association between SICI and MCCB reasoning and problem-solving score ( r  = 0.337, p  < 0.001, p Bonferroni  < 0.05). f There were significant positive association between LICI and MCCB speed of processing score ( r  = 0.247, p  = 0.005, p Bonferroni  = 0.03).

Correlations between ICI and clinical characteristics in FEDN SZ and medicated SZ patients

Partial Spearman correlation analysis was conducted to evaluate the relationship between ICI and clinical characteristics in FEDN SZ and medicated SZ patients, controlling for age (Table 2 ). In both groups, no significant correlation was found between ICI and illness course or chlorpromazine equivalent dose (both p  > 0.05). After Bonferroni correction, we found a significant negative correlation between SICI and the PANSS positive score in the FEDN SZ patient group ( r  = −0.418, p  = 0.004, p Bonferroni  = 0.016). Additionally, in the medicated SZ patient group, significant negative correlations were found between SICI and the PANSS general psychopathology score and total score after Bonferroni correction ( r  = −0.289, p  = 0.008, p Bonferroni  = 0.032; r  = −0.279, p  = 0.011, p Bonferroni  = 0.044, respectively). After Bonferroni correction, we found a significant positive correlation between SICI and speed of processing score, working memory score, verbal learning score and problem-solving score of the MCCB in the FEDN SZ patient group ( r  = 0.548, p  < 0.001, p Bonferroni  < 0.01; r  = 0.593, p  < 0.001, p Bonferroni  < 0.01; r  = 0.409, p  = 0.005, p Bonferroni  = 0.030; r  = 0.497, p  = 0.001, p Bonferroni  = 0.006, respectively). In the medicated SZ patient group, significant positive correlations were found between SICI and speed of processing score and working memory score of the MCCB after Bonferroni correction ( r  = 0.510, p  < 0.001, p Bonferroni  < 0.01; r  = 0.321, p  = 0.003, p Bonferroni  = 0.018, respectively).

The main findings of the present study can be summarized as follows: (1) SZ patients exhibited a lower degree of SICI and LICI compared to HCs. Furthermore, SICI demonstrated superior diagnostic value for distinguishing between SZ patients and HCs compared to LICI. (2) The degree of ICI was associated with psychopathological symptoms in SZ patients; (3) The degree of ICI was also associated with cognitive function in SZ patients; (4) Antipsychotic treatment may not impact the degree of ICI in SZ patients.

We observed a significantly reduced degree of SICI in SZ patients, and SICI exhibited better discriminatory performance for distinguishing between patients and HCs, which is consistent with findings from previous related studies 26 , 35 , 36 , 37 . For instance, Mehta et al. reported lower SICI in both acute episode SZ and chronic SZ patients compared to HCs, suggesting the potential utility of SICI as a biomarker for SZ 27 . This finding is further supported by some meta-analysis that focused on SICI in SZ patients 22 , 25 . However, some studies did not find reduced SICI in patients 38 , 39 . Fitzgerald et al. 38 and Peter et al. 39 reported non-significant differences in SICI among their patient cohorts, which may be attributed to confounding factors such as patient characteristics, disease heterogeneity, sample size, illness duration, and medication status. Additionally, we observed a significantly reduced degree of LICI in SZ patients, although it has a lower specificity in discriminating patients from HCs. Our findings confirmed previous meta-analysis results 22 , 25 , while providing novel evidence supporting LICI deficits in SZ patients with a larger sample size from two independent sites. Overall, our results confirmed the validity of using ICI as biomarkers for SZ.

Few studies have explored the relationships between ICI and the psychopathologies of SZ. For example, Wobrock et al. 36 reported a negative correlation between cortical inhibition and total PANSS score, and Liu et al. 37 found that SICI was inversely associated with positive symptoms. In our present study, we discovered that SICI was negatively correlated with PANSS positive, negative, general psychopathology, and total score in SZ patients, while LICI was negatively correlated with PANSS positive, general psychopathology, and total score in patients. This suggests that reduced cortical inhibition is inversely associated with symptom severity in SZ patients, a finding consistent with prior studies. Our results imply a stable correlation between symptom severity and deficits in both SICI and LICI. Therefore, our observation of decreased ICI in SZ patients may represent a characteristic marker of psychopathology. Future research should focus on replicating these findings and further exploring the nature of this relationship.

Our study found that the cognitive performance in 6 dimensions of the MCCB (speed of processing score, working memory score, verbal learning score, visual learning score, reasoning and problem-solving score, and social cognition score) were significantly impaired in SZ patients. SICI was positively associated with the performance in speed of processing, working memory, verbal learning, visual learning, and reasoning and problem-solving, while LICI was positively associated with speed of processing only. Our results support that abnormal ICI may be the neurophysiological mechanisms of cognitive impairment in SZ patients and may affect different cognitive dimensions through different neural or regional circuits. γ oscillation in the brain is a neurophysiological feature observed in cognitive activities 40 , which is closely related to cognitive processes, such as sensation and perception, information storage, retrieval, and encoding 13 , 14 . Especially, γ oscillation exhibits a prominent role in learning and memory 15 , 16 , 17 . Studies have found that GABAergic inhibitory function plays an important role in the generation of γ oscillation 18 , with PV + GI playing a prominent role. Abnormal γ oscillation in the prefrontal cortex of SZ patients has been widely reported 18 . Animal experiments have found that activation and inhibition of PV + GI in mice brains can selectively enhance and inhibit γ oscillation, respectively 41 , 42 . The frequency of γ oscillation is determined primarily by GABAA receptor-induced inhibitory postsynaptic currents (IPSC) 43 . While SICI is mainly influenced by GABAA receptors and based on the induction of IPSPs 44 . And this mechanism may be the reason why SICI is related to more cognitive dimensions in our study, and supporting the validity of SICI as biomarker of cognitive deficits in SZ. In contrast, LICI, which is primarily determined by GABAB receptor-induced slow IPSCs, involves slower inhibitory effects due to the metabotropic nature of G protein-coupled GABAB receptors 45 . A few small sample size studies have explored the LICI alterations in SZ patients and demonstrated consistent deficits in the dorsal-lateral prefrontal cortex (dlPFC) using TMS-EEG (electroencephalography) paradigms, but failed to found significant changes in the motor cortex 46 . With a larger sample size, we found significant decrease in LICI and correlation with some dimensions of the symptoms and cognitive deficits in SZ, even at a smaller extent than SICI. These results indicate that GABAB receptors may also be involved in the pathogenesis of SZ, possibly through a more distal pathway than GABAA receptors. Accordingly, prior studies have shown that LICI can inhibit the level of SICI through a presynaptic mechanism 47 , and hence may confer an indirect effect on the core pathological mechanisms of SZ.

To further explore whether ICI were trait or state dependent in SZ, and excluding the impacts of medication or illness course on ICI, we compared the ICI levels between FEDN SZ patients and medicated SZ patients. Additionally, we analyzed the correlation between ICI levels and chlorpromazine equivalent doses in medicated patients. As shown in Table 2 , both medication and illness course had no significant correlation with SICI or LICI, while SICI was significantly correlated with multiple dimensions of the psychopathology and cognitive characteristics in both FEDN SZ patients and medicated SZ patients. Our result aligns with a 2024 meta-analysis 25 , which found no significant association between SICI and medication status or dosage. However, their conclusions were limited by differences in the characteristics of included cases and the lack of information on benzodiazepine using. Benzodiazepine treatment is known to enhance SICI 23 . To control for this variable, our inclusion criteria mandated that all participants should not use benzodiazepines within the three months prior to enrollment. Furthermore, the FEDN patients in our study were used to control for medication and illness course derived changes in ICI. Based on these findings, we may conclude that ICI, especially SICI, may serve as a stable trait dependent biomarker for SZ and the GABA-inhibition related cognitive deficits.

There were several limitations in this study. Firstly, the measurement of ICI was limited to the motor cortex rather than brain regions more closely related to SZ. Therefore, our findings may not fully capture the whole pathophysiological mechanisms of SZ. Additionally, even we have enrolled the largest sample size as far as we know in this research field, the limited sample size may have constraints the statistical power, especially in the stratification analyses for LICI correlations. Therefore, future research with larger longitudinal cohorts is needed to confirm and extend our findings.

Conclusions

Our results demonstrate that the reduction of ICI could serve as a trait-dependent in-vivo biomarker of GABAergic deficits for SZ and related cognitive impairments.

Data availability

The authors declare that all relevant data of this study are available within the article or from the corresponding author on reasonable request.

Abbreviations

Analysis of variance

Area under the curve

Dorsal-lateral prefrontal cortex

Electroencephalography

Electromyography

First-episode drug-naïve

GABAergic inhibitory interneurons

Healthy controls

Intracortical inhibition

Inhibitory postsynaptic potentials

Inhibitory postsynaptic currents

Long-interval intracortical inhibition

Measurement and treatment research to improve cognition in schizophrenia

MATRICS consensus cognitive battery

Motor evoked potential

Not available

Positive and Negative Syndrome Scale

Paired-pulse transcranial magnetic stimulation

Parvalbumin-positive

Resting motor threshold

Receiver operating characteristic

Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition

Standard deviation

Short-interval intracortical inhibition

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Acknowledgements

Thanks to all participants for assessments and interviews in our research. This work was supported by Shanghai Pudong New Area Health Committee Disciplinary Leader Training Program (No. PWRd2021-06), Science and Technology Development Fund of Shanghai Pudong New Area (No. PKJ2021-Y17), Outstanding Clinical Discipline Project of Shanghai Pudong (Nos. PWZzk2022-19, PWYgy2021-02), and the Clinical Research Project of Shanghai Municipal Health Commission (No. 20204Y0173). All funding had no role in study design, data analysis, paper submission and publication.

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Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, 200124, China

Minghuan Zhu, Qi Zhang, Xiaoyan Cheng, Lei Zhang, Fengzhi Tao, Jiali Shi, Xingjia Zhu, Zhihui Wang, Xudong Zhao & Weiqing Liu

The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China

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Xudong Zhao and Weiqing Liu were responsible for the study concept and design, as well as for revising and editing the manuscript. Minghuan Zhu, Yifan Xu, Qi Zhang, Xiaoyan Cheng, Lei Zhang, Fengzhi Tao, Jiali Shi, Xingjia Zhu and Zhihui Wang collected the data. Minghuan Zhu prepared the initial draft of the manuscript. All authors have contributed to and approved the final manuscript.

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Zhu, M., Xu, Y., Zhang, Q. et al. Reduction of intracortical inhibition (ICI) correlates with cognitive performance and psychopathology symptoms in schizophrenia. Schizophr 10 , 78 (2024). https://doi.org/10.1038/s41537-024-00491-z

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DOI : https://doi.org/10.1038/s41537-024-00491-z

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