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Problem-solving therapy effective for depression with executive dysfunction

Clinical Question:
Is problem-solving therapy more effective than supportive therapy for older adults with major depression and executive dysfunction?

Bottom Line:
Problem-solving therapy is more effective than supportive therapy for older adults with major depression and executive dysfunction. (LOE = 1b)

Reference:
Arean PA, Raue P, Mackin RS, Kanellopoulos D, McCulloch C, Alexopoulos GS. Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. Am J Psychiatry 2010;167(11):1391-1398.  [PMID:20516155]

Study Design:
Randomized controlled trial (nonblinded)

Funding:
Government

Allocation:
Concealed

Setting:
Outpatient (specialty)

Synopsis:
Problem-solving therapy as treatment for depression is based on the premise that helping patients manage their lives better reduces stress with a beneficial effect on depression. In this study, patients 60 years and older (N = 221) were selected through structured clinical interviews. Inclusion criteria were diagnosis of major depression with a severity score of more than 20 on the Hamilton Depression Rating Scale (Ham-D), a Mini-Mental State Examination score of greater than 24, a Mattis Dementia Rating Scale score of less than 33 on the initiation/perseveration subscale, and a Stroop Color-Word Test score of less than 25. Exclusion criteria were current treatment with psychotherapy or antidepressants, psychosis, intent or plan to commit suicide, axis I disorders other than unipolar depression and anxiety, antisocial personality disorder, severe medical illness, use of drugs known to cause depression, and inability to perform activities of daily living. Patients were randomized to 12 weekly sessions of either (1) problem-solving therapy using a specific 5-step process to set goals, plan ways to reach goals, create action plans, and evaluate results, or (2) supportive therapy involving nondirective, nonjudgmental active listening. The attrition rate was less than 10% and did not differ between study arms. Therapists were unaware of study hypotheses and outcome assessment was masked. Therapists were documented to have adhered to the respective treatment modality through review of audiotapes of sessions. At 12 weeks, response (defined as a reduction of the Ham-D score by at least half) was greater in the problem-solving therapy group (57% vs 34%; number needed to treat [NNT] = 4; 95% CI, 3-12). Remission (defined as a Ham-D score of < 10) was also greater in the problem-solving group (46% vs 28%; NNT = 6; 3-26).

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