A pilot randomised controlled trial of Problem-Solving Treatment for Visual Impairment (POSITIVE): protocol paper.

PURPOSE: For visually impaired individuals, motivation to be mobile and the individual's emotional states are predetermining factors of functioning. In addition, loss of confidence at the time of diagnosis could inhibit the ability to make progress. The aim of this study is to evaluate whether Problem-Solving Treatment, a brief, structured psychological intervention, leads to better psychological well-being in people who have been recently diagnosed as blind or partially sighted. METHODS: A pilot randomised controlled trial: the trial aims to recruit 120 individuals who have either: (1) been diagnosed with severe, irreversible sight loss, or (2) registered as blind or partially sighted within the last 3 months. Individuals will be randomly allocated to either the intervention or control group with randomisation stratified by severity of vision loss. Those in the intervention arm will receive Problem-Solving Treatment, an established intervention that addresses individual's confidence, motivation and psychological well-being by undertaking specific tasks to help individuals work through their problems, and recognising steps to problem resolution. Both groups will continue to receive routine care, such as mobility training. STUDY OUTCOMES: The primary outcome is psychological well-being measured at 3, 6, and 9 months after recruitment and assignment to intervention or control group. Secondary outcomes include symptoms of distress, mobility and quality of life.

Psychiatric diagnosis: impersonal, imperfect and important.

Psychiatric diagnosis is in the spotlight following the recent publication of DSM-5. In this article we consider both the benefits and limitations of diagnosis in psychiatry. The use of internationally recognised diagnoses, although insufficient alone, is part of a psychiatrist's professional responsibility to provide high-quality, evidence-based care for patients.

A well-being programme in severe mental illness. Reducing risk for physical ill-health: a post-programme service evaluation at 2 years.

INTRODUCTION: Cardiovascular disease is more prevalent in patients with severe mental illness (SMI) than in the general population. METHOD: Seven geographically diverse centres were assigned a nurse to monitor the physical health of SMI patients in secondary care over a 2-year period in the "Well-being Support Programme" (WSP). A physical health screen was performed and patients were given individual weight and lifestyle advice including smoking cessation to reduce cardiovascular risk. RESULTS: Nine hundred and sixty-six outpatients with SMI >2 years were enrolled. The completion rate at 2 years was 80%. Significant improvements were observed in levels of physical activity (p<0.0001), smoking (p<0.05) and diet (p<0.0001). There were no changes in mean BMI although 42% lost weight over 2 years. Self-esteem improved significantly. Low self-esteem decreased from 43% at baseline to 15% at 2 years (p<0.0001). At the end of the programme significant cardiovascular risk factors remained, 46% of subjects smoked, 26% had hypertension and 81% had BMI >25. CONCLUSION: Physical health problems are common in SMI subjects. Many patients completed 2 years follow up suggesting that this format of programme is an acceptable option for SMI patients. Cardiovascular risk factors were significantly improved. Interventions such as the Well-being Support Programme should be made widely available to people with SMI.

Does problem-solving treatment work through resolving problems?

BACKGROUND: A randomized controlled trial of problem-solving treatment, antidepressant medication and the combination of the two treatments found no difference in treatment efficacy for major depressive disorders in primary care. In addition to treatment outcome, the trial sought to determine possible mechanisms of action of the problem-solving intervention. METHOD: Two potential mechanisms of action of problem-solving treatment were evaluated by comparison with drug treatment. First, did problem-solving treatment work by achieving problem resolution and secondly, did problem-solving treatment work by increasing the patients' sense of mastery and self-control? RESULTS: Problem-solving treatment did not achieve a greater resolution in the patients' perception of their problem severity by comparison with drug treatment, neither did problem-solving treatment result in a greater sense of mastery or self-control. CONCLUSIONS: The results from this study did not support the hypotheses that for patients with major depression, by comparison with antidepressant medication: problem-solving treatment would result in better problem resolution; or that problem-solving treatment would increase the patients' sense of mastery and self-control.

Credibility of problem-solving therapy and medication for the treatment of depression among primary care patients.

BACKGROUND: Patient beliefs in the effectiveness of treatment may have an important influence on treatment outcome. MATERIAL/METHODS: Associations between patient beliefs in the credibility of treatment and outcome were explored in a randomised controlled trial of major depression in primary care (n=155). The four treatments were antidepressant medication given by research general practitioner, problem solving treatment given by research general practitioner or research practice nurse over 12 weeks or a combination of problem solving treatment and antidepressant medication. Patients' belief in the credibility of treatment was assessed using a brief Credibility Scale, that was completed following randomisation and after treatment. Depression outcome was measured at 6, 12 and 52 weeks using the Hamilton Rating Scale for depression, and the Beck depression inventory. RESULTS: Pre-treatment, medication treatment was associated with a higher certainty of recovery than was problem-solving treatment from the nurse (p=0.018). Post-treatment, medication and combination treatment were seen as more logical than problem-solving treatment from the nurse (p<0.03). Post-treatment medication had higher certainty of recovery and was more highly recommended to a friend. Linear regression demonstrated that the depression outcome measures were not associated with either pre- or post-treatment credibility. CONCLUSIONS: Patients found all four treatments highly credible following their initial explanation. There was a significant difference both pre- and post-treatment in favour of patients finding treatment involving medication more credible than problem-solving from a nurse. Pre- and post-treatment scores of credibility were not associated with outcome.