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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

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.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

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 "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

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.

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

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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Problem Solving Treatment (PST)

Course outline.

We offer two tiers of PST training for licensed clinicians: a shorter Course in PST (Tier 1) and full PST certification (Tier 2). We encourage clinicians to pursue Tier 2: PST Certification, as skill-based practice and expert feedback are important to meeting fidelity standards. Notably, the evidence base for the effectiveness of PST has been demonstrated using clinicians at this level of clinical skill. For more information on the courses (including pricing and eligibility) click the links below, or download a detailed overview covering both PST training tiers.

A Course in PST consists of a series of online modules introducing PST principles, followed by 6 monthly group case presentation calls.

PST Certification involves online modules followed by individual simulated virtual visits, 6 monthly group case presentation calls, and in-depth expert feedback on application of clinical skills based on session audio recording review.

Become an Expert PST Trainer

Get certified as a PST Trainer, in these group training sessions participants will learn the skills needed to train others in PST.

Problem-Solving Treatment (PST) is a brief, evidence-based approach effective with most patient populations, including patients from various cultural backgrounds. The goal of PST is to teach patients problem-solving techniques that empower them to solve problems that arise from life stressors and contribute to their depression. PST is not intended to provide open-ended, ongoing therapy but aims to help patients learn skills they can use independently to reduce their psychological distress.

PST typically involves six to ten sessions as part of a treatment plan. The first appointment is approximately one hour long (this can be split into two ½ hour sessions if scheduling an hour is difficult) because it includes psychoeducation and an introduction to the PST model. Subsequent appointments are 30 minutes long.

Psychotherapy plays an important part in a patient's treatment plan, given patient preferences and the limitations of antidepressant medications. Organizations implementing an integrated care program should have the capacity to offer evidence-based psychotherapy such as PST. PST sessions can be billed by licensed providers using psychotherapy or CoCM CPT codes.

PST is the most widely used intervention to treat depression and anxiety in a primary care environment. Research shows it significantly improves patient outcomes in a wide range of settings and patient populations. PST is effective for depression among all adult populations (aged 18-100), including older adults with mild cognitive impairment.

The document below contains selected references demonstrating the efficacy of PST in primary care.

• Problem Solving Treatment: Selected References

The University of Washington AIMS Center is approved by the  American Psychological Association  (APA) to sponsor continuing education (CE) for psychologists. The AIMS Center maintains responsibility for this program and its content. APA CE credits can be used by most licensed mental health providers, including psychologists, clinical social workers, professional counselors, and marriage and family therapists. Clinicians should check their specific state requirements to confirm that credits awarded by the APA apply to them.

Participants are eligible for up to 10 CE credits (PST Tier 1) or up to 13 CE credits (PST Tier 2). To receive credits participants must attend the entire course and pass a learning evaluation.

CONFLICT OF INTEREST DISCLOSURE INFORMATION

There are no relevant financial relationships to disclose for authors or planners of this content.

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Clinical problem solving and diagnostic decision making: selective review of the cognitive literature

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This article has a correction. Please see:

• Clinical problem solving and diagnostic decision making: selective review of the cognitive literature - November 02, 2006
• Arthur S Elstein , professor ( aelstein{at}uic.edu ) ,
• Alan Schwarz , assistant professor of clinical decision making.
• Department of Medical Education, University of Illinois College of Medicine, Chicago, IL 60612-7309, USA
• Correspondence to: A S Elstein

This is the fourth in a series of five articles

This article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving 1 , 2 , 3 and decision making. 4 , 5 , 6 , 7 , 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards.

Summary points

Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods

The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy

Final conclusions should depend both on prior belief and strength of the evidence

Conclusions reached by Bayes's theorem and clinical intuition may conflict

Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies

Evidence based medicine applies decision theory to clinical diagnosis

Problem solving

Diagnosis as selecting a hypothesis.

The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data. 1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the quality of their hypotheses is higher than that of novices. Novices struggle to develop a plan and some have difficulty moving beyond collection of data to considering possibilities.

It is possible to collect data thoroughly but nevertheless to ignore, to misunderstand, or to misinterpret some findings, but also possible for a clinician to be too economical in collecting data and yet to interpret accurately what is available. Accuracy and thoroughness are analytically separable.

Pattern recognition or categorisation

Expertise in problem solving varies greatly between individual clinicians and is highly dependent on the clinician's mastery of the particular domain. 9 This finding challenges the hypothetico-deductive model of clinical reasoning, since both successful and unsuccessful diagnosticians use hypothesis testing. It appears that diagnostic accuracy does not depend as much on strategy as on mastery of content. Further, the clinical reasoning of experts in familiar situations frequently does not involve explicit testing of hypotheses. 3 10 , 11 , 12 Their speed, efficiency, and accuracy suggest that they may not even use the same reasoning processes as novices. 11 It is likely that experienced physicians use a hypothetico-deductive strategy only with difficult cases and that clinical reasoning is more a matter of pattern recognition or direct automatic retrieval. What are the patterns? What is retrieved? These questions signal a shift from the study of judgment to the study of the organisation and retrieval of memories.

Problem solving strategies

Hypothesis testing

Pattern recognition (categorisation)

By specific instances

By general prototypes

Viewing the process of diagnosis assigning a case to a category brings some other issues into clearer view. How is a new case categorised? Two competing answers to this question have been put forward and research evidence supports both. Category assignment can be based on matching the case to a specific instance (“instance based” or “exemplar based” recognition) or to a more abstract prototype. In the former, a new case is categorised by its resemblance to memories of instances previously seen. 3 11 This model is supported by the fact that clinical diagnosis is strongly affected by context—for example, the location of a skin rash on the body—even when the context ought to be irrelevant. 12

The prototype model holds that clinical experience facilitates the construction of mental models, abstractions, or prototypes. 2 13 Several characteristics of experts support this view—for instance, they can better identify the additional findings needed to complete a clinical picture and relate the findings to an overall concept of the case. These features suggest that better diagnosticians have constructed more diversified and abstract sets of semantic relations, a network of links between clinical features and diagnostic categories. 14

The controversy about the methods used in diagnostic reasoning can be resolved by recognising that clinicians approach problems flexibly; the method they select depends upon the perceived characteristics of the problem. Easy cases can be solved by pattern recognition: difficult cases need systematic generation and testing of hypotheses. Whether a diagnostic problem is easy or difficult is a function of the knowledge and experience of the clinician.

The strategies reviewed are neither proof against error nor always consistent with statistical rules of inference. Errors that can occur in difficult cases in internal medicine include failure to generate the correct hypothesis; misperception or misreading the evidence, especially visual cues; and misinterpretations of the evidence. 15 16 Many diagnostic problems are so complex that the correct solution is not contained in the initial set of hypotheses. Restructuring and reformulating should occur as data are obtained and the clinical picture evolves. However, a clinician may quickly become psychologically committed to a particular hypothesis, making it more difficult to restructure the problem.

Decision making

Diagnosis as opinion revision.

From the point of view of decision theory, reaching a diagnosis means updating opinion with imperfect information (the clinical evidence). 8 17 The standard rule for this task is Bayes's theorem. The pretest probability is either the known prevalence of the disease or the clinician's subjective impression of the probability of disease before new information is acquired. The post-test probability, the probability of disease given new information, is a function of two variables, pretest probability and the strength of the evidence, measured by a “likelihood ratio.”

Bayes's theorem tells us how we should reason, but it does not claim to describe how opinions are revised. In our experience, clinicians trained in methods of evidence based medicine are more likely than untrained clinicians to use a Bayesian approach to interpreting findings. 18 Nevertheless, probably only a minority of clinicians use it in daily practice and informal methods of opinion revision still predominate. Bayes's theorem directs attention to two major classes of errors in clinical reasoning: in the assessment of either pretest probability or the strength of the evidence. The psychological study of diagnostic reasoning from this viewpoint has focused on errors in both components, and on the simplifying rules or heuristics that replace more complex procedures. Consequently, this approach has become widely known as “heuristics and biases.” 4 19

Errors in estimation of probability

Availability —People are apt to overestimate the frequency of vivid or easily recalled events and to underestimate the frequency of events that are either very ordinary or difficult to recall. Diseases or injuries that receive considerable media attention are often thought of as occurring more commonly than they actually do. This psychological principle is exemplified clinically in the overemphasis of rare conditions, because unusual cases are more memorable than routine problems.

Representativeness —Representativeness refers to estimating the probability of disease by judging how similar a case is to a diagnostic category or prototype. It can lead to overestimation of probability either by causing confusion of post-test probability with test sensitivity or by leading to neglect of base rates and implicitly considering all hypotheses equally likely. This is an error, because if a case resembles disease A and disease B equally, and A is much more common than B, then the case is more likely to be an instance of A. Representativeness is associated with the “conjunction fallacy”—incorrectly concluding that the probability of a joint event (such as the combination of findings to form a typical clinical picture) is greater than the probability of any one of these events alone.

Heuristics and biases

Availability

Representativeness

Probability transformations

Effect of description detail

Conservatism

Anchoring and adjustment

Order effects

Decision theory assumes that in psychological processing of probabilities, they are not transformed from the ordinary probability scale. Prospect theory was formulated as a descriptive account of choices involving gambling on two outcomes, 20 and cumulative prospect theory extends the theory to cases with multiple outcomes. 21 Both prospect theory and cumulative prospect theory propose that, in decision making, small probabilities are overweighted and large probabilities underweighted, contrary to the assumption of standard decision theory. This “compression” of the probability scale explains why the difference between 99% and 100% is psychologically much greater than the difference between, say, 60% and 61%. 22

Support theory

Support theory proposes that the subjective probability of an event is inappropriately influenced by how detailed the description is. More explicit descriptions yield higher probability estimates than compact, condensed descriptions, even when the two refer to exactly the same events. Clinically, support theory predicts that a longer, more detailed case description will be assigned a higher subjective probability of the index disease than a brief abstract of the same case, even if they contain the same information about that disease. Thus, subjective assessments of events, while often necessary in clinical practice, can be affected by factors unrelated to true prevalence. 23

Errors in revision of probability

In clinical case discussions, data are presented sequentially, and diagnostic probabilities are not revised as much as is implied by Bayes's theorem 8 ; this phenomenon is called conservatism. One explanation is that diagnostic opinions are revised up or down from an initial anchor, which is either given in the problem or subjectively formed. Final opinions are sensitive to the starting point (the “anchor”), and the shift (“adjustment”) from it is typically insufficient. 4 Both biases will lead to collecting more information than is necessary to reach a desired level of diagnostic certainty.

It is difficult for everyday judgment to keep separate accounts of the probability of a disease and the benefits that accrue from detecting it. Probability revision errors that are systematically linked to the perceived cost of mistakes show the difficulties experienced in separating assessments of probability from values, as required by standard decision theory. There is a tendency to overestimate the probability of more serious but treatable diseases, because a clinician would hate to miss one. 24

Bayes's theorem implies that clinicians given identical information should reach the same diagnostic opinion, regardless of the order in which information is presented. However, final opinions are also affected by the order of presentation of information. Information presented later in a case is given more weight than information presented earlier. 25

Other errors identified in data interpretation include simplifying a diagnostic problem by interpreting findings as consistent with a single hypothesis, forgetting facts inconsistent with a favoured hypothesis, overemphasising positive findings, and discounting negative findings. From a Bayesian standpoint, these are all errors in assessing the diagnostic value of clinical evidence—that is, errors in implicit likelihood ratios.

Educational implications

Two recent innovations in medical education, problem based learning and evidence based medicine, are consistent with the educational implications of this research. Problem based learning can be understood as an effort to introduce the formulation and testing of clinical hypotheses into the preclinical curriculum. 26 The theory of cognition and instruction underlying this reform is that since experienced physicians use this strategy with difficult problems, and since practically any clinical situation selected for instructional purposes will be difficult for students, it makes sense to provide opportunities for students to practise problem solving with cases graded in difficulty. The finding of case specificity showed the limits of teaching a general problem solving strategy. Expertise in problem solving can be separated from content analytically, but not in practice. This realisation shifted the emphasis towards helping students acquire a functional organisation of content with clinically usable schemas. This goal became the new rationale for problem based learning. 27

Evidence based medicine is the most recent, and by most standards the most successful, effort to date to apply statistical decision theory in clinical medicine. 18 It teaches Bayes's theorem, and residents and medical students quickly learn how to interpret diagnostic studies and how to use a computer based nomogram to compute post-test probabilities and to understand the output. 28

We have selectively reviewed 30 years of psychological research on clinical diagnostic reasoning. The problem solving approach has focused on diagnosis as hypothesis testing, pattern matching, or categorisation. The errors in reasoning identified from this perspective include failure to generate the correct hypothesis; misperceiving or misreading the evidence, especially visual cues; and misinterpreting the evidence. The decision making approach views diagnosis as opinion revision with imperfect information. Heuristics and biases in estimation and revision of probability have been the subject of intense scrutiny within this research tradition. Both research paradigms understand judgment errors as a natural consequence of limitations in our cognitive capacities and of the human tendency to adopt short cuts in reasoning.

Both approaches have focused more on the mistakes made by both experts and novices than on what they get right, possibly leading to overestimation of the frequency of the mistakes catalogued in this article. The reason for this focus seems clear enough: from the standpoint of basic research, errors tell us a great deal about fundamental cognitive processes, just as optical illusions teach us about the functioning of the visual system. From the educational standpoint, clinical instruction and training should focus more on what needs improvement than on what learners do correctly; to improve performance requires identifying errors. But, in conclusion, we emphasise, firstly, that the prevalence of these errors has not been established; secondly, we believe that expert clinical reasoning is very likely to be right in the majority of cases; and, thirdly, despite the expansion of statistically grounded decision supports, expert judgment will still be needed to apply general principles to specific cases.

Series editor J A Knottnerus

Preparation of this review was supported in part by grant RO1 LM5630 from the National Library of Medicine.

Competing interests None declared.

“The Evidence Base of Clinical Diagnosis,” edited by J A Knottnerus, can be purchased through the BMJ Bookshop ( http://www.bmjbookshop.com/ )

• Elstein AS ,
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• Lemieux M ,
• Kassirer JP ,
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• Open access
• Published: 24 August 2021

Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

• Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
• Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
• Benjamin W. C. Chan 4 ,
• Sarah Bonato   ORCID: orcid.org/0000-0002-5174-0047 1 ,
• Madison Aitken   ORCID: orcid.org/0000-0002-4921-5462 1 , 3 ,
• Jacqueline Relihan 1 ,
• Matthew Prebeg 1 ,
• Karleigh Darnay   ORCID: orcid.org/0000-0002-0395-8674 1 ,
• Lisa D. Hawke   ORCID: orcid.org/0000-0003-1108-9453 1 , 3 ,
• Priya Watson   ORCID: orcid.org/0000-0001-9753-6490 1 , 3 &
• Peter Szatmari   ORCID: orcid.org/0000-0002-4535-115X 1 , 3 , 5  

BMC Psychiatry volume  21 , Article number:  397 ( 2021 ) Cite this article

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Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

Conclusions

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Peer Review reports

Depressive disorders are a common mental health concern in adolescence [ 1 , 2 , 3 ] and associated with functional impairment [ 4 ] and an increased risk of adverse mental health, physical health, and socio-economic outcomes in adulthood [ 5 , 6 , 7 , 8 ]. Early and effective intervention is needed to reduce the burden arising from early-onset depression. Several psychotherapies have proven modestly effective at reducing youth depression, including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) [ 9 , 10 ]. Room for improvement remains; around half of youth do not show measurable symptom reduction after an average of 30 weeks of routine clinical care for depression or anxiety [ 11 ]. One barrier to greater impact is a lack of understanding of which treatment ingredients are most critical [ 12 , 13 ]. Identifying the “active ingredients” that underpin effective approaches, and understanding when and for whom they are most effective is an important avenue for enhancing impact [ 13 ]. Distilling interventions to their most effective ingredients while removing redundant content may also help reduce treatment length and cost, freeing up resources to expand service provision. Given that youth frequently drop out of treatment early [ 14 ], introducing the most effective ingredients at the start may also help improve outcomes.

One common ingredient in the treatment of youth depression is problem-solving (PS) training [ 15 ]. Problem solving in real-life contexts (also called social problem solving) describes “the self-directed process by which individuals attempt to identify [ …] adaptive coping solutions for problems, both acute and chronic, that they encounter in everyday living” (p.8) [ 16 ]. Within a relational/problem-solving model of stress and well-being, mental health difficulties are viewed as the result of maladaptive coping behaviours that cannot adequately safeguard an individual’s well-being against chronic or acute stressors [ 17 ]. According to a conceptual model developed by D’Zurilla and colleagues ([ 16 , 17 , 18 , 19 ]; see Fig.  1 ), effective PS requires a constructive and confident attitude towards problems (i.e., a positive problem orientation ), and the ability to approach problems rationally and systematically (i.e., rational PS style ). Defeatist or catastrophizing attitudes (i.e., a negative problem orientation ), passively waiting for problems to resolve (i.e., avoidant style ), or acting impulsively without thinking through possible consequences and alternative solutions (i.e., impulsive/careless style ) are considered maladaptive [ 16 , 18 , 20 ]. Empirical studies suggest maladaptive PS is associated with depressive symptoms in adolescents and young adults [ 21 , 22 , 23 , 24 , 25 ].

Dimensions of Problem-Solving (PS) Ability

Problem-Solving Therapy (PST) is a therapeutic approach developed by D’Zurilla and Goldfried [ 26 ] in the 1970s, to alleviate mental health difficulties by improving PS ability. Conceptually rooted in Social Learning Theory [ 27 ], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by helping them develop and internalize four core PS skills: (a) defining the problem; (b) brainstorming possible solutions; (c) appraising solutions and selecting the most promising one; (d) implementing the preferred solution and reflecting on the outcome ([ 16 , 17 , 18 , 19 ]; see Fig. 1 ). PST is distinct from Solution-Focused Brief Therapy (SFBT), which has different conceptual roots and emphasizes the construction of solutions over the in-depth formulation of problems [ 28 ].

PS training is also a common ingredient of other psychosocial depression treatments [ 15 , 20 ], such as CBT and Dialectical Behaviour Therapy (DBT) [ 15 , 29 , 30 , 31 , 32 ] that typically focus on strengthening PS skills rather than problem orientation [ 20 ]. In IPT, PS training focuses on helping youth understand and resolve relationship problems [ 29 , 30 , 33 , 34 ]. PS training is also a common component of family therapy [ 35 ], cognitive reminiscence therapy [ 36 ], and adventure therapy [ 37 ]. The extent to which PS training in these contexts follows the conceptual model by D’Zurilla and colleagues varies. Hereafter, we will use the term PST (“Problem-Solving Therapy”) where problem-solving training constitutes a stand-alone intervention; and we will use the term “PS training” where it is mentioned as a part of other therapies or discussed more broadly as an active ingredient of treatment for youth depression.

Meta-analyses considering over 30 randomized control trials (RCTs) of stand-alone PST for adult depression suggest it is as effective as CBT and IPT, and more effective than waitlist or attention controls [ 38 , 39 , 40 ]. PST has been applied with children, adolescents, and young adults [ 41 , 42 , 43 , 44 , 45 , 46 ], but dedicated manuals for different developmental stages are not readily available. In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, suggesting these skills are highly transferable and relevant to youth [ 47 ]. PS training can be brief (i.e., involve fewer than 10 sessions) [ 38 ], and has been delivered to youth by trained clinicians [ 45 ], lay counsellors [ 46 ], and via online platforms [ 44 ]. It can also be adapted for primary care [ 40 ]. In light of its versatility and of its effectiveness in adults, PS training is a prime candidate for a treatment ingredient that deserves greater scrutiny in the context of youth depression. However, no systematic evidence synthesis has yet examined its efficacy and effectiveness in this population.

This study had two sequential parts. First, we conducted a mixed-methods scoping review to map the available evidence relating to PS training as an active ingredient for treating youth depression. Youth were defined as aged 14 to 24 years, broadly aligning with United Nations definitions [ 48 ]. In a subsequent step, we conducted an exploratory meta-analysis to examine the overall efficacy of free-standing PST, based on clinical trials identified in the scoping review.

Scoping review

Scoping review methodology was used to provide an initial overview of the available evidence [ 49 ]. The review was pre-registered on the Open Science Framework [ 50 ] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews checklist [ 51 ] (Additional File  1 ). The review was designed to integrate four types of literature: (a) qualitative studies reporting on young people’s experiences with PS training; (b) controlled clinical trials testing the efficacy of stand-alone PST; (c) studies examining PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapeutic interventions (e.g., CBT); and (d) clinical practice guidelines (CPGs) for youth depression. In addition, the search strategy included terms designed to identify relevant conceptual articles that are discussed here as part of the introduction [ 52 ].

Search strategy

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for (a) empirical studies published from database inception through June 2020, and (b) CPGs published between 2005 and July 2020. Reference lists of key studies were searched manually, and records citing key studies were searched using Google Scholar’s “search within citing articles” function [ 52 ]. The search strategy was designed in collaboration with a research librarian (SB) and combined topic-specific terms defining the target population (e.g., “depression”; “adolescent?”) and intervention (e.g., “problem-solving”) with methodological search filters combining database-specific subject headings (e.g., “randomized controlled trial”) and recommended search terms. The search for CPGs built upon a previous systematic search [ 53 , 54 ], which was updated and expanded to cover additional languages and databases. A multi-pronged grey literature search retrieved records from common grey literature databases and CPG repositories, websites of relevant associations, charities, and government agencies. The search strategy is provided in Additional File  2 .

Inclusion and exclusion criteria

Empirical studies were included if the mean participant age fell within the eligible range of 14 to 24 years, and at least 50% of participants showed above-threshold depressive or emotional symptoms on a validated screening tool. Controlled clinical trials had to compare the efficacy or effectiveness of PST as a free-standing intervention with a control group or waitlist condition. Secondary analyses were considered for their assessment of PS ability as a predictor, moderator, or mediator of treatment response if they reported on data from controlled clinical trials of broader therapy packages. Records were included as CPGs if labelled as practice guidelines, practice parameters, or consensus or expert committee recommendations, or explicitly aimed to develop original clinical guidance [ 53 , 54 ]; and if focused on indicated psychosocial treatments for youth depression (rather than prevention, screening, or pharmacological treatment). Doctoral dissertations were included. Conference abstracts, non-controlled trials, and prevention studies were excluded. Language of publication was restricted to English, French, German, and Spanish.

All records identified were imported into the EPPI-Reviewer 4.0 review software [ 55 ], and underwent a two-stage screening process (Fig.  2 ). Title and abstract screening was conducted in duplicate for 10% of the identified records, yielding substantial inter-rater agreement ( kappa  = .75 and .86, for empirical studies and CPGs, respectively). Of studies retained for full text screening, 20% were screened in duplicate, yielding substantial agreement ( kappa  = .68 and .71, for empirical studies and CPGs, respectively). Disagreements were resolved through discussion.

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

Data were extracted using templates tailored to each literature type (e.g., the Cochrane data collection form for RCTs). Information extracted included: citation details; study design; participant characteristics; and relevant qualitative or quantitative results. Additional information extracted from CPGs included the issuing authority, the target population, the treatment settings to which the guideline applied, and any recommendations in relation to PS training. Data from clinical trials and secondary analyses were extracted in duplicate, and any discrepancies were discussed and resolved. Data synthesis followed a five-step process of data reduction, display, comparison, conclusion drawing, and verification [ 56 ]. Scoping review findings were summarized in narrative format. In addition, effect sizes reported in PST trials for depression severity were entered into an exploratory meta-analysis (see below).

The Centre for Addiction and Mental Health (CAMH) implements a Youth Engagement Initiative that brings the voices of youth with lived experience of mental health difficulties into research and service design [ 57 , 58 , 59 ]. Two youth partners were co-investigators in this review and consulted with a panel of twelve CAMH youth advisors to inform the review process and help contextualize findings. Formal approval by a Research Ethics Board (REB) was not required, as youth were research partners rather than participants.

To incorporate a variety of perspectives, the review team convened for an inference workshop where emerging review findings and feedback from youth advisors were discussed and interpreted. The multidisciplinary team involved a methodologist; two child and adolescent psychiatrists with expertise in CBT, DBT, and IPT; a psychologist with expertise in parent-adolescent therapy; a research librarian; a family doctor; a biostatistician; a clinical epidemiologist; two youth research partners; and a youth engagement coordinator.

Exploratory Meta-analysis

Although meta-analyses are not typical components of scoping reviews [ 60 ], an exploratory meta-analysis was conducted following completion of the scoping review and narrative synthesis, to obtain an initial indication of the efficacy of stand-alone PST based on the clinical trials identified in the review. The PICO statement that guided the meta-analysis is shown in Table  1 .

Quality assessment

Risk of bias for included PST trials was appraised using the Cochrane Collaborations Risk of Bias (ROB) 2 tool [ 61 ]. Ratings were performed independently by two reviewers (KRK and MA), and consensus was formed through discussion. In addition, a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) appraisal was conducted (using the GRADEpro software; [ 62 ] to characterize the quality of the overall evidence. The evidence was graded for risk of bias, imprecision, indirectness, inconsistency, and publication bias [ 63 ]. A GRADE of “high quality” indicates a high level of confidence that the true effect lies close to the estimate; “moderate quality” indicates moderate confidence; “low quality” indicates limited confidence; and “very low quality” indicates very little confidence in the estimate. ROB ratings and GRADE appraisal results are provided in Additional File  6 .

Statistical analysis

The meta-analysis was conducted using the meta suite of commands in Stata 16.1. Effect sizes (Hedges’ g) and their confidence intervals were calculated based on the mean difference in depression severity scores between the PST and control conditions at the first post-treatment assessment [ 64 ]. Hedges’ g is calculated by subtracting the post-treatment mean score of the intervention group from the score of the control group, and by dividing the mean difference by the pooled standard deviation. Effect sizes between g = 0.2 and 0.5 indicate a small effect; g = 0.5 to 0.8 indicates a moderate effect; and g ≥ 0.8 indicates a large effect. Effect sizes were adjusted using the Hedges and Olkin small sample correction [ 64 ]. Pooled effect sizes were computed using a random effects model to account for heterogeneity in intervention settings, modes of delivery, and participant age and depression severity. The I 2 statistic was computed as an indicator of effect size heterogeneity. Higgins et al. [ 65 ] suggest that an I 2 below 30% represents low heterogeneity while an I 2 above 75% represents substantial heterogeneity. Investigations of heterogeneity are unlikely to generate valuable insights in small study samples, with at least ten studies recommended for meta-regression [ 65 ]. We conducted limited exploratory subgroup analysis by computing a separate effect size after excluding studies with high risk of bias. We inspected the funnel plot and considered conducting Egger’s test to examine the likelihood and extent of publication bias [ 66 ].

Selection and inclusion of studies

The search for empirical studies identified 563 unique records (Fig. 2 ), of which 148 were screened in full. Inclusion criteria were met by four RCTs of free-standing PST and four secondary analyses of clinical trials investigating PS-related concepts as predictors, mediators, or moderators of treatment response. No eligible qualitative studies that explicitly examined youth experiences of PS training were identified. The search for CPGs identified 9691 unique records, of which 41 were subject to full text screening, and 23 were included in the review. Below we present scoping review findings for all literature types, followed by the results from the meta-analysis for stand-alone PST trials.

Clinical trials of PST

Characteristics of the included PST trials are shown in Table  2 . Studies were published between 2008 and 2020 and included 524 participants (range: 45 to 251), with a mean age of 16.7 years (range: 12–25; 48% female). Participants had a diagnosis of major depressive disorder (MDD; k  = 1), elevated anxiety or depressive symptoms ( k  = 1), or various mild presenting problems including depression ( k  = 2). Treatment covered PS skills but not problem orientation (i.e., youth’s problem appraisals) and was delivered face to face ( k =  3) or online ( k  = 1) in five to six sessions. PST was compared with waitlist controls ( k  = 2), PS booklets ( k =  1), and supportive counselling ( k  = 1). Risk of bias was rated as medium for two [ 44 , 45 ], and high for one study [ 43 ] due to concerns about missing outcome data and the absence of a study protocol.

Eskin and colleagues [ 43 ] randomized 53 Turkish high school and university students with MDD to six sessions of PST or a waitlist. The study reports a significant treatment effect on self-reported depressive symptoms (d = − 1.20; F [1, 42] = 10.3, p  < .01.), clinician-reported depressive symptoms (d = − 2.12; F [1, 42] = 37.7, p  < .001), and recovery rates, but not on self-reported PS ability (d = − 0.46; F [1, 42] = 2.2, p  > .05). Risk of bias was rated as high due to 37% of missing outcome data in the control group and the absence of a published trial protocol.

Michelson and colleagues [ 46 ] compared PST delivered by lay counsellors in combination with booklets, to PS booklets alone in 251 high-school students with mild mental health difficulties (53% emotional problems) in low-income communities in New Delhi, India. At six weeks, the intervention group showed significantly greater progress towards overcoming idiographic priority problems identified at baseline (d = 0.36, p  = .002), but no significant difference in self-reported mental health difficulties (d = 0.16, p  = .18). Results were similar at 12 weeks, including no significant difference in self-reported emotional symptoms (d = 0.18, p  = .089). As there was no long-term follow-up, it is unknown whether reduced personal problems translated into reduced emotional symptoms in the longer term. Perceived stress at six weeks was found to mediate treatment effect on idiographic problems, accounting for 15% of the overall effect at 12 weeks.

Two trials found no significant effect of PST on primary or secondary outcomes: Hoek and colleagues [ 44 ] randomized 45 youth with elevated depression or anxiety symptoms to five sessions of online PST or a waitlist control; Parker and colleagues [ 45 ] randomized 176 youth with mixed presenting problems (54% depression) to either PST with physical activity or PST with psychoeducation, compared with supportive counselling with physical activity or psychoeducation [ 45 ]. Drop-out from PST was high in both studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ].

PS-related concepts as predictors, moderators, or mediators of treatment response

The review identified four secondary analyses of RCT data that examined PS-related concepts as predictors, moderators, or mediators of treatment response (see Table  3 , below). Studies were published between 2005 and 2014 and included data from 761 participants with MDD diagnoses, and a mean age of 15.2 years (range: 12–18; 61.2% female).

A secondary analysis of data from the Treatment for Adolescents with Depression Study (TADS, n  = 439) [ 79 ] explored whether baseline problem orientation and PS styles were significant predictors or moderators of treatment response to Fluoxetine, CBT, or a combination treatment at 12 weeks [ 70 ]. Negative problem orientation and avoidant PS style each predicted less improvement in depression symptom severity ( p  = .001 and p  = .003, respectively), while positive problem orientation predicted greater improvement ( p  = .002). There was no significant moderation effect. Neither rational PS style nor impulsive-careless PS style predicted or moderated change in depressive symptoms.

A secondary analysis of data from the Treatment of Resistant Depression in Adolescents (TORDIA) study [ 80 ] examined the impact of specific CBT components on treatment response at 12 weeks in youth treated with a selective serotonin reuptake inhibitor (SSRI) in combination with CBT ( n  = 166) [ 71 ]. Youth who received PS training were 2.3 times ( p  = .03) more likely to have a positive treatment response than those not receiving this component. A significant effect was also observed for social skills training (Odds Ratio [OR] = 2.6, p  = .04) but not for seven other CBT components. PS and social skills training had the most equal allocation ratios between youth who received them (52 and 54%, respectively) and youth who did not. Balanced allocation provides maximum power for a given sample size [ 81 ]. With allocation ratios between 1:3 and 1:5, analysis of the remaining seven components may have been underpowered. Of further note, CBT components were not randomly assigned but selected based on individual clinical needs. The authors did not correct for multiple comparisons as part of this exploratory analysis.

Dietz and colleagues [ 73 ] explored the impact of social problem solving on treatment outcome based on data from a trial comparing CBT and Systemic Behaviour Family Therapy (SBFT) with elements of PS training on the one hand, with Non-Directive Supportive Therapy on the other hand ( n  = 63). Both CBT and SBFT were associated with significant improvements in young people’s interpersonal PS behaviour (measured by coding videotaped interactions between youth and their mothers) over the course of treatment (CBT: b* = 0.41, p  = .006; SBFT: b* = 0.30, p  = .04), which in turn were associated with higher rates of remission (Wald z = 6.11, p  = .01). However, there was no significant indirect effect of treatment condition via youth PS behaviour, and hence, no definitive evidence of a formal mediation effect [ 82 ].

Kaufman and colleagues [ 72 ] examined data from a trial comparing an Adolescent Coping with Depression (CWD-A) group-based intervention with a life-skills control condition in 93 youth with comorbid depression and conduct disorder. The secondary analysis explored whether change in six CBT-specific factors, including the use of PS and conflict resolution skills, mediated the effectiveness of CWD-A. There was no significant improvement in PS ability in CWD-A, compared with the control, and hence no further mediation analysis was conducted.

PS training in clinical practice guidelines

We identified 23 CPGs from twelve countries relevant to youth depression (see Additional File  4 ), issued by governments ( k  = 6), specialty societies ( k  = 3), health care providers ( k  = 4), independent expert groups ( k  = 2), and others, or a combination of these. Of these 23 CPGs, 15 mentioned PS training in relation to depression treatment for youth, as a component of CBT ( k  = 7), IPT ( k  = 4), supportive therapy or counselling ( k  = 3), family therapy ( k  = 1), DBT ( k  = 1), and psychoeducation ( k  = 1).

None of the reviewed CPGs recommended free-standing PST as a first-line treatment for youth depression. However, five CPGs mentioned PS training as a treatment ingredient or adjunct component in the context of recommending broader therapeutic approaches. The World Health Organization’s updated Mental Health Gap Action Programme guidelines recommended PS training as an adjunct treatment (e.g., in combination with antidepressant medication) for older adolescents [ 83 ]. A guideline by Orygen (Australia) suggested that for “persistent sub-threshold depressive symptoms (including dysthymia) or mild to moderate depression”, options should include “6–8 sessions of individual guided self-help based on the principles of CBT, including behavioural activation and problem-solving techniques” [ 84 ]. The Chilean Ministry of Health recommended supportive clinical care with adjunctive psychoeducation and PS tools, or supportive counselling for individuals aged 15 and older with mild depression (p. 52) [ 85 ]. The Cincinnati Children’s Hospital Medical Centre recommended four to eight sessions of supportive therapy for mild or uncomplicated depression, highlighting “problem solving coping skills” as one element of supportive therapy (p. 1) [ 86 ]. Fifth, the American Academy of Child and Adolescent Psychiatry’s 2007 practice parameter suggested each phase of treatment for youth depression should include psychoeducation and supportive management, which might include PS training (p. 1510) [ 87 ]. CPGs did not specify whether PS training should incorporate specific modules, or whether the term was used loosely to describe unstructured PS support.

Meta-analysis

Each of the four RCTs of free-standing PST identified by the scoping review contributed one comparison to the exploratory meta-analysis of overall PST efficacy (see Fig.  3 ). Self-rated depression or emotional symptom severity scores were reported by all four studies and constituted the primary outcome for the meta-analysis. We conducted additional exploratory analysis for clinician-rated depression severity as reported in two studies [ 43 , 45 ]. The pooled effect size for self-reported depression severity was g = − 0.34 (95% CI: − 0.92 to 0.23). Heterogeneity was high ( I 2  = 88.37%; p  < .001). Due to the small number of studies included, analysis of publication bias via an examination of the funnel plot and tests of funnel plot asymmetry could not be meaningfully conducted [ 88 , 89 ]. The funnel plot is provided in Additional File  5 for reference (Fig. S3).

Forest Plot: Random Effects Model with Self-Reported Depression or Emotional Symptoms as Primary Outcome (Continuous)

To achieve the best possible estimate of the true effect size and reduce heterogeneity we computed a second model excluding the one study with high risk of bias (i.e., [ 43 ]). The resulting effect size was g = − 0.08 (95% CI: − 0.26 to 0.10), with no significant heterogeneity ( I 2  = 0.00%; p  = 0.72; see Fig. S1 in Additional File 5 ). The pooled effect size for clinician-rated depression severity was g = − 1.39 with a wide confidence interval (95% CI: − 4.03 to 1.42) and very high heterogeneity ( I 2  = 97.41%, p  < 0.001; see Fig. S2 in Additional File 5 ).

Overall quality of the evidence

According to the GRADE assessment, the overall quality of the evidence was very low, with concerns related to risk of bias, the inconsistency of results across studies, the indirectness of the evidence with regards to the population of interest (i.e., only one trial focused exclusively on youth with depression), and imprecision in the effect estimate (Table S4 in Additional File 6 ).

This scoping review aimed to provide a first comprehensive overview of the evidence relating to PS training as an active ingredient for treating youth depression. The evidence base relating to the efficacy of PST as a stand-alone intervention was scarce and of low quality. Overall, data from four trials suggested no significant effect on depression symptoms. The scoping review identified some evidence suggesting PS training may enhance treatment response in CBT. However, this conclusion was drawn from secondary analyses where youth were not randomized to treatment with and without PS training, and where primary studies were not powered to test these differences. Disproportionate exposure to comparator CBT components also limits these findings. PST was not recommended as a stand-alone treatment for youth depression in any of the 23 reviewed CPGs; however, one guideline suggested it could be provided alongside other treatments for older adolescents, and four suggested PS training as a component of low-intensity psychosocial interventions for youth with mild to moderate depression.

Given the limited evidence base, only tentative suggestions can be made as to when and for whom PS training is effective. The one PST trial with a low risk of bias enrolled high-school students from low-income communities in New Delhi, and found that PST delivered by lay counselors in combination with PST booklets was more effective at reducing idiographic priority problems than booklets alone, but not at reducing mental health symptoms [ 46 ]. Within a needs-based framework of service delivery (e.g., [ 90 ]), PST may be offered as a low-intensity intervention to youth who experience challenges and struggle with PS—including in low-resource contexts. Future research could explore whether PS training might be particularly helpful for youth facing socioeconomic hardship and related chronic stressors by attenuating potentially harmful impacts on well-being [ 91 ]. If findings are promising, PS training may be considered for targeted prevention (e.g., [ 42 ]). However, at this time there is insufficient evidence to support PS training on its own as an intervention aimed at providing symptom relief for youth experiencing depression.

The PST manual suggests cognitive overload, emotional dysregulation, negative thinking and hopelessness can interfere with PS [ 16 ]. Youth whose depression hinders their ability to engage in PST may require additional support through more comprehensive therapy packages such as CBT or IPT with PS training. In the TORDIA study [ 80 ], where PS training was found to be one of the most effective components, it was generally taught alongside cognitive restructuring, behavioural activation, and emotion regulation, which may have facilitated youths’ ability to absorb PS training [ 71 ]. The focus of these other CBT components on changing negative cognitions and attributions may fulfil a similar function as problem orientation modules in stand-alone PST. Research that is powered to explore such mechanisms is needed. Future research should also apply methodologies designed to identify the most critical elements in a larger treatment package (e.g., dismantling studies; or sequential, multiple assignment, randomized trials) to examine the role of PS training when delivered alongside other components. While one trial focusing on CBT components is currently underway [ 92 ], similar research is needed for other therapies (e.g., IPT, DBT, family therapy).

The included PST trials provided between five and six sessions and covered PS skills but not problem orientation. Meta-analyses of PST for adult depression suggest treatment effectiveness may be enhanced by longer treatment duration (≥ 10 sessions) [ 38 ], and coverage of problem orientation alongside PS skills [ 39 ]. As per the PST treatment manual, strengthening problem orientation fosters motivation and self-efficacy and is an important precondition for enhancing skills [ 93 , 94 ]. In addition, only one youth PST trial assessed PS ability at baseline [ 43 ]. A meta-analysis of PST for adult depression [ 39 ] suggests that studies including such assessments show larger effect sizes, with therapists better able to tailor PST to individual needs. Future research should seek to replicate these findings specifically for youth depression.

Drop out from stand-alone PST was high in two out of four studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ]. Since its development in the 1970s, PST has undergone several revisions [ 16 , 93 , 95 , 96 , 97 ] but tailoring to youth has been limited. To contextualize the review findings, the review team consulted a panel of twelve youth advisors at the Centre for Addiction and Mental Health (without sharing emerging findings so as not to steer the conversation). Most had participated in PS training as part of other therapies, but none had received formal PST. A key challenge identified by youth advisors was how to provide PS training that is universally applicable and relevant to different youth without being too generic, rigid or schematic; and how to accommodate youth perspectives, complex problems, and individual situations and dispositions. Youth advisors suggested reviewing and reworking PS training with youth in mind, to ensure it is youth-driven, strengths-based, comprehensive, and personalized (see Fig. S4 in Additional File  7 for more detail). Youth advisors emphasized that PS training should identify the root causes underpinning superficial problems and address these through suitable complementary intervention approaches, if needed.

Solution-focused brief therapy (SFBT) has emerged as an antithesis to PST where more emphasis is given to envisaging and constructing solutions rather than analysing problems [ 28 ]. This may be more consistent with youth preferences for strengths-based approaches but may provide insufficiently comprehensive problem appraisals. Future research should compare the effectiveness and acceptability of PST and SFBT and consider possible benefits of combining the advantages of both approaches, to provide support that is strengths-based and targets root problems. More generally, given the effectiveness of PST in adults, future studies could examine whether there are developmental factors that might contribute to reduced effectiveness in youth and should be considered when adapting PST to this age group.

Strengths and limitations

This scoping review applied a broad and systematic approach to study identification and selection. We searched five bibliographic databases, and conducted an extensive grey literature search, considering records published in four languages. Nevertheless, our search may have missed relevant studies published in other languages. We found only a small number of eligible empirical studies, several of which were likely underpowered. As stated above, studies analysing PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapies were heterogenous and limited by design and sample size constraints.

Similarly, there was heterogeneity in recruitment and intervention settings, age groups, and delivery formats across the four RCTs of stand-alone PST, and the overall quality of the evidence was very low. As reflected in our GRADE appraisal, one important limitation was the indirectness of the available evidence: Only one PST trial focused specifically on youth with an MDD diagnosis, while the remaining three included youth with a mix of mental health problems. Although outcomes were reported in terms of depression or emotional symptom severity, this was not based on a subgroup analysis focused specifically on youth with depression. Impact on this group may therefore have been underestimated. In addition, the only PST trial with a low risk of bias did not administer a dedicated depression symptom scale. Instead, our exploratory meta-analysis included scores from the 5-item SDQ emotional problems subscale, which assesses unhappiness, worries, clinginess, fears, and somatic symptoms—and may not have captured nuanced change in depression severity [ 98 , 99 ]. Other concerns that led us to downgrade the quality of the evidence related to considerable risk of bias, with only one out of four studies rated as having a low risk; and imprecision with several studies involving very small samples. Due to the small number of eligible studies, it was not possible to identify the factors driving treatment efficacy via meta-regression. The long-term effectiveness of PS training, or the conditions under which long-term benefits are likely to be realized also could not be examined [ 38 ].

PS training is a core component of several evidence-based therapies for youth depression. However, the evidence base supporting its efficacy as a stand-alone treatment is limited and of low quality. There is tentative evidence suggesting PS-training may drive positive outcomes when provided alongside other treatment components. On its own, PS training may be beneficial for youth who are not acutely distressed or impaired but require support with tackling personal problems. Youth experiencing moderate or severe depressive symptoms may require more comprehensive psychotherapeutic support alongside PS training, as there is currently no robust evidence for the ability of free-standing PST to effectively reduce depression symptoms.

High-quality trials are needed that assess PST efficacy in youth with mild, moderate, and severe depression, in relation to both symptom severity and idiographic treatment goals or priority problems. These studies should examine the influence of treatment length and module content on treatment impact. Dedicated studies are also needed to shed light on the role of PS training as an active ingredient of more comprehensive therapies such as CBT, DBT, IPT, and family therapy. Future studies should include assessments of adverse events and of cost effectiveness. Given high drop-out rates in several youth PST trials, it is important to adapt PS training approaches and therapy manuals as needed, following a youth-engaged research and service development approach [ 57 ], to ensure their relevance and acceptability to this age group.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

• Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

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Acknowledgments

We would like to thank the members of the Centre for Addiction and Mental Health (CAMH) youth advisory group for their valuable insights and suggestions. The systematic search for clinical practice guidelines presented in this review was based on a search strategy developed by Dr. Kathryn Bennett. We would like to thank Dr. Bennett for agreeing to the reuse of the strategy as part of this review. We would also like to thank the Cundill Centre for Child and Youth Depression for providing institutional support to this project.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” commission awarded to KRK, DBC and PS, and the Centre for Addiction and Mental Health, Toronto, Canada.

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Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health (CAMH), 80 Workman Way, Toronto, ON, M6J 1H4, Canada

Karolin R. Krause, Darren B. Courtney, Sarah Bonato, Madison Aitken, Jacqueline Relihan, Matthew Prebeg, Karleigh Darnay, Lisa D. Hawke, Priya Watson & Peter Szatmari

Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, London, UK

Karolin R. Krause

Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Darren B. Courtney, Madison Aitken, Lisa D. Hawke, Priya Watson & Peter Szatmari

Independent Family Doctor, Toronto, ON, Canada

Benjamin W. C. Chan

Hospital for Sick Children, Toronto, ON, Canada

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Contributions

KRK, DBC and PS formulated the research questions and designed the study. SB conducted the systematic search for clinical practice guidelines and the grey literature search, and advised on the search for retrieving empirical studies, which was led by KRK. KRK, DBC and BWCC performed the screening of records for inclusion criteria. Data extraction was performed by KRK and BWCC. The risk of bias assessment for included randomized control trials was conducted by KRK and MA. The youth consultation was led by JR, MP and KD with input from LDH and KRK. Data analysis was led by KRK. All authors contributed to the interpretation of emerging findings through an internal findings workshop and through several rounds of feedback on the draft manuscript, which was drafted by KRK. All authors have reviewed and approved the final manuscript.

Corresponding author

Correspondence to Karolin R. Krause .

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Formal approval by a Research Ethics Board was not required, as youth were consulted as research partners rather than research subjects and provided no individual data.

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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Krause, K.R., Courtney, D.B., Chan, B.W.C. et al. Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis. BMC Psychiatry 21 , 397 (2021). https://doi.org/10.1186/s12888-021-03260-9

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Received : 26 January 2021

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Published : 24 August 2021

DOI : https://doi.org/10.1186/s12888-021-03260-9

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10 Contemporary Problem-Solving Therapy: A Transdiagnostic Intervention

Arthur M. Nezu, Department of Psychology, Drexel University

Alexandra P. Greenfield, Drexel University

Christine Maguth Nezu, Department of Psychology, Drexel University

• Published: 09 June 2015
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This chapter describes problem-solving therapy, a cognitive-behavioral intervention that teaches individuals a set of adaptive problem-solving activities geared to foster their ability to cope effectively with stressful life circumstances in order to reduce negative physical and psychological symptoms. This approach is based on the notion that what is often conceptualized as psychopathology and behavioral difficulties is a function of ineffective coping with life stress. Research addressing differences between effective and ineffective problem solving and the role of social problem solving as a moderator of the stress–distress relationship is presented. In addition, studies that support the efficacy of problem-solving therapy interventions are provided. A brief overview of the clinical components of problem-solving therapy is described that address problems of cognitive overload, emotional dysregulation, negative thinking, poor motivation, and ineffective problemsolving. Future directions for clinical practice, training, and research are included.

Problem solving has traditionally been conceptualized as a major component of executive functioning that involves higher order mental or cognitive processes. In this context, research in experimental psychology has predominantly addressed the question of how humans solve problems of a cognitive or intellectual nature, such as a mathematical calculation or logic puzzle. However, these do not generally reflect the complexity of problems that people face in the real world, which are different than such cognitive problems in that they are (a) often stressful, (b) caused by or engender emotional difficulties, and (c) frequently involve other individuals. It was not until the second half of the twentieth century that research began to focus on those factors that impact one’s ability to solve the types of problems that are typically encountered in everyday life ( D’Zurilla & Nezu, 2007 ). This also led to the question of whether individuals can be trained to become better problem solvers as a means of decreasing emotional difficulties and improve their overall quality of life. It was from this context that problem-solving therapy was developed.

Problem-solving therapy (PST) is a psychosocial intervention developed within a social learning framework and based on a biopsychosocial, diathesis-stress model of psychopathology. In general, this intervention involves training individuals in a set of skills aimed to enhance their ability to cope effectively with a variety of life stressors that have the potential to generate negative health and mental health outcomes, such as chronic medical conditions, depression, and anxiety. Life stressors can include both major negative life events (e.g., death of a loved one, diagnosis and treatment of a chronic illness, loss of a job, incarceration, military combat) and chronic daily problems (e.g., continuous tension with coworkers, reduced financial resources, discrimination, marital difficulties).

PST assumes that much of what is conceptualized as psychopathology and behavioral difficulties, including significant emotional problems, is a function of continuous ineffective coping with life stressors. As a result, it is hypothesized that teaching individuals to become better problem solvers can serve to reduce extant physical and mental health difficulties. The overarching goal of PST is to promote the successful adoption of adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy) and the effective implementation of certain behaviors (i.e., adaptive emotional regulation, planful problem solving) as a means of coping with life stressors and thereby attenuating the negative effects of stress on physical and mental well-being.

The origins of PST from a social learning perspective can be traced back to the seminal article by D’Zurilla and Goldfried (1971) , who developed a prescriptive model of training for individuals to enhance their ability to cope effectively with problems encountered in daily living. Early research applying this model to clinical populations focused on PST as a treatment for adults with major depressive disorder (e.g., Nezu, 1986 ). Subsequently, researchers and clinicians all over the world have successfully applied variations of this model to a wide range of psychological disorders, medical problems, and clinical populations (see D’Zurilla & Nezu, 2007 ). In addition, PST has been effective across different modes of implementation (e.g., individual, group, telephone, Internet) and has been applied as a means of enhancing one’s adherence to other medical or psychosocial interventions ( Nezu, Nezu, & Perri, 2006 ).

As new research improves our understanding of problem solving and stress, we have continuously revised and updated the basic PST model to incorporate findings from the outcome literature, as well as basic research from the fields of affective neuroscience, cognitive psychology, and clinical psychology. As such, we refer to the current model of treatment as “contemporary PST.” This chapter will provide a broad overview of the conceptual and empirical underpinnings of this cognitive-behavioral intervention, as well as a brief description of clinical guidelines.

Problem, Solution, and Social Problem Solving

We begin by defining the constructs of problems, solutions, and social problem solving, the latter term used to describe the type of problem solving that occurs in real-life settings rather than problems of a more intellectual or academic nature.

We define a problem as a life situation, present or anticipated, that requires an adaptive response in order to prevent negative consequences from occurring but where an effective response or solution is not immediately obvious or available to the individual experiencing the situation due to the existence of various obstacles. The problem can arise from a person’s social or physical environment (e.g., conflict with a family member, poor living conditions). It can also originate internally or intrapersonally (e.g., desire to make more money, confusion about life goals).

The barriers that make the situation a problem for a given individual or set of individuals can involve a variety of factors. These can include (a) novelty (e.g., beginning a new romantic relationship); (b) ambiguity (e.g., uncertainty about how one is perceived by his or her coworkers); (c) unpredictability (e.g., lack of control over one’s job stability); (d) conflicting goals (e.g., difference between spouses/partners with regard to child-rearing philosophies); (e) performance skills deficits (e.g., difficulties with communication); (f) lack of resources (e.g., limited finances); and (g) significant emotional arousal (e.g., prolonged grief over the loss of a loved one).

An individual may recognize that a problem exists almost immediately based on one’s overall reactions (e.g., physical symptoms, negative thoughts, urge to aggress) or only after repeated attempts to cope with the situation have failed. A problem can be a single, time-limited event (e.g., misplacing one’s keys; forgetting to set one’s alarm clock), a series of similar or related events (e.g., repeated disagreements between friends; not having a job that pays well), or a chronic, ongoing situation (e.g., a serious medical illness; persistent depressive symptoms).

According to this view, a problem is not a product of either the environment or the person alone. Rather, it is best understood as a person–environment relationship represented by a real or perceived discrepancy between the demands of the situation and one’s coping ability and reactions. Problems are therefore idiographic and can be expected to change in difficulty or significance over time, depending on changes in the person, environment, or both. In other words, what a problem is for one person may not be a problem for someone else. In addition, what serves as a problem for a given person at one time may not be a problem for this same person at another point in time.

We define a solution as a situation-specific coping response that is the outcome of the problem-solving process when it is applied to a specific situation. An effective solution achieves the problem-solving goal while simultaneously maximizing positive consequences and minimizing negative consequences. The potential outcomes to consider may include possible impacts on the self and others, as well as short-term and long-term effects. Different individuals across different environments may vary in their evaluation of solutions based on the particular norms, values, and goals of the problem solver.

Social Problem Solving

Social problem solving (SPS) is the process by which individuals attempt to identify, discover, or create adaptive means of coping with a wide variety of stressful problems, both acute and chronic, encountered during the course of living ( D’Zurilla & Nezu, 2007 ). It reflects the process whereby people direct their coping efforts at altering the problematic nature of a given situation, their reactions to such problems, or both. Rather than representing a singular type of coping behavior or activity, SPS represents the multidimensional metaprocess of ideographically identifying and selecting various coping responses to implement in order to match adequately the unique features of a given stressful situation at a given time ( Nezu, 2004 ).

The construct of social problem solving should be differentiated from that of problem-focused coping. The term coping generally refers to the cognitive and behavioral activities that an individual uses to manage stressful situational demands, as well as the emotions they generate. Two major types of coping have been described in the literature: problem-focused coping and emotion-focused coping ( Lazarus & Folkman, 1984 ). Problem-focused coping includes those activities that are directed at changing the stressful situation for the better (i.e., meeting, changing, or controlling situational demands). On the other hand, emotion-focused coping includes those activities aimed at managing the negative emotions generated by a stressful situation.

Within this context, SPS has, at times, been misrepresented as being equivalent to a form of problem-focused coping, suggesting that SPS goals include only mastery goals or attempts to control the environment (e.g., change another’s behavior). However, we define SPS as a broader, more versatile coping strategy that often includes both problem-focused and emotion-focused objectives. Regardless of whether the objective is articulated as problem focused or emotion focused, the ultimate goal is to minimize the negative effects of stressful life events on well-being. It is likely that particularly stressful problems require both problem-focused and emotion-focused objectives to be successfully resolved.

A Multidimensional Model of Social Problem Solving

According to contemporary SPS theory, problem-solving outcomes are largely determined by two general, but partially independent, dimensions: (a) problem orientation and (b) problem-solving style ( D’Zurilla, Nezu, & Maydeu-Olivares, 2004 ). Problem orientation (PO) represents the set of cognitive-affective schemas regarding individuals’ generalized beliefs, attitudes, and emotional reactions about real-life problems, as well as their ability to cope successfully with such difficulties. Whereas the original model suggested that the two types of problem orientations represented opposite ends of the same continuum (e.g., D’Zurilla & Nezu, 1999 ), subsequent research suggests that they operate somewhat independent of each other ( Nezu, 2004 ). These two orthogonal orientation components are positive problem orientation and negative problem orientation.

A positive problem orientation involves the tendency for individuals to (a) perceive problems as challenges rather than major threats to one’s well-being, (b) be optimistic in believing that problems are solvable, (c) have a strong sense of self-efficacy regarding their ability to handle difficult problems, (d) believe that successful problem solving usually involves time and effort, and (e) view negative emotions as important sources of information necessary for effective problem solving.

A negative problem orientation refers to the tendency of individuals to (a) view problems as major threats to one’s well-being, (b) generally perceive problems to be unsolvable, (c) maintain doubts about their ability to cope with problems successfully, and (d) become particularly frustrated and upset when faced with problems or when they experience negative emotions.

An individual’s problem orientation can have a strong influence on his or her motivation and ability to engage in focused attempts to solve problems. As such, the importance of assessing and addressing one’s dominant orientation is considered a key component of the overall PST approach. For this reason, it is very important to include a specific and comprehensive focus on orientation variables when conducting PST. Unfortunately, some researchers have equated PST solely with “rational or logical” problem-solving skills and have de-emphasized or ignored problem-orientation variables. Because PST aims to help people cope effectively with real-life stressful problems, we firmly believe that attention must be paid to individuals’ general beliefs, attitudes, and emotional reactions to real-world problems.

In support of this point, two recent meta-analytic reviews of the extant literature of PST, in addition to a randomized, controlled trial that directly posed this question ( Nezu & Perri, 1989 ), support the notion that excluding a specific focus on problem-orientation variables consistently leads to significantly less efficacious outcome as compared to protocols that do include such training ( Bell & D’Zurilla, 2009 ; Malouff, Thorsteinsson, & Schutte, 2007 ).

The second major dimension of SPS, problem- solving style , refers to the core cognitive-behavioral activities that people engage in when attempting to solve stressful problems. Three styles have been identified ( D’Zurilla, Nezu, & Maydeu-Olivares, 2002 ; D’Zurilla et al., 2004 ): planful or rational problem solving, avoidant problem solving, and impulsive-careless problem solving.

Planful problem solving is the constructive approach that involves the systematic and planful application of the following set of specific skills: (a) problem definition and formulation (i.e., clarifying the nature of a problem, delineating a realistic set of problem-solving goals and objectives, and identifying those obstacles that prevent one from reaching such goals); (b) generation of alternatives (i.e., brainstorming a range of possible solution strategies geared to overcome the identified obstacles); (c) decision making (i.e., predicting the likely consequences of these various alternatives, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan that is geared to achieve the problem-solving goal); and (d) solution implementation and verification (i.e., carrying out the solution plan, monitoring and evaluating the consequences of the plan, and determining whether one’s problem-solving efforts have been successful or need to continue).

In addition to planful problem solving, two problem-solving styles have been further identified, both of which, in contrast, are frequently ineffective in nature ( D’Zurilla et al., 2002 , 2004 ). An impulsive/careless style is the problem-solving approach whereby an individual tends to engage in impulsive, hurried, and careless attempts at problem resolution. Avoidant problem solving is the problem-solving style characterized by procrastination, passivity, and overdependence on others to provide solutions. In general, both styles are associated with ineffective or unsuccessful coping. Moreover, people who typically engage in these styles tend to worsen existing problems and even create new ones.

It should be noted that this model does not suggest that individuals should be characterized exclusively by either type of orientation or problem-solving style across all situations. Rather, each represents a strong tendency to either view or react toward problems from a particular perspective based on one’s learning experiences. For example, it is possible for individuals to be characterized as having a positive orientation when dealing with one type of problem (e.g., work-related difficulties), while simultaneously having a negative orientation when addressing other types of problems (e.g., relationship difficulties).

In addition, it should be noted that this five-component model of SPS (i.e., positive orientation, negative orientation, planful problem-solving style, impulsive/careless style, and avoidant style) has been cross-validated numerous times across various populations, ethnic minority cultures, and age groups ( D’Zurilla & Nezu, 2007 ).

Social Problem Solving and Psychopathology

A large assumption underlying the relevance of PST as a psychosocial intervention is the notion that SPS represents a set of strategies that fosters effective coping with various forms of life stress. In support of this theory, research over the past several decades has consistently identified many pathology-related differences between individuals characterized as “effective” versus “ineffective” problem solvers across a range of age groups, populations, and cultures, and using differing measures of SPS (see D’Zurilla & Nezu, 2007 ; Nezu, Wilkins, & Nezu, 2004 , for overviews of this literature). In general, when compared to their effective counterparts, ineffective problem solvers report a greater number of life problems, more health and physical symptoms, more anxiety, more depression, and more psychological maladjustment. Moreover, a negative problem orientation has been found to be associated with negative moods under routine and stressful conditions in general, as well as significantly related to pessimism, negative emotional experiences, and clinical depression ( Nezu, 2004 ). Persons with a negative orientation also tend to worry and complain more about their health ( Elliott, Grant, & Miller, 2004 ).

In addition, problem-solving deficits have been found to be significantly related to poor self-esteem, hopelessness, suicidal risk, self-injury, anger proneness, increased alcohol intake and substance risk taking, personality difficulties, criminal behavior, alcohol dependence, physical health problems, and diminished life satisfaction ( D’Zurilla & Nezu, 2007 ).

A Problem-Solving/Stress Model of Psychopathology

Elsewhere, we have described in detail a diathesis-stress model of psychopathology that posits how SPS interacts with various biological, psychological, and social variables to influence how a given individual will respond to various life stressors and, consequently, what the outcome of this process might be (see Nezu, Nezu, & D’Zurilla, 2013 for a more detailed description of this model, particularly the distal, proximal, and immediate roles that various neurobiological, immune, and brain chemistry factors play in this process).

According to this model, certain distal factors, in the form of genetic predispositions and early life stress, have been found to produce both biological (e.g., increased stress sensitivity leading to lowered thresholds for triggering depressive reactions later in life; Nugent, Tyrka, Carpenter, & Price, 2011 ) and psychosocial (e.g., lack of opportunity to develop effective problem-solving skills due to stress-related overtaxed efforts to cope; Wilhelm et al., 2007 ) vulnerabilities that can further make one more susceptible to negative health and mental health outcomes during adolescence, adulthood, and older adulthood.

Focusing on more proximal variables, substantial research has documented the causal role of stress (in the form of major negative life events and chronic daily problems) in causing the initial onset and/or exacerbating preexisting psychopathology (e.g., depression) and certain medical disorders (e.g., heart disease, diabetes) ( Pandey, Quick, Rossi, Nelson, & Martin, 2011 ). In addition to the presence of stress as a contributor to psychopathology, there may be important biological, developmental, sociodemographic, and psychological factors that play a role in how individuals respond to stressors. Experiencing stress in the absence of effective coping can lead to increased levels of stress and distress (termed “stress generation”) and a cyclical pattern of negative symptoms. Individuals who have experienced larger amounts of early life stress and/or possess a genetic vulnerability, in the face of this stress generation process, are then especially vulnerable to negative health outcomes (e.g., Monroe et al., 2006 ).

SPS is considered to be a key component of successful coping and is therefore hypothesized to serve as an important moderator of the overall stress–distress relationship. In other words, the manner in which people cope with extant stressful events via effective SPS may affect the degree to which they will experience both acute and/or long-term psychological distress. In general, studies directly exploring this question provide evidence that SPS, in fact, is a significant moderator of the stress–distress relationship. For example, under similar levels of high stress, individuals with ineffective or poor SPS have been found to experience significantly higher levels of psychological distress as compared to individuals characterized by effective SPS ( Londahl, Tverskoy, & D’Zurilla, 2005 ; Nezu & Ronan, 1988 ; Ranjbar, Bayani, & Bayani, 2014 ).

The model further suggests that if one’s problem-solving ability is unable to adequately cope with life stress, not only is it likely that he or she will experience negative health outcomes and psychological distress, but such outcomes can also subsequently produce further life stress, as well as continuously undermine one’s problem-solving attempts. We suggest that this reciprocal “downward spiral” of stress-distress generation can lead to long-term clinical disorders.

Efficacy of Problem-Solving Therapy

PST has been applied, both as the sole intervention strategy and as part of a larger treatment package, to a wide variety of patient populations and clinical problems. In the past several years, three major meta-analyses of PST randomized, controlled trials have been published and provide support for the overall efficacy of this approach. For example, Malouff et al. (2007) conducted a meta-analysis of 32 studies, including close to 3,000 participants, that evaluated the efficacy of PST across a variety of mental and physical health problems. These authors found that PST was (a) equally as effective as other psychosocial treatments, and (b) significantly more effective than both no-treatment and attention-placebo control conditions. In addition, the inclusion of training in problem orientation and the assignment of homework led to larger effect sizes in treatment outcome.

A second meta-analysis published in the same year was conducted by Cuijpers, van Straten, and Warmerdam (2007) . This investigation focused exclusively on trials of PST for the treatment of depression. Specifically, they focused on 13 randomized, controlled trials that collectively included over 1,100 participants. Based on their results, they concluded that although additional research is needed due to an identified variability in outcomes across studies, “there is no doubt that PST can be an effective treatment for depression” (p. 9). Note that one possible explanation for such variability involves the lack of a focus on problem-orientation variables in some of the studies characterized by lower effect sizes.

A third meta-analysis that also focused exclusively on PST for depression was conducted by Bell and D’Zurilla (2009) and included seven additional studies beyond those in the Cuijpers et al. (2007) meta-analysis. These authors came to similar conclusions when looking at both post-treatment and follow-up results across investigations. Specifically, PST was found to be equally effective for the treatment of depression as compared to both alternative psychosocial therapies and psychiatric medication, and more efficacious as compared to supportive therapy and attention-control conditions. In addition, Bell and D’Zurilla found that significant moderators of treatment effectiveness included whether the PST protocol included problem-orientation training and whether all four planful problem-solving skills were included.

Although not focusing exclusively on PST, three additional meta-analyses provide further support for PST as an evidenced-based treatment. One investigation involved both a meta-analysis and metaregression of randomized, controlled trials of brief psychological therapies for adult patients with anxiety, depression, or mixed common mental health problems treated in primary care ( Cape, Whittington, Buszewicz, Wallace, & Underwood, 2010 ). Across 34 studies, involving close to 4,000 patients, it was concluded that PST for depression and mixed anxiety/depression was an effective treatment. Controlling for diagnosis, a metaregression analysis found no difference in efficacy between cognitive-behavioral therapy and PST. Another systematic review and meta-analysis evaluated the relative efficacy of various brief psychotherapy approaches (eight or fewer sessions) for depression and again found PST to be an efficacious intervention ( Nieuwsma et al., 2012 ). A more recent meta-analysis focused on different types of psychotherapy for adult depression and similarly found PST to be characterized by robust effects ( Barth et al., 2013 ). These systematic reviews provide for substantial evidence in support of the efficacy of PST-based interventions for treating a wide range of mental disorders, particularly depression.

PST as a Transdiagnostic Intervention

Because PST has been found to be an effective treatment for a wide variety of populations and clinical problems, it can be viewed as a transdiagnostic approach. Conceptually, because stress plays a significant role, either as an etiological and/or maintaining variable, regarding many forms of psychopathology and patient problems, it stands to reason why this would be the case. A brief listing of problems and populations for which PST has been found to be effective include the following: adults with major depressive disorder ( Nezu, 1986 ); medical patients also diagnosed with depression ( Harpole et al., 2005 ); adults attempting suicide ( Hatcher et al., 2011 ); adults with intellectual disabilities and comorbid psychiatric diagnoses ( C. M. Nezu, Nezu, & Arean, 1991 ); young offenders with intellectual disabilities ( Langdon et al., 2013 ); caregivers of patients with dementia ( Garand et al., 2013 ), traumatic brain injury ( Rivera et al., 2008 ), and stroke ( Grant et al., 2002 ); adolescents with conduct disorder and substance abuse problems ( Azrin et al., 2001 ); older adults with major depression and executive dysfunction ( Alexopoulos et al., 2011 ); cancer patients and their significant others ( Nezu, Nezu, Felgoise, McClure, & Houts, 2003 ); adults with hypertension ( García-Vera, Labrador, & Sanz, 1997 ); patients with lower back pain ( van den Hout, Vlaeyen, Heuts, Zijlema, & Wijen, 2003 ); low-income, Latino adults diagnosed with cancer ( Ell et al., 2008 ); and adults with type 2 diabetes ( Katon et al., 2004 ).

PST has also been used as an adjunct approach to foster the effectiveness of other behavioral intervention strategies ( Nezu et al., 2006 ). It has been found to be effective if provided individually ( Nezu et al., 2003 ), in a group format ( Nezu & Perri, 1989 ), over the telephone ( Allen et al., 2002 ), via the Internet ( Choi et al., 2014 ), and as part of a collaborative care model of health care delivery ( Unűtzer et al., 2002 ). More recently, PST has been applied to a US veteran population as a means of fostering their resilience in order to prevent future psychopathology ( Tenhula et al., 2014 ).

Problem-Solving Therapy: Overview of Clinical Guidelines

In this next section, we provide a brief overview of the clinical components of contemporary PST. According to the model, we suggest that several major obstacles can potentially exist for a given individual when attempting to resolve real-life stressful problems successfully. These include the following:

The ubiquitous human presence of “brain overload,” especially under stressful circumstances

Limited or deficient ability to engage in effective emotional regulation

Biased cognitive processing of various emotion-related information (e.g., negative automatic thoughts, poor self-efficacy beliefs, difficulties in disengaging from negative mood-congruent autobiographical memories)

Poor motivation due to feelings of hopelessness

Ineffective problem-solving strategies

PST focuses on training individuals in four major problem-solving “toolkits” that address each of the aforementioned general barriers. These toolkits include (a) problem-solving multitasking; (b) the “stop, slow down, think, and act” (SSTA) method of approaching problems while under stress; (c) healthy thinking and positive imagery; and (d) planful problem solving.

Note that a client’s specific problem-solving strengths and weaknesses should determine whether all strategies in all toolkits are taught and emphasized. In addition, when choosing which training activities to engage in, the therapist should use clinical judgment regarding the relevance of other related factors, such as the anticipated length of treatment, the severity of negative symptoms, and the subsequent progress (or lack of) being made by the individual. In other words, not all materials across all four toolkits are mandatory to employ during treatment. Rather, the therapist should use assessment and outcome data to inform the inclusion and subsequent emphasis of particular PST activities.

Problem-Solving Multitasking: Overcoming Brain Overload

This set of tools is geared to help an individual overcome the ubiquitous human limitation when attempting to cope with stressful situations in real life: “brain or cognitive overload” ( Rogers & Monsell, 1995 ). Due to basic human limitations in our ability to manipulate large amounts of information in our working memory simultaneously while attempting to solve complex problems or make effective decisions, especially when under stress, individuals are taught to use three “multitasking enhancement” skills: externalization, visualization, and simplification. These skills are considered foundational to effective problem solving, similar to those skills that may be taught as basic to effective aerobic exercise, such as stretching, breathing, and maintaining a healthy diet.

Externalization involves displaying information “externally” as often as possible. More specifically, clients are taught to write ideas down, draw diagrams or charts to determine relationships, draw maps, make lists, and audiotape ideas. In this manner, one’s working memory is not overly taxed and can allow one to concentrate more on other activities, such as creatively thinking of various solutions. The visualization tool is presented as using one’s “mind’s eye” or visual imagery to help (a) better clarify the nature of a problem, (b) practice carrying out a solution (imaginal rehearsal), and (c) reduce high levels of negative arousal (i.e., a form of guided imagery whereby one is directed imaginally to go on a peaceful vacation). Simplification involves “breaking down” or simplifying problems in order to make them more manageable. Clients are taught to break down complex problems into more manageable smaller problems, and to translate complex, vague, and abstract concepts into more simple, specific, and concrete language.

“Stop, Slow Down, Think, and Act” (SSTA): Overcoming Emotional Dysregulation and Ineffective Problem Solving under Stress

This toolkit becomes especially important to emphasize in situations where the primary goal of PST for a particular individual involves the decrease of clinically significant emotional distress (e.g., depression, suicidal ideation, generalized anxiety). It is also useful for training individuals as a means of preventing extant emotional concerns from becoming particularly problematic. In essence, clients are taught a series of steps to enhance their ability to modulate (as opposed to “eradicate”) negative emotional arousal in order to more effectively apply a systematic approach to solving problems (i.e., to be able to optimally use the various planful problem-solving skills). It is also presented to individuals as the overarching “map” to follow when attempting to cope with stressful problems that engender strong emotional reactions and is included as the major treatment strategy geared to foster adaptive emotional regulation skills. It is also included in PST as a means of minimizing impulsive/careless attempts at problem solving, as well as avoidance of the problem.

According to the SSTA method, clients are first taught to become “emotionally mindful” by being more aware of, and specifically focusing on, when and how they experience negative emotional arousal. Specifically, they are taught to notice changes in physical (e.g., headache, fatigue, pain), mood (e.g., sadness, anger, tension), cognitive (e.g., worry, thoughts of negative outcomes), and/or behavioral (e.g., urge to run away, yelling, crying) indicators. For certain individuals, additional training may be necessary to increase the accuracy by which they attempt to identify and label emotional phenomena. Next, they are taught to “Stop” and focus on what is happening in order to become more aware of what is engendering this arousal. More specifically, they are directed to engage in behaviors (e.g., shouting out loud, raising one’s hands, holding up a stop sign) that help them to “put on the brakes” in order to better modulate their emotional arousal (i.e., prevent the initial arousal from evoking a more intense form of the emotion together with its “full-blown” concomitant negative thinking, state-dependent negative memories, negative affect, and maladaptive behaviors).

Next, in order to meaningfully be able to “Stop,” clients are further taught to “Slow Down”; that is, to decrease the accelerated rate at which one’s negative emotionality can occur. Various specific techniques are provided and practiced with clients in order to offer them a choice among a pool of potentially effective “slowing-down tools.” These include counting down from 10 to 1, diaphragmatic breathing, guided imagery or visualization, “fake smiling” (in keeping with the potential positive impact related to the facial feedback hypothesis; Havas, Glenberg, Gutowski, Lucarelli, & Davidson, 2010 ), “fake yawning” (in keeping with recent neuroscience research demonstrating the efficacy of directed yawning as both a stress management strategy and a means to enhance cognitive awareness; Newberg & Waldman, 2009 ), meditation, exercise, talking to others, and prayer (if relevant to a particular individual). Individuals are also encouraged to use strategies that have been helpful to them in the past.

The “Thinking” and “Acting” steps in SSTA refer to applying the four specific planful problem-solving tasks (i.e., defining the problem and setting realistic goals, generating alternative solutions, decision making, solution implementation and verification) once one is “slowed down,” in attempting to resolve or cope with the stressful problem situation that initially evoked the negative emotional stress reaction.

Healthy Thinking and Positive Imagery: Overcoming Negative Thinking and Reduced Motivation

This toolkit is included to specifically address additional problem orientation issues if relevant to a particular individual, that is, negative thinking and feelings of hopelessness. Similar to cognitive restructuring strategies, clients are taught that “how one thinks can affect how one feels.” In essence, this toolkit entails a variety of cognitive change techniques geared to enhance optimism and enhanced self-efficacy. For example, clients are taught to use the “ABC Model of Thinking” (where “A” = the a ctivating or triggering event, “B” = a given b elief, attitude, or viewpoint, and “C” = the emotional c onsequence that is based on that belief, as compared to “reality”) in order to determine whether one needs to change such negative beliefs. They are provided with a series of “healthy thinking” rules (e.g., “Nothing is 100% perfect … problems are a normal part of life … everyone makes mistakes … every minute I spend thinking negatively takes away from enjoying my life”), as well as a list of “realistically optimistic self-statements” (e.g., “I can solve this problem;” “I’m okay—feeling sad under these circumstances is normal;” “I can’t direct the wind, but I can adjust the sails;” “Difficult and painful does not equal hopeless!”), as more optimistic examples of ways to think in order to readjust their orientation.

In addition, if a given individual has particular difficulty with changing his or her negative thinking, we also advocate having the PST therapist conduct a “reverse advocacy role play” exercise surrounding a given individual’s unique negative thinking patterns. In this exercise, a given maladaptive attitude is temporarily “adopted” by the therapist using a role-play format. The individual, who now has to adopt the role of “counselor,” has to provide reasons or arguments for why such an attitude is incorrect, maladaptive, or dysfunctional. In this manner, the client is influenced to begin verbalizing those aspects of a positive problem orientation. The process of identifying a more appropriate set of beliefs toward problems and providing justification for the validity of these attitudes helps the individual to begin to personally adopt such an orientation.

The second tool in this toolkit focuses on using visualization to enhance motivation and to decrease feelings of hopelessness. The use of visualization here, which is different than that described within the multitasking toolkit, is to help the client to sensorially experience what it “feels” like to successfully solve a difficult problem; in other words, to “see the light at the end of the tunnel or the crossing ribbon at the finishing line.” With this strategy, the therapist’s goal is to help patients create the experience of success in their “mind’s eye” and vicariously experience the potential reinforcement to be gained. Clients are specifically taught to not focus on “how” the problem got solved; rather, to focus on the feelings associated with having already solved it. The central goal of this strategy is to have individuals create their own positive consequences (in the form of affect, thoughts, physical sensations, and behavior) associated with solving a difficult problem as a major motivational step toward overcoming low motivation and feelings of hopelessness, as well as minimizing the tendency to engage in avoidant problem solving.

Planful Problem Solving: Fostering Effective Problem Solving

This last toolkit provides training in the four planful problem-solving tasks, the first being problem definition. This activity involves having clients separate facts from assumptions when describing a problem, delineate a realistic and attainable set of problem-solving goals and objectives, and identify those obstacles that prevent one from reaching such goals. Note that this model advocates delineating both problem-focused goals , which include objectives that entail changing the nature of the situation so that it no longer represents a problem, as well as emotion-focused goals , which include those objectives that involve moderating one’s cognitive-emotional reactions to those situations that cannot be changed. Strategies that might be effective in reaching such emotion-focused goals might include stress management, forgiveness of others, and acceptance that the situation cannot be changed.

The second task, generating alternatives , involves creatively brainstorming a range of possible solution strategies geared to overcome the identified obstacles to their goals using various brainstorming techniques. Decision making , the third planful problem-solving task, involves predicting the likely consequences of the various alternatives previously generated, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan geared to achieve the articulated problem-solving goal. The last activity, solution implementation and verification , entails having the person optimally carry out the solution plan, monitor and evaluate the consequences of the plan, and determine whether his or her problem-solving efforts have been successful or need to continue.

Guided Practice

A major part of the PST intervention involves providing feedback and additional training to individuals in the four toolkits as they continue to apply the model to current problems they are experiencing. In addition, PST encourages individuals to “forecast” future stressful situations, whether positive (e.g., getting a promotion and moving to a new city) or negative (e.g., the break-up of a relationship) in order to anticipate how such tools can be used in the future to minimize potential negative consequences.

Future Directions

The need to address problems effectively is a fundamental part of the human experience across time and environments. Therefore, the importance of problem solving as a construct in psychology and psychotherapy is significant. In this last section, we outline several ideas about potential future directions across clinical practice, training, and research arenas.

Clinical Practice

Patients’ self-management of chronic illnesses, such as diabetes, cancer, and heart disease, has received increasing attention as a means of enhancing one’s sense of self-efficacy and the ability to deal with the difficult exigencies associated with ongoing medical illness ( Bodenheimer, Lorig, Holman, & Grumbach, 2002 ). Within this context, teaching patients to become better problem solvers as a means of improving their self-management skills can be a potentially valuable approach.

Because ineffective problem solving has continuously been associated with mental health problems and poor adjustment to stressful events, focusing on the enhancement of problem solving prior to the experience of a stressful event can serve an important prevention role. Providing training in effective problem solving to individuals about to engage in a potentially stressful role, job, or activity may prevent them from experiencing consequent distress. For example, similar to the rationale for teaching critical thinking skills to college students as a basis for general learning, becoming a more effective problem solver may represent an important preventive approach provided to students at various educational levels as a means of enhancing overall adjustment. Additional examples can include training military personnel, firefighters, and police officers as a way to prevent burnout and ineffective adjustment to traumatic events. This concept can also apply to helping family members to become more effective caregivers when a loved one suffers from a chronic illness or dementia. All such situations represent ongoing difficult problems that can potentially be better handled through a more planful approach.

Further, it would be worthwhile for problem-solving-based approaches to be disseminated and integrated more effectively into standard health and behavioral health care delivery systems. For example, an initial evaluation of a national rollout of a PST-based intervention by the Department of Veterans Affairs, entitled Moving Forward ( Nezu & Nezu, 2014 ), has shown promising results regarding its impact on decreasing depression, enhancing problem solving, and fostering resilience among veterans ( Tenhula et al., 2014 ).

Problem-solving and causal reasoning skills are core competencies in the scientific practice of professional psychology ( Layne, Steinberg, & Steinberg, 2014 ; C. M. Nezu & Nezu, 1995 ). Effective problem solving, within a therapy context, is represented by a clinician’s ability to define the problem validly (i.e., assessment, diagnosis, and case conceptualization), identify potentially effective means of reaching treatment goals (i.e., intervention strategies), make multiple decisions about conducting therapy (e.g., which intervention to carry out and when, when to terminate therapy), and evaluate the outcomes of the treatment subsequent to its implementation.

Problem solving, in this context, can be viewed as important skills to learn as part of an overall approach to competency-based training in applied psychology ( Beck et al., 2014 ). Students at various levels of training and education in applied psychology fields can be taught problem-solving skills to apply in relation to a wide range of professional activities, including assessment, intervention, consultation, interpersonal relationships, ethical dilemmas, and research.

Possible future research directions regarding PST involve testing the validity of the previously suggested applications of problem solving in clinical practice and training via rigorous research protocols. In addition, future studies could evaluate the value of adding PST to other forms of medical and psychotherapy interventions to enhance adherence to such treatments by overcoming various barriers (e.g., poor motivation, stress). Investigating possible moderators, such as personality characteristics, age, comorbid disorders, and intellectual functioning, of the effects of PST represents another major area of needed research in the future. Another research priority should be the continued determination of whether the established association between SPS and distress, as well as the efficacy of PST, is valid among other cultures. Last, similar to other psychotherapy research endeavors, it would be important to identify mediators of PST (i.e., mechanisms of action) in order to strengthen further the effectiveness of this intervention approach.

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• Research article
• Open access
• Published: 31 July 2023

A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial

• Nusrat Husain 1 , 2 ,
• Tayyeba Kiran 3 ,
• Imran Bashir Chaudhry 1 , 4 ,
• Christopher Williams 5 ,
• Richard Emsley 6 ,
• Usman Arshad 3 ,
• Moin Ahmed Ansari 7 ,
• Paul Bassett 8 ,
• Penny Bee 9 ,
• Moti Ram Bhatia 10 ,
• Carolyn Chew-Graham 11 ,
• Muhammad Omair Husain 12 ,
• Muhammad Irfan 13 ,
• Ayesha Khaliq 3 ,
• Fareed A. Minhas 14 ,
• Farooq Naeem 15 ,
• Haider Naqvi 16 ,
• Asad Tamizuddin Nizami 17 ,
• Amna Noureen 3 ,
• Maria Panagioti 18 ,
• Ghulam Rasool 19 ,
• Sofiya Saeed 3 ,
• Sumira Qambar Bukhari 20 ,
• Sehrish Tofique 3 ,
• Zainab F. Zadeh 3 ,
• Shehla Naeem Zafar 21 &
• Nasim Chaudhry 3  

BMC Medicine volume  21 , Article number:  282 ( 2023 ) Cite this article

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Metrics details

Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm.

This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode ( n  = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016).

We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm ( n  = 440) and E-TAU arm ( N  = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower ( n  = 17) compared to the E-TAU arm ( n  = 23) at 12-month post-randomisation, but the difference was not statistically significant ( p  = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (− 3.6 (− 4.9, − 2.4)), depression (− 7.1 (− 8.7, − 5.4)), hopelessness (− 2.6 (− 3.4, − 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention.

Conclusions

Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

Peer Review reports

The World Health Organisation (WHO) reported that there are more than 700,000 suicide deaths worldwide in 2019 [ 1 ]. More than 77% of suicide deaths are in low and middle-income countries (LMICs) [ 1 ]. Self-harm is an important predictor of suicide death, typically with more than 20 attempts prior to suicide [ 2 ]. More than 39% of all suicides globally occur in South Asia [ 3 ]. However, these rates are underreported evidenced by a verbal autopsy study from a South Asian setting (India) where suicide rates were underestimated by 25% for men and 36% for women compared to the official data [ 4 ].

There are no official suicide data from Pakistan [ 5 ]. Both self-harm and suicide were considered illegal acts until recently (December 2022) when a bill was passed by the Senate abolishing the provision of punishment for those who attempt suicide, an important step towards preventing suicide [ 6 ]. Self-harm is socially and religiously condemned in Pakistan [ 7 ]. A family’s fear of the community grapevine and the perceived negative impact of self-harm and suicide on the family’s honour (izzat) has been reported by clinicians as a major barrier to help-seeking in Pakistan [ 7 ]. The problems are further exacerbated by a lack of awareness about the role of psychological services and social stigma [ 7 ]. Self-harm is reported as a consequence of a complex interplay of multiple factors including severe mental health problems, financial difficulties, interpersonal conflicts with family, and poor problem-solving abilities [ 7 ]. Service level challenges have also been reported including limited access to psychological services and a lack of training arrangements for health professionals such as general practitioners and emergency care staff [ 7 , 8 ].

The WHO (2021) has recommended a public health approach to identify and provide treatment to high-risk individuals, particularly those with a history of self-harm. There is established evidence on the management of self-harm in high-income countries [ 9 ], but there are no national recommendations for the prevention and treatment of self-harm in Pakistan. Psychosocial interventions help people at risk of suicide by addressing the underlying psychological risk factors associated with self-harm, for example by helping people improve their coping skills and solve specific problems more effectively, manage psychiatric disorders such as depression, improve self-esteem, increase a sense of social connectedness, and reduce impulsivity and harmful reactions to distressing situations [ 10 ]. Cognitive behaviour therapy (CBT) based psychological interventions help people evaluate ways in which they interpret a stressful situation and offer them support in changing how they deal with problems [ 5 , 10 , 11 ]. Problem-solving therapy is an integral part of CBT, that can be delivered as a therapy in itself [ 10 ]. A recent Cochrane review of randomised controlled trials (RCTs) on psychosocial interventions for the prevention of self-harm in the adult population has highlighted that most of the trials ( n  = 20) investigated the role of individually delivered CBT-based psychotherapy compared to limited trials on Dialectical Behaviour Therapy (DBT) ( n  = 6), Mentalisation-Based Therapy (MBT) ( n  = 1) and Emotion Regulation Psychotherapy ( n  = 2) [ 10 ]. This review reports beneficial effects for CBT-based psychological approaches at longer follow-up time points, and beneficial effects for MBT, and emotion-regulation psychotherapy at the post-intervention assessment, though these results warrant further investigation because of low to moderate level of certainty of evidence. The National Institute for Health and Care Excellence (NICE) guidelines have identified the potential role of CBT-based psychotherapy that is specifically tailored for adults who self-harm in prevention of self-harm repetition [ 12 ].

C ulturally adapted manual- a ssisted p roblem-solving intervention (CMAP) is a CBT-based intervention that has been evaluated in Pakistan in a randomised controlled trial (RCT) with adult self-harm survivors ( n  = 221) recruited from medical units in Karachi (the most populous city in Pakistan) [ 5 ]. The intervention (CMAP) was adapted (for the cultural adaptation process please see method section) from a CBT-based self-help guide called “Life after self-harm” [ 13 ]. The CMAP intervention utilises problem-solving components within a brief CBT intervention that can be widely utilised in clinical practice and also includes other components such as a session on harm minimisation by developing a crisis plan and involving family members and carers advised by NICE guidelines [ 12 ]. Since most episodes of self-harm in Pakistan are precipitated by interpersonal problems with family members, there is a strong rationale for investigating the effectiveness of an intervention which addresses such issues. In addition, CMAP is a structured intervention that is briefer than many existing CBT programmes for self-harm, facilitating its implementation within low-income countries by minimising demands on staff and services, and brief interventions in low- and middle-income countries (LMICs) have been found to be effective in reducing the number of suicide deaths [ 14 ]. The main outcome measures in this exploratory study were suicidal ideation, the severity of depression and hopelessness assessed at baseline, 3 and 6 months. There was a significant reduction from baseline in suicidal ideation, the severity of depression and hopelessness in the CMAP arm compared to the treatment-as-usual (TAU) arm at each follow-up assessment. Though the results were encouraging, the sample size was small to provide a definitive answer. Furthermore, this exploratory RCT addressed short-term outcomes to 6 months only, with participants recruited from 3 general hospitals in one city. Patients who were not admitted to the medical wards were excluded as the research team did not have the resources to include this group. All of these limitations were addressed in this current, large-scale definitive RCT of the same intervention (CMAP) added to the enhanced treatment as usual (E-TAU) compared to the E-TAU alone, for reducing repeat self-harm episodes, and several other clinical and health outcomes 12-month post-randomisation among adults presenting after episode of self-harm in five large cities across Pakistan.

Study design

The study was a multicenter, randomised controlled trial with randomisation of individual patients into either of two arms: (1) CMAP plus E-TAU and (2) E-TAU alone. The trial is reported in accordance with the guidance of the Consolidated Standards of Reporting Trials (CONSORT).

Study setting

Study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi (population 21 million), Lahore (12 million), Rawalpindi (4.7 million), Peshawar (1.9 million), and Quetta (1 million), Pakistan.

Participants

The target population was all adults presenting to recruitment sites after self-harm episodes.

Inclusion criteria

In this trial’s context, self-harm was defined as:

“an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without interventions from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences [ 5 , 15 ]”.

Individuals aged 18 years and above.

Residents of the catchment area of participating recruitment centres.

Individuals not requiring inpatient psychiatric treatment, as determined by clinical teams.

Exclusion criteria

Temporary resident with less likelihood of availability for follow-up.

Participants with serious general medical conditions, substance misuse, delirium, dementia, alcohol or drug dependence, bipolar disorder, schizophrenia, and learning disabilities, as determined by clinical teams.

Not able to engage, participate and/or respond to the trial questionnaires due to a medical or psychiatric condition, or due to living outside of the study catchment area.

Randomisation and masking

The completed baseline assessments were sent by the trained researchers to the Trial Manager who then contacted the off-site randomisation centre, where eligibility was re-checked, baseline measures recorded and participant trial numbers assigned. Treatment assignment was determined using block randomisation controlling for gender, age, and type of self-harm behaviour. For the block randomisation, study site, age group (> 30 or <  = 30), gender and type of self-harm were included as strata. However, self-harm was only included as any chemical (including bleach and pesticides) or other. A randomisation list was generated using online resource-sealed envelopes. The online resource was used with block sizes 2, 4, 6 and 8.

The off-site statistician and research team carrying out follow-up assessments were blinded to treatment allocation. Trial participants and therapists were not blinded to treatment allocation as evidence suggests that blinding of participants and therapists may compromise the effects of the active ingredients of the psychological intervention. Effective delivery of a particular psychological intervention requires extensive training, which would be difficult to implement with the blinding intact [ 16 ].

Study procedure

All procedures contributing to this work comply with the Helsinki Declaration of 1975, as revised in 2008. The study was approved by the Research Ethics Committee of the Karachi Medical and Dental College (027/15) and the University of Manchester (2019–2610-10693). The study's clinical trial registration number is NCT02742922 — registered with ClinicalTrials.gov.

All patients presenting to the participating sites following an episode of self-harm were approached for recruitment. Detailed information about the research along with a Participant Information Leaflet was given to the potential participants. Potential participants were assessed by trained researchers against study eligibility criteria. Handwritten signatures (or thumbprints) were used to obtain informed consent from eligible participants. A trained researcher scheduled time with consented participants and baseline assessments were completed face to face either at a research office or the participant’s home. Following baseline assessments, a unique identification number (ID) was assigned to each participant and a list of IDs with details on age, gender, method of self-harm and study site was prepared by the trial manager and sent for randomisation. All the participants were made aware of their respective treatment arm within 1 week of randomisation. Participants in the intervention arm were contacted by the therapist to arrange the first session. All intervention sessions were delivered face to face either at a research office or the participant’s home, at a time convenient for both the therapist and participant. Follow-up assessments with participants from both study arms were carried out at 3-, 6-, 9-, and 12-month post-randomisation. All follow-up assessments were carried out face to face either at a research office or the participant’s home.

Intervention

CMAP is a manual-assisted, CBT-informed problem-focused therapy, comprising six one-to-one sessions delivered over 3 months. This has been culturally adapted and refined with permission from a self-help guide “Life after self-harm” [ 13 ]. Intervention includes an in-depth understanding of the self-harm episodes such as discussion on triggers of self-harm episodes, the reaction of family members, crisis management for risk minimisation, problem-solving skills, CBT techniques to manage negative thinking and emotions, and strategies for relapse prevention. The last session was with the family to discuss their emotions related to the self-harm episodes, encouraging them to seek professional help if they observe any further risk of self-harm episodes. The intervention was delivered at a place of the participant’s choice (the participant’s home or an outpatient clinic/research office). The first 2 sessions were delivered weekly, and then fortnightly. Each session lasted for about 50 min.

Cultural adaptation

Before the exploratory study, a group of mental health professionals translated the content of the manual into Urdu (Pakistan’s national language). A focus group with multidisciplinary health professionals (mental health professionals, general physicians, nurses) was conducted to discuss cultural adaptations, and special consideration was given to phrases and concepts to reflect Pakistani culture. Additionally, culturally appropriate case scenarios were incorporated and a consensual view to addressing cultural factors such as gender role, family conflicts and financial difficulties was taken. Issues related to substance misuse were replaced with more emphasis on family conflicts (culturally sensitive training in assertiveness and conflict management) as these conflicts usually lead to a self-harm episode in Pakistan.

Enhanced treatment as usual (E-TAU)

Local primary care, psychiatric and medical services offer standard care according to available resources. People who self-harm would not be routinely referred to psychiatric facilities. Along with TAU, participants in the E-TAU arm received full assessments at baseline, 3, 6, 9, and 12 months, in addition to a monthly call from a designated researcher to ensure their ongoing engagement with the project.

Assessments

Demographic questionnaire.

This was a structured form specifically prepared for the study to collect demographic information (age, sex, education, etc.).

Primary outcome measure

Suicide attempt self-injury interview (sasii) [ 17 ].

Repetition of self-harm episodes at 12-month post-randomisation were recorded using the semi-structured questionnaire SASII. Information was collected about the method, time, antecedents, functions and circumstances leading to self-harm. SASII has good validity and inter-rater reliability (ICC = 0·96) [ 17 ].

Secondary outcome measures

Beck scale for suicide ideation (bsi) [ 18 ].

This is a self-report questionnaire (19 items) to assess the severity of suicidal ideation in the previous week. Scores range from 0 to 38 and higher scores on the questionnaire (≥ 6) suggest a greater risk of suicide [ 19 ]. No specific cut-off scores exist to classify severity; however, higher scores reflect greater suicide risk. The Urdu-translated version has a Cronbach’s alpha of 0.89 [ 20 ].

Beck Hopelessness Scale (BHS) [ 21 ]

This is a 20-item self-report assessment of hopelessness, feelings about the future and loss of motivation. Scores range between 0 and 20. Higher scores indicate increasing severity of hopelessness: 0–3 minimal, 4–8 mild, 9–14 moderate, and 15–20 severe. The reliability coefficient of the Urdu version is 0.93 [ 20 ].

Beck Depression Inventory (BDI) [ 22 ]

This is a 21-item instrument to assess depressive symptoms. A higher score indicates greater severity of depression. A score between 1 and 10 indicates that the ups and downs are considered normal, 11 and 16 mild mood disturbance, 17 and 20 borderline clinical depression, 21 and 30 moderate depression, 31 and 40 severe depression and a score above 40 indicate extreme depression. The Cronbach’s alpha of the Urdu-translated version was 0.97 [ 20 ].

Coping Resource Inventory (CRI) [ 23 ]

The CRI is a structured instrument to measure the coping resources available to an individual to deal with stress. The CRI has five domains;

The cognitive domain assesses the extent to which individuals maintain a positive sense of self-worth, a positive outlook towards others, and optimism about life in general. Examples of questions include: “I see myself as lovable”.

The social domain assesses the degree to which individuals are connected to social networks that provide support in stressful times. An example question is: “I am part of a group, other than my family that cares about me”.

The emotional domain assesses the degree to which individuals are able to express a range of emotions. An example question is: “I express my feelings clearly and directly”.

The spiritual/philosophical domain assesses the degree to which actions of an individual are guided by a stable set of values derived from personal philosophy or from familial, religious, or cultural tradition. An example question is: “My values and beliefs help me meet daily challenges”.

The physical domain assesses the degree to which an individual is able to perform health-promoting behaviours that can contribute to increased physical wellbeing. An example question from this domain is: “I exercise vigorously 3–4 times a week”.

A four-point rating scale is used to indicate how often an individual has engaged in the item over the past 6 months. The sums of the item responses for each scale constitute the scale scores. The total resource score is computed by adding the five individual scale scores. The higher the scores, higher is the coping resources of that individual [ 23 ].

Psychometric properties of CRI are well-established [ 23 ]. Test–retest correlation coefficients ranged from 0.60 to 0.73 and Cronbach’s alpha from 0.77 to 0.91 for the six domains. The predictive, concurrent, and discriminant validity for the scale has been established.

EuroQol – 5 Dimensions (EQ-5D) [ 24 ]

This is a standardised, self-report questionnaire covering five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). Each dimension has responses in 3 levels of intensity: (level 1) no problems, (level 2) some problems, and (level 3) extreme problems. Participants are also asked to provide a self-rating on a Visual Analogue Scale (VAS), ranging from 0 (worst imaginable health state) to 100 (best imaginable health state). The EQ-5D total score is converted into an EQ-5D index score using already established valuation sets. Pakistan does not have a preference-based value set for the EQ-5D-3L instrument; therefore, the Thailand time trade-off tariff was applied. Values, 1–3, were assigned to each level of EQ-5D-3L. Value 1 indicates perfect health, and 3 is the worst in each dimension. In the first step, all the responses of level were mentioned together for each participant such as from (1 1 1 1 1) to (3 3 3 3 3) and in the second step a crosswalk table was used to compute the index score (using Thailand tariff). Test–retest reliability assessments in the general population reported moderately weighted kappa ( k ) ( k : 0.42–0.63) and high intra-class correlation coefficients (ICCs: 0.78) [ 25 ]. Studies with individuals experiencing mental health difficulties reported ICC = 0.83 for common mental disorders such as depression and ICC = 052 for severe mental illnesses such as schizophrenia [ 26 ].

Client Satisfaction Questionnaire (CSQ) [ 27 ]

The CSQ-8 is an unidimensional measure of an individual’s satisfaction with services, assessed at 3 (end of treatment) and 12-month post-randomisation. The CSQ-8 has eight questions: quality of service, kind of service, meet needs, recommend to a friend, amount of help, deal with problems, overall satisfaction, and come back. The individual responds to these questions using a 4-point Likert scale. Their responses are scored from 1 to 4, and the total scores range from 8 to 32. Higher scores indicate greater satisfaction. Reliability testing CSQ-8 reported a high internal consistency score ranging between 0.83 and 0.93 [ 28 ].

Cognitive Therapy Rating Scale (CTRS) [ 29 ]

The CTRs is an observer-rated evaluation of a therapist’s competence in cognitive therapy skills. The questionnaire includes 12 items, scored on a 7-point Likert-type scale ranging from 0 ( poor ) to 6 ( excellent ). Items are designed to assess therapeutic relationship skills (e.g. interpersonal effectiveness), CBT-specific skills (e.g. focusing on key cognitions and behaviours), and structure (e.g. agenda setting). Internal consistency across all items is high ( α  = 0.94) [ 30 ].

Client Services Receipt Inventory [ 31 ]

Information on participants’ use of both formal and informal (such as Imams/faith healers) health services was collected at baseline and follow-up assessments using a structured form. We will submit the economic evaluation as a separate publication.

Translation: All Urdu version questionnaires mentioned above have been used before in the exploratory trial [ 5 ].

Adverse events monitoring: Adverse events were recorded on the adverse event form that was developed for the trial.

Training and supervision

Researchers were trained by senior mental health professionals in recruiting vulnerable populations (including those with severe mental illnesses), administering both qualitative and quantitative assessments, managing distressed participants, and retaining difficult-to-engage populations. The research team was trained in Good Clinical Practice (GCP), data protection and management, research and information governance. Monthly training refreshers were conducted to ensure the accuracy and concordance of ratings. These trainings involved both live role play and videotaped sessions of mock interviews. All trial therapists also received regular ongoing training. These training sessions included presentations on CMAP, role-play, discussion on how to introduce and get homework assignments completed, and feedback on role-play. All trial therapists also received regular ongoing training and supervision by national CBT therapists (ZZ, SS) as well as international experts (CW, FN). Digitally recorded sessions with the participants were rated by the CBT supervisor (ZZ) using the Cognitive Therapy Rating scale (CTRs) [ 29 ].

Sample size

Based on previous analysis of therapist-delivered intervention trials, we believe that the intra-cluster correlation coefficient (ICC) for therapists [ 32 ] is likely to have a value between 0.01 and 0.05 for this type of outcome measure. This trial used repetition of self-harm as its primary outcome measure because it is a strong risk factor of a suicide death. The expected event rates of 27.7% and 16.1% come from the study by Brown et al. [ 33 ]. Brown reported a significant difference in the rate of repetition of self-harm over an 18-month period, 24.1% in the cognitive therapy group and 41.6% in usual care. We estimated from this that the event rate would be 27.7% (two-thirds of 41.6%) in 12 months in the usual care arm and 16.1% (two-thirds of 24.1%) in the CMAP arm. Under these assumptions, a sample of 624 randomised patients was required to have 80% power to detect this difference assuming a 5% significance level. However, the funding panel advised consulting an independent statistician (KG) to increase the power to 90% thus increasing the sample size from 624 to 850. We randomised a total of 901 participants as consent was already obtained from participants across different sites.

Statistical analysis

Statistical analysis was based on intention-to-treat subject to the availability of data. The statistical analysis of the primary outcome measure, repetition of the self-harm episode, was performed using a logistic random effects model, with the therapist included as a random effect. The E-TAU group did not receive trial intervention, and thus for the purposes of the model, each E-TAU participant was considered to be in their own cluster. Also included in the model were adjustments for age, gender, type of self-harm and level of depression at baseline (see Table 2 for sub-groups).

Continuous secondary outcome measures were analysed using a linear mixed model, with a single model fitted with data across all time-points. Both therapist and the patient were included as random effects. Covariates included were for the primary outcome, plus the baseline values of the outcome.

Secondary outcomes measured on an ordinal scale (individual CSQ-8 items) were analysed using an ordinal logistic regression random effects model, with the therapist as the random effect (Table 5 ). Covariates in the model were as for the primary outcome.

A total of 3788 patients completed initial screening against eligibility criteria and 1165 met trial inclusion criteria. A total of 901 patients were randomised either into the intervention arm ( n  = 440) or the E-TAU arm ( n  = 461). The first participant was randomised on 27th April 2016 (as per the details mentioned on ClinicalTrials.gov) and the last participant on 20th May 2018. Follow-up assessments started in August 2016 and completed in July 2019. A total of 423 (96%) in the intervention arm and 430 (93%) in the E-TAU arm completed 12-month follow-up assessments (please see Fig.  1 CONSORT diagram).

CONSORT diagram

Out of 901 participants, 544 (60.4%) were women, and the mean age of participants was 26.5 years (SD = 7.97); 523 (58%) were married; 474 (52.6%) were from a nuclear family; 464 (51.5%) belonged to ultra-lower income group (earning 147 US dollars/month) and 202 (22.9%) were from the lower middle-income group (160 US dollars and above/month); 284 (31.5%) had received up to 10 years of schooling; and 539 (59.8%) were employed (Table 1 ). Overall, 457 (50.7%) participants reported they were in debt, 566 (62.8%) participants reported that they had difficulty meeting day-to-day expenses in the last month, and 346 (38.4%) reported they had gone to sleep hungry due to financial difficulties at some point during the past month (Table 1 ).

The majority of the participants presented with first self-harm attempt ( n  = 806, 89.5%). Pesticides were the most common method to attempt self-harm ( n  = 403, 44.7%) (Table 2 ). A total of 607 (67.4%) participants had clear expectations of a fatal outcome. The majority of the participants 594 (65.9%) did not communicate that they were thinking of self-harm. Similarly, the majority of the participants ( n  = 585, 65.3%) did not communicate self-harm plans to anyone. A total of 556 (61.7%) participants reported a serious/extreme intent to die. Majority of the participants ( n  = 703, 78.0%) reported interpersonal problems as the precipitant of their self-harm episode and 169 (18.8%) stated that they harmed themselves because of financial problems (Table 2 ).

Although there was a trend towards fewer repetitions in the CMAP plus E-TAU arm, there was no statistically significant difference in the proportion of repetition of self-harm between the two arms (intervention — n  = 17 (3.9%) vs. E-TAU — n  = 23 (5.1%)) at 12 months. The odds ratio was estimated to be 0.78 ( p -value = 0.459) (Table 3 ).

There were a total of 19 adverse events (not related to intervention). A total of nine in the intervention arm (2 = worsening of physical consequences of self-harm, 1 = episode of major depressive disorder, 2 = road accidents, 1 = typhoid, 1 = tuberculosis, 1 = heart disease, and 1 = appendicitis) and ten were in E-TAU (1 = worsening of physical consequences of self-harm, 3 = episode of major depressive disorder, 1 = alcohol dependence, 1 = malaria, 2 = psychosis, 1 = jaundice, and 1 = road accident).

Participants in the intervention arm compared to the E-TAU showed significantly greater improvements on all the key clinical measures correlated with suicide (suicidal ideation, depression, and hopelessness) at 3, 6, 9, and 12 months (except for suicidal ideation and hopelessness at 12 months) ( p  < 0·05). In terms of coping resources, there were statistically significant differences between the two trial arms on overall CRI score as well as on all 4 domains (cognitive, social, spiritual/philosophical, and physical) at each follow-up (except for physical domain at 9-month follow-up) and health-related quality of life at each follow-up ( p  < 0.05) (Table 4 ).

All CSQ-8 outcomes were significantly higher in the intervention arm compared to the E-TAU (all p  < 0.001). The quality of services was rated as good to excellent by 385 (90.6%) participants in the intervention arm compared to 344 (77.1%) participants in the E-TAU arm (Table 5 ).

Moreover, the session attendance log showed that 413 (93·87%) participants in the intervention arm attended 5 to 6 sessions.

The fidelity ratings of all therapists were satisfactory and ranged between 4 and 6 on 12 items of CTRs. A rating of 4 indicates “good features, but minor problems and/or inconsistencies”. A rating of 6 indicates “excellent performance, even in the face of patient difficulties” (Table 6 ).

The CMAP trial is one of the few trials which evaluated a CBT-based culturally adapted psychological intervention to reduce self-harm and clinical outcomes known to be predictive of suicide and the first trial of its kind in any low- and middle-income country (LMIC). This trial showed that the repetition rate of self-harm was low for both groups at 12 months, although the number in the intervention arm was lower ( n  = 17) compared to the E-TAU arm ( n  = 23), but the difference between the two arms was not statistically significant. There was a significant reduction in the intervention arm compared to the E-TAU arm in suicidal ideation, depression, and hopelessness at the end of intervention. Similarly, intervention arm participants reported significantly better health-related QoL and better coping skills compared to the E-TAU arm.

Consistent with our findings, a previous trial investigating the effectiveness of Volitional Help Sheets also did not report any statistically significant differences both in terms of repetition (67 intervention vs 71 TAU) and suicide rate (one in intervention vs two in TAU) [ 34 ]. For the current trial, there is a disparity between the repetition rate in Brown et al., the study used for sample size calculation, and that observed in this trial. The possible reason for this disparity in expected and observed event rate could be that Brown et al., study was conducted in a high-income country (Philadelphia) [ 33 ] and despite a different setting our sample size calculation was based on this study because of lack of evidence on the self-harm repetition rate in Pakistan and also the lack of evidence on therapist-delivered intervention trials to prevent the repetition of self-harm both in Pakistan and in other similar low-income settings. Assuming the exact event rates as per the observed data in current trial (5.1% and 3.9%) in the two groups, this is only a small difference of 1.2%. For a 5% significance level and 80% power a sample of 4684 per group, 9368 would be required in total. For a clinically meaningful difference of 2% a sample of 3372 in total would be required. Moreover, the low repetition rate in the E-TAU group in this study is supported by a recent meta-analysis of 14 studies on brief interventions delivered in a single encounter (such as brief follow-up contacts and safety planning) to those at high risk of suicide are effective at improving outcomes (such as subsequent suicide attempts) [ 35 ]. The participants in the E-TAU arm in current trial received comprehensive health assessments along with a monthly call by researchers to maintain engagement which may have had a therapeutic effect [ 35 ].

The majority of the participants in the trial reported that they had serious intent to die. In a recent report, of those who presented to hospitals with suicidal ideation, the risk of self-harm within 12 months was 10% and 18% within 5 years [ 36 ]. In the current trial participants in both study arms were in a high-risk group (score greater than six on Beck Suicide Ideation scale) at baseline and for both arms there was a reduction in suicidal ideation at each follow-up point. However, this was significantly greater in the intervention arm compared to the E-TAU arm and participants in the intervention arm were no longer in a high-risk category at the 3-month follow-up and this trend was sustained till 12-month follow-up, and those in the E-TAU arm did not achieve non-risk category until 12-month follow-up. Though the mean difference between two groups was not statistically significant at 12-month follow-up, both groups were in the non-risk category. An exploratory trial of CMAP also showed a sustained effect of CMAP on suicidal ideation at 6-month follow-up [ 5 ]. Participants in E-TAU arm achieving non-risk category on suicidal ideation is also supported by a published trial that showed a significant reduction in scores on the suicidal ideation scale at 6-month follow-up after participation in a low-intensity intervention called motivational interviewing [ 37 ].

Suicide theories such as Interpersonal–Psychological Theory of Suicide [ 38 ] and Hopelessness Theory of Suicide [ 39 ] incorporate hopelessness and depression as potential causes of suicidal thoughts or behaviours. Therefore, the management of depression and hopelessness are likely important mitigating factors in self-harm and suicide prevention. In the current trial, depression was reduced for both groups at each follow-up, however, mean scores were significantly lower in the intervention arm compared to the E-TAU arm. Moreover, participants in the intervention arm achieved remission (score < 13) earlier (at 3-month follow-up) compared to the E-TAU arm (at 9-month follow-up). Hopelessness scores were reduced for both at all follow-ups, however, mean scores were significantly lower in the intervention arm compared to the E-TAU arm at 3-, 6- and 9-month follow-ups. Though the mean difference between the two groups was not statistically significant at 12-month follow-up, both groups were in the non-risk (minimal to mild) hopelessness category. Evidence shows that CBT-based interventions have a beneficial effect on depression and hopelessness [ 10 ] with few trials showing a sustained effect of interventions at 12-month follow-up (9-h-long sessions of problem-solving intervention over 3 months) [ 40 ], (10-session CBT intervention) [ 33 ], and (5 sessions of problem-solving intervention within 1 month of index self-harm attempt) [ 41 ]. This may indicate that a long-term impact on hopelessness may require either more intervention sessions or more frequent sessions immediately after a self-harm attempt. Future trials may also consider evaluating the role of booster sessions [ 34 ].

The nature of the stressors that trigger self-harm behaviours may be difficult to change, but the coping strategies to deal with stressors are dynamic and amenable to change. Therefore, strengthening coping resources can be a helpful strategy to reduce self-harm behaviours [ 42 ]. Findings from the current trial show that participants in the intervention arm reported significantly better coping resources at each follow-up compared to the E-TAU arm for all domains (cognitive, social, emotional, and spiritual) except physical coping where the difference between the two arms was not significant at 9- and 12-month follow-up.

Mental health interventions may not only reduce suicidal behaviours but may also contribute in improving QoL [ 5 ]. The current trial shows that participants in both arms improved but those who received the intervention had significantly better QoL compared to E-TAU at each follow-up. Findings are consistent with earlier CMAP trials [ 5 ]. This also highlights the importance of assessment of QoL of those who are at risk of suicide through simple easy to administer tools such as EQ-5D [ 5 ].

Strengths and limitations

To the best of our knowledge, this was the largest therapist-delivered self-harm and suicide prevention trial across the world, with a high retention rate at a long-term follow-up. However, in most low-income settings (including Pakistan) access to trained mental health professionals/therapists is limited particularly in rural settings, telehealth solutions can address such challenges related to access. Mental health professionals in these settings may also consider how best to engage and train other allied health professionals such as nurses, and community health workers in the delivery of suicide prevention interventions or components of these interventions. Participants were recruited from a variety of settings (including primary care settings) across Pakistan, increasing the likelihood of the generalizability of findings. Moreover, the use of a detailed semi-structured tool (SASII) to assess the primary outcome, structured validated instruments to assess secondary outcomes, regular training, rigorous arrangements for supervision, and fidelity assessment have increased the validity of trial findings. In addition, a large sample size, with long-term follow-up is also a strength of the trial. However, since the risk of self-harm in those with suicidal ideation increases with time, therefore a longer-term follow-up is recommended. There was a disparity between the self-harm repetition rate expected based on sample size calculation and the repetition rate observed in the trial. A trial with an even larger sample size would be required to detect such a small difference observed in this study. Moreover, the CMAP intervention focused on different components that are likely to reduce social stigma and improve the awareness of self-harm and its prevention such as psychoeducation about the motivations behind self-harm episodes, emotional consequences of the episode, importance of seeking professional help etc. Future trials of CMAP intervention may consider assessing change in participants’ attitude and behaviours towards self-harm and suicide at end of intervention.

Further research is also needed to explore the role of brief follow-up contact, such as using postcards in low resource settings. The clinical staging model which involves multiple intervention stages have been found to be effective [ 43 ] and may also be helpful in suicide prevention. These are interventions in which the type or dosage is individualised based on patient characteristics (such as clinical presentations) and is repeatedly adjusted in response to the individual’s progress.

CMAP intervention is promising for improving clinical outcomes predictive of suicide, coping resources, health-related QoL, and perceived service quality among adult self-harm survivors in Pakistan. All individuals who participated in the trial reported low repetition rates and there were low suicide rates. These findings on the role of brief interventions and enhanced usual care in improving outcomes predictive of self-harm and suicide (hopelessness, suicidal ideation and depression) are particularly important for low-resource settings where delivering more resource-intensive interventions is challenging.

Availability of data and materials

Anonymised data will be made available on request.

Abbreviations

Low- and middle-income countries

Culturally adapted manual-assisted problem-solving intervention

Enhanced treatment as usual

• Cognitive behaviour therapy

Quality of life

World Health Organisation

Randomised controlled trials

Dialectical behaviour therapy

Mentalisation-based therapy

National Institute for Health and Care Excellence

Consolidated Standards of Reporting Trials

Identification number

Suicide Attempt Self-Injury Interview

Beck Scale for Suicide ideation

Beck Hopelessness Scale

Beck Depression Inventory

Coping resource inventory

EuroQol – 5 Dimensions

Client Satisfaction Questionnaire

Cognitive Therapy Rating Scale

Good Clinical Practice

Intra-cluster correlation coefficient

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Acknowledgements

We would like to thank our Participant and Public Involvement and Engagement (PPIE) group, all the participants who participated in the trial, their families, and our community engagement officers. We want to thank our Trial Steering Committee (Chair Prof David Kingdon, Members: Trial Statistician – RE, Service user representative – SK, Funder observer—Mary Desilva) and Data Management and Ethics Committee (DMEC) (independent statisticians – Kimberley Goldsmith, clinicians – Prof Mowadat H Rana, Dr Rashid Qadir).

We are thankful to authors Ulrike Schmidt and Kate Davidson for allowing us to translate, culturally adapt and use the self-help manual “Life after Self-Harm a Guide to the Future” as well as to the Manual Translation and Cultural Adaptation group of the Pakistan Institute of Living and Learning (PILL). We want to thank all the nurses, GPs, clinicians, heads of emergency departments, psychiatry and medical units of participating hospitals for their support in the screening and recruitment of participants for the trial. We would also like to thank all researchers and therapists involved throughout the trial (Ameer B Khoso, Shafaq Ijaz, Maham Rasheed, Majid Sanjrani, Ghulam Qadir, Sehrish Irshad, Zaib un Nisa, Tahira Khalid, Farooq Ahemd, Samia Shahid, Humera Khalid, Rab Dino, Rabia Sattar, Maheshwari Bebo, Sanum Hakro, Akhtar Zaman, Nawaz Khan, Muqaddas Jabeen, Shoaib Khalid, Raja M. Talha, Muhammad Asif, Maria Usman, Sana Farooque, Raheel Ahmed, Farhat ul Ain, Nayab Zafar, Mahum Izhar, Asif Ali (late), Ali Raza, Hadiyya tur Rehman, Muqaddas Asif, Farhat ul Ain, Qurat ul ain, Mehak Bano, Junaid Ikhlaq, Zainab Bibi, Umair Ahsan, Hira Jaffer, Sanaullah Kakar, Faster Gill, Summaiya Shahid, Uzma Attique Khan, Farah Naz, Shahida Kausar, Raees Jokhio, Bano, Nimra, Mehreen Khan, Najma Aziz). Special thanks to Sami Ansari – data manager.

Funding support for this study was provided by the MRC/Wellcome Trust/DFID ( MR/N006062/1 ) . The funders had no role in the study design, collection, analysis or interpretation of the data, writing of the manuscript, or the decision to submit the manuscript for publication.

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Contributions

The idea of the study was conceived by NH, NC, IBC, MOH and TK as well as contributing to the design and its coordination. MMA, MRB, MI, FAM, HN, ATN, SNZ, GR, and SQB shared responsibility for the training and supervision of RAs and supported the recruitment of participants across study sites and also contributed to the interpretation of results and reviewed the manuscript. CCG and PP2 offered training and supervision of the qualitative study. AK, AN, UA, and ST contributed to the recruitment of participants, carrying out assessments and intervention delivery. CW, SS, ZFZ, and FN were involved in the training and supervision of RA’s for intervention delivery and fidelity assessments and contributed to the preparation of the manuscript. RE and PB1 did data analysis and interpretation of the findings. MP has reviewed and finalised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Tayyeba Kiran .

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The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures were approved by the Research Ethics Committee of the Karachi Medical and Dental College (027/15) and the University of Manchester (2019–2610-10693). All participants provided written informed consent to participate in this study.

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Competing interests

NH has been a past Trustee of the Pakistan Institute of Living and Learning (PILL), Abaseen Foundation UK, Lancashire Mind UK and Manchester Global Foundation (MGF). He is an executive member of the Academic Faculty at the Royal College of Psychiatrists, London. He is an NIHR Senior Investigator. He has attended educational events organised by various pharmaceutical industries.

NC is the CEO of the Pakistan Institute of Living and Learning. She is Associate Director of the Global Mental Health and Cultural Psychiatry Research Group, Head of Psychological Medicine at the Remedial Centre Hospital, Consultant Psychiatrist at South City Hospital, Consultant for Manchester Global Foundation and Professor of Psychiatry, Dow University of Health Sciences. NC has received travel grants from Lundbeck and Pfizer pharmaceutical companies to attend one national and one international academic meeting and conference in the last three years. She is a chief investigator and co-investigator for a number of research projects funded by various grant bodies such as the Medical Research Council, Welcome Trust, NIH-R, and Global Challenges Research Fund.

IBC has given lectures or advice to Eli Lilly, Bristol Myers Squibb, Lundbeck, Astra Zeneca, and Janssen pharmaceuticals for which he or his employing institution have been reimbursed, outside the submitted work; Prof Chaudhry was previously a trustee of the Pakistan Institute of Living and Learning (PILL).

The authors declare no conflicts of interest associated with this trial.

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Husain, N., Kiran, T., Chaudhry, I.B. et al. A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial. BMC Med 21 , 282 (2023). https://doi.org/10.1186/s12916-023-02983-8

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Research Article

Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America

Roles Conceptualization, Writing – original draft

Affiliation Centre for Evidence and Implementation, London, United Kingdom

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Roles Conceptualization, Writing – review & editing

Affiliation Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States of America

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Affiliation Centre for Evidence and Implementation, Melbourne, Victoria, Australia

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Affiliation Department of Social Work, Monash University, Melbourne, Victoria, Australia

• Kristina Metz, 
• Jane Lewis, 
• Jade Mitchell, 
• Sangita Chakraborty, 
• Bryce D. McLeod, 
• Ludvig Bjørndal, 
• Robyn Mildon, 
• Aron Shlonsky

• Published: August 29, 2023
• https://doi.org/10.1371/journal.pone.0285949
• Peer Review
• Reader Comments

Problem-solving (PS) has been identified as a therapeutic technique found in multiple evidence-based treatments for depression. To further understand for whom and how this intervention works, we undertook a systematic review of the evidence for PS’s effectiveness in preventing and treating depression among adolescents and young adults. We searched electronic databases ( PsycINFO , Medline , and Cochrane Library ) for studies published between 2000 and 2022. Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; (d) at least one depression outcome was reported. Risk of bias of included studies was assessed using the Cochrane Risk of Bias 2.0 tool. A narrative synthesis was undertaken given the high level of heterogeneity in study variables. Twenty-five out of 874 studies met inclusion criteria. The interventions studied were heterogeneous in population, intervention, modality, comparison condition, study design, and outcome. Twelve studies focused purely on PS; 13 used PS as part of a more comprehensive intervention. Eleven studies found positive effects in reducing depressive symptoms and two in reducing suicidality. There was little evidence that the intervention impacted PS skills or that PS skills acted as a mediator or moderator of effects on depression. There is mixed evidence about the effectiveness of PS as a prevention and treatment of depression among AYA. Our findings indicate that pure PS interventions to treat clinical depression have the strongest evidence, while pure PS interventions used to prevent or treat sub-clinical depression and PS as part of a more comprehensive intervention show mixed results. Possible explanations for limited effectiveness are discussed, including missing outcome bias, variability in quality, dosage, and fidelity monitoring; small sample sizes and short follow-up periods.

Citation: Metz K, Lewis J, Mitchell J, Chakraborty S, McLeod BD, Bjørndal L, et al. (2023) Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression. PLoS ONE 18(8): e0285949. https://doi.org/10.1371/journal.pone.0285949

Editor: Thiago P. Fernandes, Federal University of Paraiba, BRAZIL

Received: January 2, 2023; Accepted: May 4, 2023; Published: August 29, 2023

Copyright: © 2023 Metz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant methods and data are within the paper and its Supporting Information files.

Funding: This work was commissioned by Wellcome Trust and was conducted independently by the evaluators (all named authors). No grant number is available. Wellcome Trust had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors declare no financial or other competing interests, including their relationship and ongoing work with Wellcome Trust. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Depression among adolescents and young adults (AYA) is a serious, widespread problem. A striking increase in depressive symptoms is seen in early adolescence [ 1 ], with rates of depression being estimated to almost double between the age of 13 (8.4%) and 18 (15.4%) [ 2 ]. Research also suggests that the mean age of onset for depressive disorders is decreasing, and the prevalence is increasing for AYA. Psychosocial interventions, such as cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT), have shown small to moderate effects in preventing and treating depression [ 3 – 6 ]. However, room for improvement remains. Up to half of youth with depression do not receive treatment [ 7 ]. When youth receive treatment, studies indicate that about half of youth will not show measurable symptom reduction across 30 weeks of routine clinical care for depression [ 8 ]. One strategy to improve the accessibility and effectiveness of mental health interventions is to move away from an emphasis on Evidence- Based Treatments (EBTs; e.g., CBT) to a focus on discrete treatment techniques that demonstrate positive effects across multiple studies that meet certain methodological standards (i.e., common elements; 9). Identifying common elements allows for the removal of redundant and less effective treatment content, reducing treatment costs, expanding available service provision and enhancing scability. Furthermore, introducing the most effective elements of treatment early may improve client retention and outcomes [ 9 – 13 ].

A potential common element for depression intervention is problem-solving (PS). PS refers to how an individual identifies and applies solutions to everyday problems. D’Zurilla and colleagues [ 14 – 17 ] conceptualize effective PS skills to include a constructive attitude towards problems (i.e., a positive problem-solving orientation) and the ability to approach problems systematically and rationally (i.e., a rational PS style). Whereas maladaptive patterns, such as negative problem orientation and passively or impulsively addressing problems, are ineffective PS skills that may lead to depressive symptoms [ 14 – 17 ]. Problem Solving Therapy (PST), designed by D’Zurilla and colleagues, is a therapeutic approach developed to decrease mental health problems by improving PS skills [ 18 ]. PST focuses on four core skills to promote adaptive problem solving, including: (1) defining the problem; (2) brainstorming possible solutions; (3) appraising solutions and selecting the best one; and (4) implementing the chosen solution and assessing the outcome [ 14 – 17 ]. PS is also a component in other manualized approaches, such as CBT and Dialectical Behavioural Therapy (DBT), as well as imbedded into other wider generalized mental health programming [ 19 , 20 ]. A meta-analysis of over 30 studies found PST, or PS skills alone, to be as effective as CBT and IPT and more effective than control conditions [ 21 – 23 ]. Thus, justifying its identification as a common element in multiple prevention [ 19 , 24 ] and treatment [ 21 , 25 ] programs for adult depression [ 9 , 26 – 28 ].

PS has been applied to youth and young adults; however, no manuals specific to the AYA population are available. Empirical studies suggest maladaptive PS skills are associated with depressive symptoms in AYA [ 5 , 17 – 23 ]. Furthermore, PS intervention can be brief [ 29 ], delivered by trained or lay counsellors [ 30 , 31 ], and provided in various contexts (e.g., primary care, schools [ 23 ]). Given PS’s versatility and effectiveness, PS could be an ideal common element in treating AYA depression; however, to our knowledge, no reviews or meta-analyses on PS’s effectiveness with AYA specific populations exist. This review aimed to examine the effectiveness of PS as a common element in the prevention and treatment of depression for AYA within real-world settings, as well as to ascertain the variables that may influence and impact PS intervention effects.

Identification and selection of studies

Searches were conducted using PsycInfo , Medline , and Cochrane Library with the following search terms: "problem-solving", “adolescent”, “youth”, and” depression, ” along with filters limiting results to controlled studies looking at effectiveness or exploring mechanisms of effectiveness. Synonyms and derivatives were employed to expand the search. We searched grey literature using Greylit . org and Opengrey . eu , contacted experts in the field and authors of protocols, and searched the reference lists of all included studies. The search was undertaken on 4 th June 2020 and updated on 11 th June 2022.

Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; and (d) at least one depression outcome was reported. Literature in electronic format published post 2000 was deemed eligible, given the greater relevance of more recent usage of PS in real-world settings. There was no exclusion for gender, ethnicity, or country setting; only English language texts were included. Randomized controlled trials (RCTs), quasi-experimental designs (QEDs), systematic reviews/meta-analyses, pilots, or other studies with clearly defined comparison conditions (no treatment, treatment as usual (TAU), or a comparator treatment) were included. We excluded studies of CBT, IPT, Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), and modified forms of these treatments. These treatments include PS and have been shown to demonstrate small to medium effects on depression [ 13 , 14 , 32 ], but the unique contribution of PS cannot be disentangled. The protocol for this review was not registered; however, all data collection forms, extraction, coding and analyses used in the review are available upon inquiry from the first author.

Study selection

All citations were entered into Endnote and uploaded to Covidence for screening and review against the inclusion/exclusion criteria. Reviewers with high inter-rater reliability (98%) independently screened the titles and abstracts. Two reviewers then independently screened full text of articles that met criteria. Duplicates, irrelevant studies, and studies that did not meet the criteria were removed, and the reason for exclusion was recorded (see S1 File for a list of excluded studies). Discrepancies were resolved by discussion with the team leads.

Data extraction

Two reviewers independently extracted data that included: (i) study characteristics (author, publication year, location, design, study aim), (ii) population (age, gender, race/ethnicity, education, family income, depression status), (iii) setting, (iv) intervention description (therapeutic or preventative, whether PS was provided alone or as part of a more comprehensive intervention, duration, delivery mode), (v) treatment outcomes (measures used and reported outcomes for depression, suicidality, and PS), and (vi) fidelity/implementation outcomes. For treatment outcomes, we included the original statistical analyses and/or values needed to calculate an effect size, as reported by the authors. If a variable was not included in the study publication, we extracted the information available and made note of missing data and subsequent limitations to the analyses.

RCTs were assessed for quality (i.e., confidence in the study’s findings) using the Cochrane Risk of Bias 2.0 tool [ 33 ] which includes assessment of the potential risk of bias relating to the process of randomisation; deviations from the intended intervention(s); missing data; outcome measurement and reported results. Risk of bias pertaining to each domain is estimated using an algorithm, grouped as: Low risk; Some concerns; or High risk. Two reviewers independently assessed the quality of included studies, and discrepancies were resolved by consensus.

We planned to conduct one or more meta-analyses if the studies were sufficiently similar. Data were entered into a summary of findings table as a first step in determining the theoretical and practical similarity of the population, intervention, comparison condition, outcome, and study design. If there were sufficiently similar studies, a meta-analysis would be conducted according to guidelines contained in the Cochrane Collaboration Handbook of Systematic Reviews, including tests of heterogeneity and use of random effects models where necessary.

The two searches yielded a total number of 874 records (after the removal of duplicates). After title and abstract screening, 184 full-text papers were considered for inclusion, of which 25 studies met the eligibility criteria and were included in the systematic review ( Fig 1 ). Unfortunately, substantial differences (both theoretical and practical) precluded any relevant meta-analyses, and we were limited to a narrative synthesis.

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https://doi.org/10.1371/journal.pone.0285949.g001

Risk of bias assessment

Risk of bias assessments were conducted on the 23 RCTs ( Fig 2 ; assessments by study presented in S1 Table ). Risk of bias concerns were moderate, and a fair degree of confidence in the validity of study findings is warranted. Most studies (81%) were assessed as ‘some concerns’ (N = 18), four studies were ‘low risk’, and one ‘high risk’. The most frequent areas of concern were the selection of the reported result (n = 18, mostly due to inadequate reporting of a priori analytic plans); deviations from the intended intervention (N = 17, mostly related to insufficient information about intention-to-treat analyses); and randomisation process (N = 13).

https://doi.org/10.1371/journal.pone.0285949.g002

Study designs and characteristics

Study design..

Across the 25 studies, 23 were RCTs; two were QEDs. Nine had TAU or wait-list control (WLC) comparator groups, and 16 used active control groups (e.g., alternative treatment). Eleven studies described fidelity measures. The sample size ranged from 26 to 686 and was under 63 in nine studies.

Selected intervention.

Twenty interventions were described across the 25 studies ( Table 1 ). Ten interventions focused purely on PS. Of these 10 interventions: three were adaptations of models proposed by D’Zurilla and Nezu [ 20 , 34 ] and D’Zurilla and Goldfried [ 18 ], two were based on Mynors-Wallis’s [ 35 ] Problem-Solving Therapy (PST) guide, one was a problem-orientation video intervention adapted from D’Zurilla and Nezu [ 34 ], one was an online intervention adapted from Method of Levels therapy, and three did not specify a model. Ten interventions used PS as part of a larger, more comprehensive intervention (e.g., PS as a portion of cognitive therapy). The utilization and dose of PS steps included in these interventions were unclear. Ten interventions were primary prevention interventions–one of these was universal prevention, five were indicated prevention, and four were selective prevention. Ten interventions were secondary prevention interventions. Nine interventions were described as having been developed or adapted for young people.

https://doi.org/10.1371/journal.pone.0285949.t001

Intervention delivery.

Of the 20 interventions, eight were delivered individually, eight were group-based, two were family-based, one was mixed, and in one, the format of delivery was unclear. Seventeen were delivered face-to-face and three online. Dosage ranged from a single session to 21, 50-minute sessions (12 weekly sessions, then 6 biweekly sessions); the most common session formar was once weekly for six weeks (N = 5).

Intervention setting and participants.

Seventeen studies were conducted in high-income countries (UK, US, Australia, Netherlands, South Korea), four in upper-middle income (Brazil, South Africa, Turkey), and four in low- and middle-income countries (Zimbabwe, Nigeria, India). Four studies included participants younger than 13 and four older than 25. Nine studies were conducted on university or high school student populations and five on pregnant or post-partum mothers. The remaining 11 used populations from mental health clinics, the community, a diabetes clinic, juvenile detention, and a runaway shelter.

Sixteen studies included participants who met the criteria for a depressive, bipolar, or suicidal disorder (two of these excluded severe depression). Nine studies did not use depression symptoms in the inclusion criteria (one of these excluded depression). Several studies excluded other significant mental health conditions.

Outcome measures.

Eight interventions targeted depression, four post/perinatal depression, two suicidal ideation, two resilience, one ‘problem-related distress’, one ‘diabetes distress’, one common adolescent mental health problem, and one mood episode. Those targeting post/perinatal depression used the Edinburgh Postnatal Depression Scale as the outcome measure. Of the others, six used the Beck Depression Inventory (I or II), two the Children’s Depression Inventory, three the Depression Anxiety Stress Scale-21, three the Centre for Epidemiologic Studies Depression Scale, one the Short Mood and Feelings Questionnaire, one the Hamilton Depression Rating Scale, one the depression subscale on the Schedule for Affective Disorders and Schizophrenia for School-Age Children, one the Strengths and Difficulties Questionnaire, one the Youth Top Problems Score, one the Adolescent Longitudinal Interval Follow-up Evaluation and Psychiatric Status Ratings, one the Kiddie Schedule for Affective Disorders and Schizophrenia, and one the Mini International Neuropsychiatric Interview.

Only eight studies measured PS skills or orientation outcomes. Three used the Social Problem-Solving Inventory-Revised, one the Problem Solving Inventory, two measured the extent to which the nominated problem had been resolved, one observed PS in video-taped interactions, and one did not specify the measure.

The mixed findings regarding the effectiveness of PS for depression may depend on the type of intervention: primary (universal, selective, or indicated), secondary or tertiary prevention. Universal prevention interventions target the general public or a population not determined by any specific criteria [ 36 ]. Selective prevention interventions target specific populations with an increased risk of developing a disorder. Indicated prevention interventions target high-risk individuals with sub-clinical symptoms of a disorder. Secondary prevention interventions include those that target individuals diagnosed with a disorder. Finally, tertiary prevention interventions refer to follow-up interventions designed to retain treatment effects. Outcomes are therefore grouped by intervention prevention type and outcome. Within these groupings, studies with a lower risk of bias (RCTs) are presented first. According to the World Health Organisation guidelines, interventions were defined as primary, secondary or tertiary prevention [ 36 ].

Universal prevention interventions

One study reported on a universal prevention intervention targeting resilience and coping strategies in US university students. The Resilience and Coping Intervention, which includes PS as a primary component of the intervention, found a significant reduction in depression compared to TAU (RCT, N = 129, moderate risk of bias) [ 37 ].

Selective prevention interventions

Six studies, including five RCTs and one QED, tested PS as a selective prevention intervention. Two studies investigated the impact of the Manage Your Life Online program, which includes PS as a primary component of the intervention, compared with an online programme emulating Rogerian psychotherapy for UK university students (RCT, N = 213, moderate risk of bias [ 38 ]; RCT, N = 48, moderate risk of bias [ 39 ]). Both studies found no differences in depression or problem-related distress between groups.

Similarly, two studies explored the effect of adapting the Penn Resilience Program, which includes PS as a component of a more comprehensive intervention for young people with diabetes in the US (RCT, N = 264, moderate risk of bias) [ 40 , 41 ]. The initial study showed a moderate reduction in diabetes distress but not depression at 4-, 8-, 12- and 16-months follow-up compared to a diabetes education intervention [ 40 ]. The follow-up study found a significant reduction in depressive symptoms compared to the active control from 16- to 40-months; however, this did not reach significance at 40-months [ 41 ].

Another study that was part of wider PS and social skills intervention among juveniles in state-run detention centres in the US found no impacts (RCT, N = 296, high risk of bias) [ 42 ]. A QED ( N = 32) was used to test the effectiveness of a resilience enhancement and prevention intervention for runaway youth in South Korea [ 43 ]. There was a significant decrease in depression for the intervention group compared with the control group at post-test, but the difference was not sustained at one-month follow-up.

Indicated prevention interventions

Six studies, including five RCTs and one QED, tested PS as an indicated prevention intervention. Four of the five RCTs tested PS as a primary component of the intervention. A PS intervention for common adolescent mental health problems in Indian high school students (RCT, N = 251, low risk of bias) led to a significant reduction in psychosocial problems at 6- and 12 weeks; however, it did not have a significant impact on mental health symptoms or internalising symptoms compared to PS booklets without counsellor treatment at 6- and 12-weeks [ 31 ]. A follow-up study showed a significant reduction in overall psychosocial problems and mental health symptoms, including internalizing symptoms, over 12 months [ 44 ]. Still, these effects no longer reached significance in sensitivity analysis adjusting for missing data (RCT, N = 251, low risk of bias). Furthermore, a 2x2 factorial RCT ( N = 176, moderate risk of bias) testing PST among youth mental health service users with a mild mental disorder in Australia found that the intervention was not superior to supportive counselling at 2-weeks post-treatment [ 30 ]. Similarly, an online PS intervention delivered to young people in the Netherlands to prevent depression (RCT, N = 45, moderate risk of bias) found no significant difference between the intervention and WLC in depression level 4-months post-treatment [ 45 ].

One RCT tested PS approaches in a more comprehensive manualized programme for postnatal depression in the UK and found no significant differences in depression scores between intervention and TAU at 3-months post-partum (RCT, N = 292, moderate risk of bias) [ 46 ].

A study in Turkey used a non-equivalent control group design (QED, N = 62) to test a nursing intervention against a PS control intervention [ 47 ]. Both groups showed a reduction in depression, but the nursing care intervention demonstrated a larger decrease post-intervention than the PS control intervention.

Secondary prevention interventions

Twelve studies, all RCTs, tested PS as a secondary prevention intervention. Four of the 12 RCTs tested PS as a primary component of the intervention. An intervention among women in Zimbabwe (RCT, N = 58, moderate risk of bias) found a larger decrease in the Edinburgh Postnatal Depression Scale score for the intervention group compared to control (who received the antidepressant amitriptyline and peer education) at 6-weeks post-treatment [ 48 ]. A problem-orientation intervention covering four PST steps and involving a single session video for US university students (RCT, N = 110, moderate risk of bias), compared with a video covering other health issues, resulted in a moderate reduction in depression post-treatment; however, results were no longer significant at 2-weeks, and 1-month follow up [ 49 ].

Compared to WLC, a study of an intervention for depression and suicidal proneness among high school and university students in Turkey (RCT, N = 46, moderate risk of bias) found large effect sizes on post-treatment depression scores for intervention participants post-treatment compared with WLC. At 12-month follow-up, these improvements were maintained compared to pre-test but not compared to post-treatment scores. Significant post-treatment depression recovery was also found in the PST group [ 12 ]. Compared to TAU, a small but high-quality (low-risk of bias) study focused on preventing suicidal risk among school students in Brazil (RCT, N = 100, low risk of bias) found a significant, moderate reduction in depression symptoms for the treatment group post-intervention that was maintained at 1-, 3- and 6-month follow-up [ 50 ].

Seven of the 12 RCTs tested PS as a part of a more comprehensive intervention. Two interventions targeted mood episodes and were compared to active control. These US studies focused on Family-Focused Therapy as an intervention for mood episodes, which included sessions on PS [ 51 , 52 ]. One of these found that Family-Focused Therapy for AYA with Bipolar Disorder (RCT, N = 145, moderate risk of bias) had no significant impact on mood or depressive symptoms compared to pharmacotherapy. However, Family-Focused Therapy had a greater impact on the proportion of weeks without mania/hypomania and mania/hypomania symptoms than enhanced care [ 53 ]. Alternatively, while the other study (RCT, N = 127, low risk of bias) found no significant impact on time to recovery, Family-Focused Therapy led to significantly longer intervals of wellness before new mood episodes, longer intervals between recovery and the next mood episode, and longer intervals of randomisation to the next mood episode in AYA with either Bipolar Disorder (BD) or Major Depressive Disorder (MDD), compared to family and individual psychoeducation [ 52 ].

Two US studies used a three-arm trial to compare Systemic-behavioural Family Therapy (SBFT) with elements of PS, to CBT and individual Non-directive Supportive therapy (NST) (RCT, N = 107, moderate risk of bias) [ 53 , 54 ]. One study looked at whether the PS elements of CBT and SFBT mediated the effectiveness of these interventions for the remission of MDD. It found that PS mediated the association between CBT, but not SFBT, and remission from depression. There was no significant association between SBFT and remission status, though there was a significant association between CBT and remission status [ 53 ]. The other study found no significant reduction in depression post-treatment or at 24-month follow-up for SBFT [ 54 ].

A PS intervention tested in maternal and child clinics in Nigeria RCT ( N = 686, moderate risk of bias) compared with enhanced TAU involving psychosocial and social support found no significant difference in the proportion of women who recovered from depression at 6-months post-partum [ 55 ]. However, there was a small difference in depression scores in favour of PS averaged across the 3-, 6-, 9-, and 12-month follow-up points. Cognitive Reminiscence Therapy, which involved recollection of past PS experiences and drew on PS techniques used for 12-25-year-olds in community mental health services in Australia (RCT, N = 26, moderate risk of bias), did not reduce depression symptoms compared with a brief evidence-based treatment at 1- or 2-month follow-up [ 56 ]. Additionally, the High School Transition Program in the US (RCT, N = 497, moderate risk of bias) aimed to prevent depression, anxiety, and school problems in youth transitioning to high school [ 57 ]. There was no reduction in the percentage of intervention students with clinical depression compared to the control group. Similarly, a small study focused on reducing depression symptoms, and nonadherence to antiretroviral therapy in pregnant women with HIV in South Africa (RCT, N = 23, some concern) found a significant reduction in depression symptoms compared to TAU, with the results being maintained at the 3-month follow-up [ 58 ].

Reduction in suicidality

Three studies measured a reduction in suicidality. A preventive treatment found a large reduction in suicidal orientation in the PS group compared to control post-treatment. In contrast, suicidal ideation scores were inconsistent at 1-,3- and 6- month follow-up, they maintained an overall lower score [ 50 ]. Furthermore, at post-test, significantly more participants in the PS group were no longer at risk of suicide. No significant differences were found in suicide plans or attempts. In a PST intervention, post-treatment suicide risk scores were lower than pre-treatment for the PST group but unchanged for the control group [ 12 ]. An online treatment found a moderate decline in ideation for the intervention group post-treatment compared to the control but was not sustained at a one-month follow-up [ 49 ].

Mediators and moderators

Eight studies measured PS skills or effectiveness. In two studies, despite the interventions reducing depression, there was no improvement in PS abilities [ 12 , 52 ]. One found that change in global and functional PS skills mediated the relationship between the intervention group and change in suicidal orientation, but this was not assessed for depression [ 50 ]. Three other studies found no change in depression symptoms, PS skills, or problem resolution [ 38 – 40 ]. Finally, CBT and SBFT led to significant increases in PS behaviour, and PS was associated with higher rates of remission across treatments but did not moderate the relationship between SBFT and remission status [ 53 ]. Another study found no changes in confidence in the ability to solve problems or belief in personal control when solving problems. Furthermore, the intervention group was more likely to adopt an avoidant PS style [ 46 ].

A high-intensity intervention for perinatal depression in Nigeria had no treatment effect on depression remission rates for the whole sample. Still, it was significantly effective for participants with more severe depression at baseline [ 55 ]. A PS intervention among juvenile detainees in the US effectively reduced depression for participants with higher levels of fluid intelligence, but symptoms increased for those with lower levels [ 42 ].The authors suggest that individuals with lower levels of fluid intelligence may have been less able to cope with exploring negative emotions and apply the skills learned.

This review has examined the evidence on the effectiveness of PS in the prevention or treatment of depression among 13–25-year-olds. We sought to determine in what way, in which contexts, and for whom PS appears to work in addressing depression. We found 25 studies involving 20 interventions. Results are promising for secondary prevention interventions, or interventions targeting clinical level populations, that utilize PS as the primary intervention [ 12 , 47 – 49 ]. These studies not only found a significant reduction in depression symptoms compared to active [ 48 , 49 ] and non-active [ 12 , 47 ] controls but also found a significant reduction in suicidal orientation and ideation [ 12 , 47 , 49 ]. These findings are consistent with meta-analyses of adult PS interventions [ 21 , 22 , 23 ], highlighting that PS interventions for AYA can be effective in real-world settings.

For other types of interventions (i.e., universal, selective prevention, indicated prevention), results were mixed in reducing depression. The one universal program was found to have a small, significant effect in reducing depression symptoms compared to a non-active control [ 37 ]. Most selective prevention programs were not effective [ 39 , 40 , 56 ], and those that did show small, significant effects had mixed outcomes for follow-up maintenance [ 41 , 42 ]. Most indicated prevention programs were not effective [ 30 , 31 , 45 – 47 ], yet a follow-up study showed a significant reduction in internalizing symptoms at 12-month post-treatment compared to an active control [ 44 ]. Given that these studies targeted sub-clinical populations and many of them had small sample sizes, these mixed findings may be a result of not having sufficient power to detect a meaningful difference.

Our review found limited evidence about PS skills as mediator or moderator of depression. Few studies measured improvements in PS skills; fewer still found interventions to be effective. The absence of evidence for PS abilities as a pathway is puzzling. It may be that specific aspects of PS behaviours and processes, such as problem orientation [ 59 ], are relevant. Alternatively, there may be a mechanism other than PS skills through which PS interventions influence depression.

Studies with PS as part of a wider intervention also showed mixed results, even amongst clinical populations. Although there was no clear rationale for the discrepancies in effectiveness between the studies, it is possible that the wider program dilutes the focus and impact of efficacious therapeutic elements. However, this is difficult to discern given the heterogeneity in the studies and limited information on study treatments and implementation factors. A broad conclusion might be that PS can be delivered most effectively with clinical populations in its purest PS form and may be tailored to a range of different contexts and forms, a range of populations, and to address different types of problems; however, this tailoring may reduce effectiveness.

Although the scale of impact is broadly in line with the small to moderate effectiveness of other treatments for youth depression [ 6 ], our review highlights shortcomings in study design, methods, and reporting that would allow for a better understanding of PS effectiveness and pathways. Studies varied in how well PS was operationalised. Low dosage is consistent with usage described in informal conversations with practitioners but may be insufficient for effectiveness. Fidelity was monitored in only half the studies despite evidence that monitoring implementation improves effectiveness [ 60 ]. There were references to implementation difficulties, including attrition, challenges in operationalizing online interventions, and skills of those delivering. Furthermore, most of the studies had little information about comorbidity and no analysis of whether it influenced outcomes. Therefore, we were unable to fully examine and conceptualize the ways, how and for whom PS works. More information about study populations and intervention implementation is essential to understand the potential of PS for broader dissemination.

Our review had several limitations. We excluded studies that included four treatments known to be effective in treating depression among AYA (e.g., CBT) but where the unique contribution of PS to clinical outcome could not be disentangled. Furthermore, we relied on authors’ reporting to determine if PS was included: details about operationalization of PS were often scant. Little evidence addressing the fit, feasibility, or acceptability of PS interventions was found, reflecting a limited focus on implementation. We included only English-language texts: relevant studies in other languages may exist, though our post-2000 inclusion criteria may limit this potential bias due to improved translation of studies to English over the years. Finally, the heterogeneity of study populations, problem severity, comparison conditions, outcome measures, and study designs, along with a relatively small number of included studies, limits confidence in what we can say about implementation and treatment outcomes.

Overall, our review indicates that PS may have the best results when implemented its purest form as a stand-alone treatment with clinical level AYA populations; tailoring or imbedding PS into wider programming may dilute its effectiveness. Our review also points to a need for continued innovation in treatment to improve the operationalizing and testing of PS, especially when included as a part of a more comprehensive intervention. It also highlights the need for study methods that allow us to understand the specific effects of PS, and that measure the frequency, dosage, and timing of PS to understand what is effective for whom and in what contexts.

Supporting information

S1 file. list of excluded studies..

https://doi.org/10.1371/journal.pone.0285949.s001

S2 File. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0285949.s002

S1 Table. Individual risk of bias assessments using cochrane RoB2 tool by domain (1–5) and overall (6).

https://doi.org/10.1371/journal.pone.0285949.s003

Acknowledgments

All individuals that contributed to this paper are included as authors.

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Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression

Kristina Metz

1 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America

2 Centre for Evidence and Implementation, London, United Kingdom

Jade Mitchell

Sangita chakraborty, bryce d. mcleod.

3 Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States of America

Ludvig Bjørndal

Robyn mildon.

4 Centre for Evidence and Implementation, Melbourne, Victoria, Australia

Aron Shlonsky

5 Department of Social Work, Monash University, Melbourne, Victoria, Australia

Associated Data

All relevant methods and data are within the paper and its Supporting Information files.

Problem-solving (PS) has been identified as a therapeutic technique found in multiple evidence-based treatments for depression. To further understand for whom and how this intervention works, we undertook a systematic review of the evidence for PS’s effectiveness in preventing and treating depression among adolescents and young adults. We searched electronic databases ( PsycINFO , Medline , and Cochrane Library ) for studies published between 2000 and 2022. Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; (d) at least one depression outcome was reported. Risk of bias of included studies was assessed using the Cochrane Risk of Bias 2.0 tool. A narrative synthesis was undertaken given the high level of heterogeneity in study variables. Twenty-five out of 874 studies met inclusion criteria. The interventions studied were heterogeneous in population, intervention, modality, comparison condition, study design, and outcome. Twelve studies focused purely on PS; 13 used PS as part of a more comprehensive intervention. Eleven studies found positive effects in reducing depressive symptoms and two in reducing suicidality. There was little evidence that the intervention impacted PS skills or that PS skills acted as a mediator or moderator of effects on depression. There is mixed evidence about the effectiveness of PS as a prevention and treatment of depression among AYA. Our findings indicate that pure PS interventions to treat clinical depression have the strongest evidence, while pure PS interventions used to prevent or treat sub-clinical depression and PS as part of a more comprehensive intervention show mixed results. Possible explanations for limited effectiveness are discussed, including missing outcome bias, variability in quality, dosage, and fidelity monitoring; small sample sizes and short follow-up periods.

Introduction

Depression among adolescents and young adults (AYA) is a serious, widespread problem. A striking increase in depressive symptoms is seen in early adolescence [ 1 ], with rates of depression being estimated to almost double between the age of 13 (8.4%) and 18 (15.4%) [ 2 ]. Research also suggests that the mean age of onset for depressive disorders is decreasing, and the prevalence is increasing for AYA. Psychosocial interventions, such as cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT), have shown small to moderate effects in preventing and treating depression [ 3 – 6 ]. However, room for improvement remains. Up to half of youth with depression do not receive treatment [ 7 ]. When youth receive treatment, studies indicate that about half of youth will not show measurable symptom reduction across 30 weeks of routine clinical care for depression [ 8 ]. One strategy to improve the accessibility and effectiveness of mental health interventions is to move away from an emphasis on Evidence- Based Treatments (EBTs; e.g., CBT) to a focus on discrete treatment techniques that demonstrate positive effects across multiple studies that meet certain methodological standards (i.e., common elements; 9). Identifying common elements allows for the removal of redundant and less effective treatment content, reducing treatment costs, expanding available service provision and enhancing scability. Furthermore, introducing the most effective elements of treatment early may improve client retention and outcomes [ 9 – 13 ].

A potential common element for depression intervention is problem-solving (PS). PS refers to how an individual identifies and applies solutions to everyday problems. D’Zurilla and colleagues [ 14 – 17 ] conceptualize effective PS skills to include a constructive attitude towards problems (i.e., a positive problem-solving orientation) and the ability to approach problems systematically and rationally (i.e., a rational PS style). Whereas maladaptive patterns, such as negative problem orientation and passively or impulsively addressing problems, are ineffective PS skills that may lead to depressive symptoms [ 14 – 17 ]. Problem Solving Therapy (PST), designed by D’Zurilla and colleagues, is a therapeutic approach developed to decrease mental health problems by improving PS skills [ 18 ]. PST focuses on four core skills to promote adaptive problem solving, including: (1) defining the problem; (2) brainstorming possible solutions; (3) appraising solutions and selecting the best one; and (4) implementing the chosen solution and assessing the outcome [ 14 – 17 ]. PS is also a component in other manualized approaches, such as CBT and Dialectical Behavioural Therapy (DBT), as well as imbedded into other wider generalized mental health programming [ 19 , 20 ]. A meta-analysis of over 30 studies found PST, or PS skills alone, to be as effective as CBT and IPT and more effective than control conditions [ 21 – 23 ]. Thus, justifying its identification as a common element in multiple prevention [ 19 , 24 ] and treatment [ 21 , 25 ] programs for adult depression [ 9 , 26 – 28 ].

PS has been applied to youth and young adults; however, no manuals specific to the AYA population are available. Empirical studies suggest maladaptive PS skills are associated with depressive symptoms in AYA [ 5 , 17 – 23 ]. Furthermore, PS intervention can be brief [ 29 ], delivered by trained or lay counsellors [ 30 , 31 ], and provided in various contexts (e.g., primary care, schools [ 23 ]). Given PS’s versatility and effectiveness, PS could be an ideal common element in treating AYA depression; however, to our knowledge, no reviews or meta-analyses on PS’s effectiveness with AYA specific populations exist. This review aimed to examine the effectiveness of PS as a common element in the prevention and treatment of depression for AYA within real-world settings, as well as to ascertain the variables that may influence and impact PS intervention effects.

Identification and selection of studies

Searches were conducted using PsycInfo , Medline , and Cochrane Library with the following search terms: "problem-solving", “adolescent”, “youth”, and” depression, ” along with filters limiting results to controlled studies looking at effectiveness or exploring mechanisms of effectiveness. Synonyms and derivatives were employed to expand the search. We searched grey literature using Greylit . org and Opengrey . eu , contacted experts in the field and authors of protocols, and searched the reference lists of all included studies. The search was undertaken on 4 th June 2020 and updated on 11 th June 2022.

Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; and (d) at least one depression outcome was reported. Literature in electronic format published post 2000 was deemed eligible, given the greater relevance of more recent usage of PS in real-world settings. There was no exclusion for gender, ethnicity, or country setting; only English language texts were included. Randomized controlled trials (RCTs), quasi-experimental designs (QEDs), systematic reviews/meta-analyses, pilots, or other studies with clearly defined comparison conditions (no treatment, treatment as usual (TAU), or a comparator treatment) were included. We excluded studies of CBT, IPT, Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), and modified forms of these treatments. These treatments include PS and have been shown to demonstrate small to medium effects on depression [ 13 , 14 , 32 ], but the unique contribution of PS cannot be disentangled. The protocol for this review was not registered; however, all data collection forms, extraction, coding and analyses used in the review are available upon inquiry from the first author.

Study selection

All citations were entered into Endnote and uploaded to Covidence for screening and review against the inclusion/exclusion criteria. Reviewers with high inter-rater reliability (98%) independently screened the titles and abstracts. Two reviewers then independently screened full text of articles that met criteria. Duplicates, irrelevant studies, and studies that did not meet the criteria were removed, and the reason for exclusion was recorded (see S1 File for a list of excluded studies). Discrepancies were resolved by discussion with the team leads.

Data extraction

Two reviewers independently extracted data that included: (i) study characteristics (author, publication year, location, design, study aim), (ii) population (age, gender, race/ethnicity, education, family income, depression status), (iii) setting, (iv) intervention description (therapeutic or preventative, whether PS was provided alone or as part of a more comprehensive intervention, duration, delivery mode), (v) treatment outcomes (measures used and reported outcomes for depression, suicidality, and PS), and (vi) fidelity/implementation outcomes. For treatment outcomes, we included the original statistical analyses and/or values needed to calculate an effect size, as reported by the authors. If a variable was not included in the study publication, we extracted the information available and made note of missing data and subsequent limitations to the analyses.

RCTs were assessed for quality (i.e., confidence in the study’s findings) using the Cochrane Risk of Bias 2.0 tool [ 33 ] which includes assessment of the potential risk of bias relating to the process of randomisation; deviations from the intended intervention(s); missing data; outcome measurement and reported results. Risk of bias pertaining to each domain is estimated using an algorithm, grouped as: Low risk; Some concerns; or High risk. Two reviewers independently assessed the quality of included studies, and discrepancies were resolved by consensus.

We planned to conduct one or more meta-analyses if the studies were sufficiently similar. Data were entered into a summary of findings table as a first step in determining the theoretical and practical similarity of the population, intervention, comparison condition, outcome, and study design. If there were sufficiently similar studies, a meta-analysis would be conducted according to guidelines contained in the Cochrane Collaboration Handbook of Systematic Reviews, including tests of heterogeneity and use of random effects models where necessary.

The two searches yielded a total number of 874 records (after the removal of duplicates). After title and abstract screening, 184 full-text papers were considered for inclusion, of which 25 studies met the eligibility criteria and were included in the systematic review ( Fig 1 ). Unfortunately, substantial differences (both theoretical and practical) precluded any relevant meta-analyses, and we were limited to a narrative synthesis.

Risk of bias assessment

Risk of bias assessments were conducted on the 23 RCTs ( Fig 2 ; assessments by study presented in S1 Table ). Risk of bias concerns were moderate, and a fair degree of confidence in the validity of study findings is warranted. Most studies (81%) were assessed as ‘some concerns’ (N = 18), four studies were ‘low risk’, and one ‘high risk’. The most frequent areas of concern were the selection of the reported result (n = 18, mostly due to inadequate reporting of a priori analytic plans); deviations from the intended intervention (N = 17, mostly related to insufficient information about intention-to-treat analyses); and randomisation process (N = 13).

Study designs and characteristics

Study design.

Across the 25 studies, 23 were RCTs; two were QEDs. Nine had TAU or wait-list control (WLC) comparator groups, and 16 used active control groups (e.g., alternative treatment). Eleven studies described fidelity measures. The sample size ranged from 26 to 686 and was under 63 in nine studies.

Selected intervention

Twenty interventions were described across the 25 studies ( Table 1 ). Ten interventions focused purely on PS. Of these 10 interventions: three were adaptations of models proposed by D’Zurilla and Nezu [ 20 , 34 ] and D’Zurilla and Goldfried [ 18 ], two were based on Mynors-Wallis’s [ 35 ] Problem-Solving Therapy (PST) guide, one was a problem-orientation video intervention adapted from D’Zurilla and Nezu [ 34 ], one was an online intervention adapted from Method of Levels therapy, and three did not specify a model. Ten interventions used PS as part of a larger, more comprehensive intervention (e.g., PS as a portion of cognitive therapy). The utilization and dose of PS steps included in these interventions were unclear. Ten interventions were primary prevention interventions–one of these was universal prevention, five were indicated prevention, and four were selective prevention. Ten interventions were secondary prevention interventions. Nine interventions were described as having been developed or adapted for young people.

Notes: Psychiatric measures: A-LIFE = Adolescent Longitudinal Interval Follow-up Evaluation; BDI = Beck Depression Inventory; BDI-II = Beck Depression Inventory-II; BSS = Beck Suicide Scale; CDI = Children’s Depression Inventory; CDRS-R = Children’s Depression Rating Scale, Revised; CES-D = Centre for Epidemiological Studies Depression Scale; DASS-21 = Depression Anxiety Stress Scale-21; DEP13 = 13 items from Schedule for Affective Disorders and Schizophrenia for School-Age Children; DSM-IV = Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Health Disorders, fourth edition, text revision; DSM-5 = Diagnostic and Statistical Manual of Mental Health Disorders, fifth edition; EPDS = Edinburgh Postnatal Depression Scale; GHQ = General Health Questionnaire; GHQ-D = General Health Questionnaire Depression Scale; HDRS = Hamilton Depression Rating Scale; ICD-10 = International Classification of Diseases, 10 th revision

ISO-30 = Inventory of Suicide Orientation; K10 = Kessler Psychological Distress Scale; K-SADS = Kiddie Schedule for Affective Disorders and Schizophrenia; MADRS = Montgomery-Åsberg Depression Rating Scale; MFQ = Mood and Feelings Questionnaire; PSRs = Psychiatric Status Ratings; PSS-4 = Perceived Stress Scale-4; SCAN = Schedules for Clinical Assessment in Neuropsychiatry; SCIV = Structured Clinical Interview Clinical Version for DSM-IV Axis 1; SDQ = Strengths and Difficulties Questionnaire; SPS = Suicide Probability Scale; SWEMWBS = Short Warwick–Edinburgh Mental Well-Being Scale; YMRS = Young Mania Rating Scale; YTP = Youth Top Problems

Problem-solving measures: PSI = Problem Solving Inventory; SPSI = Social Problem-Solving Inventory; SPSI-R = Social Problem-Solving Inventory-Revised

Other terms: CAST = Coping and Support Training; CBT = Cognitive Behavioural Therapy; MYLO = Manage Your Life Online; NICE = National Institute of Health and Care Excellence; NST = Nondirective Supportive Therapy; PCT = Perceptual Control Therapy; PS = Problem Solving; PST = Problem-Solving Therapy; PST-PC = Problem-Solving Therapy for Pediatric Care; QED = Quasi-Experimental Design; RCT = Randomized Controlled Trial; SBFT = Systematic-Behavioural Family Therapy; TAU = Treatment As Usual; WLC = Waitlist Control; BP = Bipolar Disorder; MDD = major depressive disorder

Intervention delivery

Of the 20 interventions, eight were delivered individually, eight were group-based, two were family-based, one was mixed, and in one, the format of delivery was unclear. Seventeen were delivered face-to-face and three online. Dosage ranged from a single session to 21, 50-minute sessions (12 weekly sessions, then 6 biweekly sessions); the most common session formar was once weekly for six weeks (N = 5).

Intervention setting and participants

Seventeen studies were conducted in high-income countries (UK, US, Australia, Netherlands, South Korea), four in upper-middle income (Brazil, South Africa, Turkey), and four in low- and middle-income countries (Zimbabwe, Nigeria, India). Four studies included participants younger than 13 and four older than 25. Nine studies were conducted on university or high school student populations and five on pregnant or post-partum mothers. The remaining 11 used populations from mental health clinics, the community, a diabetes clinic, juvenile detention, and a runaway shelter.

Sixteen studies included participants who met the criteria for a depressive, bipolar, or suicidal disorder (two of these excluded severe depression). Nine studies did not use depression symptoms in the inclusion criteria (one of these excluded depression). Several studies excluded other significant mental health conditions.

Outcome measures

Eight interventions targeted depression, four post/perinatal depression, two suicidal ideation, two resilience, one ‘problem-related distress’, one ‘diabetes distress’, one common adolescent mental health problem, and one mood episode. Those targeting post/perinatal depression used the Edinburgh Postnatal Depression Scale as the outcome measure. Of the others, six used the Beck Depression Inventory (I or II), two the Children’s Depression Inventory, three the Depression Anxiety Stress Scale-21, three the Centre for Epidemiologic Studies Depression Scale, one the Short Mood and Feelings Questionnaire, one the Hamilton Depression Rating Scale, one the depression subscale on the Schedule for Affective Disorders and Schizophrenia for School-Age Children, one the Strengths and Difficulties Questionnaire, one the Youth Top Problems Score, one the Adolescent Longitudinal Interval Follow-up Evaluation and Psychiatric Status Ratings, one the Kiddie Schedule for Affective Disorders and Schizophrenia, and one the Mini International Neuropsychiatric Interview.

Only eight studies measured PS skills or orientation outcomes. Three used the Social Problem-Solving Inventory-Revised, one the Problem Solving Inventory, two measured the extent to which the nominated problem had been resolved, one observed PS in video-taped interactions, and one did not specify the measure.

The mixed findings regarding the effectiveness of PS for depression may depend on the type of intervention: primary (universal, selective, or indicated), secondary or tertiary prevention. Universal prevention interventions target the general public or a population not determined by any specific criteria [ 36 ]. Selective prevention interventions target specific populations with an increased risk of developing a disorder. Indicated prevention interventions target high-risk individuals with sub-clinical symptoms of a disorder. Secondary prevention interventions include those that target individuals diagnosed with a disorder. Finally, tertiary prevention interventions refer to follow-up interventions designed to retain treatment effects. Outcomes are therefore grouped by intervention prevention type and outcome. Within these groupings, studies with a lower risk of bias (RCTs) are presented first. According to the World Health Organisation guidelines, interventions were defined as primary, secondary or tertiary prevention [ 36 ].

Universal prevention interventions

One study reported on a universal prevention intervention targeting resilience and coping strategies in US university students. The Resilience and Coping Intervention, which includes PS as a primary component of the intervention, found a significant reduction in depression compared to TAU (RCT, N = 129, moderate risk of bias) [ 37 ].

Selective prevention interventions

Six studies, including five RCTs and one QED, tested PS as a selective prevention intervention. Two studies investigated the impact of the Manage Your Life Online program, which includes PS as a primary component of the intervention, compared with an online programme emulating Rogerian psychotherapy for UK university students (RCT, N = 213, moderate risk of bias [ 38 ]; RCT, N = 48, moderate risk of bias [ 39 ]). Both studies found no differences in depression or problem-related distress between groups.

Similarly, two studies explored the effect of adapting the Penn Resilience Program, which includes PS as a component of a more comprehensive intervention for young people with diabetes in the US (RCT, N = 264, moderate risk of bias) [ 40 , 41 ]. The initial study showed a moderate reduction in diabetes distress but not depression at 4-, 8-, 12- and 16-months follow-up compared to a diabetes education intervention [ 40 ]. The follow-up study found a significant reduction in depressive symptoms compared to the active control from 16- to 40-months; however, this did not reach significance at 40-months [ 41 ].

Another study that was part of wider PS and social skills intervention among juveniles in state-run detention centres in the US found no impacts (RCT, N = 296, high risk of bias) [ 42 ]. A QED ( N = 32) was used to test the effectiveness of a resilience enhancement and prevention intervention for runaway youth in South Korea [ 43 ]. There was a significant decrease in depression for the intervention group compared with the control group at post-test, but the difference was not sustained at one-month follow-up.

Indicated prevention interventions

Six studies, including five RCTs and one QED, tested PS as an indicated prevention intervention. Four of the five RCTs tested PS as a primary component of the intervention. A PS intervention for common adolescent mental health problems in Indian high school students (RCT, N = 251, low risk of bias) led to a significant reduction in psychosocial problems at 6- and 12 weeks; however, it did not have a significant impact on mental health symptoms or internalising symptoms compared to PS booklets without counsellor treatment at 6- and 12-weeks [ 31 ]. A follow-up study showed a significant reduction in overall psychosocial problems and mental health symptoms, including internalizing symptoms, over 12 months [ 44 ]. Still, these effects no longer reached significance in sensitivity analysis adjusting for missing data (RCT, N = 251, low risk of bias). Furthermore, a 2x2 factorial RCT ( N = 176, moderate risk of bias) testing PST among youth mental health service users with a mild mental disorder in Australia found that the intervention was not superior to supportive counselling at 2-weeks post-treatment [ 30 ]. Similarly, an online PS intervention delivered to young people in the Netherlands to prevent depression (RCT, N = 45, moderate risk of bias) found no significant difference between the intervention and WLC in depression level 4-months post-treatment [ 45 ].

One RCT tested PS approaches in a more comprehensive manualized programme for postnatal depression in the UK and found no significant differences in depression scores between intervention and TAU at 3-months post-partum (RCT, N = 292, moderate risk of bias) [ 46 ].

A study in Turkey used a non-equivalent control group design (QED, N = 62) to test a nursing intervention against a PS control intervention [ 47 ]. Both groups showed a reduction in depression, but the nursing care intervention demonstrated a larger decrease post-intervention than the PS control intervention.

Secondary prevention interventions

Twelve studies, all RCTs, tested PS as a secondary prevention intervention. Four of the 12 RCTs tested PS as a primary component of the intervention. An intervention among women in Zimbabwe (RCT, N = 58, moderate risk of bias) found a larger decrease in the Edinburgh Postnatal Depression Scale score for the intervention group compared to control (who received the antidepressant amitriptyline and peer education) at 6-weeks post-treatment [ 48 ]. A problem-orientation intervention covering four PST steps and involving a single session video for US university students (RCT, N = 110, moderate risk of bias), compared with a video covering other health issues, resulted in a moderate reduction in depression post-treatment; however, results were no longer significant at 2-weeks, and 1-month follow up [ 49 ].

Compared to WLC, a study of an intervention for depression and suicidal proneness among high school and university students in Turkey (RCT, N = 46, moderate risk of bias) found large effect sizes on post-treatment depression scores for intervention participants post-treatment compared with WLC. At 12-month follow-up, these improvements were maintained compared to pre-test but not compared to post-treatment scores. Significant post-treatment depression recovery was also found in the PST group [ 12 ]. Compared to TAU, a small but high-quality (low-risk of bias) study focused on preventing suicidal risk among school students in Brazil (RCT, N = 100, low risk of bias) found a significant, moderate reduction in depression symptoms for the treatment group post-intervention that was maintained at 1-, 3- and 6-month follow-up [ 50 ].

Seven of the 12 RCTs tested PS as a part of a more comprehensive intervention. Two interventions targeted mood episodes and were compared to active control. These US studies focused on Family-Focused Therapy as an intervention for mood episodes, which included sessions on PS [ 51 , 52 ]. One of these found that Family-Focused Therapy for AYA with Bipolar Disorder (RCT, N = 145, moderate risk of bias) had no significant impact on mood or depressive symptoms compared to pharmacotherapy. However, Family-Focused Therapy had a greater impact on the proportion of weeks without mania/hypomania and mania/hypomania symptoms than enhanced care [ 53 ]. Alternatively, while the other study (RCT, N = 127, low risk of bias) found no significant impact on time to recovery, Family-Focused Therapy led to significantly longer intervals of wellness before new mood episodes, longer intervals between recovery and the next mood episode, and longer intervals of randomisation to the next mood episode in AYA with either Bipolar Disorder (BD) or Major Depressive Disorder (MDD), compared to family and individual psychoeducation [ 52 ].

Two US studies used a three-arm trial to compare Systemic-behavioural Family Therapy (SBFT) with elements of PS, to CBT and individual Non-directive Supportive therapy (NST) (RCT, N = 107, moderate risk of bias) [ 53 , 54 ]. One study looked at whether the PS elements of CBT and SFBT mediated the effectiveness of these interventions for the remission of MDD. It found that PS mediated the association between CBT, but not SFBT, and remission from depression. There was no significant association between SBFT and remission status, though there was a significant association between CBT and remission status [ 53 ]. The other study found no significant reduction in depression post-treatment or at 24-month follow-up for SBFT [ 54 ].

A PS intervention tested in maternal and child clinics in Nigeria RCT ( N = 686, moderate risk of bias) compared with enhanced TAU involving psychosocial and social support found no significant difference in the proportion of women who recovered from depression at 6-months post-partum [ 55 ]. However, there was a small difference in depression scores in favour of PS averaged across the 3-, 6-, 9-, and 12-month follow-up points. Cognitive Reminiscence Therapy, which involved recollection of past PS experiences and drew on PS techniques used for 12-25-year-olds in community mental health services in Australia (RCT, N = 26, moderate risk of bias), did not reduce depression symptoms compared with a brief evidence-based treatment at 1- or 2-month follow-up [ 56 ]. Additionally, the High School Transition Program in the US (RCT, N = 497, moderate risk of bias) aimed to prevent depression, anxiety, and school problems in youth transitioning to high school [ 57 ]. There was no reduction in the percentage of intervention students with clinical depression compared to the control group. Similarly, a small study focused on reducing depression symptoms, and nonadherence to antiretroviral therapy in pregnant women with HIV in South Africa (RCT, N = 23, some concern) found a significant reduction in depression symptoms compared to TAU, with the results being maintained at the 3-month follow-up [ 58 ].

Reduction in suicidality

Three studies measured a reduction in suicidality. A preventive treatment found a large reduction in suicidal orientation in the PS group compared to control post-treatment. In contrast, suicidal ideation scores were inconsistent at 1-,3- and 6- month follow-up, they maintained an overall lower score [ 50 ]. Furthermore, at post-test, significantly more participants in the PS group were no longer at risk of suicide. No significant differences were found in suicide plans or attempts. In a PST intervention, post-treatment suicide risk scores were lower than pre-treatment for the PST group but unchanged for the control group [ 12 ]. An online treatment found a moderate decline in ideation for the intervention group post-treatment compared to the control but was not sustained at a one-month follow-up [ 49 ].

Mediators and moderators

Eight studies measured PS skills or effectiveness. In two studies, despite the interventions reducing depression, there was no improvement in PS abilities [ 12 , 52 ]. One found that change in global and functional PS skills mediated the relationship between the intervention group and change in suicidal orientation, but this was not assessed for depression [ 50 ]. Three other studies found no change in depression symptoms, PS skills, or problem resolution [ 38 – 40 ]. Finally, CBT and SBFT led to significant increases in PS behaviour, and PS was associated with higher rates of remission across treatments but did not moderate the relationship between SBFT and remission status [ 53 ]. Another study found no changes in confidence in the ability to solve problems or belief in personal control when solving problems. Furthermore, the intervention group was more likely to adopt an avoidant PS style [ 46 ].

A high-intensity intervention for perinatal depression in Nigeria had no treatment effect on depression remission rates for the whole sample. Still, it was significantly effective for participants with more severe depression at baseline [ 55 ]. A PS intervention among juvenile detainees in the US effectively reduced depression for participants with higher levels of fluid intelligence, but symptoms increased for those with lower levels [ 42 ].The authors suggest that individuals with lower levels of fluid intelligence may have been less able to cope with exploring negative emotions and apply the skills learned.

This review has examined the evidence on the effectiveness of PS in the prevention or treatment of depression among 13–25-year-olds. We sought to determine in what way, in which contexts, and for whom PS appears to work in addressing depression. We found 25 studies involving 20 interventions. Results are promising for secondary prevention interventions, or interventions targeting clinical level populations, that utilize PS as the primary intervention [ 12 , 47 – 49 ]. These studies not only found a significant reduction in depression symptoms compared to active [ 48 , 49 ] and non-active [ 12 , 47 ] controls but also found a significant reduction in suicidal orientation and ideation [ 12 , 47 , 49 ]. These findings are consistent with meta-analyses of adult PS interventions [ 21 , 22 , 23 ], highlighting that PS interventions for AYA can be effective in real-world settings.

For other types of interventions (i.e., universal, selective prevention, indicated prevention), results were mixed in reducing depression. The one universal program was found to have a small, significant effect in reducing depression symptoms compared to a non-active control [ 37 ]. Most selective prevention programs were not effective [ 39 , 40 , 56 ], and those that did show small, significant effects had mixed outcomes for follow-up maintenance [ 41 , 42 ]. Most indicated prevention programs were not effective [ 30 , 31 , 45 – 47 ], yet a follow-up study showed a significant reduction in internalizing symptoms at 12-month post-treatment compared to an active control [ 44 ]. Given that these studies targeted sub-clinical populations and many of them had small sample sizes, these mixed findings may be a result of not having sufficient power to detect a meaningful difference.

Our review found limited evidence about PS skills as mediator or moderator of depression. Few studies measured improvements in PS skills; fewer still found interventions to be effective. The absence of evidence for PS abilities as a pathway is puzzling. It may be that specific aspects of PS behaviours and processes, such as problem orientation [ 59 ], are relevant. Alternatively, there may be a mechanism other than PS skills through which PS interventions influence depression.

Studies with PS as part of a wider intervention also showed mixed results, even amongst clinical populations. Although there was no clear rationale for the discrepancies in effectiveness between the studies, it is possible that the wider program dilutes the focus and impact of efficacious therapeutic elements. However, this is difficult to discern given the heterogeneity in the studies and limited information on study treatments and implementation factors. A broad conclusion might be that PS can be delivered most effectively with clinical populations in its purest PS form and may be tailored to a range of different contexts and forms, a range of populations, and to address different types of problems; however, this tailoring may reduce effectiveness.

Although the scale of impact is broadly in line with the small to moderate effectiveness of other treatments for youth depression [ 6 ], our review highlights shortcomings in study design, methods, and reporting that would allow for a better understanding of PS effectiveness and pathways. Studies varied in how well PS was operationalised. Low dosage is consistent with usage described in informal conversations with practitioners but may be insufficient for effectiveness. Fidelity was monitored in only half the studies despite evidence that monitoring implementation improves effectiveness [ 60 ]. There were references to implementation difficulties, including attrition, challenges in operationalizing online interventions, and skills of those delivering. Furthermore, most of the studies had little information about comorbidity and no analysis of whether it influenced outcomes. Therefore, we were unable to fully examine and conceptualize the ways, how and for whom PS works. More information about study populations and intervention implementation is essential to understand the potential of PS for broader dissemination.

Our review had several limitations. We excluded studies that included four treatments known to be effective in treating depression among AYA (e.g., CBT) but where the unique contribution of PS to clinical outcome could not be disentangled. Furthermore, we relied on authors’ reporting to determine if PS was included: details about operationalization of PS were often scant. Little evidence addressing the fit, feasibility, or acceptability of PS interventions was found, reflecting a limited focus on implementation. We included only English-language texts: relevant studies in other languages may exist, though our post-2000 inclusion criteria may limit this potential bias due to improved translation of studies to English over the years. Finally, the heterogeneity of study populations, problem severity, comparison conditions, outcome measures, and study designs, along with a relatively small number of included studies, limits confidence in what we can say about implementation and treatment outcomes.

Overall, our review indicates that PS may have the best results when implemented its purest form as a stand-alone treatment with clinical level AYA populations; tailoring or imbedding PS into wider programming may dilute its effectiveness. Our review also points to a need for continued innovation in treatment to improve the operationalizing and testing of PS, especially when included as a part of a more comprehensive intervention. It also highlights the need for study methods that allow us to understand the specific effects of PS, and that measure the frequency, dosage, and timing of PS to understand what is effective for whom and in what contexts.

Supporting information

Acknowledgments.

All individuals that contributed to this paper are included as authors.

Funding Statement

This work was commissioned by Wellcome Trust and was conducted independently by the evaluators (all named authors). No grant number is available. Wellcome Trust had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors declare no financial or other competing interests, including their relationship and ongoing work with Wellcome Trust. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Data Availability

• PLoS One. 2023; 18(8): e0285949.

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PONE-D-23-00042Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression among 13-25-year-oldsPLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

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Reviewer #1: Thank you for providing a very well-written, clear, and detailed manuscript of a very interesting and worthwhile study. It was a pleasure to read and I commend you on your work. I have only a few minor comments which are mostly just points of proofreading:

- Some abbreviations in Table 1 are either not detailed before usage here, or in fact aren't expanded upon at all. Please check and detail abbreviations in your notes section (namely PST, PCT, PST-PC, NST, DSM). I recognise that readers may be familiar with some of these or could hazard a well-educated guess, but for ease of readability and for clarity it would be beneficial to amend this.

- It would be beneficial, if possible from your data, to add more detail about the ages of participant in Table 1, or to provide more details in your results section. You explained that some studies included under 13s and/or over 25s, but it is unclear which studies did so. It would also help the reader to assess the included literature more effectively if the mean/median age of participants (as per your inclusion criteria) was noted in the table.

- Lines 200-202 are unclear and confusing to read

- While I recognise the need for your review, I'm not entirely sold on your research question by your introduction section. Particularly, why you have chosen this specific intervention for this population. It may be beneficial to expand on the final paragraph (lines 83-95).

- It may be beneficial to also add your thoughts on what your results mean for clinical practitioners in your discussion. You provide some good recommendations for research, but general expansion here would be helpful.

These are the only minor edits I see as being required as your paper is strong. The results and conclusion are well written and thorough. Thank you also for providing detailed supplementary materials.

Best of luck with your ongoing work

Reviewer #2: The systematic review summarizes 25 studies concerning the efficacy of problem-solving interventions for preventing or treating depression. The topic is thoroughly examined, and the results provide insight into the development of evidence-based interventions and the enhancement of mental health outcomes for adolescents and young adults.

I have some minor concerns which I will elaborate on below:

1. The use of "13-25 years olds" in the title can be misleading as it implies a full age range rather than the mean or median age.

Introduction:

2. While the introduction is logically structured, it would be beneficial to introduce problem-solving (PS) as a technique for depression treatment early on. PS intervention is a key concept, yet it is not mentioned until the last paragraph.

3. The rationale for focusing on the effect of PS interventions on depression needs further clarification. What makes PS a more relevant technique than other techniques? I agree that maladaptive PS is associated with depressive symptoms (line 84), while the construct of PS as a coping strategy may be different from PS as an intervention technique.

4. The relationship between PS technique and evidence-based treatments is slightly confusing. EBTs such as CBT have shown small to moderate effects in preventing and treating depression (line 66), so emphasis might move to discrete treatment techniques such as PS (line 75). However, PS is usually a component of CBT, a technique used in multiple sessions. What might account for a part of the therapy being more effective than the entire therapy?

5. Line 90 refers to the complex relationship between PS and depression. Although details can be found in the results section, it would be clearer to provide a specific explanation here for “complex.”

Discussion:

6. In line 381, the authors “sought to determine in what way, in which contexts, and for whom PS appears to work in addressing depression.” However, outcomes are not discussed by context or study population. Studies conducted among students could differ from those conducted among peripartum women. Did the comparisons between contexts/populations bring forth any conclusions?

7. Among studies that found a significant reduction in depression, some reported that the effect was not sustained (e.g., line 262, line 268, line 302) while others reported the opposite (e.g., line 311, line 350). Is there a possible explanation for this discrepancy?

6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2:  Yes:  Tianyue Mi

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Author response to Decision Letter 0

24 Apr 2023

See below. Also replicated in the "Response to Reviewers" document.

Thank you to the two reviewers for their thoughtful and comprehensive review of our manuscript. We have carefully considered all the comments and made requested modifications. As a result, we believe that the manuscript is improved.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #1: N/A

Response to Reviewer 1 comments:

Reviewer #1: Thank you for providing a very well-written, clear, and detailed manuscript of a very interesting and worthwhile study. It was a pleasure to read and I commend you on your work. I have only a few minor comments which are mostly just points of proofreading:

Thank you for your keen eye and this suggestion. We have updated the manuscript to ensure that all acronyms in the table are in the notes section.

Thank you for this suggestion. We have added this information into the Table 1 under the “study population” information.

Thank you for this feedback. We have adjusted the sentence to hopefully increase comprehension. Please let us know if the sentence (now lines 198-199) is still unclear and/or confusing to read.

Thank you for this feedback. We have re-worked the introduction section to include more information on PS and its potential as an active ingredient for AYA depression treatment. Please see lines 71-94.

Thank you for this feedback. We have summarized the recommendations more clearly at the end of the paper. Please see lines 436-437 for clinical implications.

Thank you so much for the thorough and thoughtful review. We believe your comments aided to the creation of an improved manuscript.

Response to Reviewer 2 comments:

Reviewer #2: The systematic review summarizes 25 studies concerning the efficacy of problem-solving interventions for preventing or treating depression. The topic is thoroughly examined, and the results provide insight into the development of evidence-based interventions and the enhancement of mental health outcomes for adolescents and young adults.

Thank you for this suggestion. We have edited the title to only include the reference to adolescents and young adults to be more fitting.

Thank you for this feedback. We have re-worked the introduction section to have PS introduced earlier in the introduction.

Thank you for this feedback. We have re-worked the introduction section to include more information on background treatments using PS amongst adults and its potential as an active ingredient for AYA depression treatment. Please see lines 71-94.

Thank you for this feedback and question. We have added information to the manuscript that discusses a meta-analysis on PS within adult populations that found Problem Solving Therapy (PST) to be as effective as CBT and IPT, and more effective than WLC. We have additionally added information around the potential benefits of distilling common elements with this AYA population. Please see lines 71-94.

Thank you for this feedback and question. Due to all the additional PS information added to the introduction, we removed this statement and only addressed in the discussion section.

Thank you for this feedback and question. Unfortunately, due to the heterogeneity in the study samples and settings as well as limited implementation factors discussed in the publications, these factors were unable to be explored. I added this limitation to lines 412-423.

Thank you for this question. Unfortunately, the heterogeneity of study populations, problem severity, comparison conditions, outcome measures, and study designs, along with a relatively small number of included studies, limits confidence in what we can say about implementation and treatment outcomes. This includes an explanation for the discrepancies in sustained effects.

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Tianyue Mi

Submitted filename: Response to Reviewers.docx

Decision Letter 1

PONE-D-23-00042R1

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/ , click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at gro.solp@gnillibrohtua .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact gro.solp@sserpeno .

Thiago P. Fernandes, PhD

Additional Editor Comments (optional):

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: Thank you for returning the manuscript with all comments addressed. I feel this manuscript is now strong and of good quality and details an interesting, well articulated, and important piece of research.

Reviewer #2: (No Response)

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #1:  Yes:  Leah Attwell

Reviewer #2: No

Acceptance letter

11 May 2023

Dear Dr. Metz:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno .

If we can help with anything else, please email us at gro.solp@enosolp .

Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

Dr. Thiago P. Fernandes

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Brief Problem-solving Intervention in Different Formats for the Prevention of Suicide in Adults Over 50 (SOLPROSU50+)

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