Emotional Disorders In Primary Care Research Articles

Estudio piloto sobre la eficacia de un tratamiento transdiagnóstico para trastornos emocionales en Atención Primaria

Abstract: This study aimed to evaluate and determine the efficacy of a brief transdiagnostic treatment in group format for people with mild and moderate emotional disorders, and to establish correlations between the changes after treatment in the different variables. This work had a single-group experimental design with pre-post measures. Participants (n =18) were randomly assigned to the PsicAP-Cost project design, from which the experimental group data have been extracted. Participants were assessed pre- and post-intervention with the following measures: PHQ-15, PHQ-9, GAD-7, PSQW-A, RRS-B, and CERQ-18. Brief transdiagnostic therapy was found to be effective in reducing depressive symptoms (p = .001), anxious symptoms (p = .011), and worry (p = .018) with high/moderate effect sizes. In addition, significant positive correlations were found between changes in depressive symptoms and worry variables, and between changes in anxious symptoms and rumination. In conclusion, brief transdiagnostic treatments can be a treatment to consider for patients with mild and moderate emotional disorders in Primary Care due to their efficacy in some symptoms and their characteristics.

Worry, rumination and negative metacognitive beliefs as moderators of outcomes of Transdiagnostic group cognitive-behavioural therapy in emotional disorders

BackgroundDespite the relevance of cognitive processes such as rumination, worry, negative metacognitive beliefs in emotional disorders, the existing literature about how these cognitive processes moderate the effect of treatment in treatment outcomes is limited. The aim of the present study was to explore the potential moderator effect of baseline cognitive processes—worry, rumination and negative metacognitive beliefs—on the relationship between treatment allocation (transdiagnostic cognitive-behavioural therapy —TD-CBT plus treatment as usual—TAU vs. TAU alone) and treatment outcomes (anxiety and depressive symptoms, quality of life [QoL], and functioning) in primary care patients with emotional disorders. MethodsA total of 631 participants completed scales to evaluate worry, rumination, negative metacognitive beliefs, QoL, functioning, and anxiety and depressive symptoms. ResultsWorry and rumination acted as moderators on the effect of treatment for anxiety (b = −1.25, p = .003; b = −0.98, p = .048 respectively) and depressive symptoms (b = −1.21, p = .017; b = −1.34, p = .024 respectively). Individuals with higher baseline levels of worry and rumination obtained a greater reduction in emotional symptoms from the addition TD-CBT to TAU. Negative metacognitive beliefs were not a significant moderator of any treatment outcome. LimitationsThe study assesses cognitive processes over a relatively short period of time and uses self-reported instruments. In addition, it only includes individuals with mild or moderate anxiety or depressive disorders, which limits generalization to other populations. ConclusionsThese results underscore the generalization of the TD-CBT to individuals with emotional disorders in primary care with different cognitive profiles, especially those with high levels of worry and rumination.

Cost-effectiveness and cost-utility evaluation of individual vs. group transdiagnostic psychological treatment for emotional disorders in primary care (PsicAP-Costs): a multicentre randomized controlled trial protocol

BackgroundEmotional disorders are common, and they have become more prevalent since the COVID-19 pandemic. Due to a high attendance burden at the specialized level, most emotional disorders in Spain are treated in primary care, where they are usually misdiagnosed and treated using psychotropic drugs. This contributes to perpetuate their illness and increase health care costs. Following the IAPT programme and the transdiagnostic approach, the PsicAP project developed a brief group transdiagnostic cognitive-behavioural therapy (tCBT) as a cost-effective alternative. However, it is not suitable for everyone; in some cases, one-on-one sessions may be more effective. The objective of the present study is to compare, in cost-benefit terms, group and individual tCBT with the treatment usually administered in Spanish primary care (TAU).MethodsA randomized, controlled, multicentre, and single-blinded trial will be performed. Adults with mild to moderate emotional disorders will be recruited and placed in one of three arms: group tCBT, individual tCBT, or TAU. Medical data and outcomes regarding emotional symptoms, disability, quality of life, and emotion regulation biases will be collected at baseline, immediately after treatment, and 6 and 12 months later. The data will be used to calculate incremental cost-effectiveness and cost-utility ratios.DiscussionThis trial aims to contribute to clinical practice research. The involvement of psychologists in primary care and the implementation of a stepped-care model for mental disorders are recommended. Group therapy and a transdiagnostic approach may help optimize health system resources and unblock waiting lists so that people can spend less time experiencing mental health problems.Trial registrationClinicalTrials.gov: NCT04847310; Protocols.io: bx2npqde. (April 19, 2021)

The mediating role of emotion regulation in transdiagnostic cognitive behavioural therapy for emotional disorders in primary care: Secondary analyses of the PsicAP randomized controlled trial

BackgroundEmotional disorders are highly prevalent in primary care. Transdiagnostic cognitive behavior therapy (TD-CBT) is a promising treatment of emotional disorders. In this study, we evaluated several emotion regulation strategies as potential mediators of treatment outcomes in a clinical sample of primary care. MethodsA total of 1061 primary care patients were included in a randomized clinical trial comparing treatment-as-usual (TAU) to TD-CBT+TAU. Of these, 631 (TAU=316; TD-CBT+TAU=315) completed the full treatment and all pre- and post-treatment scales to assess symptoms (anxiety, depression, somatization), emotion regulation strategies (worry, rumination, negative metacognition, suppression, cognitive reappraisal), overall functioning, and quality of life (QoL). ResultsTreatment and direct effects showed that TD-CBT+TAU was superior to TAU alone. On the multivariate mediation analysis of indirect effects, three maladaptive strategies (worry, rumination and negative metacognition) had significant effects on all emotional symptoms. Suppression was also significant for depression. Rumination and negative metacognition were significant mediators of functioning, while only negative metacognition was significant for QoL. Reappraisal had no effect on any outcome. LimitationsWe focused mainly on maladaptive cognitive emotion regulation strategies and only studied one behavioural strategy (suppression) and one adaptive strategy (reappraisal). ConclusionsTargeting certain maladaptive emotion regulation strategies (worry, rumination, suppression, negative metacognition) as mediators for treatment with TD-CBT could reduce emotional symptoms and improve well-being. Negative metacognition was the most transdiagnostic strategy, whereas an adaptive strategy such as reappraisal was not a mediator. Thus, maladaptive emotion regulation strategies are key mediators in transdiagnostic therapy for emotional disorders in primary care.

Brief psychological therapies for emotional disorders in primary care: A systematic review and meta-analysis.

Brief psychological therapies for emotional disorders in primary care: A systematic review and meta-analysis.

Effectiveness of brief group transdiagnostic therapy for emotional disorders in primary care: A randomized controlled trial identifying predictors of outcome

Brief transdiagnostic psychotherapy is a possible approach for emotional disorders in primary care. The objective of the present randomized controlled trial was to determine its effectiveness compared with the treatment as usual based on pharmacological interventions in patients with mild/moderate symptoms. In addition, emotional regulation strategies and cognitive factors were studied as potential predictors. Participants (N = 105) were assigned to brief group therapy based on the Unified Protocol (n = 53) or treatment as usual (n = 52). They were assessed before and after the interventions. Mean differences and stepwise regression analyses were performed. Brief group transdiagnostic psychotherapy was more effective than medication in reducing all clinical symptoms (p = .007 for generalized anxiety; p = .000 for somatization; p = .000 for panic disorder; and p = .041 for depression) and in modifying emotional regulation strategies and cognitive processes (p = .000 for cognitive reappraisal, expressive suppression, worry, rumination, and metacognition) with moderate/high effect sizes. Besides, it was found that these variables acted as predictors of the therapeutic change. It is concluded that brief therapies could be an accurate treatment for mild/moderate emotional disorders in primary care due to their cost-effective characteristics.

Moderators and predictors of treatment outcome in transdiagnostic group cognitive-behavioral therapy for primary care patients with emotional disorders.

Transdiagnostic group cognitive behavior therapy (TD-GCBT) has shown to be efficacious in the treatment of emotional disorders in primary care. However, little is known about possible moderators or predictors of treatment outcome. We aimed to explore the potential predictors and moderators of outcome in a large multicentre randomized controlled trial comparing TD-GCBT plus treatment as usual (TAU) to TAU alone. Putative demographic and baseline clinical variables were examined using the PROCESS macro as potential predictors/moderators of depressive and anxiety symptoms at posttreatment and 1-year follow-up. Analyses were based on a study completer sample of 1061 participants randomized to TD-CBT + TAU (n = 527) or TAU alone (n = 534), with 631 participants assessed at the posttreatment evaluation and 388 at the 1-year follow-up. Individuals working or with a partner among sociodemographic variables, and higher baseline comorbidities and more severity of symptoms among clinical variables obtained more benefits from adding TDCBT to TAU. Those taking medication before treatment obtained less benefits from the TD-GCBT than those without prescribed antidepressant medications, after controlling for baseline severity of symptoms. Overall, the moderating effect of clinical (but not sociodemographic) variables remained at 1-year follow-up. Findings support largely the generalization of the TD-GCBT for emotional disorders in primary care to a variety of sociodemographic and clinical groups. However, TD-GCBT seems to work to a greater extent for those individuals with a more severe clinical profile. Providing TD-GCBT before prescribing antidepressant medication and while people are still working may enhance the effects of adding this psychological treatment to TAU in primary care.

Transdiagnostic group cognitive behavioural therapy for emotional disorders in primary care: the results of the PsicAP randomized controlled trial.

Emotional disorders are highly prevalent in primary care. We aimed to determine whether a transdiagnostic psychological therapy plus treatment-as-usual (TAU) is more efficacious than TAU alone in primary care adult patients. A randomized, two-arm, single-blind clinical trial was conducted in 22 primary care centres in Spain. A total of 1061 adult patients with emotional disorders were enrolled. The transdiagnostic protocol (n = 527) consisted of seven 90-min sessions (8-10 patients) delivered over a 12-14-week period. TAU (n = 534) consisted of regular consultations with a general practitioner. Primary outcome measures were self-reported symptoms of anxiety, depression, and somatizations. Secondary outcome measures were functioning and quality of life. Patients were assessed at baseline, post-treatment, and at 3, 6, and 12 months. Intention-to-treat and per-protocol analyses were performed. Post-treatment primary outcomes were significantly better in the transdiagnostic group compared to TAU (anxiety: p < 0.001; Morris's d = -0.65; depression: p < 0.001; d = -0.58, and somatic symptoms: p < 0.001; d = -0.40). These effects were sustained at the 12-month follow-up (anxiety: p < 0.001; d = -0.44; depression: p < 0.001; d = -0.36 and somatic symptoms: p < 0.001; d = -0.32). The transdiagnostic group also had significantly better outcomes on functioning (d = 0.16-0.33) and quality of life domains (d = 0.24-0.42), with sustained improvement at the 12-month follow-up in functioning (d = 0.25-0.39) and quality of life (d = 0.58-0.72). Reliable recovery rates showed large between-group effect sizes (d > 0.80) in favour of the transdiagnostic group after treatment and at the 12-month follow-up. Adding a brief transdiagnostic psychological intervention to TAU may significantly improve outcomes in emotional disorders treated in primary care. isrctn.org identifier: ISRCTN58437086.

The association between different domains of quality of life and symptoms in primary care patients with emotional disorders

Despite the importance of quality of life (QoL) in primary care patients with emotional disorders, the specific influence of the symptoms of these disorders and the sociodemographic characteristics of patients on the various QoL domains has received scant attention. The aim of the present study of primary care patients with emotional disorders was to analyse the associations between four different QoL domains and the most prevalent clinical symptoms (i.e., depression, anxiety and somatization), while controlling for sociodemographic variables. A total of 1241 participants from 28 primary care centres in Spain were assessed with the following instruments: the Patient Health Questionnaire (PHQ)-9 to evaluate depression; the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety; PHQ-15 for somatization; and the World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) to assess four broad QoL domains: physical health, psychological health, social relationships, and environment. The associations between the symptoms and QoL domains were examined using hierarchical regression analyses. Adjusted QoL mean values as a function of the number of overlapping diagnoses were calculated. The contribution of sociodemographic variables to most QoL domains was modest, explaining anywhere from 2% to 11% of the variance. However, adding the clinical variables increased the variance explained by 12% to 40% depending on the specific QoL domain. Depression was the strongest predictor for all domains. The number of overlapping diagnoses adversely affected all QoL domains, with each additional diagnosis reducing the main QoL subscales by 5 to 10 points. In primary care patients with a diagnostic impression of an emotional disorders as identified by their treating GP, clinical symptoms explained more of the variance in QoL than sociodemographic factors such as age, sex, level of education, marital status, work status, and income. Given the strong relationship between depressive symptoms and QoL, treatment of depression may constitute a key therapeutic target to improve QoL in people with emotional disorders in primary care.

Cost-Effectiveness and Cost-Utility Analysis of the Treatment of Emotional Disorders in Primary Care: PsicAP Clinical Trial. Description of the Sub-study Design.

Introduction: In the primary care (PC) setting in Spain, the prevalence of emotional disorders (EDs) such as anxiety, depression and somatoform disorder is high. In PC patients, these disorders are not always managed in accordance with the recommendations provided by clinical practice guidelines, resulting in major direct and indirect economic costs and suboptimal treatment outcomes. The aim is to analyze and compare the cost-effectiveness and cost-utility of group-based psychological therapy versus treatment as usual (TAU).Methods: Multicenter, randomized controlled trial involving 300 patients recruited from PC centers in Madrid, Spain, with symptoms or possible diagnosis of anxiety, mood (mild or moderate), or somatoform disorders. Patients will be randomized to one of two groups: an experimental group, which will receive group-based transdiagnostic cognitive-behavioral therapy (TD-CBT); and a control group, which will receive TAU (mainly pharmacological interventions) prescribed by their general practitioner (GP). Clinical assessment will be performed with the Patient Health Questionnaire (PHQ). Direct and indirect costs will be calculated and relevant socio-demographic variables will be registered. The Spanish version of the EuroQol 5D-5L will be administered. Patients will be assessed at baseline, immediately after treatment finalization, and at 6 and 12 months post-treatment.Discussion: To our knowledge, this is the first study to compare TD-CBT to TAU in the PC setting in Spain. This is the first comparative economic evaluation of these two treatment approaches in PC. The strength of the study is that it is a multicenter, randomized, controlled trial of psychotherapy and TAU for EDs in PC.Trial registration: Protocol code: ISCRCTN58437086; 20/05/2013. EUDRACT: 2013-001955-11. Protocol Version: 6, 11/01/2014.

A computerized version of the Patient Health Questionnaire-4 as an ultra-brief screening tool to detect emotional disorders in primary care

BackgroundThe Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief self-report consisting of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2). The aim of the present study is to determine the psychometric properties of a computerized version of the PHQ-4 used to detect emotional disorders (anxiety and depression) in the primary care setting. MethodA total of 1052 patients with suspected anxiety, depression, or somatic symptoms were recruited from 28 primary care centres participating in the PsicAP trial and completed the full version of the computerized PHQ. In addition, 178 of these patients also underwent in clinical interviews as a gold standard. ResultsConfirmatory factor analyses showed very good fit indices for a two-factor solution. This model was structurally invariant among the various age and gender groups and internal consistency was acceptable (PHQ-4; α = .83, PHQ-2; α = .86, and GAD-2; α = .76). The best cut-off points to obtain high sensitivity values was 3, on both the PHQ-2 (major depressive disorder) and the GAD-2 (generalized anxiety disorder). The criterion validity (sensitivity and specificity) for the PHQ-2 were .90 and .61 and for the GAD-2, .88 and 0.61. LimitationsThe study was not designed as a prevalence study. Therefore, does not contain information on patients whose general practitioners do not consider them to suffer emotional disorders. ConclusionThis is the first study to provide evidence for the reliability and validity of a computerized version of the PHQ-4. This computerized tool can be used to detect depression and anxiety in a primary care setting.

Tratamiento psicológico de los trastornos emocionales en Atención Primaria: el manual de tratamiento transdiagnóstico del estudio PsicAP

A substantial percentage of primary care (PC) visits are motivated by some type of emotional disorder, especially depression, anxiety and somatization. These common mental disorders represent a significant burden for the people affected and for the society. Despite the availability of effective psychological therapies for these disorders, psychological interventions are rarely used in PC. The aim of the Psychology in Primary Care (PsicAP) project is to demonstrate the efficacy of a transdiagnostic cognitive-behavioural group therapy to treat the most prevalent emotional disorders in PC. This therapy, which involves only 7 sessions, is especially appropriate for PC settings. In the present article, we present the treatment manual, session by session, with extracts that illustrate key contents of the sessions. Finally, we discuss the implications of a protocol of this type at a time when clinical psychologists and clinical psychology interns are starting to be integrated into the PC setting in Spain.

Christopher M Callahan and German E Berrios, Reinventing depression: a history of the treatment of depression in primary care, 1940–2004, Oxford University Press, 2005, pp. xvii, 214, £30.50 (hardback 0-19-516523-3).

Over the last ten years, according to the WHO, depression has emerged as the leading cause of disability amongst young adults in developed countries. It is estimated that 3 per cent of the global population now suffer from the disease and over twenty million take Prozac. The apparent growth of this illness and the appearance of new treatments (especially the SSRIs) has attracted widespread critical comment. Sceptical psychiatrists, such as David Healey and Elliot Valenstein, have traced the role of the major pharmaceutical companies in the identification and marketing of psychiatric conditions and pharmaceutical solutions; bioethicists and therapists, such as Carl Elliott and Peter Kramer, have argued that we are entering an era of cosmetic pharmacology as new pharmaceutical treatments make possible new conceptions of identity and agency. Yet despite the considerable critical and philosophical comment that the rise of the new anti-depressant treatments has attracted, few have engaged in any serious examination of the actual coalface of depression treatment—the frontline prescribing work of general practitioners and family doctors in Britain and the USA. Reinventing depression does just this. It provides a welcome and necessary intervention in both the debate over anti-depressant use and the historiography of late-twentieth-century psychiatry. Callahan and Berrios argue that the persistence of depression in industrialized countries can be attributed to the ongoing attempt to treat mental illness as a clinical rather than a public health problem. The appearance of new pharmaceutical treatments has moved in tandem with the development of materialist models of the disease. This faith in neurobiological aetiologies has led, the authors argue, to our under-estimation of the social and psychological factors that contribute to the illness and to the under-recognition of the burden of depression in the wider community. The failure of our current approach to depression does not arise from any particular inadequacy in the newer forms of drug treatments or clinical investigation, rather it is an artefact of wider political changes in the status and organization of general practice and primary care psychiatry. In their exploration of the connections between our changing conceptions of depressive illness and the changing practice of primary care, Callahan and Berrios have produced an exemplary and deeply nuanced piece of medical history. They begin their case contesting the myths of the “old time doctor” and the idea (advanced by Edward Shorter) of a traditional empathic doctor–patient relationship. Instead they draw on early post-war surveys of primary care by J S Collings and Stephen Taylor to argue for a long tradition of overworked and under-funded local practitioners prescribing non-specific sedatives and hypnotics to patients presenting for psychological distress. They claim that levels of psychiatric morbidity in the community have remained fairly constant although they recognise that the clinical profiles of certain mental diseases are mutable and reflect wider social and environmental transformations. Callahan and Berrios make perceptive connections between the changing clinical profile of depression, new developments in pharmacology and epidemiology and the political organization of general practice. They demonstrate the limited impact of the new anti-depressants of the 1950s (chlorpromazine, imipramine and the monoamine oxidase inhibitors) outside asylum psychiatry, arguing that it was market driven promotion of the non-specific minor tranquillizers that established the treatment regime for emotional disorders in primary care. Likewise the development of new gradualist models of morbidity in cardiology (notably Pickering's work on hypertension) led to new measurements of the severity of depression, which in turn supported new epidemiological investigations into the under-reporting of emotional distress in the wider community. My only minor cavil with this sophisticated reading is that it tends to under-estimate the role of general practitioners themselves in the development of new psychiatric treatment regimes. Certainly many of the authors' arguments for the unique opportunities afforded to the general practitioner for longitudinal studies of the history and context of emotional disorder were made by visionary general practitioners like C A H Watts back in the early 1950s. Similarly the role of the Royal College of General Practitioners in fostering primary care research into psychiatric epidemiology is not acknowledged, which is surprising given that this contributed in part to the new assessment of psychiatric morbidity described in the volume. These are, however, very minor quibbles in what is an extremely thoughtful and impressive piece of work.

Was bewirken hausärztliche Interventionen bei Patienten mit psychischen Störungen?

The introduction of psychosomatic primary care provides for the first time the possibility for general practitioners to treat emotional and psychosomatic disorders and problems which in the past were often not recognized. Using computer-based searches in data bases and journals we surveyed controlled studies in which general practitioners performed psychosocial interventions. The studies were assessed according to standardized procedures for systematic reviews. A total of 9 studies were found which took place between 1966 and 2003. The clinical effects attained were usually limited and of short duration. Studies with specific therapeutic approaches in specific disorders showed the best results. Psychosocial interventions by the general practitioner are effective, but there is need for improvement. Further conceptual development of structured psychosocial interventions which can be applied in the general practice for the most common emotional disorders is necessary. Considering the large number of patients with emotional disorders in primary care, these efforts will undoubtedly be worthwhile.

Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues.

Emotional disorders in primary care.

Emotional disorders in primary care.

Prevalencia de depresión en mayores de 65 años. Perfil del anciano de riesgo

To calculate the prevalence of emotional disorders in primary care, using a screening test--the Yesavage--and the association of emotional disorders with other variables, with the aim of identifying the profile of an elderly person most likely to be depressed at some juncture of his/her life. Cross-sectional, descriptive study. Urban health care. Sample of 173 patients over 64 years old. An integrated geriatric assessment was conducted. The complete version of the Yesavage scale was used (30 items). 16% prevalence of depression (score over 15) was established. The following variables were associated with depression in a statistically significant way: feminine sex (p = 0.000009), age > or = 75 (p = 0.04), illiteracy or completion of only primary education (p = 0.01), dependence in one or more activities of daily life according to the Katz index (p = 0.0000006), personal history of depression (p = 0.01), current treatment for depression (p = 0.0002), daily consumption of three or more drugs (p = 0.0009) and social isolation (p = 0.00006). Multivariate analysis revealed that low educational level (p = 0.006), dependence in one or more activities of daily life (p = 0.008) and social isolation (p = 0.0008) are the variables most associated with depression. The association between low educational level and depression may be due to difficulty in understanding certain questions. A therapeutic intervention into established undiagnosed depressions took place. The Yesavage geriatric scale was useful in primary care for identifying undetected cases of emotional disorder.

Clinical interview skills and identification of emotional disorders in primary care.

The aim of this research was to study the relationship between the clinical interview skills of primary care physicians and their psychodiagnostic ability during office visits. Ten doctors took part in the study, and 233 patients were assessed. The patients were seen and diagnosed by their physicians and interviewed afterward by a psychiatrist using the Present State Examination. All the interviews with the primary care physicians were recorded on videotape, and the Physician's Skills Observation Scale was used to analyze 10 interviews per doctor, five psychiatric cases and five nonpsychiatric cases. The physician's active listening (eye contact, posture, and absence of verbal interruptions) and ability to ask questions with psychological content were associated with the ability to identify the patient's emotional problems. This association was shown to be independent of the physician's characteristics (social, academic, attitudinal, and professional), the sociodemographic characteristics of the patients, the time spent in exploration during the office visit, and the severity of the emotional or somatic disorder. The findings of this research highlight the need to train primary care physicians in specific interview skills, in order to improve their ability to identify mental disorders in their practices.

Evaluation of a brief psychological treatment for emotional disorders in primary care

A randomized trial in general practice compared: (i) a brief psychological treatment (problem-solving) given by a psychiatrist; (ii) any treatment of the GP's choice, whether psychological or pharmacological. The patients had recent onset emotional disorders of poor prognosis. Patients in the problem-solving group showed significantly greater reductions in symptoms. Problem-solving as given by a psychiatrist was feasible in primary care and acceptable to patients. Problem-solving is now being evaluated as given by general practitioners trained in the method.