Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care

OBJECTIVES: To determine whether problem solving treatment combined with antidepressant medication is more effective than either treatment alone in the management of major depression in primary care. To assess the effectiveness of problem solving treatment when given by practice nurses compared with general practitioners when both have been trained in the technique. DESIGN: Randomised controlled trial with four treatment groups. SETTING: Primary care in Oxfordshire. PARTICIPANTS: Patients aged 18-65 years with major depression on the research diagnostic criteria—a score of 13 or more on the 17 item Hamilton rating scale for depression and a minimum duration of illness of four weeks. INTERVENTIONS: Problem solving treatment by research general practitioner or research practice nurse or antidepressant medication or a combination of problem solving treatment and antidepressant medication. MAIN OUTCOME MEASURES: Hamilton rating scale for depression, Beck depression inventory, clinical interview schedule (revised), and the modified social adjustment schedule assessed at 6, 12, and 52 weeks. RESULTS: Patients in all groups showed a clear improvement over 12 weeks. The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone. There was no difference in outcome irrespective of who delivered the problem solving treatment. CONCLUSIONS: Problem solving treatment is an effective treatment for depressive disorders in primary care. The treatment can be delivered by suitably trained practice nurses or general practitioners. The combination of this treatment with antidepressant medication is no more effective than either treatment alone.