General discussion

The aim o f this thesis was to

investigate the fe a s ib ility o f Problem ­ solving tre a tm e n t (PST) during general p ra ctice (GP) residency and the e ffe c tiv e n e s s o f PST, when provided by GP re g istra rs, fo r p a tie n ts w ith em otional sym ptom s in p rim a ry care. In th is final chapter, the results of the foregoing chapters will be discussed in relation to each o ther and the literature. Also, some m ethodological issues will be considered. And finally, suggestions fo r fu rth e r research and fo r general p ra ctice w ill be made, follow ed by a main conclusion. T h roughout th is thesis we referred to the same ca te g o ry o f pa tie n ts w ith the term s e m o tio n a l s y m p to m s , e m o tio n a l p r o b le m s and m e n ta l h e a lth p ro blem s .

Regarding the fe a s ib ility o f PST during residency, we found th a t PST training is feasible. Our observational and questionnaire s tu d y showed th a t training in PST during residency is feasible because GP re g istra rs p a rticip a te d in the tw o -d a y training program m e and subsequent

supervision, and th e ir evaluation of the training was positive. Furtherm ore, th e y provided PST as ta u g h t in the protocol and p a tie n ts w ere w illing to receive PST of the re g istra rs (Chapter 2). Besides being feasible, PST training w as also helpful during residency, as w as shown in the focus group s tu d y (Chapter 3). R egistrars th o u g h t th a t PST training provided them w ith a practical tool in the m anagem ent of em otional problems. In daily practice, however, they would prefer im plem enting elem ents rather than the entire tre a tm e n t, because th e y th o u g h t the entire tre a tm e n t co sts too much tim e and is not

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the experiences of the re g istra rs was th e ir o b lig a to ry p a rticip a tio n in this study. This prom pted our in te re s t in the views of re g istra rs about p a rticip a tio n in research in general. A questionnaire survey on this topic showed th a t re g istra rs are interested in p a rtic ip a tin g in research, especially when they can learn a new skill, b u t p a rticip a tio n should not be com pulsory, and re g istra rs p refer to choose th e ir own research subjects (Chapter 4).

Regarding the e ffe c tiv e n e s s o f PST fo r p a tie n ts w ith em otional problems in prim ary care, the Cochrane review indicated th a t PST was more e ffe c tiv e than control tre a tm e n ts fo r major depression in p rim a ry care (Chapter 5). In m ajor depression, PST p a tie n ts had a s ta tis tic a lly sig n ific a n t and clinically im p o rta n t b e tte r S F -3 6 social fu n c tio n score and a higher recovery rate at the BDI (2 .5 4 , 9 5 % Cl 1 .8 5 to 3 .5 0 ) than usual care p a tie n ts a t 6-m onth follow -up. Also, PST pa tie n ts had s ta tis tic a lly sig n ific a n t and clinically im p o rta n t higher recovery rates at the HDRS than p a tie n ts in the placebo m edication group a t 3 -m o n th follow - up (RR 2 .2 5 , 9 5 % Cl 1 .1 6 to 4.36). For em otional problem s o ther than major depression, however, there was in s u ffic ie n t evidence to show s ta tis tic a lly sig n ific a n t d iffe re n ce s betw een PST and usual care, (placebo) m edication, or o th e r psychological tre a tm e n ts. F u rth e r research o f PST fo r these problem s was recom mended. The co ntrolled clinical trial described in this thesis provided indications th a t PST by m otivated re g istra rs m ight be more favourable fo r p a tie n ts w ith em otional sym ptom s than usual care by re g istra rs (Chapter 6). A t 9-m onth

follow -up PHQ recovery rates fo r som atoform disorder and a n xie ty were higher in the PST group (OR 6 .5 0 , p = 0 .0 1 re sp e ctive ly OR 1 1 .2 5 , p = 0 .0 3 ). D epressive sym ptom s did not improve sig n ific a n t d iffe re n tly betw een tre a tm e n t groups. PST p a tie n ts had im proved s ig n ific a n tly more on the 1 0 0 -p o in t S F -3 6 domains social fu n ctio n in g , role lim ita tio n due to em otional problem s and general health perception (B -c o e ffic ie n t of the mean d iffe re n ce re sp e ctive ly 9 .8 3 , p = 0 .0 3 ; 17.18, p = 0 .0 4 ; 1 0 .4 8 , pcO.OOl). However, due to a considerably com prom ised v a lid ity o f the trial, it remains unclear w h e th e r the e ffe c t in this trial can be a ttrib u te d to the intervention. This w ill be described and discussed below.

In the p e rform ance o f the studies described in this thesis we faced several them es and problems. We categorised these into fo u r main them es: A. S tre n g th s and w eaknesses; B. S pecific and non-specific e ffe cts; C. General considerations o f research of psychological interventions; D. Realization of training during GP residency.

A. Strengths and weaknesses

There w ere a num ber of s tre n g th s in the studies described in this thesis. - Overall, it is an im p o rta n t stre n g th

th a t we used mixed m ethods by p e rfo rm in g both q u a n tita tive and qua litative studies. Using a mixed m ethods design gives the b ro a d e st view possible,1 in this case on the fe a s ib ility of PST training during GP residency and the use of PST in daily practice. On the one side we q u a n tita tiv e ly analysed data on p a rticip a tio n in

the training, recru ite d patients and tim e investm ent. And on the o th e r side we q u a lita tiv e ly analysed re g is tra rs 'v ie w s on PST during residency. In this w ay we came to both objective and subjective fin d in gs w hich inform ed us about the fa c ts , barriers and enablers of PST during residency and PST in everyday practice. For instance, we found th a t re g istra rs appreciated sp e cific elem ents o f PST b u t th a t th e y th o u g h t the entire tre a tm e n t co st too much time. Furtherm ore, qua litative research has the

advantage of generating unexpected insights. We, fo r instance, g o t to know re g is tra rs 'v ie w s on th e ir role in mental health care management. - The perform ance o f a system atic

review and m eta-analysis by means of a Cochrane review is also a stro n g point in this thesis. Cochrane reviews are generally regarded as the s tro n g e s t level o f evidence. A lthough more reviews on PST have been p e rfo rm e d ,2 4 these did not s p e cifica lly focus on PST in prim a ry care. In our review, we included all kinds of em otional problem s ra ther than only depression and we focused on prim a ry care studies.

- Also, pe rfo rm in g a controlled trial w ith a large num ber of re g istra rs (n=81) w ho provided eith e r PST or usual care is a stre n g th . A trial w ith this num ber of re g istra rs had not been done before in PST research nor in studies of o th e r psychological tre a tm e n ts.

- Furtherm ore, the trial described in this thesis was unique because it was the fir s t w ith physicians of the p a tie n ts 'o w n practice providing PST. T herapists in all o ther PST studies so fa r w ere unfam iliar to the patient, in

the sense th a t PST was headed over to a provider outside of the practice. - A n o th e r stre n g th of the trial was

the highly pragm atic ch a ra cte r w hich re fle cte d daily practice. For instance, we included the broad range and/or m ixture o f emotional sym ptom s w hich characterises general practice as GPs o ften see mixed sym ptom s rather than specific, full blown D SM -IV d is o rd e rs .5 M o st mental health research, however, is undertaken on people experiencing a 'pure' fo rm of a p sychiatric disorder, fo r instance major depression. V arieties or co-m orbid sym ptom s are often d e lib e ra te ly excluded from studies, dim inishing the external validity, especially in general p ra ctice .6

This, however, also brings us to some m ethodological lim ita tio n s of the trial. - The fir s t lim itation was the release

o f random isation of registrars. We s ta rte d our e ffe c tiv e n e s s s tu d y as a random ised controlled trial w ith the re g istra rs being random ised in groups. However, as described in C hapter 6, re g istra rs who did not feel co m fo rta b le w ith or m otivated fo r PST, did not re c ru it patients. We th e re fo re had to change the design in o rder to allow any com parison betw een PST and usual care. This led to selection o f re g istra rs p a rtic ip a tin g in the PST group. Probably, these re g istra rs are more m otivated to deliver mental health care than th e ir non-PST colleagues w ho provided care as usual. This higher m otivation intensifies non­ sp e cific elem ents of the tre a tm e n t. T herefore, this m ight have caused an overestim ation of the e ffe c ts

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the e ffe c ts o f usual care. The use o f a form al in stru m e n t to measure the level o f m otivation o f re g istra rs to w a rd s mental health care or their a ttitu d e s to w a rd s psychosocial issues w ould have helped us to reveal the significance o f this d ifference. U nfortunately, however, we did not measure m otivation. A second m ethodological lim itation in the trial was the selection of patients. The re g istra rs selected p a tie n ts w ho all m et the inclusion c rite ria of: 1. being diagnosed w ith em otional sym ptom s; 2. a score of 4 or more a t the 1 2 -ite m General Health Q uestionnaire; 3. having had 3 or more co n su lta tio n s in the past half year. N ext to that, re g istra rs considered patients to be appro p ria te fo r the typ e of tre a tm e n t th e y o ffe re d , w hich re fle c ts daily practice: d octors o ffe r tre a tm e n ts w ith the highest chance o f success fo r the individual patient. This is im p o rta n t as p a tie n t and physician choice determ ine outcom e im p o rta n tly.7 From this pragm atic perspective, the external v a lid ity o f the trial was th e re fo re high. However, there w ere d iffe re n ce s in the selection o f p a tie n ts betw een intervention and control group. R egistrars in the in te rve n tio n group selected p a tie n ts them selves; re g istra rs in the usual care group p a rtly did so, b u t to reach the num bers planned in advance, had to be assisted by a research assistant. This has resulted in a biased selection of p a tie n ts w ith the supposed result th a t p a tie n ts who were selected in the in te rve n tio n group w ere more suitable and m otivated fo r the tre a tm e n t whereas p a tie n ts selected

fo r the usual care group w ere not s p e cifica lly m otivated. This lim itation also re su lts in more influence o f non­ s p e cific elem ents in the tre a tm e n t and, in this study, favours the in te rve n tio n group.

We conclude th a t the selection bias of both re g istra rs and patients com prom ised the v a lid ity of the trial considerably enhancing the non­ s p e cific elem ents of the tre a tm e n t, thus causing an overestim ation of the in te rve n tio n as com pared w ith usual care. Therefore, we cannot be sure w h e th e r the positive trial fin d in gs w ere the re su lt of a. specific PST techniques, b. non-specific e ffe c ts because PST re g istra rs were probably more m otivated, c. more open a ttitu d e s of PST p a tie n ts tow ards active tre a tm e n t, or d. a tre a tm e n t like PST as a valuable vehicle fo r re g istra rs to incorporate non-specific skills b e tte r into th e ir co nsultations w ith p a tie n ts w ith em otional problems. The last option m ight be realistic, because the fo cu s group s tu d y showed th a t re g is tra rs th o u g h t th a t th e y im plem ented many new skills during PST. R egistrars m entioned to appreciate the co ncretising and s tru c tu rin g character, the patient- centered and p a tie n t em pow ering character, including the activa tio n of p a tie n ts to th in k of and im plem ent th e ir own solutions in daily life, w ith p a tie n ts being responsible fo r th e ir own solutions. P atient em pow ering skills are increasingly valued as im p o rta n t w ith in p rim a ry care, especially in mental health ca re .8 T herefore, we th in k th a t a tre a tm e n t like PST m ight be a practical vehicle fo r re g istra rs to incorporate non-specific tre a tm e n t skills more m a n ife stly in

th e ir p a tie n t contacts.

B. Specific and non-specific