Problem-solving training for Veterans in home based primary care: an evaluation of intervention effectiveness.

BACKGROUND: Veterans enrolled in Veterans Health Administration (VHA) Home Based Primary Care (HBPC), a program providing in-home medical and mental health care by an interdisciplinary care team, often face substantial physical, cognitive, and mental health challenges. This program evaluation examined the impact of a brief problem-solving intervention on depressive symptoms, quality of life, and problem-solving abilities for Veterans enrolled in HBPC. DESIGN: Pre- and post-intervention outcomes for Veterans, and qualitative feedback from Veterans and clinicians regarding program satisfaction. PARTICIPANTS AND SETTING: A total of 230 HBPC patients (mean age in years = 72.1, SD = 11.6) within the U.S. national VHA health care system. INTERVENTION: Six-session, individual Problem-Solving Training (PST-HBPC). METHOD: Licensed psychologists and social workers (n = 115) completed training and administered the treatment with HBPC Veterans between 2014 and 2017. MEASUREMENTS AND RESULTS: From baseline to post-intervention, Veterans completing five or more PST-HBPC sessions (n = 199) reported significant reductions in depressive symptoms on the Patient Health Questionnaire 9-item (PHQ-9), in difficulty functioning due to depressive symptoms (PHQ-9 item 10), and in thoughts of death (PHQ-9 item 9). They also reported more effective problem-solving on the Social Problem-Solving Inventory - Revised: Short form (total score and subscales), and improved quality of life across life domains on the World Health Organization Quality of Life-BREF (WHOQOL-BREF) scale. Both clinicians and Veterans also reported satisfaction with the program. CONCLUSIONS: Preliminary findings support the continued dissemination and implementation of this brief PST intervention for HBPC Veterans, and its potential for use with non-VA home care populations with complex comorbidities.

Social problem solving as a mediator of stress and chronic prostatitis symptomology.

Social problem solving (SPS), the process by which individuals attempt to cope with stressful life problems, has previously been found to mediate the relationship between stress and disorder-related symptomatology among several medical patient populations. The present study sought to identify a similar relationship among a sample of 63 men diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Results found that SPS mediated the relationship between two different measures of stress and CP/CPPS symptoms. These results suggest that attempts to foster patients' SPS efficacy may help reduce CP/CPPS-related negative symptoms.

A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer.

PURPOSE: Breast cancer (BC) is a risk factor for major depressive disorder (MDD), yet little research has tested the efficacy of different psychotherapies for depressed women with BC. This study, the largest to date, compared outcomes of three evidence-based, 12-week therapies in treating major depressive disorder among women with breast cancer. METHODS: This randomized trial compared interpersonal psychotherapy (IPT), problem solving therapy (PST), and brief supportive psychotherapy (BSP). Conducted at the outpatient clinic of the New York State Psychiatric Institute/Columbia University, the trial offered bilingual treatment by treatment-specific psychotherapists supervised by treatment experts. The primary outcome was change in the Hamilton Depression Rating Scale (HAM-D) at 12 weeks. Secondary outcomes included other validated patient-reported outcomes for depression and quality of life. RESULTS: Of 179 women with breast cancer screening positive for depression at the Columbia Cancer Center, 134 eligible patients signed informed treatment consent. Half of patients were Hispanic and economically disadvantaged. Most women had stage I (35.2%) or II (36.9%) BC; 9% had stage IV. The three brief psychotherapies showed similar improvements on the HAM-D, with large pre-post effect sizes (d ~ 1.0); a priori defined response rates were 35% for IPT, 50% for PST and 31% for BSP, and remission rates 25%, 30% and 27%, respectively. The three treatments also showed similar improvements in the Quality of Life Enjoyment and Satisfaction Questionnaire. Dropout was high, ranging from 37 to 52% across treatments. Predictors of dropout included having < 16 years of education and annual family income < $20,000. CONCLUSIONS: Among patients who completed treatment, all three psychotherapies were associated with similar, meaningful improvements in depression. Physical distance between the oncology and psychiatric treatment sites might have contributed to high dropout. This study suggests various psychotherapy approaches may benefit patients with breast cancer and major depression.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.

BACKGROUND: Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. OBJECTIVE: The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. METHODS: DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. RESULTS: DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). CONCLUSIONS: Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.

Case formulation and the therapeutic alliance in contemporary problem-solving therapy (PST).

In addition to providing psychoeducation and sharing clinical explanations and treatment goals, case formulation serves as a potential mechanism by which therapists may facilitate an alliance with their patients. This article illustrates how a case formulation shared with a patient early in the process of contemporary problem-solving therapy (PST) may yield both a road map to treatment and a means to build and adapt a therapeutic alliance based on patient attributes. We provide a description of a clinical case in which PST was carried out with a woman who, in the midst of alcohol recovery, experienced symptoms of anxiety, depression, and binge eating.

Positive and negative religious coping, depressive symptoms, and quality of life in people with HIV.

The present study examined the relationships of positive and negative types of religious coping with depression and quality of life, and the mediating role of benefit finding in the link between religious coping and psychological outcomes among 198 individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). The results of multiple hierarchical analyses revealed that negative religious coping was significantly associated with a high level of depressive symptoms and a low level of quality of life, controlling for demographic and clinical variables. On the other hand, positive religious coping was significantly associated with positive domains of outcome measures such as positive affect and life satisfaction, but not with overall depressive symptoms or quality of life. Tests of mediation analyses showed that benefit finding fully mediated the relationship between positive religious coping and the positive sub-domains of psychological outcomes. The importance of investigating both positive and negative types of religious coping in their relationships with psychological adaptation in people with HIV was discussed, as well as the significance of benefit finding in understanding the link between religious coping and psychological outcomes.

Coping and social problem solving correlates of asthma control and quality of life.

In a sample of adults with asthma receiving care and medication in an outpatient pulmonary clinic, this study tested for statistical associations between social problem-solving styles, asthma control, and asthma-related quality of life. These variables were measured cross sectionally as a first step toward more systematic application of social problem-solving frameworks in asthma self-management training. Recruitment occurred during pulmonology clinic service hours. Forty-four adults with physician-confirmed diagnosis of asthma provided data including age, gender, height, weight, race, income, and comorbid conditions. The Asthma Control Questionnaire, the Mini Asthma Quality of Life Questionnaire (Short Form), and peak expiratory force measures offered multiple views of asthma health at the time of the study. Maladaptive coping (impulsive and careless problem-solving styles) based on transactional stress models of health were assessed with the Social Problem-Solving Inventory-Revised: Short Form. Controlling for variance associated with gender, age, and income, individuals reporting higher impulsive-careless scores exhibited significantly lower scores on asthma control (ß = 0.70, p = 0.001, confidence interval (CI) [0.37-1.04]) and lower asthma-related quality of life (ß = 0.79, p = 0.017, CI [0.15-1.42]). These findings suggest that specific maladaptive problem-solving styles may uniquely contribute to asthma health burdens. Because problem-solving coping strategies are both measureable and teachable, behavioral interventions aimed at facilitating adaptive coping and problem solving could positively affect patient's asthma management and quality of life.

Social problem solving moderates emotion reactivity in predicting suicide ideation among college students.

Objective: To evaluate the hypothesis that social problem solving (SPS) moderates strong emotion reactivity (ER) to stressful events in predicting suicide ideation (SI). Participants: 200 college students: mean age = 20.33; 75% women; 58% white. Methods: Participants completed the following self-report inventories: Beck Scale for Suicide Ideation, Emotion Reactivity Scale, and Social Problem-Solving Inventory-Revised. Results: Regression and slope analyses found SPS to moderate the association between ER and SI. Specifically, (a) as ER increased, SI increased significantly less for average problem solvers as compared to ineffective problem solvers, and (b) SI increased only slightly for effective problem solvers as ER increased. A secondary exploratory analysis found 20 college students who previously attempted suicide reported more negative ER, less effective SPS, and higher SI, as compared to a group of 20 sex-and age-matched peers. Conclusions: Effective social problem solving serves to decrease the likelihood that college students will experience higher levels of suicide ideation even when their negative emotion reactivity is high. Clinical implications for treatment and prevention are discussed.

Beyond maintaining safety: Examining the benefit of emotion-centered problem solving therapy added to safety planning for reducing late life suicide risk.

Few clinical trials have examined brief non-pharmacological treatments for reducing suicide risk in older Veterans, a high-risk group. Problem Solving Therapy (PST) is a promising psychosocial intervention for reducing late life suicide risk by increasing adaptive coping to problems through effective problem solving and related coping skills. The current randomized clinical trial will compare the efficacy of six telephone-delivered sessions of Safety Planning (enhanced usual care; EUC) only or an updated version of PST (emotion-centered PST [EC-PST]) + EUC to determine the added clinical benefit of EC-PST for reducing severity of suicidal ideation and for increasing reasons for living, a critical protective factor. Participants randomized to EC-PST + EUC or EUC only will be 150 Veterans (75 each) with active suicidal ideation who are aged 60 or older; have a current DSM-5 anxiety, depressive, and/or trauma-related disorder; and without significant cognitive impairment. Primary outcomes (Geriatric Suicide Ideation Scale and Reasons for Living-Older Adults scale) will be assessed at 11 timepoints: baseline, after each of 6 treatment sessions, posttreatment, and at follow-up at 1, 3, and 6 months posttreatment, and analyzed using mixed effects modeling. Additionally, moderators and mediators of primary outcomes will be examined-functional disability, executive dysfunction, and problem-solving ability. Qualitative feedback from participants will identify potential Veteran-centric changes to the EC-PST protocol and to EUC. Ultimately, the goal of this study is to inform the evidence-based clinical practice guidelines for treatments to reduce suicide risk in older Veterans and specifically to inform clinical decision-making regarding the merit of adding EC-PST to EUC.

Social problem solving and depression in couples coping with cancer.

OBJECTIVE: When one person in a couple has cancer, both members may experience depressive symptoms and may react as an emotional system. However, the variables that influence this depressive system have not been identified. This study examined whether social problem solving, an important moderator of individual cancer-related depression, is related to depression in the couple system. METHODS: Sixty-three couples with one partner diagnosed with cancer completed self-report questionnaires regarding depressive symptoms, social problem solving, and relationship satisfaction. RESULTS: Multiple regression correlations supported the hypothesis that depression occurs in an emotional system (patient depression predicted partner depression and partner depression predicted patient depression). When examining how partner social problem solving impacts transmission from patient to partner, hierarchical multiple regression demonstrated that one social problem-solving component (positive problem orientation) eliminated the prediction of partner depression by patient depression. No other component of partner social problem solving eliminated the prediction of partner depression by patient depression. Partner social problem solving had no effect on whether partner depression predicted patient depression. CONCLUSIONS: Partners with more positive beliefs about solving problems were less likely to experience depression together with the patients. Further investigation into the role of social problem solving in the interpersonal depression system is warranted.

Modifying a social problem-solving program with the input of individuals with intellectual disabilities and their staff.

Social problem-solving programs have shown success in reducing aggressive/challenging behaviors among individuals with intellectual disabilities in clinical settings, but have not been adapted for health promotion in community settings. We modified a social problem-solving program for the community setting of the group home. Multiple sequential methods were used to seek advice from community members on making materials understandable and on intervention delivery. A committee of group home supervisory staff gave advice on content and delivery. Cognitive interviews with individuals with intellectual disabilities and residential staff provided input on content wording and examples. Piloting the program provided experience with content and delivery. The process provides lessons on partnering with vulnerable populations and community stakeholders to develop health programs.

Reducing mental health disparities by increasing the personal relevance of interventions.

One of the most persistent health disparities is the underutilization of mental health services by people of color. Neither evidence-based treatments (universal focus) nor culturally adapted treatments (group focus) have reduced these disparities. We propose the personal relevance of psychotherapy (PROP) model, which integrates universal, group, and individual dimensions to determine the personal relevance of interventions. A cultural example of personal relevance among people of East Asian ancestry involves "face" (i.e., one's prestige and position in society), which may moderate treatment outcomes. Pragmatic intervention approaches focused on helping individuals cope with specific external problems, compared to managing a "personal" disease, can effectively "restore" face. Thus, social problem-solving interventions may be more personally relevant to many people of East Asian ancestry than are approaches that are internally focused. In addition, we posit that social neuroscience can offer unique opportunities above and beyond self-report measures when assessing the impact of PROP and the personal relevance of interventions for diverse populations. Our preliminary evidence upon testing this hypothesis indicated that among Asian Americans, exposure to problem-solving therapy content elicited significantly greater neural activity in brain areas associated with personal relevance compared to exposure to cognitive-behavioral therapy content. Identifying personally relevant interventions has the potential to reduce mental health disparities by increasing engagement with mental health services for diverse groups. The increased client engagement produced by personally relevant interventions also has the potential to make mental health services more effective for diverse groups. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Adaptive Mobile Health Intervention for Adolescents with Asthma: Iterative User-Centered Development.

BACKGROUND: Adolescents diagnosed with persistent asthma commonly take less than 50% of their prescribed inhaled corticosteroids (ICS), placing them at risk for asthma-related morbidity. Adolescents' difficulties with adherence occur in the context of normative developmental changes (eg, increased responsibility for disease management) and rely upon still developing self-regulation and problem-solving skills that are integral for asthma self-management. We developed an adaptive mobile health system, Responsive Asthma Care for Teens (ReACT), that facilitates self-regulation and problem-solving skills during times when adolescents' objectively measured ICS adherence data indicate suboptimal rates of medication use. OBJECTIVE: The current paper describes our user-centered and evidence-based design process in developing ReACT. We explain how we leveraged a combination of individual interviews, national crowdsourced feedback, and an advisory board comprised of target users to develop the intervention content. METHODS: We developed ReACT over a 15-month period using one-on-one interviews with target ReACT users (n=20), national crowdsourcing (n=257), and an advisory board (n=4) to refine content. Participants included 13-17-year-olds with asthma and their caregivers. A total of 280 adolescents and their caregivers participated in at least one stage of ReACT development. RESULTS: Consistent with self-regulation theory, adolescents identified a variety of salient intrapersonal (eg, forgetfulness, mood) and external (eg, changes in routine) barriers to ICS use during individual interviews. Adolescents viewed the majority of ReACT intervention content (514/555 messages, 93%) favorably during the crowdsourcing phase, and the advisory board helped to refine the content that did not receive favorable feedback during crowdsourcing. Additionally, the advisory board provided suggestions for improving additional components of ReACT (eg, videos, message flow). CONCLUSIONS: ReACT involved stakeholders via qualitative approaches and crowdsourcing throughout the creation and refinement of intervention content. The feedback we received from participants largely supported ReACT's emphasis on providing adaptive and personalized intervention content to facilitate self-regulation and problem-solving skills, and the research team successfully completed the recommended refinements to the intervention content during the iterative development process.

Responsive Asthma Care for Teens (ReACT): development protocol for an adaptive mobile health intervention for adolescents with asthma.

INTRODUCTION: Asthma is a leading cause of youth morbidity in the USA, affecting >8% of youth. Adherence to inhaled corticosteroids (ICS) can prevent asthma-related morbidity; however, the typical adolescent with asthma takes fewer than 50% of their prescribed doses. Adolescents are uniquely vulnerable to suboptimal asthma self-management due to still-developing executive functioning capabilities that may impede consistent self-regulation and weaken attempts to use problem solving to overcome barriers to ICS adherence. METHODS AND ANALYSIS: The aims of this project are to improve adherence to ICS as an important step towards better self-management among adolescents aged 13-17 years diagnosed with asthma by merging the efficacious behaviour change strategies found in behavioural health interventions with scalable, adaptive mobile health (mHealth) technologies to create the Responsive Asthma Care for Teens programme (ReACT). ReACT intervention content will be developed through an iterative user-centred design process that includes conducting (1) one-on-one interviews with 20 teens with asthma; (2) crowdsourced feedback from a nationally representative panel of 100 adolescents with asthma and (3) an advisory board of youth with asthma, a paediatric pulmonologist and a behavioural health expert. In tandem, we will work with an existing technology vendor to programme ReACT algorithms to allow for tailored intervention delivery. We will conduct usability testing of an alpha version of ReACT with a sample of 20 target users to assess acceptability and usability of our mHealth intervention. Participants will complete a 4-week run-in period to monitor their adherence with all ReACT features turned off. Subsequently, participants will complete a 4-week intervention period with all ReACT features activated. The study started in October 2018 and is scheduled to conclude in late 2019. ETHICS AND DISSEMINATION: Institutional review board approval was obtained at the University of Kansas and the University of Florida. We will submit study findings for presentation at national research conferences that are well attended by a mix of psychologists, allied health professionals and physicians. We will publish study findings in peer-reviewed journals read by members of the psychology, nursing and pulmonary communities.

Social problem solving as a mediator of the stress-pain relationship among individuals with noncardiac chest pain.

OBJECTIVE: The present study tested the hypothesis that social problem solving (SPS) served to mediate the relationship between preceived stress and noncardiac chest pain (NCCP). DESIGN: Adults undergoing stress myocardial perfusion imaging (MPI) to determine the presence of underlying cardiovascular disease related to the experience of chest pain were recruited prior to stress testing to complete a series of self-report inventories. MAIN OUTCOME MEASURES: MPI results were used to identify individuals with NCCP (N = 166; 91 men, 75 women; mean age = 53.92 years, SD = 11.98). Measures included perceived stress, SPS, and chest pain frequency and intensity. RESULTS: In direct tests of the mediational effects of SPS, it was found that two problem-solving dimensions, negative problem orientation and rational problem solving, each served as significant mediators of the effects of stress on both NCCP intensity and frequency. CONCLUSION: These results support a mediational analysis of NCCP that includes stress and SPS. As such, it identifies SPS as a potentially important clinical target to consider when developing future psychosocial-based therapy protocols for treating individuals with NCCP.

Acculturative Stress, Social Problem Solving, and Depressive Symptoms among Korean American Immigrants.

The present study examined the relationship among acculturative stress, social problem solving, and depressive symptoms among 107 Korean American immigrants. Hierarchical regression analysis showed that acculturative stress significantly predicted depressive symptoms controlling for different domains of acculturation. With regard to the role of social problem solving, among the five dimensions of social problem solving (i.e., positive problem orientation, negative problem orientation, rational problem solving, impulsive/careless style, and avoidant style), negative problem orientation and impulsive/careless style significantly predicted depressive symptoms. Avoidant style significantly interacted with acculturative stress, indicating that avoidant style is associated with depressive symptoms when acculturative stress is high. The study underscores the impact of culture as well as severity of stress on the relationship among acculturative stress, coping, and depressive symptoms among Korean American immigrants.

Intent of reporting standards: Reply to Rossiter (2018).

In this reply to Rossiter (2018), we note that the goal of developing Journal Article Reporting Standards has been to specify the kinds of information that should be provided to the readers of scientific articles in order to allow maximal understanding of the work being reported-in the case of psychometrics, information that demonstrates the underlying adequacy of the measures used in the research being reported. Although we illustrate some kinds of items that might be utilized to make these demonstrations, the illustrations are not proscriptive. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Journal article reporting standards for quantitative research in psychology: The APA Publications and Communications Board task force report.

Following a review of extant reporting standards for scientific publication, and reviewing 10 years of experience since publication of the first set of reporting standards by the American Psychological Association (APA; APA Publications and Communications Board Working Group on Journal Article Reporting Standards, 2008), the APA Working Group on Quantitative Research Reporting Standards recommended some modifications to the original standards. Examples of modifications include division of hypotheses, analyses, and conclusions into 3 groupings (primary, secondary, and exploratory) and some changes to the section on meta-analysis. Several new modules are included that report standards for observational studies, clinical trials, longitudinal studies, replication studies, and N-of-1 studies. In addition, standards for analytic methods with unique characteristics and output (structural equation modeling and Bayesian analysis) are included. These proposals were accepted by the Publications and Communications Board of APA and supersede the standards included in the 6th edition of the Publication Manual of the American Psychological Association (APA, 2010). (PsycINFO Database Record

Social problem solving and noncardiac chest pain.

OBJECTIVE: To investigate differences in social problem solving (SPS) between individuals with noncardiac chest pain (NCCP) and persons with chest pain who tested positive for underlying cardiac disease. METHODS: The major design involved a matched case-control methodology and compared a group of patients with NCCP (n = 53) with a group of patients with cardiac disease-related chest pain (n = 53) with regard to a battery of psychological distress, stress, and pain measures as well as a multidimensional measure of SPS. RESULTS: Initial analyses found no differences between the groups regarding reported levels of chest pain intensity or frequency. However, patients with NCCP, as compared with their matched counterparts, reported significantly higher levels of depression, anxiety, perceived stress, and anger. In the analysis that addressed SPS differences between groups, general negative affectivity and prior history of cardiac disease served as covariates and revealed that individuals with NCCP were characterized by less effective problem solving on three of five dimensions assessed as compared with their matched counterparts. Moreover, the relationship between SPS and pain among patients with NCCP was found to be above and beyond that related to general negative affectivity. CONCLUSIONS: These findings both support and add to the literature regarding psychosocial correlates of NCCP and identify SPS as a potentially important factor in its pathogenesis.

Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients.

The efficacy of problem-solving therapy (PST) to reduce psychological distress was assessed among a sample of 132 adult cancer patients. A second condition provided PST for both the patient and a significant other. At posttreatment, all participants receiving PST fared significantly better than waiting list control patients. Further, improvements in problem solving were found to correlate significantly with improvements in psychological distress and overall quality of life. No differences in symptom reduction were identified between the 2 treatment protocols. At a 6-month follow-up, however, patients who received PST along with their significant other reported lower levels of psychological distress as compared with members of the PST-alone condition on approximately half of the outcome measures. These effects were further maintained 1-year posttreatment.