Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study

Abstract

England’s national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective.

Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?

“…Interestingly, Gyani et al (2013) found that IAPT services with a higher step-up rate also had a higher recovery rate, highlighting some potential for utilizing a stepped-care system that encouraged patients to continue from low-to high-intensity work where appropriate. Moreover, Boyd et al (2019) highlight that following a stepped-care progression model, rather than a stratified model, was associated with more reliable recovery rates. They suggested that individuals who were more severely depressed benefitted from receiving simpler, more structured elements of CBT (e.g., behavioural activation).…”

“…Outcomes in the stepped-care model Seven papers reported on the utility of the IAPT stepped-care model. One study compared the progressive model (step-by-step) with a stratified model (assessment then assigned to the appropriate treatment step), reporting that recovery was associated with the former where most service users received Step 2 (low-intensity) treatment only (Boyd, Baker, & Reilly, 2019). Another identified that services with a higher 'step-up' rate also had overall higher reliable recovery rate (Gyani, Shafran, Layard, & Clark, 2013).…”

Adapting IAPT services to support frontline NHS staff during the Covid-19 pandemic: the Homerton Covid Psychological Support (HCPS) pathway

“…Since 2008, services under the IAPT programme have offered evidence-based psychological interventions to individuals with common mental health difficulties (anxiety disorders and depression) across England (Clark, 2011). These interventions, which have been predominantly CBT orientated, are delivered in line with guidance from the National Institute for Health and Care Excellence (NICE) that advocates a stepped-care model of service delivery, which has been shown to allow services to see more patients in a manner that is clinically and cost effective (NICE, 2011;Boyd et al, 2019). As part of this model, a range of high-intensity interventions are recommended that have expanded beyond CBT to include Interpersonal Therapy (IPT), Couples Therapy, Dynamic Interpersonal Therapy (DIT) and Counselling for Depression (CfD), as well as Eye Movement Desensitisation Re-processing therapy (EMDR) for PTSD (NICE, 2018).…”

Digital cognitive behavioural therapy for insomnia: the answer to a major public health issue?

“…Although evidence for the cost-effectiveness of stepped care is scarce, services that deliver care in a progressive delivery model have been shown to achieve better outcomes than services with a stratified treatment model. 10 We therefore endorse the stepped care principles, although more research is warranted. In summary, Vedaa and colleagues' study shows that large effects can be achieved through SHUTi, and adds to the compelling evidence for dCBT-I.…”