Stepped care: Doing more with less?

Abstract

Several issues concerning stepped care are discussed: the constraints of using Diagnostic and Statistical Manual of Mental Disorders diagnoses in randomized clinical trials (RCTs), the importance of basic and process research, the unintended negative effects of exaggerated claims of effectiveness and efficiency, the limits of RCTs in evaluating improvement and deterioration, the self-correcting nature of stepped care, the link between stepped care and empirically supported treatments, clinical judgment in clinical work, the concept of the least restrictive alternative, the costs of using low-intensity but ineffective psychosocial treatments, and the costs of both ineffective and effective psychotropic drug therapy. An analysis of stepped care can lead to an appreciation that the dialectic operating between science and practice affords an opportunity to synthesize the seemingly irreconcilable standards and needs of researchers and clinicians.

The clinical effectiveness of concise cognitive behavioral therapy with or without pharmacotherapy for depressive and anxiety disorders; a pragmatic randomized controlled equivalence trial in clinical practice

“…In addition, treatment success of concise care was evaluated at the end of treatment. When either the patient or therapist is convinced that the clinical effects are insufficient or patients are insufficiently helped by the initial treatments in concise care, 'stepping up' or continuation of (additional) standard treatment, in line with stepped-care principles, was possible (Haaga, 2000;Davison, 2000). Pharmacotherapy in concise care was also evaluated after 7 weeks, and continued when necessary according to the (inter) national clinical guidelines.…”

“…However, in concise care the treatments are limited in time and in number of (weekly) sessions (maximum 7) and offered as first (brief) step in a stepped-care model (Haaga, 2000;Davison, 2000). Standard care is not confined to a maximum number of sessions or limited time-period (van Fenema et al, 2012).…”

Pesquisas em psicoterapia: seções especiais de periódico (1995 a 2005)

“…Dentro da perspectiva de emprego de intervenções de baixo custo encontram-se medidas de aprendizagem de técnicas de terapia que não necessitem da presença do terapeuta como videotapes, métodos de auto-ajuda, entre outros que, como sugere Newman (2000), podem incluir pacientes que são tipicamente excluídos dos ensaios clínicos randomizados ou aqueles que são resistentes a esses tratamentos. As propostas pretendem, como salienta Davison (2000), fazer mais com menos, ou seja, atender a um maior número de pessoas sendo possível denotar menos tempo a cada uma. São propostos modelos de tratamento para transtorno de ansiedade (Newman, 2000), transtorno de pânico (Otto, Pollack & Maki, 2000), transtornos alimentares (Wilson, Vitousek & Loeb, 2000) e problemas com álcool (Sobell & Sobell, 2000).…”

A randomized controlled trial of the efficacy and cost-effectiveness of a brief intensified cognitive behavioral therapy and/or pharmacotherapy for mood and anxiety disorders: Design and methods

“…cognitive behavioral therapy (CBT) and interpersonal therapy specifically developed for these disorders, as well as pharmacotherapy (mainly antidepressants) [14,15]. As important differences in effectiveness between the treatments are absent [13] guidelines were developed advocating a stepped-care model [16,17]. Moreover, to enhance effectiveness, for each of these treatments protocols and guidelines became available based on those used in randomized controlled trials (RCT) [4,[18][19][20].…”

“…However, these improvements may not yet be fully realized as adherence to the guidelines and protocols remains questionable [17,[21][22][23], even when ROM is added [19,20]. This implies that treatments last longer, consist of too many sessions and, thus, unnecessarily prolong suffering and increase related costs [17,21,22]. Moreover, the current economic situation offers a strong incentive to make treatments as cost-effective as possible.…”