The clinical effectiveness of stepped care systems for depression in working age adults: A systematic review

Abstract

Background: Stepped care service delivery models involve treatments that become increasingly intense through successive steps, with patients reassigned via pre-defined decision criteria. This article reviews the clinical effectiveness of stepped care systems for depression in working age adults. Methods: Systematic literature review of quantitative clinical outcome evidence comprising 14 controlled and uncontrolled studies meeting specified criteria. Principal outcomes were (a) recovery rates, defined as patients no longer meeting clinical cutoff criteria for the specific outcome measure and (b) treatment response rates, defined as a 50% decrease in outcome measure score. Results: Stepped care systems had recovery rates ranging predominantly between 40-60% and response rates approximating 60%. Studies comparing stepped care with usual/enhanced usual care tended to find significant differences favouring stepped care. The median recovery odds ratio was 1.31 (interquartile intervals of 1.05 and 1.66; k = 7 studies). The median comparative Cohen's d effect size estimate was 0.41 (interquartile intervals 0.25 and 0.45; k = 5 studies). Limitations: The inclusion of uncontrolled studies could be seen as reducing the overall quality of evidence and a meta-analysis was not included due to limitations with the available data. Conclusions: Evidence suggested that stepped care interventions for depression are at least as effective as usual care. However, the clinical and organisational superiority of stepped care is yet to be scientifically verified. Differential benefits of stepped care may ultimately depend on service quality. Further research investigating and comparing the specific components and configurations of stepped care interventions is indicated.

Treatments for compulsive buying: A systematic review of the quality, effectiveness and progression of the outcome evidence

“…Although selection bias was uncontrolled through a lack of randomization, internal validity was improved by clear sourcing of participants, standardized assessment tools, and intention-to-treat analysis on dropouts. In a smaller CBT group pilot ( N =  9 ) , Filomensky and Tavares (2009) delivered the same Mitchell et al. (2006) protocol within an extended 20-week program to more actively target CBD cognitions.…”

“…This is because the evidence suggests that a low-intensity GSH approach to treating CBD was comparative to high-intensity group CBT. If patients can be treated with effective, brief, and less intensive psychological intervention first, then this can increase service throughput and efficiency (Firth, Barkham, & Kellett, 2015). Investigation of contemporary interventions such as internet-based therapist-assisted self-help programs also usefully mimic the shift of consumer behavior toward online shopping (Ridgeway, Kukar-Kinney, & Monroe, 2011).…”

The Efficacy and Acceptability of Third-Wave Behavioral and Cognitive eHealth Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

“…Furthermore, subgroup analyses revealed no statistically significant differences in ES as a function of type of intervention: universal, selective/indicated, and treatment. Given that thirdwave approaches focus on promoting broad and flexible repertoires and neutralizing or reversing the ubiquitous psychological processes theorized to be responsible for much human suffering, third-wave eHealth may hold promise for improving access to mental health services (Clark, 2011) and existing stepped care approaches (Firth, Barkham, & Kellett, 2015). However, further research, particularly studies investigating third-wave universal and treatment eHealth interventions, is necessary to substantiate such assertions.…”

Quality Improvement in Behavioral Health

“…For example, a systematic review of stepped care for depression in adults identifi ed 14 controlled/uncontrolled clinical trials (Firth, Barkham, & Kellett, 2015 ). For example, a systematic review of stepped care for depression in adults identifi ed 14 controlled/uncontrolled clinical trials (Firth, Barkham, & Kellett, 2015 ).…”

“…Currently, there is notable heterogeneity across stepped care approaches for depression, including the number, type, and sequencing of steps as well as the decision rules for assigning and transitioning between steps (Firth et al, 2015 ). There is a clear need for CPS in validating specifi c stepped care protocols that could be implemented in systems of care.…”