Method

Stepped care had to include psychological therapy and comprise more than one
psychological therapy of different intensities OR more than one treatment of different
modalities. We did not require treatment to be organised in terms of progressive
treatment intensity. Decisions about stepping up had to involve systematic clinical
evaluation.
Defining stepped care

Stepped care is a method for deciding who gets what treatment and when.














References
Abstract

Is stepped care an effective system for depression treatment? What components of stepped care may be associated with more or less effect? We started to address these questions in a
systematic review and meta-analysis of all randomised controlled trials involving stepped care published up to April 2012. Although stepped care had a moderate effect on depression, we
found only limited evidence to suggest that it should have prominence in treatment guidelines. A fully powered clinical trial is required to determine whether stepped care truly delivers on its
promise of equivalence and efficiency compared with other systems for depression treatment.
A systematic review and meta-analysis of stepped care
treatment for depression
Jacqueline J Hill,
1
Exeter Graduate Fellow; Professors Annemieke van Straten,
2
David A Richards,
1
and Pim Cuijpers
2

1
University of Exeter, UNITED KINGDOM,
2
VU University, Amsterdam, NETHERLANDS

Interpretation

There is currently only limited evidence to suggest that stepped care should be the
dominant model of treatment organization.

Stepped care effect sizes were moderate and all studies used care-as-usual as a trial
comparator. A fully powered clinical trial of stepped psychological care vs, high-intensity
treatment alone is required to help determine if stepped care really should have
prominence in treatment guidelines.

It was not possible to identify any optimal component of stepped care or to
suggest a preferred model for delivery.

Interventions based on progressive treatment intensity performed worse than those
without a clear intensity order. However, we think that a definitive conclusion in respect
of this difference would be premature.

Databases
searched

PubMed, PsyINFO, EMBASE, Cochrane Central Register of Controlled
Trials

Search
terms

We combined terms indicative of depression with those of stepped care


Inclusion
criteria



RCT
Aimed at adults with depression
Investigating stepped care*

Meta-analysis: We calculated a between group effect size for each study; the pooled
(mean) reported effect size was calculated across all studies. In addition, we performed
sub-group analyses. Heterogeneity and publication bias were tested.
Why implement stepped care?

The burden of depression is well documented (WHO, 2004)
Yet access to treatment is poor (Simon & von Korff,1995; McManus et al, 2009).
Stepped care assumes equivalent clinical effects and greater efficiency compared to
alternative systems (Bower & Gilbody, 2005).
Based on these assumptions, many clinical guidelines worldwide recommend stepped
care as a means to improve treatment access (Andrews et al, 2006; NICE, 2009).

Low
intensity
monitoring
High
intensity
In stepped care treatment for depression, almost all
patients start with a treatment of low intensity as a first
step (Davison, 2000). Progress is monitored
systematically and those patients who do not respond
adequately will step up to a subsequent treatment of
higher intensity (Bower & Gilbody, 2005.

The concept of intensity readily applies to psychological
therapies. However, the term stepped care is also
used to define treatment that is not organised in terms
of increasing intensity; at each step patients switch or
add treatments of different modalities (pharmacological,
psychological etc.) and patients may start with intensive
therapy. (Araya et al, 2003; Katon et al, 2004; Ell et al,
2008).

Why a review and meta-analysis?

In England, stepped care has been adopted by Improving Access to Psychological (IAPT)
Services (www.iapt.nhs.uk). However, in their narrative review, Bower & Gilbody (2005)
conclude that the equivalence and efficiency of stepped care are un-tested. Moreover,
NICE itself offers no clear guidance on how it should be delivered. Services respond by
implementing it in very diverse ways (Richards et al. ,2012).

To develop an intervention, it is important to identify the relevant and existing evidence
base (Craig et al, 2008). Up to now, no systematic review of randomised trials on
stepped care had been published. Such a review is required to establish existing
research on the effectiveness of stepped care and to explore whether stepped care that
has been implemented in different ways, is associated with more or less effect.

Results



























343 unique
records
identified
61 full text
articles
assessed
for eligibility
14 studies
included, 10
meta-analysed

5194 patients, 2560 randomised to stepped
care
11 treatment trials, three aimed at prevention
All compared stepped care to usual care
Six trials aimed at depression among patients
with comorbid physical health problems
Five aimed at older adults
Six US based, six in The Netherlands




Characteristics of the stepped care interventions

In six studies, care was delivered through steps of increasing intensity, typically watchful
waiting first, then psycho-education and/or bibliotherapy and then CBT, life review, IPT, or
PST for example.

In eight studies there was no progression of treatment intensity. Seven of these were
based on the same clinical protocol involving Problem Solving Treatment and
antidepressant medication. At each step patients switched, added or intensified the
original treatment.
Effect size N
comp
D 95% CI I
2
P value

Post intervention
6 months

10
10

0.38
0.34

0.18 to 0.57
0.20 to 0.48

81.53
68.11

NA
NA
Sub-group analysis on six month outcomes

Progressive intensity
yes
no


2
8

0.07
0.41

-0.08 to 0.22
0.33 to 0.49

0.00
44.03

< 0.01
Meta-analysis
We found no other difference between subgroups of studies.
Further information: Jacqueline J. Hill E j.j.hill@exeter.ac.uk
van Straten, A., Hill, J., Richards, D. A. & Cuijpers, P. (2014) Stepped care treatment
delivery for depression: a systematic review and meta-analysis. Psychological Medicine.
Accepted for publication.