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Psychol Med. 2018 Jul;48(10):1644-1654. doi: 10.1017/S0033291717003129. Epub 2017 Nov 2.

Stepped care in primary care - guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial.

Author information

1
Department of Clinical Neuroscience,Division of Psychology,Karolinska Institutet,Stockholm,Sweden.
2
Department of Neurobiology,Care Sciences and Society (NVS),H1, Division of Family Medicine,Karolinska Institutet,Stockholm,Sweden.
3
Department of Clinical Neuroscience,Osher Center for Integrative Medicine, Karolinska Institutet,Stockholm,Sweden.

Abstract

BACKGROUND:

Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT.

METHODS:

Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale.

RESULTS:

After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%.

CONCLUSIONS:

Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

KEYWORDS:

Adjustment Disorder; Anxiety; CBT; Common Mental Disorders; Depression; Exhaustion Disorder; Face-to-Face CBT; Guided Self-Help; Insomnia; Primary Care; Stepped care

PMID:
29095133
DOI:
10.1017/S0033291717003129
[Indexed for MEDLINE]

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