Stepped Care

Moving Beyond the Vision to the Evidence

John F. Anderson, MD

Reprinted from "Self-Management" issue of Visions Journal, 2003, 1 (18), pp. 30-31

Background: Shared Care and Stepped Care

In 1997, a Canadian Psychiatric Association (CPA) and College of Family Physicians of Canada (CFPC) combined task force released a joint discussion paper entitled Shared mental health care in Canada.1 The first author is Dr. Nick Kates, a psychiatrist who has pioneered a shared care approach between the departments of psychiatry and family medicine at McMaster University. The CPA/CFPC shared care paper emphasizes the importance of collaborative care between psychiatrists and family physicians.

The concept of collaborative or shared care has evolved to include the idea of stepped care, i.e., that the level of intensity of care should be matched to the complexity of the condition. Depending on complexity, and on other factors, the most appropriate (and cost-effective) level of care may range from brief, non-intensive interventions that can be initiated by the family physician, to interventions requiring the coordinated, ongoing efforts of a range of professionals in addition to the family physician. As will be discussed later, many of these interventions are consistent with the principles of self-management. The concepts of shared care and stepped care are also integral to the Chronic Disease Prevention and Management approach, described elsewhere in this edition of Visions.

Stepped Care and Managing Mental Health Problems

For many persons with mental health problems, the family physician’s office is the first point of contact with the mental health system and, for many of these, the only contact. The high rate of contact between family physicians and people with mental health problems can be viewed as a window of opportunity for family physicians to provide interventions known to benefit those seeking assistance and care.

In order to meet the needs of as many people with mental health problems as possible, a stepped care approach to primary mental health care should include:

  • entry-level prevention and treatment interventions, such as brief interventions (described below)

  • strategies to meet the needs of those who don’t respond to initial interventions (enhanced treatment)

  • aftercare strategies for those patients who require longer term follow-up and supervision

Entry-Level Interventions

Entry-level prevention and treatment interventions share some of the following characteristics:

  • minimally intrusive

  • easy to implement

  • relevant to a broad range of mental health problems

  • likely to be effective for most people

  • likely to generate a population health benefit; that is, it may benefit groups of people, rather than just individuals

  • cost-effective

There is evidence in the medical literature that suggests that the delivery of these interventions by family physicians can be effective. Many of these options, such as those known as brief interventions, are consistent with self-management principles and are aimed at helping people build skills or motivation to remain healthy or deal with symptoms outside of the office setting. Some of the relevant findings include studies showing that:

  • the impact of family physician brief interventions on both smoking cessation and reductions in alcohol consumption can be substantial2,3

  • a brief school-based intervention for children can produce durable reductions in anxiety problems: a recent Australian study found evidence of success in a child and family-focused group intervention for preventing anxiety problems in at-risk children through a range of strategies, for instance, by theyoung people developing problem-solving skills for social situations.4 The intervention could be extended to other settings including family physician offices.

Currently, the Cochrane Collaboration — an organization dedicated to understanding which interventions are evidence-based, or proven effective through rigourous studies — is systematically reviewing all studies examining brief psychological treatments for depression.5 Depending upon the results of this review, the implementation of brief psychotherapeutic interventions — such as manual-based self-management interventions based on the principles of cognitive behavioural therapy (CBT) — could have a profound impact on the large number of people receiving treatment for depression from family physicians. The Depression Self-Care Guide — see page 5 in this issue of Visions — is an example of such a manual-based self-management intervention, also known as bibliotherapy.

Enhanced Treatment

A stepped care approach also includes a strategy for targeting enhanced treatment to those patients who do not respond to the initial simpler intervention(s). These approaches also include self-management-related interventions, such as psychoeducation. Some of the relevant findings include:

  • a recent study that reported on a multifaceted program targeting depressed individuals whose depressive symptoms persisted six to eight weeks after initiation of antidepressant medication by their primary care physicians.6 Patients in the intervention group received enhanced education as well as increased visits by a psychiatrist working in collaboration with the primary care physician. The enhanced treatment improved adherence to antidepressants, patient satisfaction with care, and depressive outcomes compared with usual care.

  • review showing that a sequential or stepped approach to the treatment of bulimia may be as effective as standard cognitive-behavioural treatment (CBT) and can considerably reduce the amount of therapist contact required. In one study, patients who received a self-care manual followed, if necessary, by a brief version of CBT achieved similar outcomes to those who received standard CBT.7

More research is required to understand the needs of those who don’t respond to initial interventions. In some areas, such as problem drinking, additional research is needed to identify target groups most likely to benefit from brief interventions8 as well as to identify individuals not responding to treatment.9 In other areas, such as eating disorders, more effective treatments are required for those who fail to respond to self-help and other brief, costeffective therapies.10

Follow-up or Aftercare

Finally, stepped care defines a role for family physicians in the delivery of aftercare for patients who require follow-up of a mental health problem, such as for people who have attempted suicide. The authors of a recent review11 note the frequency of suicide attempts seen in general practice, and conclude that family physicians have a crucial role in preventing suicide through aftercare and ongoing monitoring of patients who have made attempts. Research cited above6 also indicates the importance of the family physician in the ongoing management of depression, including the role of the family physician in supporting the development of self-management skills.

Conclusion

Attention to evidence, some of which is outlined above, should assist in removing the obstacles that interfere with making evidence-based interventions — including those based on self-management principles — available to people with mental illness. The same evidence should also provide an impetus to the necessary collaboration among health professionals as they help people manage their conditions

 
About the author

John is an Adjunct Professor (appt. pending) with the Department of Psychiatry, Faculty of Medicine at the University of British Columbia. Dr. Anderson can be reached by phone about this article at (250)952-2301 or by email at John.Anderson@gems3.gov.bc.ca

Footnotes:
  1. Kates, N., Craven, M., Bishop, J., et al. (1997). Shared mental health care in Canada. Ottawa: Canadian Psychiatric Association.
  2. Silagy, C. & Ketteridge, S. (1999). “Physician advice for smoking cessation (Cochrane Review).” The Cochrane Library, 4. Oxford: Update
  3. Kahan, M., Wilson, L. & Becker L. (1995). “Effectiveness of physician-based interventions with problem drinkers: A review.” Canadian Medical Association Journal, 152(6), 851-859.
  4. Dadds, M.R., Holland, D.E., Laurens, K.R., et al. (1999). “Early intervention and prevention of anxiety disorders in children: Results at 2-year follow-up.” Journal of Consulting and Clinical Psychology, 67(1),145-50.
  5. Hunot, V., Churchill, R., Corney, R. et al. (1999). “Brief psychological treatments for depression (Protocol for a Cochrane Review).” The Cochrane Library, 4. Oxford: Update Software.
  6. Katon, W., Von Korff, M., Lin, E., et al. (1999). “Stepped collaborative care for primary care patients with persistent symptoms of depression: A randomized trial.” Archives of General Psychiatry, 56(12), 1109-15.
  7. Treasure, J., Schmidt, U., Troop, N., et al. (1996). “Sequential treatment for bulimia nervosa incorporating a self-care manual.” British Journal of Psychiatry, 168(1), 94-8.
  8. Drummond, D.C. (1997). “Alcohol interventions: Do the best things come in small packages?” Addiction, 92(4), 375-9.
  9. Breslin, F.C., Sobell, M.B. & Sobell, L.C. (1998). “Problem drinkers: Evaluation of a stepped care approach.” Journal of Substance Abuse, 10(3), 217-32.
  10. Wilson, G.T. (1999). “Cognitive behaviour therapy for eating disorders: Progress and problems.” Behaviour Research and Therapy, 37(Suppl 1), S79-95.
  11. Links, P.S., Balchand, K., Dawe I., et al. (1999). “Preventing recurrent suicidal behaviour.” Canadian Family Physician, 45, 2656-60.

 

Close