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Stratified Care for Depression Shows Reliable Improvements, Study Suggests
Researchers found that stratified depression treatment is more practical to include for improving conditions at a modest incremental cost, according to findings published in JAMA Psychiatry.
“Clinical guidelines for the management of depression recommend psychological interventions organized in a stepped care model, in which most patients access only low-intensity treatments such as guided self-help, and patients who remain symptomatic after this step can access more intensive and costly psychotherapies such as cognitive behavioral therapy,” said the authors of the study. “Stratified medicine aims to identify individuals who will have the most clinical benefit or least harm from specific treatments.”
Researchers created a cluster, multisite, pragmatic randomized trial in which four IAPT services “stepped care in line” to national guidelines. As this study was conducted via telephone, participants were patients already seeking psychological treatment that were recruited by clinicians through a standardized recruitment script that assessed suitability as well as consent.
Clinicians conducted the same semi-structured interview schedule among two cohorts— patients either receiving stratified or stepped care. Phone-based interviews of an average of 40 minutes that followed specific IAPT services guidelines, and conversation topics included the patients’ history, present circumstances, current problems and impact, and treatment goals. Race and ethnicity information were also self-reported by participants.
Clinicians in the stratified care group recommended personalized treatment plans (either high or low intensity), while clinicians in the stepped care group entered patient data and based patient treatment off guidelines.
Related: Placebo Run-In Periods in Randomized Clinical Trials of Antidepressants Not Effective
Posttreatment follow-through was measured on a session-by-session basis using the 9-item Patient Health Questionnaire. Each of these items is ranked on a Likert scale from 0-3, which represents symptom frequency in the past two weeks, totaling from 0-27. A change of 6 points shows statistical reliable change while a score of 10 shows a potential need for a further assessment.
In total, 95 participants were included in the study (618 women among 950 with data available [65.1%]; mean [SD] age, 38.27 [14.53] years). The proportion of cases of reliable and clinically significant improvement (RCSI) was significantly higher in the stratified care group than the stepped care group (264 of 505 [52.3%] vs 134 of 297 [45.1%]; odds ratio, 1.40 [95% CI, 1.04-1.87]; P = .03). Stratified care patients saw more of a need for more intense treatment (332 of 583 [56.9%] vs 107 of 368 [29.1%]; χ2 = 70.51; P < .001), which means there was a higher mean additional cost per patient (£104.5 [95% CI, £67.5-£141.6] [$139.83 (95% CI, $90.32-$189.48)]; P < .001). However, this additional cost resulted in an approximately 7% increase in the probability of RCSI.
“In this cluster randomized clinical trial of adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms compared with stepped care. Stratified care can improve depression treatment outcomes at a modest additional cost,” the study authors concluded.
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