Stepped care for depression in primary care: what should be offered and how?
ABSTRACT Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of "watchful waiting", as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.
SourceAvailable from: Brett McDermott[Show abstract] [Hide abstract]
ABSTRACT: BackgroundFrom a global perspective, natural disasters are common events. Published research highlights that a significant minority of exposed children and adolescents develop disaster-related mental health syndromes and associated functional impairment. Consistent with the considerable unmet need of children and adolescents with regard to psychopathology, there is strong evidence that many children and adolescents with post-disaster mental health presentations are not receiving adequate interventions.ObjectiveTo critique existing child and adolescent mental health services (CAMHS) models of care and the capacity of such models to deal with any post-disaster surge in clinical demand. Further, to detail an innovative service response; a child and adolescent stepped-care service provision model.MethodA narrative review of traditional CAMHS is presented. Important elements of a disaster response – individual versus community recovery, public health approaches, capacity for promotion and prevention and service reach are discussed and compared with the CAMHS approach.ResultsDifficulties with traditional models of care are highlighted across all levels of intervention; from the ability to provide preventative initiatives to the capacity to provide intense specialised posttraumatic stress disorder interventions. In response, our over-arching stepped-care model is advocated. The general response is discussed and details of the three tiers of the model are provided: Tier 1 communication strategy, Tier 2 parent effectiveness and teacher training, and Tier 3 screening linked to trauma-focused cognitive behavioural therapy.ConclusionIn this paper, we argue that traditional CAMHS are not an appropriate model of care to meet the clinical needs of this group in the post-disaster setting. We conclude with suggestions how improved post-disaster child and adolescent mental health outcomes can be achieved by applying an innovative service approach.European Journal of Psychotraumatology 07/2014; 5. DOI:10.3402/ejpt.v5.24294 · 2.40 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: The purpose of the study was to examine the impact of computerized cognitive behavior therapy (CBT) self-help treatment for obsessive-compulsive disorder (OCD) (BT Steps) both alone and when supported by coaching from either a lay non-therapist coach or an experienced CBT therapist. Eighty-seven subjects with clinically significant OCD were recruited through newspaper ads and randomly assigned to receive 12 weeks of treatment with either BT Steps alone (n = 28), BT Steps with non-therapist coaching (n = 28), or BT Steps with CBT therapist coaching (n = 31). Subjects worked on BT Steps at their own pace. Subjects receiving BT Steps alone received a welcome call from the project manager. Subjects randomized to either of the coaching arms received regularly scheduled weekly phone calls for coaching, encouragement, and support. No formal therapy was provided by the coaches; thus, both lay and CBT coaches completed the same tasks. All three treatment arms showed a significant reduction in Yale-Brown Obsessive Compulsive Scale (YBOCS) scores, with mean (SD) changes of 6.5 (5.7), 7.1 (6.1), and 6.5 (6.1) for the no coaching, lay coaching, and therapist coaching arms, respectively (all p's < .001). These represent effect sizes of 1.16, 1.41, and 1.12, respectively. No significant differences were found between treatment arms on YBOCS change scores, F(2) = 0.10, p = .904, or number of exposures sessions done (F(2) = 0.033, p = .967). When asked which method of therapy (computer vs. clinician) they preferred, 48% said computer, 33% said face-to-face therapy, and 19% had no preference. Results support the use of online self-help for the treatment of moderate OCD. The addition of coaching by either a lay coach or a CBT therapist coach did not significantly improve outcomes.Annals of General Psychiatry 12/2015; 14(1):10. DOI:10.1186/s12991-015-0048-0 · 1.53 Impact Factor
Article: Behavior medicine specialist.[Show abstract] [Hide abstract]
ABSTRACT: A behavioral medicine specialist is a psychologist who works in the medical home with the primary care physician. The key to achieving Total Health will be to transform the current health care system from a focus on treating disease to a focus on preventing disease. This transformation will require complex behavior change interventions and services not usually provided in the medical home. The behavioral medicine specialist will bring the knowledge and experience used to treat mental illness into the medical home to help the primary care physician improve the care of all patients in the medical home.The Permanente journal 01/2014; 18(4):52-7. DOI:10.7812/TPP/14-035