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Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial
Open accessAbstract
Importance: Depression is a major cause of disability worldwide. Although empirically supported treatments are available, there is scarce evidence on how to effectively personalize psychological treatment selection. Objective: To compare the clinical effectiveness and cost-effectiveness of 2 treatment selection strategies: stepped care and stratified care. Design, Setting, and Participants: This multisite, cluster randomized clinical trial recruited participants from the English National Health Service from July 5, 2018, to February 1, 2019. Thirty clinicians working across 4 psychological therapy services were randomly assigned to provide stratified (n = 15) or stepped (n = 15) care. In stepped care, patients sequentially access low-intensity guided self-help followed by high-intensity psychotherapy. In stratified care, patients are matched with either low- or high-intensity treatments at initial assessment. Data were analyzed from May 18, 2020, to October 13, 2021, using intention-to-treat principles. Interventions: All clinicians used the same interview schedule to conduct initial assessments with patients seeking psychological treatment for common mental disorders, but those in the stratified care group received a personalized treatment recommendation for each patient generated by a machine learning algorithm. Eligible patients received either stratified or stepped care (ie, treatment as usual). Main Outcomes and Measures: The preregistered outcome was posttreatment reliable and clinically significant improvement (RCSI) of depression symptoms (measured using the 9-item Patient Health Questionnaire). The RCSI outcome was compared between groups using logistic regression adjusted for baseline severity. Cost-effectiveness analyses compared incremental costs and health outcomes of the 2 treatment pathways. Results: A total of 951 patients were included (618 women among 950 with data available [65.1%]; mean [SD] age, 38.27 [14.53] years). The proportion of cases of RCSI was significantly higher in the stratified care arm compared with the stepped care arm (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 was associated with 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) because more patients accessed high-intensity treatments (332 of 583 [56.9%] vs 107 of 368 [29.1%]; χ2 = 70.51; P < .001), but this additional cost resulted in an approximately 7% increase in the probability of RCSI. Conclusions and Relevance: 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. Trial Registration: isrctn.org Identifier: ISRCTN11106183.
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“A two-arm waitlist-controlled RCT showed that increased pre–post global trait mindfulness mediated the effect of MBSR on lower posttreatment distress and avoidance in cancer patients [12].”
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eXplainable AI for routine outcome monitoring and clinical feedback
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“While the work of Delgadillo et al. (2022) in depression reported that stratified care was associated with a higher mean additional cost per patient (because more patients accessed high-intensity treatments), the additional cost resulted in an approximately 7% increase in the probability of a…”
Metadata
- Authors
- Delgadillo, J., Ali, S., Fleck, K., Agnew, C., Southgate, A., Parkhouse, L., Cohen, Z. D., DeRubeis, R. J., & Barkham, M.
- Affiliations
- Humber Teaching NHS Foundation Trust (GB)
- Western University (CA)
- Lancashire Care NHS Foundation Trust (GB)
- University of California, Los Angeles (US)
- University of Pennsylvania (US)
- University of Sheffield (GB)
- Corresponding author
- Delgadillo, Jaime
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2022-02-01
- Volume
- 79
- Issue
- 2
- Pages
- 101
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC8655665
- OpenAlex
- W4200371774
- Cited by
- 194
- References
- 26
- Citations by year
- 2026: 45 · 2025: 48 · 2024: 43 · 2023: 37 · 2022: 20
- FWCI
- 22.30
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- JAMA Psychiatry (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Scholarship@Western (Western University) (submittedVersion)
- Research Portal (King's College London) (submittedVersion, cc-by)
- Funders
- National Institute for Health and Care Research (28/05/18)
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- depression, stratified care, stepped care, treatment selection, personalized treatment recommendations, machine learning algorithms, guided self-help, psychotherapy, common mental disorders, cost-effectiveness, clinical effectiveness, National Health Service
- MeSH terms
- Distance Counseling, Adult, Depression, Female, Humans, Male, Middle Aged, Psychotherapy, Surveys and Questionnaires, Self Care, Treatment Outcome, Young Adult, Eye Movement Desensitization Reprocessing
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