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Stepped care in psychological therapies: access, effectiveness and efficiency: Narrative literature review
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Background: There is a significant gap between the demand for psychological therapy services and the available supply. One proposal to overcome this problem is to increase efficiency of provision through the adoption of briefer ‘minimal interventions' within stepped care models. Aims: To examine the theoretical underpinnings of stepped care, together with the practicalities of the adoption of this system of care. Method: Narrative literature review. Results: The potential clinical and economic benefits of stepped care are dependent upon underlying assumptions of equivalence in terms of clinical outcomes, efficiency in terms of resource use and costs, and acceptability of ‘minimal interventions' to patients and therapists. Illustrative studies of these issues are considered. Conclusions: Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.
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“but usually offered on an individual basis (Bower and Gilbody, 2005).”
From Do depressed and anxious men do groups? What works and what are the barriers to help seeking? (2014) · cites this paper as Bower and Gilbody, 2005
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“Therefore, treatment costs tend to be higher compared to primary care (Spijker et al., 2013) in combination with long waiting lists due to treatment duration and limited financial resources (Bower and Gilbody, 2005, Lovell and Richards, 2000).”
From Development and initial evaluation of blended cognitive behavioural treatment for major depression in routine specialized mental health care (2016) · cites this paper as Bower and Gilbody, 2005
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“Finally, the fact that few participants had previously consulted suggests that online interventions are attractive for first time consultations; they may demystify treatment and act as a stepping stone toward other more intensive intervention modalities (Bower and Gilbody, 2005).”
From Online and Mobile Interventions for Problem Gambling, Alcohol, and Drugs: A Systematic Review (2017) · cites this paper as Bower and Gilbody, 2005
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Demarzo, M., Cebolla, A., & García‐Campayo, J. (2014) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2014.11.013 · Cited by 101
“This general framework facilitates addressing the unresolved research questions of MBIs, specifically those related to its implementation in healthcare systems [4,5,24], which generally are as follows:”
BackgroundFirth, N., Barkham, M., & Kellett, S. (2014) · Journal of Affective Disorders · doi:10.1016/j.jad.2014.08.030 · Cited by 100
Nordin, S., Carlbring, P., Cuijpers, P. J., & Andersson, G. (2010) · Behavior Therapy · doi:10.1016/j.beth.2009.06.001 · Cited by 101
Hague, B., Hall, J., & Kellett, S. (2016) · Journal of Behavioral Addictions · doi:10.1556/2006.5.2016.064 · Cited by 99
“Results also need to be considered in light of the stepped care delivery model for psychological interventions (Bower & Gilbody, 2005).”
BackgroundMethodEnrique, A., Palacios, J. E., Ryan, H., & Richards, D. (2019) · Journal of Medical Internet Research · doi:10.2196/12775 · Cited by 81
Adjustment Disorder with Depressed Mood
Baumeister, H., Maercker, A., & Casey, P. (2009) · Psychopathology · doi:10.1159/000207455 · Cited by 92
“More usually, less invasive interventions such as monitoring, psycho-education and empowerment programs or stepped care models may be more appropriate for those patients [11;12].”
BackgroundHudson, J. L., Moss-Morris, R., Game, D., Carroll, A., McCrone, P., Hotopf, M., Yardley, L., & Chilcot, J. (2016) · BMJ Open · doi:10.1136/bmjopen-2016-011286 · Cited by 90
“A practical approach to address this problem is to implement a stepped-care health service delivery model.(11) Within this model, individuals begin with low-intensity interventions unless their distress is deemed too severe to benefit”
MethodLeeuw, I. M. V., de Bree, R., Keizer, A. L., Houffelaar, T., Cuijpers, P. J., van der Linden, M. H., & Leemans, C. R. (2009) · Oral Oncology · doi:10.1016/j.oraloncology.2009.01.012 · Cited by 90
“A stepped care model may be cost-effective to manage high levels of distress with watchful waiting and self-management as first steps.(37) Careful monitoring is of major importance in any generic stepped care model but certainly in cancer care because of the varying burden on the patient by the disease itself, the tre…”
Littlewood, E., Duarte, A., Hewitt, C. E., Knowles, S. E., Palmer, S., Walker, S., Andersen, P., Araya, R., Barkham, M., Bower, P., et al. (2015) · Health Technology Assessment · doi:10.3310/hta191010 · Cited by 92
“This is important, as the effectiveness of free-to-use cCBT would need to be comparable to pay-to-use CBT if it were to be a viable alternative within a stepped care pathway.(9) l Evaluations of all the commercially available and free-to-use packages of cCBT have been conducted by researchers responsible for their dev…”
BackgroundSelf-citationMeza, R. D., Triplett, N. S., Woodard, G. S., Martin, P., Khairuzzaman, A. N., Jamora, G., & Dorsey, S. (2021) · Implementation Science · doi:10.1186/s13012-021-01104-4 · Cited by 76
“For instance, a majority of providers in community mental health receive group-based supervision [117] and providers often use a team-approach to treatment delivery such group-based treatments [118] and team approaches for treating highrisk clients and severe mental illness [35, 119].”
BackgroundLewis, C., Roberts, N. P., Simon, N., Bethell, A., & Bisson, J. I. (2019) · Acta Psychiatrica Scandinavica · doi:10.1111/acps.13079 · Cited by 91
Stepped Care: A Method to Deliver Increased Access to Psychological Therapies
Richards, D. A. (2012) · The Canadian Journal of Psychiatry · doi:10.1177/070674371205700403 · Cited by 89
Therapist Competence, Comorbidity and Cognitive-Behavioral Therapy for Depression
Kuyken, W., & Tsivrikos, D. (2008) · Psychotherapy and Psychosomatics · doi:10.1159/000172619 · Cited by 90
“and then have the skill to implement them. This premise rests on an empirical evaluation of whether therapists with greater competence are indeed better able to help clients with greater comorbidity [”
BackgroundSlater, H., Dear, B. F., Merolli, M. A., Li, L. C., & Briggs, A. M. (2016) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2016.08.006 · Cited by 88
Batstra, L., & FRANCES, A. J. (2012) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e318257c4a2 · Cited by 99
“Stepped diagnosis includes stepped care, a model of health care delivery in which the first-line interventions are the least intensive and in which continuous assessments of the patient’s condition ensures timely ‘‘stepping up’’ if a lesser intervention is not achieving significant health gain (Bower and Gilbody, 2005…”
BackgroundEvaluating the promise of health IT to enhance/expand the reach of mental health services
Clarke, G., & Yarborough, B. J. (2013) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2013.03.013 · Cited by 88
“Even if HIT interventions are found to have lower potency, they may still have a role to play in a progression of interventions such as a stepped-care sequence of treatments from least to most intensive/ costly [56–58].”
BackgroundA Three-Tier Model of Parent Education in Early Childhood
McIntyre, L. L., & Phaneuf, L. (2008) · Topics in Early Childhood Special Education · doi:10.1177/0271121407311239 · Cited by 87
“This logic stems from the stepped care literature (e.g., Bower & Gilbody, 2005) and the schoolwide positive behavior support literature (e.g., Ervin, Schaughency, Matthews, Goodman, & McGlinchey, 2007).”
Banerjee, M., Cavanagh, K., & Strauss, C. (2017) · Mindfulness · doi:10.1007/s12671-017-0740-z · Cited by 80
“Self-help approaches might be more efficient in terms of costs and use of resource and are also acceptable Bminimal interventions^ for participants and therapists (Bower and Gilbody 2005, p. 11).”
BackgroundHudson, J. L., Moss-Morris, R. E., Norton, S., Picariello, F., Game, D. S., Carroll, A., Spencer, J., McCrone, P., Hotopf, M. H., Yardley, L., et al. (2017) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2017.09.009 · Cited by 86
“Online CBT can be delivered using a stepped-care health service delivery model [27].”
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Montero-Marín, J., Araya, R., Pérez-Yus, M. C., Mayoral, F., Gili, M., Botella, C., Baños, R., Castro, A., Romero-Sanchiz, P., López-Del-Hoyo, Y., et al. (2016) · Journal of Medical Internet Research · doi:10.2196/jmir.5695 · Cited by 75
“Nevertheless, delivering face-to-face psychotherapeutic interventions to a population is challenging given the lack of specialized resources [7], so there is a need for other alternatives that allow these interventions to be offered.”
Patient preferences for psychological support in inflammatory arthritis: a multicentre survey
Dures, E. K., Almeida, C., Caesley, J., Peterson, A., Ambler, N., Morris, M., Pollock, J. I., & HEWLETT, S. E. (2014) · Annals of the Rheumatic Diseases · doi:10.1136/annrheumdis-2014-205636 · Cited by 83
Adaptive Interventions in Child and Adolescent Mental Health
Almirall, D., & Chronis-Tuscano, A. M. (2016) · Journal of Clinical Child & Adolescent Psychology · doi:10.1080/15374416.2016.1152555 · Cited by 89
“…algorithms (Hughes et al., 2007; Pliszka et al., 2006), which focus on individualized sequences of pharmacotherapy, and stepped-care interventions (Bower & Gilbody, 2005; Haaga, 2000; Sobell & Sobell, 2000), which focus on providing gradually more intensive services in a sequence that begins with…”
BackgroundIncreasing Access to CBT: Stepped Care and CBT Self-Help Models in Practice
Williams, C., & Martinez, R. (2008) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465808004864 · Cited by 81
“The approach of diversifying delivery of CBT fits theoretically within the so-called “stepped care models” (Bower and Gilbody, 2005).”
BackgroundRapee, R. M., Lyneham, H. J., Wuthrich, V., Chatterton, M. L., Hudson, J. L., Kangas, M., & Mihalopoulos, C. (2017) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2017.08.001 · Cited by 81
Treatment of active-duty military with PTSD in primary care: Early findings.
Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko‐Mullen, A., & Peterson, A. L. (2011) · Psychological Services · doi:10.1037/a0022740 · Cited by 84
Metadata
- Authors
- Bower, P., & Gilbody, S.
- Affiliations
- University of Manchester (GB)
- University of Leeds (GB)
- Corresponding author
- Bower, Peter
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2005-01
- Volume
- 186
- Issue
- 1
- Pages
- 11-17
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2160548159
- Cited by
- 1,084
- References
- 66
- Citations by year
- 2026: 76 · 2025: 61 · 2024: 71 · 2023: 72 · 2022: 73 · 2021: 62 · 2020: 68 · 2019: 63 · 2018: 65 · 2017: 51 · 2016: 62 · 2015: 55 · 2014: 48 · 2013: 45 · 2012: 54
- FWCI
- 3.42
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Keywords
- stepped care, psychotherapy, minimal intervention, brief intervention, access to mental health care, service supply and demand, treatment efficiency, cost-effectiveness, treatment acceptability, resource utilization (health care)
- MeSH terms
- Mental Disorders, Humans, Patient Acceptance of Health Care, Psychotherapy, Treatment Outcome
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