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Stepped care in psychological therapies: access, effectiveness and efficiency: Narrative literature review
Open accessAbstract
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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ResultStepped and Standard Care for Childhood Trauma
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“Some stepped care models have all patients start with a lower intensity of care and proceed through the steps as needed (Bower & Gilbody, 2005).”
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“A potential solution is a stepped care model where brief treatments delivered by nonspecialists such as PRISM serve as “entry‐level” care and “stepped up” (advanced level) treatments delivered by social workers and psychologists are limited to those with determined psychosocial needs.(23)”
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“IAPT services operate a stepped-care approach to the delivery of psychological care (Bower & Gilbody, 2005).”
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“IAPT is grounded in a stepped care service model (Bower and Gilbody 2005), offering access to low and high intensity interventions according to need and patients’ response to entry-level low intensity interventions.”
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“A stepped-care approach is a multi-tiered program with less intensive supports provided initially, and more intensive supports provided as needed (Bower & Gilbody, 2005).”
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“One way to cope with this lack of delivery of psychological services could be step care models (Bower & Gilbody, 2005).”
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“highest level of stepped DRT (Table 1) (Bower and Gilbody, 2005; Heggestad et al., 2011).”
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“In attempting to control the costs of delivering psychological interventions, the stepped care approach has been strongly advocated as being potentially cost-effective [28].”
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“This approach, from an intervention design perspective, is closely aligned with stepped care models, wherein measurable, emergent patient-specific data guides “next steps” (Bower & Gilbody, 2005; Espie, 2009).”
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“This is necessary in the current economic climate (Bower and Gilbody, 2005).”
Should CBT Rest on Its Success?
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“Alternative approaches to service delivery, such as stepped care (Bower & Gilbody, 2005), and less therapist-demanding treatment applications such as guided selfhelp (Cuijpers & Schuurmans, 2007) might facilitate the dissemination of CBT.”
BackgroundFarrand, P. A., Woodford, J., Llewellyn, D. J., Anderson, M. P., Venkatasubramanian, S., Ukoumunne, O. C., Adlam, A., & Dickens, C. M. (2016) · Pilot and Feasibility Studies · doi:10.1186/s40814-016-0083-x · Cited by 20
“However, these studies focused on the use of experienced geriatricians to deliver face-to-face therapy [36, 43], analogous to CBT ‘high-intensity’ support within a stepped care model of delivery [30].”
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“This would involve monitoring outcome before offering further therapy, which would be in line with a stepped-care model of intervention delivery (Bower & Gilbody, 2005).”
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Storch, E. A., Schneider, S. C., Olsen, S. M., Ramírez, A. C., Berry, L. N., Goin‐Kochel, R. P., McNeel, M. M., Candelari, A. E., Guzick, A. G., Cepeda, S. L., et al. (2022) · Journal of Autism and Developmental Disorders · doi:10.1007/s10803-022-05775-w · Cited by 22
“An important component of stepped-care interventions involves pre-established monitoring systems to assess symptom status and subsequent treat-ment needs (Bower & Gilbody, 2005).”
Psychosocial Issues and Care for Patients with Systemic Sclerosis
Jewett, L. R., Kwakkenbos, L., Delisle, V. C., Levis, B., & Thombs, B. D. (2016) · Springer eBooks · doi:10.1007/978-3-319-31407-5_45 · Cited by 20
Moving From Efficacy to Effectiveness
Saunders, J. M., Robbins, M. W., & Ober, A. J. (2017) · Criminology & Public Policy · doi:10.1111/1745-9133.12316 · Cited by 19
Amos, R., Morris, L., Mansell, W., & Edge, D. (2018) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12200 · Cited by 24
“Improving access to psychological therapies aims to provide nationwide access to empirically validated treatments (Clark, 2011) and follows a ‘stepped care model’ in which the intensity of an intervention matches the severity of one’s condition (Bower & Gilbody, 2005).”
BackgroundMethodVerbeek, J. G. E., Atema, V., Mewes, J. C., van Leeuwen, M., Oldenburg, H. S. A., van Beurden, M., Hunter, M. S., van Harten, W. H., Aaronson, N. K., & Retèl, V. P. (2019) · Breast Cancer Research and Treatment · doi:10.1007/s10549-019-05410-w · Cited by 22
Wong, K.-Y., Chung, K., & Au, C. W. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2020.1764000 · Cited by 20
“The foundation of the model is a highly accommodating, effective and inexpensive treatment for insomnia (Bower & Gilbody, 2005).”
BackgroundDoes coaching psychology need the concept of formulation?
Lane, D. A., & Corrie, S. (2009) · International Coaching Psychology Review · doi:10.53841/bpsicpr.2009.4.2.195 · Cited by 20
Dear, B. F., Courtney, C., Khor, K. E., McDonald, S., Ricciardi, T., Gandy, M., Fogliati, V. J., & Titov, N. (2018) · The Clinical Journal of Pain · doi:10.1097/ajp.0000000000000565 · Cited by 19
“, intensive face-to-face programs) on the basis of clinical need.(39) However, there are numerous ways in which internet-delivered programs could be employed and there are still relatively little data to guide decisions about the optimal provision of these programs or the suitability of these programs for different pa…”
BackgroundMüller, B. H., Kull, S., Wilhelm, F. H., & Michael, T. (2011) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2010.12.001 · Cited by 19
Adapting CBT to treat depression in Armed Forces Veterans: qualitative study
Farrand, P. A., Mullan, E., Rayson, K., Engelbrecht, A., Mead, K. R., & Greenberg, N. L. (2019) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465819000171 · Cited by 19
“Furthermore, enhancing cultural competence in the CBT workforce at both Steps 2 and 3 within a Stepped Care service delivery model (Bower and Gilbody, 2005) may be especially important in achieving service access rates specified by the Armed Forces Covenant (Ministry of Defence, 2011).”
BackgroundSim, A. L., Ahmad, A., Hammad, L., Shalaby, Y., & Georgiades, K. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-09682-3 · Cited by 19
Psychotherapies in opioid use disorder: toward a step-care model
Durpoix, A., Rolling, J., Coutelle, R., & Lalanne, L. (2023) · Journal of Neural Transmission · doi:10.1007/s00702-023-02720-8 · Cited by 20
“The stepped-care model aims to reduce the time required for a specialist therapist without compromising effectiveness (Bower and Gilbody 2005).”
BackgroundSimon, N. A., Ploszajski, M., Lewis, C., Smallman, K., Roberts, N. P., Kitchiner, N., Brookes‐Howell, L., & Bisson, J. I. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12341 · Cited by 22
“…typically delivered via a website browser or mobile App (Ebert et al., 2018) and are more commonly developed and offered in the context of mild to moderate severity disorders, but may be delivered at both low intensity (LI) and high intensity (HI) within stepped-care models (Bower & Gilbody, 2005).”
BackgroundPereira, A. I., Marques, T., Russo, V., Barros, L., & Barrett, P. M. (2014) · Psychology in the Schools · doi:10.1002/pits.21767 · Cited by 19
Geraghty, A. W. A., Muñoz, R. F., Yardley, L., McSharry, J., Little, P. S., & Moore, M. V. (2016) · JMIR Mental Health · doi:10.2196/mental.5845 · Cited by 22
The Treatment of Drinking Problems
Marshall, E. J., Humphreys, K. N., Ball, D. M., & Edwards, G. (2010) · Cambridge University Press eBooks · doi:10.1017/cbo9780511910081 · Cited by 22
Pols, A. D., Adriaanse, M. C., van Tulder, M. W., Heymans, M. W., Bosmans, J. E., van Dijk, S. E., & van Marwijk, H. W. J. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-020412 · Cited by 18
“16 Offering preventive psychological interventions in a stepped-care format could be an efficient approach, as patients start with minimally intensive evidence-based treatments and only those who do not improve adequately step up to a treatment of higher intensity.(17) Recently, we conducted a randomised controlled tr…”
MethodAcceptability of a guided self-help mental health intervention in general practice
Collings, S. C., Mathieson, F. M., Dowell, A. C., Stanley, J., Jenkin, G. L. S., Goodyear‐Smith, F., & Hatcher, S. (2011) · Family Practice · doi:10.1093/fampra/cmr066 · Cited by 18
Janse, A., Wiborg, J. F., Bleijenberg, G., Tummers, M., & Knoop, H. (2016) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000085 · Cited by 18
O’Mara, M., Greene, D., Watson, H. J., Shafran, R., Kenworthy, I., Cresswell, C., & Egan, S. J. (2022) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2022.101777 · Cited by 19
Meeuwissen, J. A. C., Lemmens, L. C., Drewes, H. W.-T., Lemmens, K. M. M., Steuten, L., Elissen, A., Vrijhoef, H. J., & Baan, C. A. (2012) · Research portal (Tilburg University) · doi:10.5750/ijpcm.v2i4.312 · Cited by 18
Self-Management of Depression: A Manual for Mental Health and Primary Care Professionals
Yeung, A., Feldman, G. C., & D, M. F. M. (2009) · Medical Entomology and Zoology · Cited by 18
Psychiatric Mental Health Nursing Workforce Agenda
Delaney, K. R. (2016) · Journal of the American Psychiatric Nurses Association · doi:10.1177/1078390316636938 · Cited by 18
“…health providers, new configurations of health services teams will emerge, including greater use of ancillary personal and RNs to deliver protocol-based care (Bodenheimer & Smith, 2013) which may lead to greater utilization of steppedcare models1 in mental health services (Bower & Gilbody, 2005).”
BackgroundStover, C. S., & Keeshin, B. R. (2016) · Clinical Psychology Review · doi:10.1016/j.cpr.2016.11.002 · Cited by 21
Benedict, C., Thom, B., Teplinsky, E., Carleton, J., & Kelvin, J. F. (2016) · Clinical Breast Cancer · doi:10.1016/j.clbc.2016.12.002 · Cited by 18
Savard, M., & Savard, J. (2017) · Current Sleep Medicine Reports · doi:10.1007/s40675-017-0067-2 · Cited by 17
Need, access, and the reach of integrated care: A typology of patients.
Bridges, A. J., Villalobos, B. T., Anastasia, E. A., Dueweke, A. R., Gregus, S. J., & Cavell, T. A. (2017) · Families Systems & Health · doi:10.1037/fsh0000268 · Cited by 18
“Such protocols are consistent with recommendations for stepped care treatments that titrate intensity of clinical services to the patient needs (e.g., Bower & Gilbody, 2005).”
What Are the Options for the Treatment of Stuttering in Preschool Children?
Santayana, G., & Shenker, R. C. (2018) · Seminars in Speech and Language · doi:10.1055/s-0038-1667160 · Cited by 18
“TREATMENT A stepped care model is a system of delivering and monitoring treatments so that the most effective, yet least resource-intensive treatment is delivered to clients first, only “stepping up” to intensive or specialist services as clinically required.(49,50) The goal is to have the right service in the right p…”
BackgroundKellett, S., Simmonds‐Buckley, M., Limon, E., Hague, J., Hughes, L., Stride, C., & Millings, A. (2020) · Behavior Therapy · doi:10.1016/j.beth.2020.01.006 · Cited by 19
Cromarty, P., Gallagher, D., & Watson, J. (2020) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x20000343 · Cited by 19
“Training of these Australian low and high-intensity services adheres closely to the UK IAPT Curricula, the National Institute for Health and Care Excellence (NICE) guidelines (NICE, 2011) and stepped care mental health principles (Bower and Gilbody, 2005).”
BackgroundImplementing the NICE OCD/BDD guidelines
Lovell, K., & Bee, P. (2008) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608308x320107 · Cited by 18
Recent developments in the treatment of anxiety disorders in children and adolescents
Creswell, C., & Waite, P. (2016) · Evidence-Based Mental Health · doi:10.1136/eb-2016-102353 · Cited by 27
“…relatively simple, first-line treatments routinely to service users with a relatively good prognosis, reserving more intensive treatments for those who do not respond to the first-line treatment and those whose prognostic profile indicates that they require more input (e.g., Bower & Gilbody, 2005).”
BackgroundDecision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?
Delgadillo, J., Gellatly, J. L., & Stephenson-Bellwood, S. (2013) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s135246581300091x · Cited by 18
“Stepped care is based on the premise that differing levels of intensity of treatment are required by different patients, and therefore organizing treatments according to escalating levels of intensity and cost may be an efficient way to allocate scarce resources (Haaga, 2000; Bower and Gilbody, 2005).”
BackgroundJolstedt, M., Vigerland, S., Mataix-Cols, D., Ljótsson, B., Wahlund, T., Nord, M., Högström, J., Öst, L.-G., & Serlachius, E. (2021) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-020-01645-x · Cited by 17
Simmonds‐Buckley, M., Bennion, M. R., Kellett, S., Millings, A., Hardy, G. E., & Moore, R. K. (2020) · Journal of Medical Internet Research · doi:10.2196/17049 · Cited by 16
“The increasing demand for primary care psychological services globally has provided the context within which e-therapies have been integrated into the offer of a suite of low-intensity (LI) psychological interventions [3], often delivered within stepped-care systems [4,5].”
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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