Cited by 1,084Psychotherapy Techniques and ApplicationsPsychiatric care and mental health servicesMental Health Treatment and Access

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Stepped care in psychological therapies: access, effectiveness and efficiency: Narrative literature review

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Bower, Peter, Gilbody, Simon·2005·British Journal of Psychiatry

DOI 10.1192/bjp.186.1.11

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Abstract

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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“As many have argued (e.g., Bower & Gilbody, 2005; Haaga, 2000; Saxena, Thornicroft, Knapp, & Whiteford, 2007), there is a widening gap between the CONTACT Shadi Beshai shadi.beshai@uregina.ca Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK, S4S 0A2, Canada © 2016…”
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“To test equivalence and efficiency, a fully powered clinical trial of stepped care compared with an alternative system which has the potential to be as clinically effective is required [14,17].”
BackgroundInfluential
An evaluation of the impact of a large group psycho-education programme (Stress Control) on patient outcome: does empathy make a difference?
Joice, A., & Mercer, S. W. (2010) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x10000012 · Cited by 8
“…Behavioural and Cognitive Psychotherapies 2010 delivery (Simon et al. 2001; Scogin et al. 2003; National Collaborating Centre for Mental Health, 2004; Bower & Gilbody, 2005; Scottish Executive, 2005) and can meet the needs of large numbers of people with mild mental-health problems (MHP) therefore…”
Background
Low-Intensity Guided Help Through Mindfulness (LIGHTMIND): study protocol for a randomised controlled trial comparing supported mindfulness-based cognitive therapy self-help to supported cognitive behavioural therapy self-help for adults experiencing depression
Strauss, C., Arbon, A., Barkham, M., Byford, S., Crane, R. S., de Visser, R. O., Heslin, M., Bibby-Jones, A.-M., Jones, F. W., Lea, L., et al. (2020) · Trials · doi:10.1186/s13063-020-04322-1 · Cited by 8
Making decisions about patient progress: the application of routine outcome measurements in stepped care psycholological therapy services
Pj, B., Gilbody, S. M., & Barkham, M. (2006) · Mental Health in Family Medicine · Cited by 8
Self-citation
Developing evidence-based and acceptable stepped care systems in mental health care: an operational research project
Richards, D. A., Weaver, A., Utley, M., Bower, P., Cape, J. D., GALLIVAN, S., Gilbody, S. M., Hennessy, S., Leibowitz, J., Lovell, K., et al. (2010) · UCL Discovery (University College London) · Cited by 8
Self-citation
Are we getting closer to treating heart and mind together and bridging the gap for individual patients attending cardiac rehabilitation?
Pedersen, S. S., Skov, O., & Ahm, R. (2023) · European Heart Journal · doi:10.1093/eurheartj/ehac820 · Cited by 8
Parents’ Perspectives on Guided Parent-Delivered Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Qualitative Study
Allard, C., Thirlwall, K., Cooper, P., Brown, A., O’Brien, D., & Creswell, C. (2022) · Journal of Emotional and Behavioral Disorders · doi:10.1177/10634266211028199 · Cited by 7
“…fit within a stepped care model where low-intensity treatments are routinely offered for mild–moderate presentations while more intensive treatments are reserved for those presenting with severe anxiety disorders and those who do not respond to low-intensity interventions (Bower & Gilbody, 2005).”
Background
Coping support factors among Australians affected by terrorism: 2002 Bali bombing survivors speak
Stevens, G. J., Dunsmore, J. C., Agho, K., Taylor, M. R., Jones, A. L., & Raphael, B. (2013) · The Medical Journal of Australia · doi:10.5694/mja13.10540 · Cited by 7
Clinical profiles of people enrolling in alcohol and other drug treatment in Australia: Do youth differ from young adults and adults?
Campbell, G., Pocuca, N., Newland, G., Ellem, R., Glasgow, S., Dignan, J., Stokes, H., & Hides, L. M. (2024) · Drug and Alcohol Review · doi:10.1111/dar.13925 · Cited by 7
The potential of single session intervention approaches to enhance the mental health and resilience of older adults, care partners, and healthcare systems
Bannon, S. M., Rapoport, A., Applebaum, A. J., & Schleider, J. L. (2025) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1515440 · Cited by 7
Facilitated Versus Patient-Directed Advance Care Planning Among Patients With Advanced Cancer: A Randomized Clinical Trial
Schenker, Y., Belin, S. C., Wang, T., Sudore, R. L., Hammes, B. J., Arnold, R. M., Flowers, R., Chiu, E., Hall, J., Dudley-Morrissey, Y., et al. (2025) · JCO Oncology Practice · doi:10.1200/op-25-00046 · Cited by 7
Effectiveness of a group intervention to improve mental health in siblings of children with chronic disorders: a cluster randomized controlled trial
Kirchhofer, S. M., Fredriksen, T., Orm, S., Botta, M., Zahl, E. L., Cogo-Moreira, H., Prentice, C. M., Vatne, T., Haukeland, Y., Silverman, W., et al. (2025) · Journal of Pediatric Psychology · doi:10.1093/jpepsy/jsaf021 · Cited by 7
“A stepped-care model approach targeting siblings who exceed thresholds for emotional and behavioral problems may be more useful than delivering SIBS independent of siblings’ risk profiles (Bower & Gilbody, 2005; Richards, 2012).”
Symptom trajectories of early responders and remitters among youth with OCD
Rech, M., Weinzimmer, S. A., GELLER, D. A., Mcguire, J. F., Schneider, S. C., Patyk, K. C., Nadai, A. S. D., Cepeda, S. C., Small, B. J., Murphy, T. K., et al. (2020) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2020.100580 · Cited by 7
Efficiency and/or Effectiveness in Managing Organizations
Najar, B. W. (2020) · Journal of Education and Culture Studies · doi:10.22158/jecs.v4n2p131 · Cited by 7
“He also puts emphasis on outputs, because higher outputs increase profits (Bower & Gilbody, 2005).”
BackgroundInfluential
Treatment outcomes for young people at clinical high risk for psychosis: Data from a specialized clinic
West, M. L., Parrish, E. M., & Friedman‐Yakoobian, M. S. (2021) · Early Intervention in Psychiatry · doi:10.1111/eip.13187 · Cited by 6
Acceptability of an online intervention for insomnia in children with neurodevelopmental disorders
Tan-MacNeill, K. M., Smith, I. M., & Corkum, P. V. (2023) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2023.104423 · Cited by 6
A pilot evaluation of the role of a children’s wellbeing practitioner (CWP) in a child and adolescent mental health service (CAMHS)
Turnbull, M. J., Kirk, H., Lincoln, M., Peacock, S., & Howey, L. (2023) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045231157621 · Cited by 7
“Within this service delivery model treatments are offered in differing intensities by a range of professionals depending on the type and severity of mental health difficulty, and monitored by way of evaluating outcomes (Bower & Gilbody, 2005).”
Background
Brief relationship support as a selective suicide prevention intervention: Piloting the Relationship Checkup in veteran couples with relationship and mental health concerns
Crasta, D. J., Funderburk, J. S., Gray, T. D., Córdova, J. V., & Britton, P. C. (2023) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12983 · Cited by 11
Utilizing digital technologies to promote well-being in university students: the ‘DigiWell’ research protocol
Ruini, C., Vescovelli, F., Cesarano, V. P., Angelis, G. D., Marco, E. D., Marco, E. L. D., Galeazzi, G. M., Pira, G. L., Pingani, L., & Limone, P. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1397870 · Cited by 12
“Promoting psychological well-being could represent a protective factor for mental health (Petrillo et al., 2014; Bower and Gilbody, 2005).”
BackgroundInfluential
‘Life just kind of sparkles’: clients’ experiences of being in cognitive behavioural group therapy and its impact on reducing shame in obsessive compulsive disorder
Spragg, M., & Cahill, S. (2015) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x15000100 · Cited by 10
Mental Healthcare in Rural and Underserved Primary Care Settings: Benefits of Telemental Health, Integrated Care, Stepped Care and Interdisciplinary Team Models
Green, D. M. H. J. (2015) · Journal of Nursing & Care · doi:10.4172/2167-1168.1000237 · Cited by 7
“In a stepped care model, all eligible patients start with an evidencebased treatment of low intensity as a first step, [49-51] with progress monitored so that patients who do not respond adequately can ‘step up’ to a subsequent treatment of higher intensity [52].”
Background
Towards Ontologies for Technology in Mental Health Interventions
Coyle, D., & Doherty, G. J. (2008) · International Workshop on Ontologies in Interactive Systems (ONTORACT) · doi:10.1109/ontoract.2008.12 · Cited by 7
Psychologists and Pediatricians in the Primary Care Sandbox: Communication is Key to Cooperative Play
Pidano, A. E., Arora, P. G., Gipson, P. Y., Hudson, B. O., & Schellinger, K. B. (2018) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-017-9522-y · Cited by 7
“Consistent with a stepped care model (Bower & Gilbody, 2005), in our primary care clinics, the Frankel Program falls along a continuum of behavioral health services available to children and families.”
Method
Parent-led, stepped-care cognitive-behavioral therapy for youth with autism and co-occurring anxiety: study rationale and method
Ramírez, A. C., Grebe, S. C., McNeel, M. M., Limon, D. L., Schneider, S. C., Berry, L. N., Goin‐Kochel, R. P., Cepeda, S. L., Voigt, R. G., Salloum, A., et al. (2020) · Brazilian Journal of Psychiatry · doi:10.1590/1516-4446-2020-0897 · Cited by 7
Psychiatriereform in der Bundesrepublik Deutschland
Reumschüssel-Wienert, C. (2021) · transcript Verlag eBooks · doi:10.1515/9783839458136 · Cited by 7
Technology-Assisted Stepped-Care to Promote Adherence in Adolescents with Asthma: A Pilot Study
Ramsey, R. R., Plevinsky, J. M., Guilbert, T. W., Carmody, J. K., & Hommel, K. A. (2022) · Journal of Clinical Psychology in Medical Settings · doi:10.1007/s10880-022-09905-5 · Cited by 8
“…Hospital, Boston, USA 7 Department of Psychiatry and Behavioral Sciences, Harvard Medical School, Boston, USA 1 3 needs to ensure that individuals receive the lowest intensity treatment expected to be effective (e.g., less time/cost intensive) (Bower & Gilbody, 2005; Nicholas et al., 2019).”
Background
Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study
Johnson, E. M., Possemato, K., Chinman, M., True, G., Hedges, J., Hampton, B. N., Edelman, E. J., & Maisto, S. A. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-10324-x · Cited by 7
A Pilot Study Investigating Differences in Sleep and Life Preoccupations in Chronic and Acute Insomnia
Man, S., Freeston, M. H., Ellis, J. G., & Lee, D. R. (2013) · Sleep Medicine Research · doi:10.17241/smr.2013.4.2.43 · Cited by 7
Psychotherapy professionals in the UK: Expansion and experiment
Mace, C. J., Rowland, N., Evans, C., Schroder, T. A., & Halstead, J. E. (2009) · European Journal of Psychotherapy & Counselling · doi:10.1080/13642530902927337 · Cited by 7
“Planned and personally tailored psychotherapies would only be provided if simpler interventions, such as attendance at educational sessions or computerised therapy are assessed as being unlikely to help, according to the principles of a ‘stepped-care’ model of provision (Bower & Gilbody, 2005).”
Method
A randomized controlled trial of the efficacy and cost-effectiveness of a brief intensified cognitive behavioral therapy and/or pharmacotherapy for mood and anxiety disorders: Design and methods
Meuldijk, D., Carlier, I. V. E., van Vliet, I. M., Marle, M. E. V. D. A., & Zitman, F. G. (2012) · Contemporary Clinical Trials · doi:10.1016/j.cct.2012.05.002 · Cited by 7
“The optimal content and organization of how to provide this stepped care is unclear, and implementation and acceptability of stepped care as a method of delivering psychological/ psychiatric services has not yet been adopted [21,22].”
BackgroundMethodInfluential
Evaluation and Management of Psychosocial Issues
Jewett, L. R., Haythornthwaite, J. A., & Thombs, B. D. (2011) · Springer eBooks · doi:10.1007/978-1-4419-5774-0_53 · Cited by 7
Thinking Outside the Box: Novel Delivery Methods for Treating Hoarding
Muroff, J. (2011) · International Journal of Cognitive Therapy · doi:10.1521/ijct.2011.4.3.280 · Cited by 7
A potential model for primary care mental health services in Ireland
Kierans, J., & Byrne, M. (2010) · Irish Journal of Psychological Medicine · doi:10.1017/s0790966700001361 · Cited by 7
Integrated Modular Treatment for Borderline Personality Disorder
Livesley, W. J. (2017) · Cambridge University Press eBooks · doi:10.1017/9781107298613 · Cited by 29
Evaluating a Web-Based Mental Health Service for Secondary School Students in Australia: Protocol for a Cluster Randomized Controlled Trial
O’Dea, B., KING, C. A., Subotic-Kerry, M., Anderson, M., Achilles, M. R., Parker, B., Mackinnon, A. J., Anderson, J., Cockayne, N. L., & Christensen, H. M. (2019) · JMIR Research Protocols · doi:10.2196/12892 · Cited by 7
“Although complex, this approach can be efficient, as it provides tailored help as required and aims to prevent serious mental illness by detecting symptoms early [15,16].”
The governance of primary mental health planning by Primary Health Networks
Henderson, J., Javanparast, S., Baum, F. E., Freeman, T., Ziersch, A. M., Mackean, T., & Fuller, J. D. (2019) · Australian Journal of Social Issues · doi:10.1002/ajs4.71 · Cited by 7
Evaluating a primary care psychology service in Ireland: a survey of stakeholders and psychologists
Corcoran, M., & Byrne, M. (2016) · Health & Social Care in the Community · doi:10.1111/hsc.12410 · Cited by 7
Repositioning Social Work Practice in Mental Health in Nova Scotia
Brown, C. G., Johnstone, M., & Ross, N. (2021) · DalSpace (Dalhousie University) · Cited by 7
Primary care mental health teams: Where are all the older people?
Broomfield, N. M., & Birch, L. (2009) · Clinical Psychology Forum · doi:10.53841/bpscpf.2009.1.198.16 · Cited by 7
A new workforce to deliver IAPT: a case study
Turpin, G., Clarke, J. C., Duffy, R., & Hope, R. (2009) · The Journal of Mental Health Training Education and Practice · doi:10.1108/17556228200900017 · Cited by 7
Study protocol for the evaluation of Fear-Less: a stepped-care program for fear of cancer recurrence in survivors with early-stage disease
Tran, M. J., Jefford, M., Smith, A. B., Lynch, F., Dhillon, H. M., Shaw, J., McDowell, L. J., White, A., Halloran, C., Wiesenfeld, D., et al. (2022) · Pilot and Feasibility Studies · doi:10.1186/s40814-022-01123-y · Cited by 8
“For mild-to-moderate symptoms, a low-intensity intervention is offered that is accessible and convenient for survivors and requires minimal specialist time to deliver [25, 26].”
Background

Authors: Bower, P., & Gilbody, S.
Affiliations: University of Manchester (GB)
University of Leeds (GB)
Corresponding author: Bower, Peter
ORCID: Bower, Peter
Gilbody, Simon
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
DOI: 10.1192/bjp.186.1.11
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
Licence: www.cambridge.org/core/terms (unspecified, 4749 d)
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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Stepped care in psychological therapies: access, effectiveness and efficiency: Narrative literature review

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