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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Self-citation
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“…where a number of less intensive treatments (or ‘minimal interventions’) have been developed, for example brief therapies (Scott et al, 1997), group treatments (Dowrick et al, 2000) and self-help approaches such as bibliotherapy (Cuijpers, 1997) and computerised treatments (Proudfoot et al, 2004).”
Background
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2003, Depression – Core Interventions in the Management of Depression in Primary and Secondary Care (National Clinical Practice Guideline – Draft for Consultation)
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Sapkota, R. P., Gretton, A., Wilhelms, A., Bisby, M. A., Dear, B. F., Titov, N., & Hadjistavropoulos, H. D. (2025) · Internet Interventions · doi:10.1016/j.invent.2025.100852 · Cited by 4
“Interventions such as the TYD intervention may also have a role as an initial intervention in a stepped care mental health system (Bower and Gilbody, 2005).”
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“This means that patients are assigned to treatment based on their specific needs and severity of symptomatology starting with the least intensive interventions and -if ineffective-stepping up through more specialized treatment as needed in a self-correcting manner (Bower & Gilbody, 2005).”
Written Exposure Therapy as Step One in Reducing the Burden of PTSD: The Composite Cases of "Alex," "Bruno," and "Charles"
Austern, D. J. (2017) · Pragmatic Case Studies in Psychotherapy · doi:10.14713/pcsp.v13i2.2003 · Cited by 4
Extending empathy to physical symptoms
Nicolaou, T., Elliott, R., & Robinson, A. (2022) · Person-Centered & Experiential Psychotherapies · doi:10.1080/14779757.2022.2159503 · Cited by 4
“One such national-level dissemination programme, Improving Access to Psychological Therapies (IAPT), receives around 1.25 million annual referrals and delivers psychological treatments following stepped care principles (Bower & Gilbody, 2005).”
BackgroundInfluential
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“0%) Self-report fatigue score (1-10)^ 7 (3-10) 7 (4-10) 8 (3-10) Distance from treating hospital (km) 44.”
Parent Perceptions of Participating in a Parent-Mediated Program for Young Autistic Children
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“In a stepped-care approach, less intensive supports are offered initially, with higher tiers of more intensive supports available as needed on individual bases (Bower & Gilbody, 2005).”
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United Kingdom perspective
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100 psychosexual therapy clients: a complex specialism
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“…health services in the UK now adopting ‘stepped care’ processes, whereby greater client need is addressed by higher levels of service provision (Bower & Gilbody, 2005; Care Services Improvement Partnership/National Institute for Mental Health in England, 2007; National Institute for Clinical…”
Background
Feasibility of Recruiting Spouses With DSM-IV Diagnoses for Caregiver Interventions
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“With the help of stepped care approach AI systems also play a major role in reducing overall healthcare cost [32].”
Background
Therapy of the Adjustment Disorder
Baumeister, H., Bachem, R., & Domhardt, M. (2022) · Springer eBooks · doi:10.1007/978-3-662-64057-9_21 · Cited by 4
Initiation and Withdrawal of Invasive Ventilation for Patients with Amyotrophic Lateral Sclerosis: A Narrative Literature Review
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The Relationship Between Covid-19 Risk Perception and Vaccine Hesitancy in Cancer Patients: The Moderating Role of Externalizing Traits.
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“CI = confidence interval for B. 358 Clinical Neuropsychiatry (2022) 19, 6 360 Clinical Neuropsychiatry (2022) 19, 6 in psycho-oncology) on stepped-care, in which the goal is to obtain the maximum clinical improvement with the minimum impact on the patient (Bower & Gilbody, 2005).”
Background
A retrospective cost‐effectiveness analysis of different cognitive‐behavioral therapy for insomnia intervention delivery approaches in adult cancer survivors
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“Thus stepped care is a rational evidence-based and economic approach to psychological therapies delivery that its exponents argue has the potential for deriving the greatest benefit from available therapeutic and economic resources available (Bower & Gilbody, 2005).”
Background
Modulare Psychotherapie im Kindes- und Jugendalter
Schmidt, S. J., & SCHIMMELMANN, B. G. (2016) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917/a000452 · Cited by 4
Cognitive Behavioural Therapy
Marshman, Z., & Williams, C. (2017) · Springer eBooks · doi:10.1007/978-3-319-48729-8_13 · Cited by 4
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Parikh, S. V. (2015) · The Canadian Journal of Psychiatry · doi:10.1177/070674371506000602 · Cited by 4
The Westmead Program
Trajkovski, N. (2012) · doi:10.1002/9781118702796.ch15 · Cited by 4
A randomised controlled trial of Memory Flexibility training (MemFlex) to enhance memory flexibility and reduce depressive symptomatology in individuals with Major Depressive DisorderPreprint
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“Thus, stepped-care approaches have emerged as resource-economical interventions that can be gradually escalated in accordance with symptom severity and response [110–113].”
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Servi, A., Gardner-Bougaard, E., Mohamed, S., McDermott, A., Rodrigues, R., Aveyard, B., Zalk, N. V., Hampshire, A., Dewa, L. H., & Simplicio, M. C. D. (2025) · JMIR Formative Research · doi:10.2196/79496 · Cited by 4
“Therefore, we lack a stepped care model for SH [10], starting with a brief early intervention for SH in young people prior to long, complex treatments.”
Feasibility of the “LvL UP” trial: a pilot sequential multiple assignment randomised trial of an adaptive, holistic mHealth lifestyle coaching intervention
Zheng, S., Castro, Ó., Mair, J. L., Jabir, A. I., Tan, S. Y. X., Shenoi, A., Negi, S., Mathews, R. A., Koh, R. W. S., Yan, X., et al. (2026) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-025-01869-7 · Cited by 2
“Adaptive intervention strategies, tailoring support intensity based on individual needs, can optimise both effectiveness and resource allocation [21, 22].”

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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