Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-10T14:44:04.433Z Has data issue: false hasContentIssue false
  • English
  • Français

Stepped care in primary care – guided self-help and face-to-face cognitive behavioural therapy for common mental disorders: a randomized controlled trial

Published online by Cambridge University Press:  02 November 2017

Sigrid Salomonsson ,
Fredrik Santoft ,
Elin Lindsäter ,
Kersti Ejeby ,
Brjánn Ljótsson ,
Lars-Göran Öst ,
Martin Ingvar ,
Mats Lekander  and
Erik Hedman-Lagerlöf
Sigrid Salomonsson*
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
Fredrik Santoft
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
Elin Lindsäter
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
Kersti Ejeby
Affiliation:
Department of Neurobiology, Care Sciences and Society (NVS), H1, Division of Family Medicine, Karolinska Institutet, Stockholm, Sweden
Brjánn Ljótsson
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden
Lars-Göran Öst
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden Department of Psychology, Stockholm University, Stockholm, Sweden
Martin Ingvar
Affiliation:
Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
Mats Lekander
Affiliation:
Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden Stress Research Institute, Stockholm University, Stockholm, Sweden
Erik Hedman-Lagerlöf
Affiliation:
Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden
*
Author for correspondence: Sigrid Salomonsson, E-mail: sigrid.salomonsson@sll.se
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Common mental disorders (CMD) cause large suffering and high societal costs. Cognitive behavioural therapy (CBT) can effectively treat CMD, but access to treatment is insufficient. Guided self-help (GSH) CBT, has shown effects comparable with face-to-face CBT. However, not all patients respond to GSH, and stepping up non-responders to face-to-face CBT, could yield larger response rates. The aim was to test a stepped care model for CMD in primary care by first evaluating the effects of GSH-CBT and secondly, for non-responders, evaluating the additional effect of face-to-face CBT.

Methods

Consecutive patients (N = 396) with a principal disorder of depression, anxiety, insomnia, adjustment or exhaustion disorder were included. In Step I, all patients received GSH-CBT. In Step II, non-responders were randomized to face-to-face CBT or continued GSH. The primary outcome was remission status, defined as a score below a pre-established cutoff on a validated disorder-specific scale.

Results

After GSH-CBT in Step I, 40% of patients were in remission. After Step II, 39% of patients following face-to-face CBT were in remission compared with 19% of patients after continued GSH (p = 0.004). Using this stepped care model required less than six therapy sessions per patient and led to an overall remission rate of 63%.

Conclusions

Stepped care can be effective and resource-efficient to treat CMD in primary care, leading to high remission rates with limited therapist resources. Face-to-face CBT speeded up recovery compared with continued GSH. At follow-ups after 6 and 12 months, remission rates were similar in the two groups.

Keywords

CBTStepped careGuided Self-HelpFace-to-Face CBTCommon Mental DisordersAnxietyDepressionInsomniaAdjustment DisorderExhaustion DisorderPrimary Care
Type
Original Articles
Information
Psychological Medicine , Volume 48 , Issue 10 , July 2018 , pp. 1644 - 1654
Copyright
Copyright © Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Åkerstedt, T, Kecklund, G and Axelsson, J (2007). Impaired sleep after bedtime stress and worries. Biological Psychology 76, 170–173.CrossRefGoogle ScholarPubMed
Andersson, G, Bergström, J, Holländare, F, Lenndin, J, Vernmark, K, (2007). Ut ur depression och nedstämdhet med kognitiv beteendeterapi, ett effektivt självhjälpsprogram, Viva.Google Scholar
Andersson, G, Cuijpers, P, Carlbring, P, Riper, H and Hedman, E (2014). Guided internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry 13, 288–295.CrossRefGoogle ScholarPubMed
Andrews, G and Titov, N (2006). A Needs-Based, Costed Stepped-Care Model for Mental Health Services. Sydney: World Health Organization, Collaborating Centre for Classification in Mental Health.Google Scholar
Asplund, MR and Rosengren, E-L (2012). Fri Från Tvång. Steg för Steg med Kognitiv Beteendeterapi. Stockholm: Natur och Kultur.Google Scholar
Attkison, CC and Greenfield, TK (1996). The client satisfaction questionnaire (CSQ) scales and the service satisfaction Scale-30 (SSS-30). In Outcomes Assessment in Clinical Practice (eds Sederer, L. I. and Dickey, B.), pp. 120–127.Google Scholar
Bastien, CH, Vallieres, A and Morin, CM (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine 2, 297–307.CrossRefGoogle ScholarPubMed
Borkovec, TD and Costello, E (1993). Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psychology 61, 611–619.CrossRefGoogle ScholarPubMed
Brown, TA, Di Nardo, PA, Lehman, CL and Campbell, LA (2001). Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders. Journal of Abnormal Psychology 110, 49–58.CrossRefGoogle ScholarPubMed
Carlbring, P and Hanell, Å (2011). Ingen Panik: Fri Från Panik- och ångestattacker i 10 Steg med Kognitiv Beteendeterapi. Stockholm: Natur & Kultur.Google Scholar
Carta, MG, Balestrieri, M, Murru, A and Hardoy, MC (2009). Adjustment disorder: epidemiology, diagnosis and treatment. Clinical Practice and Epidemiology in Mental Health 5, 1745–0179.CrossRefGoogle ScholarPubMed
Clark, DM (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience. International Review of Psychiatry 23, 318–327.CrossRefGoogle ScholarPubMed
Clark, DM, Ehlers, A, Mcmanus, F, Hackmann, A, Fennell, M, Campbell, H, Flower, T, Davenport, C and Louis, B (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology 71, 1058–1067.CrossRefGoogle ScholarPubMed
Clark, DM, Salkovskis, PM, Hackmann, A, Middleton, H, Anastasiades, P and Gelder, M (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry 164, 759–769.CrossRefGoogle ScholarPubMed
Cloninger, CR, Svrakic, DM and Przybeck, TR (2006). Can personality assessment predict future depression? A twelve-month follow-up of 631 subjects. Journal of Affective Disorders 92, 35–44.CrossRefGoogle ScholarPubMed
Cohen, S and Williamson, GM (1988). Perceived Stress in a Probability Sample of the United States. Newbury Park, CA: Sage.Google Scholar
Comer, JS, Blanco, C, Hasin, DS, Liu, SM, Grant, BF, Turner, JB and Olfson, M (2011). Health-related quality of life across the anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions (NESARC). Journal of Clinical Psychiatry 72, 43–50.CrossRefGoogle ScholarPubMed
Cuijpers, P, Berking, M, Andersson, G, Quigley, L, Kleiboer, A and Dobson, KS (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 58, 376–385.CrossRefGoogle ScholarPubMed
Cuijpers, P, Donker, T, Van Straten, A, Li, J and Andersson, G (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine 40, 1943–1957.CrossRefGoogle ScholarPubMed
Danhof-Pont, MB, Van Veen, T and Zitman, FG (2011). Biomarkers in burnout: a systematic review. Journal of Psychosomatic Research 70, 505–524.CrossRefGoogle ScholarPubMed
De Zwart, BC, Frings-Dresen, MH and Van Duivenbooden, JC (2002). Test-retest reliability of the work ability index questionnaire. Occupational Medicine 52, 177–181.CrossRefGoogle ScholarPubMed
Di Nardo, PA, Moras, K, Barlow, DH, Rapee, RM and Brown, TA (1993). Reliability of dsm-iii-r anxiety disorder categories: using the anxiety disorders interview schedule – revised (adis-r). Archives of General Psychiatry 50, 251–256.CrossRefGoogle ScholarPubMed
Farchione, TJ, Fairholme, CP, Ellard, KK, Boisseau, CL, Thompson-Hollands, J, Carl, JR, Gallagher, MW and Barlow, DH (2012). Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior Therapy 43, 666–678.CrossRefGoogle ScholarPubMed
Fernandez, A, Mendive, JM, Salvador-Carulla, L, Rubio-Valera, M, Luciano, JV, Pinto-Meza, A, Haro, JM, Palao, DJ, Bellon, JA and Serrano-Blanco, A (2012). Adjustment disorders in primary care: prevalence, recognition and use of services. British Journal of Psychiatry 201, 137–142.CrossRefGoogle ScholarPubMed
Firth, N, Barkham, M and Kellett, S (2015). The clinical effectiveness of stepped care systems for depression in working age adults: a systematic review. Journal of Affective Disorders 170, 119–130.CrossRefGoogle ScholarPubMed
Foa, EB, Huppert, JD, Leiberg, S, Langner, R, Kichic, R, Hajcak, G and Salkovskis, PM (2002). The obsessive-compulsive inventory: development and validation of a short version. Psychological Assessment 14, 485–496.CrossRefGoogle ScholarPubMed
Foa, EB, Liebowitz, MR, Kozak, MJ, Davies, S, Campeas, R, Franklin, ME, Huppert, JD, Kjernisted, K, Rowan, V, Schmidt, AB, Simpson, HB and Tu, X (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry 162, 151–161.CrossRefGoogle ScholarPubMed
Fresco, DM, Coles, ME, Heimberg, RG, Liebowitz, MR, Hami, S, Stein, MB and Goetz, D (2001). The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats. Psychological Medicine 31, 1025–1035.CrossRefGoogle Scholar
Frisch, MB, Clark, MP, Rouse, SV, Rudd, MD, Paweleck, JK, Greenstone, A and Kopplin, DA (1992). Clinical validation of the quality of life inventory: a measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment 4, 92–101.CrossRefGoogle Scholar
Furmark, T, Holmström, A, Sparthan, E, Carlbring, P and Andersson, G (2013). Social Fobi: Effektiv Hjälp med Kognitiv Beteendeterapi. Stockholm: Liber.Google Scholar
Grossi, G, Perski, A, Osika, W and Savic, I (2015). Stress-related exhaustion disorder-clinical manifestation of burnout? A review of assessment methods, sleep impairments, cognitive disturbances, and neurobiological and physiological changes in clinical burnout. Scandinavian Journal of Psychology 56, 626–636.CrossRefGoogle ScholarPubMed
Gyani, A, Shafran, R, Layard, R and Clark, DM (2013). Enhancing recovery rates: lessons from year one of IAPT. Behaviour Research and Therapy 51, 597–606.CrossRefGoogle ScholarPubMed
Haug, T, Nordgreen, T, Öst, LG, Kvale, G, Tangen, T, Andersson, G, Carlbring, P, Heiervang, ER and Havik, OE (2015). Stepped care versus face-to-face cognitive behavior therapy for panic disorder and social anxiety disorder: predictors and moderators of outcome. Behaviour Research and Therapy 71, 76–89.CrossRefGoogle ScholarPubMed
Hedman, E, Andersson, G, Ljótsson, B, Andersson, E, Rück, C, Mörtberg, E and Lindefors, N (2011). Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: a randomized controlled non-inferiority trial. PloS ONE, 6, e18001.CrossRefGoogle ScholarPubMed
Hedman, E, Ljótsson, B, Kaldo, V, Hesser, H, El Alaoui, S, Kraepelien, M, Andersson, E, Rück, C, Svanborg, C, Andersson, G and Lindefors, N (2014). Effectiveness of internet-based cognitive behaviour therapy for depression in routine psychiatric care. Journal of Affective Disorders 155, 49–58.CrossRefGoogle ScholarPubMed
Hedman, E, Ljótsson, B, Rück, C, Bergstrom, J, Andersson, G, Kaldo, V, Jansson, L, Andersson, E, Andersson, E, Blom, K, El Alaoui, S, Falk, L, Ivarsson, J, Nasri, B, Rydh, S and Lindefors, N (2013). Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica 128, 457–467.CrossRefGoogle ScholarPubMed
Henderson, M, Harvey, SB, Overland, S, Mykletun, A and Hotopf, M (2011). Work and common psychiatric disorders. Journal of the Royal Society of Medicine 104, 198–207.CrossRefGoogle ScholarPubMed
Hiller, W, Schindler, AC and Lambert, MJ (2012). Defining response and remission in psychotherapy research: a comparison of the RCI and the method of percent improvement. Psychotherapy Research 22, 1–11.CrossRefGoogle ScholarPubMed
Hofmann, SG, Asnaani, A, Vonk, IJ, Sawyer, AT and Fang, A (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research 36, 427–440.CrossRefGoogle ScholarPubMed
Houck, PR, Spiegel, DA, Shear, MK and Rucci, P (2002). Reliability of the self-report version of the panic disorder severity scale. Depression and Anxiety 15, 183–185.CrossRefGoogle ScholarPubMed
Jacobson, NS and Truax, P (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.CrossRefGoogle ScholarPubMed
Jernelöv, S (2008). Sov Gott!: Råd och Tekniker Från KBT. Stockholm: Wahlström & Widstrand.Google Scholar
Kaldo, V, Jernelöv, S, Blom, K, Ljótsson, B, Brodin, M, Jorgensen, M, Kraepelien, M, Rück, C and Lindefors, N (2015). Guided internet cognitive behavioral therapy for insomnia compared to a control treatment – a randomized trial. Behaviour Research and Therapy 71, 90–100.CrossRefGoogle ScholarPubMed
Kessler, RC, Berglund, P, Demler, O, Jin, R, Merikangas, KR and Walters, EE (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry 62, 593–602.CrossRefGoogle ScholarPubMed
Koopmans, PC, Bultmann, U, Roelen, CA, Hoedeman, R, Van Der Klink, JJ and Groothoff, JW (2011). Recurrence of sickness absence due to common mental disorders. International Archives of Occupational and Environmental Health 84, 193–201.CrossRefGoogle ScholarPubMed
Kroenke, K, Spitzer, RL and Williams, JB (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16, 606–613.CrossRefGoogle ScholarPubMed
Layard, R, Clark, D, Knapp, M and Mayraz, G (2007). Cost-benefit analysis of psychological therapy. National Institute Economic Review 202, 90–98.CrossRefGoogle Scholar
Layard, R and Clark, DM (2014). Thrive: The Power of Psychological Therapy. London: Penguin Books Ltd.Google Scholar
Lejuez, CW, Hopko, DR, Acierno, R, Daughters, SB and Pagoto, SL (2011). Ten year revision of the brief behavioral activation treatment for depression: revised treatment manual. Behavior Modification 35, 111–161.CrossRefGoogle ScholarPubMed
Loerinc, AG, Meuret, AE, Twohig, MP, Rosenfield, D, Bluett, EJ and Craske, MG (2015). Response rates for CBT for anxiety disorders: need for standardized criteria. Clinical Psychology Review 42, 72–82.CrossRefGoogle ScholarPubMed
Melamed, S, Kushnir, T and Shirom, A (1992). Burnout and risk factors for cardiovascular diseases. Behavioral Medicine 18, 53–60.CrossRefGoogle ScholarPubMed
Meyer, TJ, Miller, ML, Metzger, RL and Borkovec, TD (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy 28, 487–495.CrossRefGoogle ScholarPubMed
Morin, CM (1993). Insomnia: Psychological Assessment and Management. New York: The Guilford Press.Google Scholar
Morin, CM and Benca, R (2012). Chronic insomnia. Lancet 379, 1129–1141.CrossRefGoogle ScholarPubMed
Murphy, LR (1996). Stress management in work settings: a critical review of the health effects. American Journal of Health Promotion 11, 112–135.CrossRefGoogle ScholarPubMed
National Collaborating Centre for Mental Health (2009). Depression: The Treatment and Management of Depression in Adults: NICE Clinical Guideline 90 [Online]. London: The National Institute for Health and Clinical Excellence. Available at https://www.nice.org.uk/guidance/cg90 (Accessed 7 July 2017).Google Scholar
National Institute for Health and Clinical Excellence [Nice] (2011). Common Mental Health Disorders: Identification and Pathways to Care – Clinical Guideline [Online]. Leicester, UK: National Institute for Health and Clinical Excellence. Available at https://www.nice.org.uk/guidance/cg123 (Accessed 27 June 2017).Google Scholar
Nordgreen, T, Haug, T, Öst, LG, Andersson, G, Carlbring, P, Kvale, G, Tangen, T, Heiervang, E and Havik, OE (2016). Stepped care versus direct face-to-face cognitive behavior therapy for social anxiety disorder and panic disorder: a randomized effectiveness trial. Behavior Therapy 47, 166–183.CrossRefGoogle ScholarPubMed
OECD (2012). Sick on the Job? Paris: OECD Publishing.Google Scholar
Ohayon, MM (2002). Epidemiology of insomnia: what we know and what we still need to learn. Sleep Medicine Reviews 6, 97–111.CrossRefGoogle ScholarPubMed
Öst, L-G (1987). Applied relaxation: description of a coping technique and review of controlled studies. Behaviour Research and Therapy 25, 397–409.CrossRefGoogle ScholarPubMed
Öst, L-G (2006). Applied Relaxation: Manual of A Behavioral Coping-Strategy. Stockholm: Lars-Göran Öst.Google Scholar
Öst, L-G (2008). Cognitive behavior therapy for anxiety disorders: 40 years of progress. Nordic Journal of Psychiatry 47, 5–10.CrossRefGoogle Scholar
Pilling, S, Mayo-Wilson, E, Mavranezouli, I, Kew, K, Taylor, C and Clark, DM (2013). Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance. BMJ 346, f2541.CrossRefGoogle ScholarPubMed
Seekles, W, Van Straten, A, Beekman, A, Van Marwijk, H and Cuijpers, P (2011). Stepped care treatment for depression and anxiety in primary care. A randomized controlled trial. Trials 12, 171.CrossRefGoogle ScholarPubMed
Shafran, R, Clark, DM, Fairburn, CG, Arntz, A, Barlow, DH, Ehlers, A, Freeston, M, Garety, PA, Hollon, SD, Ost, LG, Salkovskis, PM, Williams, JM and Wilson, GT (2009). Mind the gap: improving the dissemination of CBT. Behaviour Research and Therapy 47, 902–909.CrossRefGoogle Scholar
Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E, Hergueta, T, Baker, R and Dunbar, GC (1998). The mini-international neuropsychiatric interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 20, 22–33.Google Scholar
Soderstrom, M, Jeding, K, Ekstedt, M, Perski, A and Akerstedt, T (2012). Insufficient sleep predicts clinical burnout. Journal of Occupational Health Psychology 17, 175–183.CrossRefGoogle ScholarPubMed
Svanborg, P and Asberg, M (1994). A new self-rating scale for depression and anxiety states based on the comprehensive psychopathological rating scale. Acta Psychiatrica Scandinavica 89, 21–28.CrossRefGoogle ScholarPubMed
The National Board of Health and Welfare (2003). Utmattningssyndrom. Stressrelaterad Psykisk Ohälsa. [Exhaustion Syndrome. Stress Related Mental Illness] (in Swedish). Stockholm: National Board of Health and Welfare.Google Scholar
The Swedish Social Insurance Agency (2014). Social Insurance Report 2014:4. Stockholm: DanagårdLiTHOGoogle Scholar
Tolin, DF, Diefenbach, GJ and Gilliam, CM (2011). Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs. Depression and Anxiety 28, 314–323.CrossRefGoogle ScholarPubMed
Van Der Klink, JJ, Blonk, RW, Schene, AH and Van Dijk, FJ (2001). The benefits of interventions for work-related stress. American Journal of Public Health 91, 270–276.Google ScholarPubMed
Van Straten, A, Hill, J, Richards, DA and Cuijpers, P (2015). Stepped care treatment delivery for depression: a systematic review and meta-analysis. Psychological Medicine 45, 231–246.CrossRefGoogle ScholarPubMed
Wells, KB, Stewart, A, Hays, RD, Burnam, MA, Rogers, W, Daniels, M, Berry, S, Greenfield, S and Ware, J (1989). The functioning and well-being of depressed patients. Results from the medical outcomes study. JAMA 262, 914–919.CrossRefGoogle ScholarPubMed
Wolitzky-Taylor, K, Zimmermann, M, Arch, JJ, De Guzman, E and Lagomasino, I (2015). Has evidence-based psychosocial treatment for anxiety disorders permeated usual care in community mental health settings? Behaviour Research and Therapy 72, 9–17.CrossRefGoogle ScholarPubMed
Zigmond, AS and Snaith, RP (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica 67, 361–370.CrossRefGoogle ScholarPubMed
Supplementary material: File

Salomonsson et al supplementary material 1

Salomonsson et al supplementary material

Download Salomonsson et al supplementary material 1(File)
File 19.4 KB