Effectiveness of stepped versus usual care for mental health service delivery: a systematic review and meta-analysis

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Abstract

BACKGROUND: Stepped models of care provide a sequential approach in the treatment of mental health conditions, with the level of care prescribed varying in intensity according to the severity of mental health concern for the individual. This systematic review and meta-analysis evaluate the effectiveness of stepped care compared to usual care for mental health-related clinical outcomes, quality of life, cost-effectiveness and satisfaction across mental health conditions. METHODS: A systematic literature search across eight databases (February 2024) identified randomised controlled trials of stepped care models for diagnosed mental health conditions. Standardised mean differences (SMDs), risk ratios (RR) and 95% confidence intervals (CIs) were calculated using random effects models. Effect sizes were interpreted using Cohen's d (d < 0.5; small, 0.5 < d < 1.2; medium and d > 1.2; large). RESULTS: Forty-one studies were eligible and 31 included in the meta-analyses. Stepped care showed large and statistically significant effects from baseline to post-treatment that was greater when compared to usual care for mental health-related quality of life and PTSD symptoms (SMD [95% CI] 3.13 [2.08 to 4.18] and 1.39 [0.61 to 2.17], respectively). Further, compared to usual care, stepped care had an increased likelihood of depression remission (RR [95% CI] 1.64 [1.24 to 2.16]) and response (RR [95% CI] 1.78 [1.35 to 2.35]). For general health-related quality of life, stepped care showed a statistically significant, medium effect from baseline to post-treatment compared to usual care (SMD [95% CI] 0.62 [0.19 to 1.06]). From baseline to post-treatment, stepped care showed medium, but non-significant improvements for depression and anxiety (SMD [95% CI] 0.73 [-0.26 to 1.72] and 0.92 [-0.20 to 2.03], respectively) when compared to usual care. There were no significant differences in direct costs (MD [95% CI] 195.16 [-137.96 to 528.28], however, indirect costs were significantly lower with stepped care (MD [95% CI] -962.19 [-1412.55 to -511.83]). CONCLUSIONS: Stepped care demonstrates better outcomes than usual care and is more cost-effective for indirect costs. Future research should standardise and compare outcomes, populations, and conditions to ensure meaningful results and reduce heterogeneity. More research is needed to develop personalised stepped care models.

Abstract as published, via PubMed.