title: The clinical effectiveness of stepped care systems for depression in working age adults: a systematic review.
abstract: BACKGROUND
  Stepped care service delivery models involve treatments that become increasingly intense through successive steps, with patients re-assigned via pre-defined decision criteria. This article reviews the clinical effectiveness of stepped care systems for depression in working age adults.
  
  
  METHODS
  Systematic literature review of quantitative clinical outcome evidence comprising 14 controlled and uncontrolled studies meeting specified criteria. Principal outcomes were (a) recovery rates, defined as patients no longer meeting clinical cut-off criteria for the specific outcome measure and (b) treatment response rates, defined as a 50% decrease in outcome measure score.
  
  
  RESULTS
  Stepped care systems had recovery rates ranging predominantly between 40% and 60% and response rates approximating 60%. Studies comparing stepped care with usual/enhanced usual care tended to find significant differences favouring stepped care. The median recovery odds ratio was 1.31 (interquartile intervals of 1.05 and 1.66; k=7 studies). The median comparative Cohen's d effect size estimate was 0.41 (interquartile intervals 0.25 and 0.45; k=5 studies).
  
  
  CONCLUSIONS
  The inclusion of uncontrolled studies could be seen as reducing the overall quality of evidence and a meta-analysis was not included due to limitations with the available data.
  
  
  CONCLUSIONS
  Evidence suggested that stepped care interventions for depression are at least as effective as usual care. However, the clinical and organisational superiority of stepped care is yet to be scientifically verified. Differential benefits of stepped care may ultimately depend on service quality. Further research investigating and comparing the specific components and configurations of stepped care interventions are indicated.
authors.affiliation: Clinical Psychology Unit, University of Sheffield, Western Bank, Sheffield S10 2TN, UK. Electronic address: nick.firth@gmail.com.
authors.forename: Nick
authors.initials: N
authors.lastname: Firth
authors.affiliation: Centre for Psychological Services Research, University of Sheffield, Western Bank, Sheffield S10 2TN, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Barkham
authors.affiliation: Centre for Psychological Services Research, University of Sheffield, Western Bank, Sheffield S10 2TN, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Kellett
mesh_terms: D000328:Adult; D000367:Age Factors; D003863:Depression / Q000628:therapy*; D004651:Employment; D006801:Humans; D011613:Psychotherapy / Q000379:methods*; D016896:Treatment Outcome
keywords: Depression; Effectiveness; Intervention; Review; “Stepped Care”; “Stepped-Care”