Clinical Psychology Unit, University of Sheffield, Western Bank, Sheffield S10 2TN, UK.
Centre for Psychological Services Research, University of Sheffield, Western Bank, Sheffield S10 2TN, UK.
J Affect Disord. 2015 Jan 1;170:119-30. doi: 10.1016/j.jad.2014.08.030. Epub 2014 Aug 27.
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.
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.
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).
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.
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.
阶梯式护理服务模式涉及通过连续步骤逐渐增强的治疗方法，患者通过预先定义的决策标准重新分配。本文综述了针对工作年龄成年人抑郁症的阶梯式护理系统的临床效果。
对符合特定标准的 14 项对照和非对照研究进行了定量临床结果证据的系统文献回顾。主要结果是(a)恢复率，定义为不再符合特定结局测量临床截止标准的患者，和(b)治疗反应率，定义为结局测量评分降低 50%。
阶梯式护理系统的恢复率主要在 40%至 60%之间，反应率接近 60%。将阶梯式护理与常规/增强常规护理进行比较的研究往往发现有利于阶梯式护理的显著差异。恢复优势比的中位数为 1.31（四分位间距 1.05 和 1.66；k=7 项研究）。比较性 Cohen's d 效应量估计值的中位数为 0.41（四分位间距 0.25 和 0.45；k=5 项研究）。
纳入非对照研究可能被视为降低了总体证据质量，并且由于可用数据的限制，未进行荟萃分析。
证据表明，针对抑郁症的阶梯式护理干预至少与常规护理一样有效。然而，阶梯式护理的临床和组织优势尚未得到科学验证。阶梯式护理的差异化益处最终可能取决于服务质量。需要进一步研究以调查和比较阶梯式护理干预的具体组成部分和配置。
