Department of Clinical Neuroscience,Division of Psychology,Karolinska Institutet,Stockholm,Sweden.
Department of Neurobiology,Care Sciences and Society (NVS),H1, Division of Family Medicine,Karolinska Institutet,Stockholm,Sweden.
Psychol Med. 2018 Jul;48(10):1644-1654. doi: 10.1017/S0033291717003129. Epub 2017 Nov 2.
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.
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.
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%.
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.
常见精神障碍（CMD）会导致巨大的痛苦和高昂的社会成本。认知行为疗法（CBT）可以有效地治疗 CMD，但获得治疗的机会不足。指导性自助（GSH）CBT 已显示出与面对面 CBT 相当的效果。然而，并非所有患者对 GSH 有反应，将无反应者升级为面对面 CBT，可能会产生更高的反应率。目的是通过首先评估 GSH-CBT 的效果，其次对于无反应者，评估面对面 CBT 的额外效果，来检验初级保健中 CMD 的分级护理模式。
连续纳入了 396 名患有主要抑郁、焦虑、失眠、适应不良或衰竭障碍的患者。在第 I 步中，所有患者均接受 GSH-CBT。在第 II 步中，无反应者被随机分配到面对面 CBT 或继续 GSH。主要结局是缓解状态，定义为在经过验证的特定疾病量表上的得分低于预先设定的截止值。
在第 I 步的 GSH-CBT 后，40%的患者缓解。在第 II 步后，接受面对面 CBT 的患者中有 39%缓解，而继续 GSH 的患者中有 19%缓解（p=0.004）。使用这种分级护理模式，每位患者需要的治疗次数少于六次，总体缓解率达到 63%。
在初级保健中，分级护理可以有效地治疗 CMD，并且资源效率高，利用有限的治疗师资源可以达到高缓解率。与继续 GSH 相比，面对面 CBT 可加快恢复。在 6 个月和 12 个月的随访中，两组的缓解率相似。
