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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
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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 

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