Stepped care is conceptual approach to healthcare that is driven primarily by economics. In essence it starts with the cheapest and simplest intervention and then you work your way through more and more expensive interventions. At each stage it is hoped that large proportions of the anxious and depressed are cured leaving only the difficult where potentially the really expensive treatment options can be explored.
It is relatively intuitive solution and assumes that the ability to ‘cure’ someone does not decrease over time. That is no harm comes to the patient if you spends months treating someone with a less effective treatment. Stepped care can be flexible or inflexible. Steps maybe based on risk or a time period, with time dependencies the least flexible.
The study completed in 2012 treated 185 aged care residents using stepped care or standard treatment. In this study there were 4 steps and the four steps were:
1. Watchful waiting of one month
2. Activity scheduling (doing fun stuff in the context of a CBT program)
3. Life review and consultation with a GP
4. Visit GP for additional support
There are multiple factors that make such an intervention difficult to interpret.
(a) In aged care the person is in a context where control over your environment is reduced. Individuals frequently have long term worsening medical conditions that can impact mood and so the affected person can be affected by long term, life threatening and painful events that may respond poorly to minor interventions.
(b) The aged care facility itself should be providing a high baseline level of care and the additional measures above that may not be of measurable worth.
(c) Short term treatment interventions performed by a GP may not be the ideal strategy for patients with cognitive deficits.
(d) One of the additional issues with this study is the role of a strong authority figure (GP) which may have positively influenced the outcome.
The study found that it demonstrated improvements in depression but made anxiety worse. These results raise three important questions
1. What was the baseline level of ‘standard care’ in the aged care facility. If the facility were to engage in very high levels of resident activity engagement would the depression have emerged in the first place?
2. Are GPs best placed to provide anxiety treatment over the timespan required?
3. Was the treatment program adequate to address anxiety for people who are aged care residents?
Contradictory effects for prevention of depression and anxiety in residents in homes for the elderly: a pragmatic randomized controlled trial Dozeman, Els; van Marwijk, Harm W J; van Schaik, Digna J F; Smit, Filip; Stek, Max L; van der Horst, Henriëtte E; Bohlmeijer, Ernst T; Beekman, Aartjan T F . International Psychogeriatrics, suppl. Focus on late life depression ; Cambridge Vol. 24, Iss. 8, (Aug 2012): 1242-51.