Stepped care for the treatment of depression: a systematic review and meta-analysis

The Stepped Care Model (SCM) proposes a sequential approach in the treatment of depression, applying interventions of increasing intensity according to the level of severity of the individual.

A systematic review was carried out until January 2020 in eight electronic databases. We included randomized (RCT) and non-randomized controlled trials comparing the SCM to usual non-sequential care.

Eighteen RCT with patients with confirmed or probable depression diagnosis were included. Meta-analyses yielded high heterogeneity, and subgroup analyses showed significant effects of the SCM only in studies with baseline moderately severe symptoms on average, compared to samples with mild/moderate depression. In the former subgroup, effects at 3-6 and 9-12 months were small for symptoms' reduction (g = -0.33, 95%CI: -0.55, -0.17 and -0.34, 95%CI: -0.53, -0.16) and moderate-to-strong in response and remission (Risk Ratios between 1.70-1.90). Overall, a significant benefit on quality of life was also observed (6 months: g = 0.31, 95%CI: 0.12, 0.49; 12 months: g = 0.18, 95%CI: 0.06, 0.31). More patients in the SCM groups were prescribed antidepressants at 6 months (RR = 1.31, 95%CI: 1.09, 1.57; I² = 87%).

The search does not guarantee the identification of all the relevant literature. Most included studies show uncertain or high risk of bias.

The SCM seems to outperform usual care in populations with at least moderately severe symptoms on average. Results show high heterogeneity and future research should explore its sources.