Stratified care improves depression treatment outcomes at small cost
Stratified care correlated with better depression outcomes compared with stepped care among adults with common mental disorders, according to results of a cluster randomized clinical trial published in JAMA Psychiatry.
“Recent studies have indicated that stratified care has potential to improve the effectiveness of psychological care for depression,” Jaime Delgadillo, PhD, of the department of psychology at the University of Sheffield in the U.K., and colleagues wrote. “However, most of these studies draw their conclusions from post hoc analyses of retrospective data, and the only prospective study was underpowered to test its primary hypothesis. Rigorous and adequately powered experimental studies are necessary to determine whether stratified care may be an effective and affordable way to organize psychological interventions.”
To address this research gap, the researchers compared the clinical effectiveness and cost-effectiveness of stepped care and stratified care among 951 participants (65.1% women; mean age, 38.27 years) recruited via the English National Health Service between July 5, 2018, and Feb. 1, 2019. They randomly assigned clinicians who worked across four psychological therapy services to provide stratified (n = 15) or stepped (n = 15) care, with the former involving patients being matched with low- or high-intensity treatments at initial assessment and the latter involving patients sequentially accessing low-intensity guided self-help followed by high-intensity psychotherapy.
Interventions involved the same interview schedule for initial assessment of patients who sought psychological treatment for common mental disorders; however, a machine learning algorithm generated a personalized treatment recommendation for each patient in the stratified care group. Posttreatment reliable and clinically significant improvement (RCSI) of depression symptoms, assessed via the nine-item Patient Health Questionnaire, served as the main outcomes and measures. The researchers used logistic regression adjusted for baseline severity to compare the RCSI outcome between groups and cost-effectiveness analyses to compare incremental costs and health outcomes between the forms of care.
Results showed a significantly higher proportion of cases of RCSI among the stratified care group compared with the stepped care group (52.3% vs. 45.1%, respectively; OR = 1.4; 95% CI, 1.04-1.87). Delgadillo and colleagues noted an association between stratified care and higher mean additional cost per patient ($139.83; 95% CI, $90.32-$189.48) because more patients accessed high-intensity treatments (56.9% vs. 29.1%); however, the additional cost led to an approximately 7% increase in RCSI probability.
“Overall, the present findings indicate that stratified care is feasible to implement in routine [Improving Access to Psychological Therapies] services, improving the efficiency and precision of psychological assessments in a way that preserves shared decision-making,” the researchers wrote. “Implementation of stratified care resulted in better depression treatment outcomes albeit with an additional cost per treatment.”