Stepped Care: A Definitive Quenza™ Guide

Cost-effective, high-quality therapy for more individuals who need it sounds idyllic to most practitioners. But in practice, it can be hard to achieve – especially on a societal, national, or even global scale.

Stepped Care Models offer a potential way for overburdened healthcare systems to address the mental healthcare requirements of individuals on a broader scale, through the strategic design of relevant treatments and how they will be delivered.

In this article, we’ll introduce the Stepped Care model and consider its applications in the field of mental health.

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What is Stepped Care?

In the field of mental healthcare, the Stepped Care Model is a service delivery framework designed to bridge the gap between a high existing need for psychological solutions and their available supply.

It is commonly applied within public healthcare systems, where scarce resources and organizational funding often result in many mental health conditions going untreated.[1]

What Does It Look Like?

To overcome this problem, Stepped Care Models aim to deliver general and mental healthcare solutions to as many individuals as require it by implementing a ‘tiered’ approach:[2][3]

• Each ‘tier’ involves treatments of differing resource intensity: In Stepped Care Models, the lowest-intensity step encompasses interventions requiring fewer resources, e.g. therapist expertise or one-on-one therapy time.
• Lower intensity services are recommended to individuals with less intensive treatment needs. Patients or individuals with sub-threshold or sub-clinical symptoms that can be successfully managed and treated through low-intensity interventions are treated here. Individuals with mild depressive symptoms in lower steps, for instance, may be offered interventions such as self-help resources, psychoeducation, or they may be placed on a ‘watch and wait’ list.
• Higher intensity services are more appropriate for patients with more severe conditions, or where lower-intensity interventions are not successful. Examples might include medication or frequent, regular specialist therapeutic interventions.

Bower and Gilbody’s diagram below shows the Stepped Care model paradigm.[2]

Principles of Stepped Care

In order to ensure as many individuals as possible can access quality mental healthcare solutions, Stepped Care models are guided by two principles:[2]

1. Recommended treatments should be the least restrictive of those offered, while still appropriate to promote positive health outcomes, and
2. The outcomes of interventions and decisions are routinely assessed so that patients can be referred up or down as required. As such, they are considered ‘self-correcting.’[4]

In the next section, we’ll take a closer look at some of the model’s common applications.

Therapeutic Stepped Care Models

For an even better idea of what Stepped Care looks like in mental healthcare, this section considers two therapeutic frameworks.

Stepped Care in CBT

Cognitive Behavioral Therapy (CBT), an established framework for the treatment of mental health conditions like depression and anxiety, can integrate a tiered approach to ensure more cost-effective use of scarce healthcare resources.[5]

The image below illustrates how five separate tiers can be identified, each corresponding to a different ‘step’ in the framework:

• Self-administered CBT (Step 1), considered a minimal intervention[2]
• Brief, small group, trained therapist-delivered CBT (Step 2), a slightly more resource-intensive psychological treatment
• Individual or small group, graduate psychologist-delivered CBT (Step 3)
• Tailored one-on-one CBT programs administered by a clinical psychologist (Step 4), and
• The most resource-intensive treatments – Expert CBT programs delivered by a Behavioral Sleep Medicine specialist (Step 5)

Within this framework, proposed by Espie as an approach to insomnia treatment, patients are allocated resources in relation to their assessed need.

At the bottom, the majority of patients are managed with self-administered cognitive-behavioral treatments such as iCBT:

We’ve used online therapy app Quenza to demonstrate what a typical low-intensity iCBT treatment might look like. Here, a client would be learning iCBT fundamentals such as cognitive restructuring techniques on their mobile.

Step 5 represents the use of higher intensity CBT tools with the smallest category of insomnia patients.

Individuals are referred up or down the model as required on the basis of healthcare assessments.

The IAPT Initiative

The UK’s Improving Access to Psychological Therapies (IAPT) initiative provides another good illustration of the Stepped Care model in practice.

Established in 2008 by the British National Health Service (NHS), the program delivers conventional and e-mental health services to the British public and reaches at least 1 million individuals annually.[6][7]

As the diagram above shows, the IAPT Stepped Care model operates on a 3-tier framework:

• Primary Care Interventions (Step 1): Individuals who don’t fulfill IAPT intervention requirements, but can still benefit from primary care, fall into this band. They may undergo psychological wellbeing assessments for mental health symptoms, be referred to psychoeducational resources, or signposted within the public health system.
• IAPT Low-Intensity Service Lead Interventions (Step 2): Individuals in this tier meet the IAPT criteria for the program’s less intensive solutions, such as therapist-supported self-help interventions. Examples include graded exposure, CBT techniques such as cognitive restructuring, or behavioral activation.
• IAPT High-Intensity Service Lead Interventions (Step 3): This category corresponds to the most urgent tier, in which individuals, couples, or groups are recommended for more comprehensive treatments, such as one-to-one, in-person CBT with a therapist, couples counseling, EMDR, interpersonal therapy, and depression counseling.

The IAPT Stepped Care model integrates both traditional and telehealth solutions, which enables the public healthcare system to deliver evidence-based treatments at a high standard to a hugely broad population.

Remote therapy solutions such as e-counseling and video therapy often play important roles as lower-intensity treatments in Stepped Care models.

Pros and Cons of Stepped Care

As we have seen, Stepped Care Models are commonly implemented as a way to make treatments more accessible to those living with health and mental health conditions, through the more efficient use of organizational or governmental resources.

Whether this translates in practice, however, may depend on the particular conditions in question, as well as the treatments involved. Because no consensus yet exists on the structure of Stepped Care Models for different disciplines and health conditions, there may be no clear answer. At the very least, researchers argue, more studies are needed.

Additionally, cost-effectiveness is only one element in determining whether a framework is successful overall – its effectiveness and patient impact are also vital elements to consider when evaluating the pros and cons of Stepped Care.

Is It Effective?

Stepped Care Models have shown some promise as effective treatments for several mental health conditions.

Most recently, researchers have examined its efficacy in treating individuals with anxiety- and depression-related symptoms in a meta-analysis, which examined the results of 10 randomized controlled trials side by side.

Looking at both prevention and treatment frameworks, they found the following:[9]

• Anxiety: With data revealing that Stepped Care treatments performed slightly better than conventional treatments in reducing anxiety symptoms. Patients also showed a significantly higher treatment response rate, but there was no significant difference between the models when it came to how well they helped patients prevent anxiety.
• Depression: In the same study, Ho and colleagues found no significant difference between traditional and Stepped Care Models when it came to improving depressive symptoms, suggesting that both CAU and a stepped approach had similar health outcomes for depressed patients.

The Role of Technology

One particularly important component of Stepped Care Models is that many low-intensity therapeutic treatments include self-administered psychotherapy treatments.

These ‘minimal interventions’ often leverage digital technologies such as mental health apps, online psychoeducational resources, and self-administered therapies such as iCBT to help patients and individuals self-manage less severe symptoms at lower tiers of the framework. Besides iCBT, they can cover a wide scope of treatments, such as exposure, narrative, or mindfulness-based therapies:

These will generally be designed by therapists before being subject to a review process, then ultimately designed and delivered using specialized e-therapy technology. Here, we used mental health app Quenza.

By design, this approach allows more patients to access demonstrated, science-based treatments in a cost-effective way while keeping both organizational and patient costs to a minimum.

Some Stepped Care Models, such as the IAPT initiative introduced earlier, also research and develop online therapies that are integrated into the existing framework, which can be self- or therapist-guided at different ‘steps’ of the model.

In a similar vein, remote therapy solutions such as e-counseling and video therapy often play an important role as lower-intensity treatments within many e-mental health Stepped Care systems.

Final Thoughts

Given the high global demand for quality mental healthcare in increasingly overburdened systems around the world, Stepped Care frameworks are becoming ever more prevalent. The promise of more accessible, yet effective science-based treatments on a wider scale mean that as it is implemented on a broader scale, we are sure to see more studies into its efficacy, cost-effectiveness, and patient outcomes.

For now, some gray areas still exist. One thing that remains clear, however, is that Stepped Care Models are a great example of how blended care solutions can play a critical role in facilitating more affordable, wide-reaching treatments at a societal – if not global – level.

Is your goal to enhance the mental health and wellbeing of others? To start delivering stepped care solutions online, don’t forget to start your Quenza trial.

Our software will give you all the tools you need to design, build, and implement your online stepped care solutions, so you can further improve the lives and wellbeing of those you help.

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