Stepped care treatment for depression and anxiety in primary care. a randomized controlled trial

BACKGROUND Depressive and anxiety disorders are common in general practice but not always treated adequately. Introducing stepped care might improve this. In this randomized trial we examined the effectiveness of such a stepped care model. METHODS The study population consisted of primary care attendees aged 18-65 years with minor or major DSM-IV depressive and/or anxiety disorders, recruited through screening. We randomized 120 patients to either stepped care or care as usual. The stepped care program consisted of (1) watchful waiting, (2) guided self-help, (3) short face-to-face problem solving treatment and (4) pharmacotherapy and/or specialized mental health care. Patients were assessed at baseline and after 8, 16 and 24 weeks. RESULTS Symptoms of depression and anxiety decreased significantly over time for both groups. However, there was no statistically significant difference between the two groups (IDS: P = 0.35 and HADS: P = 0.64). The largest, but not significant, effect (d = -0.21) was found for anxiety on T3. In both groups approximately 48% of the patients were recovered from their DSM-IV diagnosis at the final 6 months assessment. CONCLUSIONS In summary we could not demonstrate that stepped care for depression and anxiety in general practice was more effective than care as usual. Possible reasons are discussed. TRIAL REGISTRATION Current Controlled Trails: ISRCTN17831610.