Delgadillo2022 - Stratified Care vs Stepped Care for Depression, A Cluster Randomized Clinical Trial

  • Type:#article
  • Date read: 2022-10-28
  • Subject: Depression
  • Bibtex: @delgadillo2022
  • Bibliography: Delgadillo, J., Ali, S., Fleck, K., Agnew, C., Southgate, A., Parkhouse, L., Cohen, Z. D., DeRubeis, R. J., & Barkham, M. (2022). Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial. JAMA Psychiatry, 79(2), 101–108.

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Key takeaways

  • Two treatment selection strategies: stepped care and stratified care
    • Stratified care selection was based on machine-learning algorithm
    • Input into ML algorithm: PHQ-9, GAD-7, WSAS, personality, demographics
    • “Poor expected prognosis” get high-intensity right away
  • Low-intensity care is 8 30min sessions with a PWP. High-intensity care is up to 20 1 hour sessions with HI-CBT.
    • But high-intensity interventions were messy and included a bunch of things like EMDR, experiential counseling.
    • “Consistent with the pragmatic trial design, we did not record, monitor, or modify these interventions in any way to preserve the integrity of routinely delivered psychological care”
  • Randomization per therapist, so 15 therapists in each arm
  • Logistic regression on proportion of clinically significant improvement, full CEA analysis
  • n = 951
  • Proportion improved 52.3% in stratified care, 45.1% in stepped care. OR = 1.40 (95% CI 1.02 - 1.87).
    • In their power calculation they expected an OR of 2.2 but wanted to have power for the complex cases too (expected to be 30% of sample). So they powered for 760 cases. Why did they end up with 951, seems like a very big overshoot? And the significance is just beyond the threshold…
  • Higher cost for stratified care because 57% received high intensity treatment right away, versus 29.1% in stepped-care group.
  • Their strengths of stratified care
    • Improved outcomes through personalized treatment selection
    • Feasibility to implement the model (high adherence)
    • More efficient clinician assessments compared to stepped-care

Author conclusion:

In this cluster randomized clinical trial of adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms compared with stepped care. Stratified care can improve depression treatment outcomes at a modest additional cost.

So they are seeing that stratified care is likely more expensive since not all patients in stepped-care need high-intensity trt, but they argue that it gets better results. What do I believe will be true for BDD? Stepped-care likely to be pretty good since we have the BDD-NET.