Stepped care for depression in primary care: what should be offered and how

* Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. * In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. * We deliver a stepped-care model targeting patients with depression. o The first step consists of “watchful waiting”, as half of all patients with a depressive episode recover spontaneously within 3 months. o The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. o The third step consists of brief face-to-face psychotherapy. o Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. * Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. * The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. * Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model