Stepped Care Model Research Articles

A COLLABORATIVE, INTEGRATIVE MENTAL HEALTH APPROACH: "THE STEPPED CARE MODEL.

Dear Editor, In this paper, it is aimed to raise awareness about the stepped care model as an approach in the organization of mental health services related to the protection, development, care and treatment of mental health. Concerning mental health, World Health Organization emphasizes that "Mental Health is more than mental disorders. It is a state of well-being that includes using one's own abilities, self-realization, coping with the stresses in the natural flow of life, learning to be well and trying to heal, working efficiently and contributing to the society in which they live." (World Health Organization 2022a). It has been reported that the disease burden of common mental disorders (depression, anxiety, post-traumatic stress disorder, psychoactive substance use disorders, suicide, etc.) is gradually increasing (World Health Organization 2021). Especially in the last century, the importance and seriousness of endemic and pandemic events (HIV, SARS virus, and still continuing Covid-19, etc.) or non-communicable diseases (cancer, heart diseases, diabetes, etc.), climate changes, economic, socio-political dynamics and wars are noteworthy as a predisposition and/or precipitating factors in terms of mental health (World Health Organization 2022a, World Health Organization 2022b). Protection and improvement of mental health, together with individual, social, and structural mental health determinants, predict interventions that reduce risks, increase resilience, and create a supportive environment for mental health. These interventions are recommended to be designed individually, in a way to be disseminated to special groups across the community. Globally, one person dies by suicide every 40 seconds, and more than 18 million health workers are needed in terms of human resources.

Care pathways for people with major depressive disorder: a European Brain Council Value of Treatment study.

AbstractBackgroundDespite well-established guidelines for managing major depressive disorder, its extensive disability burden persists. This Value of Treatment mission from the European Brain Council aimed to elucidate the nature and extent of “gaps” between best-practice and current-practice care, specifically to:1.Identify current treatment gaps along the care pathway and determine the extent of these gaps in comparison with the stepped-care model and2.Recommend policies intending to better meet patient needs (i.e., minimize treatment gaps).MethodsAfter agreement upon a set of relevant treatment gaps, data pertaining to each gap were gathered and synthesized from several sources across six European countries. Subsequently, a modified Delphi approach was undertaken to attain consensus among an expert panel on proposed recommendations for minimizing treatment gaps.ResultsFour recommendations were made to increase the depression diagnosis rate (from ~50% episodes), aiming to both increase the number of patients seeking help, and the likelihood of a practitioner to correctly detect depression. These should reduce time to treatment (from ~1 to ~8 years after illness onset) and increase rates of treatment; nine further recommendations aimed to increase rates of treatment (from ~25 to ~50% of patients currently treated), mainly focused on targeting the best treatment to each patient. To improve follow-up after treatment initiation (from ~30 to ~65% followed up within 3 months), seven recommendations focused on increasing continuity of care. For those not responding, 10 recommendations focused on ensuring access to more specialist care (currently at rates of ~5–25% of patients).ConclusionsThe treatment gaps in depression care are substantial and concerning, from the proportion of people not entering care pathways to those stagnating in primary care with impairing and persistent illness. A wide range of recommendations can be made to enhance care throughout the pathway.

Management of psychiatric disorders in patients with cancer.

Management of psychiatric disorders in patients with cancer.

The Italian consensus conference on psychological therapies for anxiety and depressive disorders: findings and recommendations.

A Consensus Conference of clinicians, researchers, public health specialists and users was convened in Italy to review efficacy, effectiveness, treatment appropriateness and access to care for anxiety and depression, and to consider the role of psychological therapies. Expert opinion was sought concerning identification of people requiring psychological therapies according to levels of symptom severity matched to corresponding levels of treatment intensity, suitability of psychological therapies for subclinical anxiety or depression, definition of a minimum level of information on evidence-based psychotherapies to be provided by university medical and psychology courses, initiatives to raise awareness among potential users and decision makers on the role and effectiveness of psychological therapies in healthcare. The expert jury concluded that a number of psychological therapy models endorsed by most authoritative guidelines are supported by research showing their effectiveness at least equal to the drugs used in common mental disorders (CMDs). Such therapies are under-represented in the Italian public health system, leading many people to resort to the private sector, resulting in unacceptable wealth discrimination. The difficulty of accessing psychological treatments often entails the use of drug therapies in cases where they are not indicated. Starting from these assumptions, the experts recommended the promotion of better and timely recognition of anxiety and depressive disorders and their classification in terms of symptom intensity and functional impairment, differentiating subthreshold mood swings from clinical forms, to foster outcome studies of psychotherapies in CMDs in Italy, to introduce a stepped care model structured according to levels of intensity of treatment, based on wellbeing support strategies in nonmedical contexts for subthreshold situations, self-help, support and psychoeducation as frontline interventions in mild clinical forms, evidence-based psychotherapies in moderate and severe forms, with the option of combining psychological treatment and appropriate drug therapy in the most severe cases.

Tracing the missteps of stepped care: Improving the implementation of stepped care through contextual behavioral science

Stepped care is an organizational model of healthcare service provision that organizes interventions into a hierarchy from least-to-most intensive, intrusive, and costly. The intervention intensity should be based on feasibility, cost, severity of the presenting case, and patient and clinician preferences. Patients can be “stepped” up or down, depending on progress. Despite the rich, theoretical literature suggesting the effectiveness of stepped care, its implementation is accompanied by challenges that impede its proliferation in applied settings. This paper provides a review of the barriers to stepped care, including negative perceptions, tendency toward defensive medicine, lack of guidance in decision-making, the need for measurement tools designed for stepped care, and healthcare system factors that discourage stepped care. Specific recommendations are discussed for how a contextual behavioral science approach can reduce barriers to implementing stepped care models of behavioral health service delivery.

Stepped care model for developing pathways of screening, referral, and brief intervention for depression in pregnancy: A mixed-method study from development phase

Stepped care model for developing pathways of screening, referral, and brief intervention for depression in pregnancy: A mixed-method study from development phase

Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guideline-appropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders. Level of EvidenceV, expert opinion

Assessing the Acceptability and Feasibility of the Role of a Psychological Wellbeing Assistant in Inpatient Neurorehabilitation

Inpatient neurorehabilitation guidelines recommend comprehensive psychological care for service users to support their cognitive, behavioural, and emotional needs following a neurological diagnosis (BPS, 2017; NHS England, 2016). The Psychological Wellbeing Assistant (PWA) role was developed to meet Level 1 psychological needs, following Kneebone’s (2016) stepped model of psychological care. This study assessed the acceptability and feasibility of the PWA role in three inpatient neurorehabilitation wards. In addition, two PWAs recorded clinical contacts and clinical supervision, and confidence in clinical competencies was measured via questionnaire. The implications of the study are discussed.

Towards a Stepped Care Model for Managing Fear of Cancer Recurrence or Progression in Cancer Survivors.

BackgroundFear of cancer recurrence or progression (FCR) is common amongst cancer survivors and an important minority develop clinically significant levels of FCR. However, it is unclear how current clinical services might best support the growing numbers of cancer survivors.PurposeThe aim of this study is to develop recommendations for future research in the management of FCR and propose a model of care to help manage FCR in the growing population of cancer survivors.MethodsThis is a narrative review and synthesis of empirical research relevant to managing FCR. We reviewed meta-analyses, systematic reviews and individual studies that had investigated interventions for FCR.ResultsA recent, well-conducted meta-analysis confirmed a range of moderately effective treatments for FCR. However, many survivors continued to experience clinical levels of FCR after treatment, indicating a clear need to improve the gold standard treatments. Accessibility of interventions is arguably a greater concern. The majority of FCR treatments require face-to-face therapy, with highly skilled psycho-oncologists to produce moderate changes in FCR. With increasing numbers of cancer survivors, we need to consider how to meet the unmet need of cancer survivors in relation to FCR. Although there have been attempts to develop minimal interventions, these are not yet sufficiently well supported to warrant implementation. Attempts to help clinicians to provide information which might prevent the development of clinically significant FCR have shown some early promise, but research is needed to confirm efficacy.ConclusionThe next decade of research needs to focus on developing preventative approaches for FCR, and minimal interventions for those with mild-to-moderate symptoms. When evidence-based approaches to prevent FCR or manage moderate levels of FCR are available, stepped care approaches that could meet the needs of survivors could be implemented. However, we also need to improve existing interventions for severe FCR.

Patient reported self-help strategies and the perceived benefits for managing sub-threshold depressive symptoms: A nested qualitative study of Australian primary care attendees.

Subthreshold depression is common in primary care, but there is little information about the self-help strategies that patients use and the perceived benefits of these. This study sought to elicit the self-help strategies that primary care attendees identified as beneficial for the self-management of subthreshold depressive symptoms and the implications for general practitioners. Semi-structured telephone interviews were conducted with 14 people (April-May 2017) from the Target-D randomised controlled trial (RCT). Target-D investigated whether using a patient-centred clinical prediction tool and an e-health platform to match mental health management options to prognosis was beneficial for improving depressive symptoms at 3months compared to usual care. Interviews were thematically analysed to identify self-help strategies and their perceived benefits. Four overarching domains for the self-management strategies were identified: social, cognitive, behavioural and restorative. Interviewees reported using strategies across multiple domains, which included undertaking enjoyable, immersive activities, that provided relief from automatic negative thoughts and had a perceived cognitive benefit. Differences in the perceived sense of agency were noted around the self-regulation of mood, which indicated more explicit direction to patient-identified self-help management strategies by general practitioners for some may be of benefit in routine care. Some of the reported self-management strategies aligned with evidence-based approaches such as physical activity and mindfulness for mental health symptom management. These findings can inform low-intensity interventions within stepped care models for mental health in primary care, social prescribing models and, help to guide the management of patients by GPs for subthreshold depression.

Family-based treatment for adolescent anorexia nervosa: Outcomes of a stepped-care model.

Stepped-care models of treatment are underexplored in eating disorders. To enhance treatment outcomes, and informed by literature about adaptations to family-based treatment (FBT), we developed an FBT-based stepped-care model for adolescents with anorexia nervosa (AN) that was consistent with family preference (i.e., tailored) and responsive to adolescent needs (i.e., intensity). The aim of this study was to evaluate the effectiveness of this model in terms of remission at end-of-treatment. Adolescents (N=82), aged 12-18 years (M=15.1, SD=1.8) and meeting Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria for AN, were assessed at baseline, Weeks 24 and 48. FBT was tailored to family preference and clinical need, with 16-18 sessions by Week 24. This was followed by three FBT booster sessions or an extension of FBT plus booster sessions (Week 48). The primary outcome was defined as weight> 95% of %median body mass index plus within 1 SD of the Eating Disorder Examination (EDE) global score community norms. Remission rates were 45.1% and 52.4% at Weeks 24 and 48, respectively. Commensurable improvements were evident across secondary outcomes (e.g., EDE subscale scores). As a reference point, remission rates compared positively with results from a recent randomized clinical trial from the same center and at the same time points (Week 24:45.1% vs. 32.1% and Week 48:52.4% vs. 30.2%). Controlling for propensity score, no statistically significant differences were observed. This stepped-care model, designed to be responsive to the individual needs of adolescents and their families, achieved encouraging rates of remission. This study provides an important signal that supports future clinical trials of stepped-care models for adolescents with AN.

23.2 TEAM UP FOR CHILDREN: INTEGRATING BEHAVIORAL HEALTH SERVICES INTO PEDIATRIC SETTINGS AT FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)

This presentation aims to create a pediatric behavioral health integration (BHI) model that was specifically responsive to the needs of children and families served by Federally Qualified Health Centers (FQHCs), where a disproportionate amount of the patient population experiences multiple risk factors to healthy development, including poverty, structural racism, and exposure to other traumatic stressors. To address evidence gaps related to pediatric BHI, an interdisciplinary team co-developed Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP), a stepped-care model utilizing a practice transformation framework to expand screening and behavioral health (BH) care through a multidisciplinary care team including community health workers (CHWs) and behavioral health clinicians (BHCs). TEAM UP built the capacity of 3 FQHCs serving a total of 21,000 children, to deliver high-quality, evidence-based integrated BH care to children and families. TEAM UP FQHCs successfully used a consensus-driven governance structure to develop a shared clinical model, and a data-driven practice transformation framework to identify and resolve implementation barriers across the 3 unique health center environments. Given the central role that FQHCs play in caring for the nation’s most structurally marginalized children, adaptations that improve the fit of BHI within the FQHC environment could extend the benefits of improved behavioral outcomes and access to services for traditionally underserved populations. CHWs and BHCs play a critical role in responding to the needs of racially and ethnically diverse patient populations.

Specific content for collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care

BackgroundIn primary care (PC) many patients suffer from multimorbidity involving depression and/or anxiety. Collaborative care (CC) has shown promising results for patients with depression, anxiety, and multimorbidity involving depression. However, specific content in CC for patients with multimorbidity involving depression and/or anxiety is unknown.Objective(i) To examine the effect of CC interventions in patients with multimorbidity involving depression and/or anxiety compared with usual care; (ii) to identify specific content of CC.MethodsWe conducted a systematic literature review of randomized controlled trial studies evaluating CC models for adults with multimorbidity involving depression and/or anxiety in PC settings. PubMed, CINAHL, Web of Science, and PsycInfo were searched in December 2019. We conducted a qualitative synthesis using an existing framework and developed a new framework to map the content for each studied intervention.ResultsWe identified 1,447 studies. Twelve publications were included. Eleven had medium-to-high quality of CC for patients with multimorbidity involving depression. Specific content of CC in these studies is: A stepped care model, involving medication and psychotherapy delivered by a nurse or psychologist Care Manager (CM) focusing on problem-solving techniques; follow-up including monitoring of symptoms and function, and relapse prevention strategies; scheduled CM supervision.ConclusionsSpecific content for CC for patients with multimorbidity involving depression is identified from current research. Research gaps were found regarding CC for patients with multimorbidity and anxiety, depression and anxiety, and depression and/or anxiety and more than 2 diseases.

Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial

BackgroundMalawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease—including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes.MethodsWe will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model’s cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model.DiscussionThis study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence.Trial registrationClinicalTrials.govNCT04777006. Registered on 1 March, 2021

Acupuncture Treatment Modulates the Hypothalamus Functional Connectivity in Patients With Chronic Insomnia Disorder

Evidence suggests that behavioral therapies for insomnia, typically combined with cognitive interventions, are an enduring and effective treatment for chronic insomnia. Over decades of theory-driven use and research, several behavioral insomnia techniques have emerged, including stimulus control therapy, sleep restriction therapy, relaxation training, paradoxical intention, and sleep hygiene therapy, with varying levels of efficacy and considerations for use. Behavioral treatment implementation has been somewhat limited by availability of trained providers and patient adherence barriers. A stepped-care model of treatment, including utilization of newer online interactive treatment programs, may offer a solution to these implementation barriers.

Tools, Time, Training, and Team-Military Primary Care Providers' Perspectives on Improving Chronic Pain Assessment and Management.

Primary care providers are on the front lines of chronic pain management, with many reporting frustration, low confidence, and dissatisfaction in handling the complex issues associated with chronic pain care. Given the importance of their role and reported inadequacies and dissatisfaction in managing this challenging population, it is important to understand the perspectives of primary care providers when considering approaches to chronic pain management. This qualitative descriptive study aimed to comprehensively summarize the provider challenges and suggestions to improve chronic pain care in military primary care settings. Semi-structured interviews with 12 military primary care providers were conducted in a single U.S. Army medical center. All interviews were audio-recorded and lasted between 30 and 60 minutes. Interview transcripts were analyzed using ATLAS 9.0 software. Narratives were analyzed using a general inductive approach to content analysis. The Framework Method was used to organize the codes and emergent categories. All study procedures were approved by the Institutional Review Board of the University of Washington. Four categories captured providers' challenges and suggestions for improving chronic pain care: (1) tools for comprehensive pain assessment and patient education, (2) time available for each chronic pain appointment, (3) provider training and education, and (4) team-based approach to chronic pain management. Providers suggested use of the Pain Assessment Screening Tool and Outcomes Registry, more time per visit, incorporation of chronic pain care in health sciences curriculum, consistent provider training across the board, insurance coverage for complementary and integrative therapies, patient education, and improved access to interdisciplinary chronic pain care. Lack of standardized multifaceted tools, time constraints on chronic pain appointments, inadequate provider education, and limited access to complementary and integrative health therapies are significant provider challenges. Insurance coverage for complementary and integrative health therapies needs to be expanded. The Stepped Care Model of Pain Management is a positive and definite stride toward addressing many of these challenges. Future studies should examine the extent of improvement in guidelines-concordant chronic pain care, patient outcomes, and provider satisfaction following the implementation of the Stepped Care Model of Pain Management in military health settings.

Matched emotional supports in health care (MESH) framework: A stepped care model for health care workers.

Frontline health care workers (HCWs) are experiencing a range of emotional responses to the COVID-19 pandemic, including anxiety, traumatic stress, and burnout. As many as half of all HCWs will exhibit clinically significant distress. This distress may endure for years, and health care institutions must respond to these emotional needs. We propose the Matched Emotional Supports in Health Care (MESH) Framework to guide institutions in implementing a tiered, or "stepped care" model for deploying sustainable emotional support programs for HCWs for COVID-19 and beyond. Recognizing the variability in HCWs' response to stress, MESH outlines a continuum of services, including universal (e.g., self-help), selected (e.g., support from trained volunteers), and indicated (e.g., professional therapy, psychotropic medication management) interventions matched to individual need. We provide a targeted review of evidence-based resources available at each level of care and potential processes for determining when higher levels of care are needed. Finally, we delineate key implementation factors for institutions to consider in developing, implementing, and sustaining services for HCWs. Employing the MESH Framework may also facilitate health care institutions' ability to meet the fourth aim of the Quadruple Aims of Health Care to ensure a healthy workforce for this and future crises. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Filling the gap between theory and practice: A pilot study on parents' perceptions of integrated care for patients with borderline personality disorder.

Clinical pathways are known to be key in managing chronic conditions in an effective and sustainable way. This is particularly true in psychiatry, characterized by chronicity and managerial challenges. In particular, the borderline personality disorder is a highly complicated disorder to manage. Although numerous international guidelines converge on the urge of defining clinical pathways and a stepped‐care model for its effective treatment, it is unknown to what extent these guidelines have been implemented into concrete changes in the provision of care. The objective of this study is to pursue a preliminary assessment of whether there exists coherence between the provision of formal health dispositions or guidelines and end‐users’ perception of the change they should imply. A pilot study investigating the perception of parents of patients with borderline disorder on continuity of care has been conducted in three Italian regions. Results suggest that pathways do exist and are partially able to reach their intended effects, although concrete accessibility is still a major issue. Future studies should build on these preliminary results through quantitative investigation and further explore their causes.

Cost-effectiveness of Internet-Delivered vs In-Person Cognitive Behavioral Therapy for Children and Adolescents With Obsessive-Compulsive Disorder

Therapist-guided, internet-delivered cognitive behavioral therapy is an effective treatment option for children and adolescents with obsessive-compulsive disorder, but to our knowledge, its cost-effectiveness compared with traditional in-person treatment has not been established. To evaluate the cost-effectiveness of guided internet-delivered cognitive behavioral therapy implemented within a stepped-care model compared with in-person cognitive behavioral therapy for young people with obsessive-compulsive disorder. This economic evaluation of a randomized noninferiority trial conducted at 2 specialist obsessive-compulsive disorder clinics in Sweden enrolled 152 children and adolescents aged 8 to 17 years with obsessive-compulsive disorder, mainly through clinician referrals (110 [72%]). Recruitment began October 6, 2017, and ended May 24, 2019. Follow-up ended April 14, 2020. Participants were randomly assigned to receive either guided internet-delivered cognitive behavioral therapy or in-person cognitive behavioral therapy during a 16-week period. At the 3-month follow-up, nonresponders in both groups were offered additional in-person cognitive behavior therapy sessions. Health outcomes were treatment response rates (primary outcome), remission rates, and quality-adjusted life-years. Cost data were collected before treatment, after treatment, at 3-month follow-up, and at 6-month follow-up (primary end point) and are presented in 2020 US dollars. The differences in incremental costs and health outcomes were compared between the groups and presented from the health care professional, health care sector, and societal perspectives. A total of 152 participants (94 girls [62%]; mean [SD] age, 13.4 [2.5] years) were randomized; 151 (99%) completed the trial. At the 6-month follow-up, 50 of 74 participants (68%) in the stepped-care group and 52 of 77 participants (68%) in the in-person cognitive behavioral therapy group were classified as treatment responders (odds ratio, 1.00 [95% CI, 0.51-1.98]; P = .99). Health economic analyses showed that the stepped-care group used fewer therapist resources than the in-person cognitive behavioral therapy group, resulting in a mean cost savings of $2104 (95% CI, $1202-$3006) per participant for the full study period of 10 months, corresponding to a relative savings of 39%. The cost savings remained largely comparable when taking wider health care sector and societal perspectives. This study suggests that, for young people with obsessive-compulsive disorder, a low-cost digital intervention followed by in-person treatment for nonresponders was cost-effective compared with in-person cognitive behavior therapy alone.

All together: Integrated care for youth with type 1 diabetes.

ObjectiveWe describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes‐related quality of life (DRQoL), emotional well‐being, and depression.Research Design and MethodsThe care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods.ResultsThere were 236 adolescents (aged 13–18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well‐being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self‐direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team.ConclusionThe initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.