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

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.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.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.Current Controlled Trails: ISRCTN17831610.Depressive and anxiety disorders are common in general practice [1]. These disorders are often associated with serious functional impairment, reduced quality of life [2,3], high levels of service use and rising economic costs [4,5]. Persons with depressive and anxiety disorders often seek help in primary care [6]. Although evidence based clinical guidelines are available for the treatment of depressive and anxiety disorders in primary care [7,8], initiation of, and adherence to effective treatment is usually poor [9-12]. An important problem is the underrecognition of these disorders [13]. For depression approximately half of all patients are not recognized by their general practitioner (GP) as having psychological problems [14,15]. For anxiety disorders this is about 75% [16]. Another problem is that most patients who do receive treatment, receive antidepressants [17-19