Study data published in JAMA Psychiatry support the efficacy of stratified care over stepped care for the treatment of depression. In a clinical trial of patients with common mental disorders, care stratified by intensity at baseline was more effective in reducing symptoms than a “stepped” model, in which care intensity increased over time.

Stepped care has been widely implemented in England through the Improving Access to Psychological Therapies (IAPT) program. The stepped care system provides patients with access to low-intensity treatments, such as guided self-help, at initial presentation. Patients who remain symptomatic are then moved to more intensive psychotherapies.

Stratified care, by contrast, provides psychotherapies based on baseline symptom severity.

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While stepped care is widely used, stratified care may also offer significant benefits. To test the relative efficacies of these two treatment approaches, investigators conducted a cluster randomized clinical trial at 4 IAPT sites in northern England between 2018 and 2019.

The number of clinicians assigned to stratified care was 15 and the same number of clinicians were assigned to stepped care. Clinicians in the stratified care group received a personalized treatment recommendation for each patient. Clinicians in the stepped care group proceeded with treatment as usual.

The primary outcome was post-treatment reliable and clinically significant improvement (RCSI) of depression symptoms on the 9-item Patient Health Questionnaire. The proportion of patients achieving RCSI was compared between groups using logistic regression. Models were adjusted for baseline depression severity. Cost-effectiveness analyses were also conducted.

A total of 951 patients were enrolled, among whom 618 (65.1%) were women and 906 (95.3%) were White. Mean age was 38.3 ± 14.5 years. Overall, 583 patients received stratified care and 368 patients received stepped care.

The proportion of patients with RCSI was significantly higher in the stratified arm compared with the stepped care arm (52.3% vs 45.1%). Patients in the stratified care group were 40% more likely to achieve RCSI compared with the stepped care group (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.04-1.87; P =.03).  A greater proportion of patients in the stratified care group accessed high-intensity treatment compared with the stepped care group (56.9% vs 29.1%).

The estimated incremental cost of stratified care was $139.85 per patient (95% CI, $90.32-189.48). Incremental cost was higher with stratified vs stepped care because patients in stratified care accessed higher-intensity interventions over a greater mean number of sessions. However, these higher-cost intensive treatments were estimated to increase the probability of RCSI by 7%.

This study had some limitations. Patients had reported their outcomes and there was not any formal diagnostic or consequences which were observer rated. Relying only on patient reports implies that there could be biases such as motivated responding and social desirability bias.

Results from this study support the efficacy and cost-effectiveness of stratified care for patients with depression. Compared with patients in stepped care, the stratified care group was more likely to achieve significant improvement in symptoms. The additional cost with stratified care was modest but may still be a barrier to some patients. Further study is necessary to explore means of stratified care implementation.

“Overall, the present findings indicate that stratified care is feasible to implement in routine IAPT services, improving the efficiency and precision of psychological assessments in a way that preserves shared decision-making,” the investigators wrote.

Disclosure: Two study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Delgadillo J, Ali S, Fleck K, et al. Stratified care vs stepped care for depression: a cluster randomized clinical trial. JAMA Psychiatry. Published online December 8, 2021. doi:10.1001/jamapsychiatry.2021.3539