Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial.
Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial.
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DOI：
10.1001/jamapsychiatry.2021.3539
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发表时间：
2022-02-01
期刊：
影响因子：
25.8
通讯作者：
Barkham M
中科院分区：
文献类型：
--
作者：
Delgadillo J;Ali S;Fleck K;Agnew C;Southgate A;Parkhouse L;Cohen ZD;DeRubeis RJ;Barkham M
与阶梯式护理相比，分层护理是否是一种有效且成本效益高的心理治疗选择方法？在这项对951名患有常见精神障碍的成年人进行的随机分组临床试验中，分层护理相对于阶梯式护理对抑郁症状的治疗有效且具有成本效益。这些研究结果表明，分层护理有可能以适度的增量成本改善抑郁症的治疗效果。这项随机分组临床试验评估了分层护理与常规阶梯式护理相比，在寻求心理治疗的常见精神疾病（包括抑郁症）患者中是否有效且具有成本效益。抑郁症是全球残疾的主要原因。虽然有经验支持的治疗方法，但缺乏证据表明如何有效地个性化心理治疗选择。比较阶梯式护理和分层护理两种治疗选择策略的临床效果和成本效果。这项多中心、群集随机临床试验于2018年7月5日至2019年2月1日从英国国民健康服务体系招募了参与者。在4个心理治疗服务工作的30名临床医生被随机分配到提供分层（n = 15）或阶梯式（n = 15）护理。在阶梯式护理中，患者依次获得低强度的指导性自助，然后是高强度的心理治疗。在分层护理中，患者在初始评估时与低强度或高强度治疗相匹配。使用意向治疗原则分析了2020年5月18日至2021年10月13日的数据。所有临床医生都使用相同的访谈时间表对寻求常见精神障碍心理治疗的患者进行初步评估，但分层护理组中的患者会收到由机器学习算法生成的针对每位患者的个性化治疗建议。合格患者接受分层或阶梯式治疗（即，照常治疗）。预登记的结果是治疗后抑郁症状的可靠和临床显著改善（RCSI）（使用9项患者健康问卷测量）。使用校正基线严重程度的logistic回归，比较两组之间的RCSI结局。成本效益分析比较了2种治疗途径的增量成本和健康结果。共纳入951例患者（950例患者中有618例为女性，数据可用[65.1%];平均[SD]年龄为38.27 [14.53]岁）。分层治疗组中RCSI病例比例显著高于分级治疗组（264/505 [52.3%] vs 134/297 [45.1%];比值比，1.40 [95%CI，1.04-1.87]; P = 0.03）。分层护理与每位患者的平均额外费用较高相关（£104.5 [95% CI，£67.5-£141.6] [$139.83（95% CI，$90.32-$189.48）]; P < .001），因为更多患者接受高强度治疗（332/583 [56.9%] vs 107/368 [29.1%]; χ2 = 70.51; P <0.001），但这一额外成本导致RCSI的概率增加约7%。在这项针对成人常见精神障碍患者的随机分组临床试验中，与阶梯式护理相比，分层护理对抑郁症状的治疗是有效的，并且具有成本效益。分层护理可以以适度的额外成本改善抑郁症的治疗效果。isrctn.org标识符：ISRCTN 11106183
Is stratified care an efficacious and cost-effective approach to psychological treatment selection compared with stepped care? In this cluster randomized clinical trial of 951 adults with common mental disorders, stratified care was efficacious and cost-effective for the treatment of depression symptoms relative to stepped care. These findings suggest that stratified care has the potential to improve depression treatment outcomes at a modest incremental cost. This cluster randomized clinical trial assesses whether stratified care is effective and cost-effective compared with usual stepped care among patients seeking psychological treatment for common mental disorders, including depression. Depression is a major cause of disability worldwide. Although empirically supported treatments are available, there is scarce evidence on how to effectively personalize psychological treatment selection. To compare the clinical effectiveness and cost-effectiveness of 2 treatment selection strategies: stepped care and stratified care. This multisite, cluster randomized clinical trial recruited participants from the English National Health Service from July 5, 2018, to February 1, 2019. Thirty clinicians working across 4 psychological therapy services were randomly assigned to provide stratified (n = 15) or stepped (n = 15) care. In stepped care, patients sequentially access low-intensity guided self-help followed by high-intensity psychotherapy. In stratified care, patients are matched with either low- or high-intensity treatments at initial assessment. Data were analyzed from May 18, 2020, to October 13, 2021, using intention-to-treat principles. All clinicians used the same interview schedule to conduct initial assessments with patients seeking psychological treatment for common mental disorders, but those in the stratified care group received a personalized treatment recommendation for each patient generated by a machine learning algorithm. Eligible patients received either stratified or stepped care (ie, treatment as usual). The preregistered outcome was posttreatment reliable and clinically significant improvement (RCSI) of depression symptoms (measured using the 9-item Patient Health Questionnaire). The RCSI outcome was compared between groups using logistic regression adjusted for baseline severity. Cost-effectiveness analyses compared incremental costs and health outcomes of the 2 treatment pathways. A total of 951 patients were included (618 women among 950 with data available [65.1%]; mean [SD] age, 38.27 [14.53] years). The proportion of cases of RCSI was significantly higher in the stratified care arm compared with the stepped care arm (264 of 505 [52.3%] vs 134 of 297 [45.1%]; odds ratio, 1.40 [95% CI, 1.04-1.87]; P = .03). Stratified care was associated with a higher mean additional cost per patient (£104.5 [95% CI, £67.5-£141.6] [$139.83 (95% CI, $90.32-$189.48)]; P < .001) because more patients accessed high-intensity treatments (332 of 583 [56.9%] vs 107 of 368 [29.1%]; χ2 = 70.51; P < .001), but this additional cost resulted in an approximately 7% increase in the probability of RCSI. 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. isrctn.org Identifier: ISRCTN11106183
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影响因子：
10.5
作者：
Moran, P;Leese, M;Mann, A
通讯作者：
Mann, A
影响因子：
4.1
作者：
Goddard, Elizabeth;Wingrove, Janet;Moran, Paul
通讯作者：
Moran, Paul
影响因子：
5.9
作者：
Delgadillo, Jaime;Huey, Dale;McMillan, Dean
通讯作者：
McMillan, Dean
影响因子：
5.9
作者：
JACOBSON, NS;TRUAX, P
通讯作者：
TRUAX, P
影响因子：
4.1
作者：
Delgadillo, Jaime;Moreea, Omar;Lutz, Wolfgang
通讯作者：
Lutz, Wolfgang