Like the recovery model, stepped care is not so much a type of therapy as a general treatment approach. Because clients vary considerably in their condition, progress and circumstances, a one-size-fits-all therapeutic stance has definite limits. Stepped care simply involves a continual assessment of the clients’ response to the treatment offered and the initiation of another level or a different approach if the client hasn’t shown the expected improvement. In integrated behavioral care, stepped care often involves reassessment of medication and counseling effectiveness and, in some cases, replacement of one with the other.
Jurgen Unutzer, a leading research involved in the IMPACT model for treating depression, emphasizes aggressive medication tracking and switching or modifying medication regimens according to an established algorithm if improvement is not shown. In a September, 2007 presentation for the Hogg Foundation for Mental Health, he advised that improvement should be seen in six to eight weeks for most clients given an antidepressant medication. If there is none, re-evaluation of the treatment plan should take place within eight to ten weeks. The main drawback of usual care, he says, is that practitioners “sit on treatment plans too long”; clients receive one antidepressant and simply stay on it for years without any re-assessment of effectiveness.
A federal study published in the New England Journal of Medicine validates Dr. Unutzer’s remarks. Only 37% of persons with depression went into remission when given an antidepressant medication. But about 25% of the nonresponders showed an improvement with a second medication, and 67% eventually responded with up to four rounds of treatment. At least with regard to depression, treatment success appears largely dependent on the practitioners willingness to try multiple treatment approaches.