The stepped-care model provides a framework in which to organise the provision of services, and supports patients, carers and practitioners in identifying and accessing the most effective interventions (see table below).

In stepped care the least intrusive, most effective intervention is provided first; if a patient does not benefit from the intervention initially offered, or declines an intervention, they should be offered an appropriate intervention from the next step.

Depending on the whether the patient scores low, moderate or high on the screening tool, the stepped care model recommended by NICE below supports the health professional on the focus of the intervention and the nature of the intervention. NICE Clinical guideline [CG91] provides further detailed assessments and interventions.

Complex depression includes depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms, and/or is associated with significant psychiatric comorbidity or psychosocial factors.

Collaborative care for step 3 is only for depression where the person has a chronic physical health problem and associated functional impairment.

NICE Clinical guideline [CG91]. Depression in adults with a chronic physical health problem: recognition and management

Level One - no distress

(PHQ-4 score 0-2)

Responses:

Assessment/monitoring

Education

Reassurance

Level Two - mild distress

(PHQ-4 score 3-5)

Responses:

Signposting to information/self-help resources based on patient preference.
Offer referral to psychology if appropriate

Level Three - moderate/severe distress

(PHQ-4 score ≥6)

Action Required!
Highly specialist psychological assessment and intervention including group or onward referral

Responses

Signpost

Aimed at those experiencing stress or other forms of psychological distress, and may include:

• Provision of information
• Psycho-education
• Prescribed exercise
• Counselling or the use of psychological principles within another healthcare context.

Identify what your local services provide for your patients

Low intensity support

Protocol-driven interventions aimed at less complex mental illness and disorder and normally lasting between two and six sessions.

Ready access to care & follow-up in exacerbations: specialist care as appropriate

Highly specialist psychological therapies and interventions - individually tailored and based on case formulations drawn from a range of psychological models, aimed at service users with highly complex and/or enduring mental illness and disorder, and normally lasting for 16 sessions and above

Family support

For families or carers who are involved in supporting a patient with severe or chronic (symptoms more or less continuously for 2 years or more) depression and a chronic physical health problem, see recommendations in the NICE guideline on supporting adult carers on identifying, assessing and meeting the caring, physical and mental health needs of families and carers.

See NICE guideline [NG150]. Supporting adult carers.Published: 22 January 2020.

NOTE: Services should be aware of local mental health risk management protocols

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