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Obesity is a chronic condition associated with risk factors for many medical complications and comorbidities such as cardiovascular diseases, some types of cancer, osteoarthritis, hypertension, dyslipidemia, hypercholesterolemia, type-2 diabetes, obstructive sleep apnea syndrome, and different psychosocial issues and psychopathological disorders. Obesity is a highly complex, multifactorial disease: genetic, biological, psychological, behavioral, familial, social, cultural, and environmental factors can influence in different ways. Evidence-based strategies to improve weight loss, maintain a healthy weight, and reduce related comorbidities typically integrate different interventions: dietetic, nutritional, physical, behavioral, psychological, and if necessary, pharmacological and surgical ones. Such treatments are implemented in a multidisciplinary context with a clinical team composed of endocrinologists, nutritionists, dietitians, physiotherapists, psychiatrists, psychologists, and sometimes surgeons. Cognitive behavioral therapy (CBT) is traditionally recognized as the best established treatment for binge eating disorder and the most preferred intervention for obesity, and could be considered as the first-line treatment among psychological approaches, especially in a long-term perspective; however, it does not necessarily produce a successful weight loss. Traditional CBT for weight loss and other protocols, such as enhanced CBT, enhanced focused CBT, behavioral weight loss treatment, therapeutic education, acceptance and commitment therapy, and sequential binge, are discussed in this review. The issue of long-term weight management of obesity, the real challenge in outpatient settings and in lifestyle modification, is discussed taking into account the possible contribution of mHealth and the stepped-care approach in health care.

While existing literature describing the use of co-design has focused on its application within individual-level or group-level health interventions, the use of co-design to plan and support the implementation of mental health and substance use health stepped care (MHSUH) models and other MHSUH system transformation initiatives is more limited. In this commentary, the authors describe the Populating the Model Series , a co-design-based, system-level planning intervention specifically developed for sites implementing the Stepped Care 2.0 (SC2.0) model of care. The use of co-design, which is a core component of the SC2.0 model, distributes risk through engagement across the community, broadens the system of care to include and acknowledge informal and formal options, creates person-centricity, and incorporates access points and care modalities that are tailored to the intervention site’s context. Seven steps are identified within the Populating the Model Serie s including assessing intervention site readiness, understanding site context, planning and adjusting engagement of key groups for co-design, learning through workshop sessions and co-design, validation with key groups, understanding findings, and application of findings. This guidance provides an actionable process framework for the application of co-design in the planning and implementation of SC2.0 and other stepped care models.

In stepped care models patients typically start with a low-intensity evidence-based treatment. Progress is monitored systematically and those patients who do not respond adequately step up to a subsequent treatment of higher intensity. Despite the fact that many guidelines have endorsed this stepped care principle it is not clear if stepped care really delivers similar or better patient outcomes against lower costs compared with other systems. We performed a systematic review and meta-analysis of all randomized trials on stepped care for depression. We carried out a comprehensive literature search. Selection of studies, evaluation of study quality and extraction of data were performed independently by two authors. A total of 14 studies were included and 10 were used in the meta-analyses (4580 patients). All studies used screening to identify possible patients and care as usual as a comparator. Study quality was relatively high. Stepped care had a moderate effect on depression (pooled 6-month between-group effect size Cohen's d was 0.34; 95% confidence interval 0.20-0.48). The stepped care interventions varied greatly in number and duration of treatment steps, treatments offered, professionals involved, and criteria to step up. There is currently only limited evidence to suggest that stepped care should be the dominant model of treatment organization. Evidence on (cost-) effectiveness compared with high-intensity psychological therapy alone, as well as with matched care, is required.

Introduction: After a small successful pilot, and a revision of our implementation model, we trained and worked closely with urban and rural primary health care networks (PHNs) in Australia to implement and evaluate the acceptability, feasability, utility and cost effectiveness of an integrated online stepped care service (StepCare) for adults with anxiety and depression in general practices. Theory/Methods: Patients in a range of general practice settings were screened via a mobile tablet in their GP’s waiting room with immediate feedback to them and their doctor. Individuals were recommended the least intensive evidenced-based intervention likely to lead to health gain, and then stepped up (or down) the pathway according to changing needs and in response to treatment. A range of internet, face to face therapy and/or pharmacotherapy interventions, together with links to other care providers, were recommended based on symptom severity. Online monitoring allowed appropriate feedback to patient and GP and recommendations for follow-up. Following implementation, the acceptability, feasibility, utility and cost effectiveness of the service was examined.  Results: Results from the digital screening and 10 week follow-up of over 1000 patients in more than 20 general practices revealed high levels of acceptability and feasibility as rated by GPs, practice staff and patients. In addition GPs rated the service as effective in the early detection of hitherto undiagnosed anxiety and depression and helpful in the development and implementation of mental health treatment plans. Initial results of cost effectiveness evaluation suggest that the StepCare service is cost-saving over a 12 month period. A detailed final cost evaluation will be presented. Discussion: This study examined the acceptability, feasibility and effectiveness of an integrated stepped mental health care service (StepCare) in Australian primary care. Results showed that it could be implemented via a Train the Trainer model involving PHN staff (and is therefore capable of being implemented at scale), it integrates smoothly into general practices (thus normalising into routine practice) and it produces clinical changes (it is effective).    Conclusions: StepCare is the first fully integrated and digitally enabled stepped mental health care service to be implemented and evaluated in Australian primary care. Lessons learned: Despite the effort expended by the StepCare team to integrate the Service seamlessly into the workflow of general practices, some fine-tuning needs to be considered. For example, alternatives that allow for electronic screening to take place without impacting practice staff workflow may be required, such as self-service kiosks and an app available on patients’ personal smartphones.  Limitations: Our study suffered from low participant response rates, common in primary care research, but reducing generalizability of results. Our research design had strengths including mixed method and multi-stakeholder approach but lacked a control group. Improvements in patients symptoms over time may therefore have been due to spontaneous symptom remission, the effects of fortnightly review or factors other than recommended clinical care.    Suggestions for future research: Improvements are already being addressed in the StepCare Service through a structured program of upgrade prior to wider implementation across Australia, together with further evaluation of the service.

A stepped care approach, beginning with a low-intensity e-Health program followed by a high-intensity Participatory Approach led by a return-to-work (RTW) coordinator is a promising intervention to promote RTW of employees on sick leave with distress. As this approach is new, determinants of its successful implementation remain unknown. This study aimed to identify the potential facilitators and barriers for a stepped care approach to promote RTW of employees with distress, from the perspective of employees, employers, and occupational physicians. A qualitative study was performed consisting of individual semi-structured interviews with 10 employees, 5 supervisors, and two focus groups with 15 occupational physicians. The verbatim transcripts were inductively thematically coded. The Consolidated Framework for Implementation Research (CFIR) was applied to classify themes within its domains. Themes were constructed belonging to either the implementation or the content of the stepped care approach, falling within the CFIR domains \"innovation,\" \"outer setting,\" \"inner setting,\" and \"characteristics of the individual.\" From all three stakeholder groups, identified facilitators were the tailored program, enabling task adjustments, and the RTW coordinator to stimulate a good communicative relationship between employee and supervisor. Barriers identified were the timing of the stepped care approach, integrating the approach in the current RTW system, and low digital skills. Both facilitators and barriers were found for the implementation of the stepped care approach. This underlines the importance of an adaptive implementation strategy that takes into account workplace dynamics and tailored approaches to support the stakeholder groups' needs. ISRCTN: 90663076. Registered on October 5, 2023.

Abstract Study Objectives Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I). Methods A total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step. Results Results indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores. Conclusion(s) The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients. Trial registration ClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).

Digital health interventions (DHIs) often struggle with participant engagement. A stepped care approach, starting with low-resource intensity strategies and escalating as needed, can optimize resource use. Yet its application and cost implications remain underexplored. This study uses data from the iSIPsmarter experimental arm of a 2-group randomized controlled trial targeting sugar-sweetened beverage consumption in rural Appalachia. This study examines the demand and implementation costs associated with iSIPsmarter's stepped care engagement approach and simulates how variations in monitoring efficiency, demand, and stepped care intensity influence resource use and implementation costs to inform future implementation. iSIPsmarter's stepped care process combined automated and human-supported components to enhance engagement across 6 web-based modules (\"Cores\") over 9 weeks. Participants who did not complete a Core received an automated email, followed by stepped care if still incomplete: a text (step 1, low-resource intensity) after 7 days and up to 3 telephone attempts (step 2, high-resource intensity) after another 7 days. Staff time was tracked to estimate implementation costs: monitoring averaged 3 minutes (US $1.68), texts 2.83 minutes (US $1.58), and calls 5.1 minutes (US $2.85). Simulations explored 18 scenarios varying monitoring efficiency (20%, 50%, and 80% of trial-observed monitoring time and costs), stepped care demand (20%, 50%, and 80% of participants needing stepped care), and intervention intensity (low vs high). Among 126 participants, the mean stepped care contact was 1.2 (SD 1.3): 52 (41%) required none, 42 (33%) required 1 Core contact, 26 (21%) required 2, and 7 (6%) required 3. On average, participants completed 5.2 (SD 1.6) of 6 Cores. The mean stepped care implementation time per participant was 26.46 (SD 11.02) minutes, with a corresponding mean cost of US $14.80 (SD 6.16). Monitoring accounted for 78% of total cost (mean cost US $11.61, SD 2.37), with initial monitoring contributing 58% of total cost (mean cost US $8.51, SD 2.35). Simulations showed variation in time and cost based on monitoring efficiency. In low-demand, low-intensity scenarios, efficient monitoring required mean of 7.47 (95% CI 7.36-7.57) minutes and mean cost of US $4.18 (95% CI 4.12-4.24), while inefficient monitoring required a mean of 19.58 (95% CI 19.21-19.95) minutes and mean cost of US $10.95 (95% CI 10.74-11.16). In high-demand, high-intensity scenarios, efficient monitoring required a mean of 101.80 (95% CI 101.65-101.96) minutes and mean cost of US $56.92 (95% CI 56.84-57.01), while inefficient monitoring increased time to a mean of 146.32 (95% CI 145.92-146.71) minutes and mean cost of US $81.82 (95% CI 81.60-82.04). A stepped care approach can efficiently sustain engagement in DHIs by targeting support to higher-need participants. These findings offer actionable guidance for designing scalable, cost-effective interventions for real-world settings, as resource-efficient engagement strategies remain a persistent challenge for DHIs.

In the last decade, Europe has seen a rise in natural disasters. Due to climate change, an increase of such events is predicted for the future. While natural disasters have been a rare phenomenon in Europe so far, other regions of the world, such as Central and North America or Southeast Asia, have regularly been affected by Hurricanes and Tsunamis. The aim of the current study is to synthesize the literature on child development in immediate stress, prolonged reactions, trauma, and recovery after natural disasters with a special focus on trajectories of (mal-)adaptation. In a literature search using PubMed, Psychinfo and EBSCOhost, 15 studies reporting about 11 independent samples, including 11,519 participants aged 3–18 years, were identified. All studies identified resilience, recovery, and chronic trajectories. There was also evidence for delayed or relapsing trajectories. The proportions of participants within each trajectory varied across studies, but the more favorable trajectories such as resilient or recovering trajectory were the most prevalent. The results suggested a more dynamic development within the first 12 months post-disaster. Female gender, a higher trauma exposure, more life events, less social support, and negative coping emerged as risk factors. Based on the results, a stepped care approach seems useful for the treatment of victims of natural disasters. This may support victims in their recovery and strengthen their resilience. As mental health responses to disasters vary, a coordinated screening process is necessary, to plan interventions and to detect delayed or chronic trauma responses and initiate effective interventions.

IntroductionRefugees have been shown to be a vulnerable population with increased psychiatric morbidity and lack of access to adequate mental health care. By establishing cooperations between psychosocial centers and psychiatric clinics the state funded project refuKey by NTFN e.V. and DGPPN aims to improve access to and quality of mental health care for traumatized refugees pursuing a stepped-care model.ObjectivesAs part of a larger project evaluation study four focus-groups among experts were conducted to explore the impact of refuKey on refugees’ mental health care.MethodsData analysis was conducted using Mayring qualitative content analysis as well as an additional quantitative survey with state refugee reception centers’ employees.ResultsThe results indicate that refuKey faciliated the access to mental health care for refugees in terms of systematic identification of mental disorders, eased transitions and increased networking between the mental health care institutions and sectors. Planning and implementation of treatment is described as being more coordinated, solution oriented and sustainable due to multiprofessional collaboration and regular use of qualified interpreters. Reduced distress as well as increased transcultural expertise was found for professionals.ConclusionsThe persisting barriers for refugees in access to mental health care, especially to psychotherapeutic treatment and the emotional burden for professionals underlines the need for further support and research. The experts highly endorse the continuance of refuKey. Furthermore, they call for expansion of the project in terms of staff and new sites and changes of health policies to guarantee the access to adequate health care for traumatized refugees.DisclosureNo significant relationships.

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client’s evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.