Effectiveness of a stepped care intervention for anxiety and depression in people with diabetes, asthma or COPD in primary care: A randomized controlled trial

•Depression and anxiety are common comorbidities in people with a chronic disease.•Guidelines recommend using stepped care although the effectiveness is not yet known.•We tested the effectiveness of stepped care plus monitoring.•This model was effective in reducing symptoms of anxiety and depression.

BackgroundDepression and anxiety are common in people with a chronic somatic disease. Although guidelines recommend stepped care, the effectiveness of this approach has not been evaluated in people with diabetes, asthma, or COPD in primary care.Methods3559 People were sent screening questionnaires (41% response). Of 286 persons with anxiety and/or depression (Generalized Anxiety Disorder questionnaire, GAD-7, cut-off ≥8 and/or Patient Health Questionnaire, PHQ-9, cut-off ≥7), 46 were randomized into the intervention (stepped care and monitoring of symptoms; n=23) or control (usual care) group (n=23). Main outcomes were symptoms of anxiety and depression after the 12-months intervention and six months post intervention. Analysis of covariance was first adjusted for condition and baseline GAD-7/PHQ-9 scores and additionally for age, sex and education.ResultsThe intervention group had a significantly lower level of anxiety symptoms at the end of the program (GAD-7 6±6 vs. 9±6; Cohen's d=0.61). This effect was still present six months post intervention. The effect on depression was statistically significant in the first model (PHQ-9 6±4 vs. 9±6; p=0.035), but not in the fully adjusted model (p=0.099), despite a large effect size (d=0.63). At six months post intervention there was no statistically significant difference in symptoms of depression between the two groups although the difference in symptoms was still clinically significant (Cohen's d=0.61).LimitationsMany people were screened, but relatively few participated in the randomized controlled trial.ConclusionsStepped care with monitoring resulted in a lower level of symptoms of anxiety and depression in people with a chronic condition.