Common Mental Disorders Depression - New Zealand Doctor

2.3 Managing depression:
the stepped care model
Management options for depression in primary care sit on a continuum from simple
advice and monitoring to intensive multidisciplinary intervention. Most individuals with
depression present with relatively mild disorders, which are of recent onset and are
amenable to treatment in a primary care setting. The minority with severe or chronic
disorders require more intensive management, with secondary mental health care input. 65
A ‘stepped care’ approach to management entails choosing the least intrusive
intervention required to achieve clinical change for an individual. It is often possible
to ‘do more with less’, by starting with a low-intensity therapy, monitoring patient
response and moving to more intensive treatments only if the problem persists.
The stepped care model guides treatment using a combination of evidence-based
principles and continuous clinical assessment. Progression through levels of care is
determined on the basis of patient response. 137,138 Support for self-care is a major
feature of this approach. 139
The choice of initial therapy will inevitably depend not only on the individual’s needs
and preferences but also on service availability. Minimum intervention should not be
used as a triaging device as this would risk delaying access to therapy to those with
serious need, or loss to follow-up for some who fail to respond at the lower level of
input. There also needs to be a clear plan on how to decide whether a treatment is
effective and when to employ another approach. 137,138
2.4 Practitioner roles
The term ‘practitioner’ in this guideline is used to refer to any health care practitioner
in the primary care or community setting. However, practitioners involved in targeted
screening for common mental disorders in primary care will, in most cases, be health
professionals working in a general practice setting (eg, GP, practice nurse, nurse
practitioner), an educational setting (eg, school nurse or guidance counsellor), or a
maternity setting (eg, midwife). Other health care practitioners working in first-point-of
contact settings could also undertake this role, if supported to do so by local protocols
(eg, public health nurses, occupational health nurses, iwi and Pacific providers, district
nurses, Plunket nurses, counsellors, social workers and psychologists). Any practitioner
administering screening for common mental disorders needs to have a high standard
of communication skills, to be educated in the use and limitations of the screening
questions, be aware of the appropriate management of individuals who screen
positive, and to be able to action referral for further assessment and treatment.
Practitioners involved in the diagnosis and treatment of depression in primary care
are likely to be members of the general practitioner/practice nurse team, or therapists
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Identification of Common Mental Disorders and Management of Depression in Primary Care