Stepped-care treatment of anxiety and depression in older adults: A narrative review

Aust J Rural Health. 2019 Aug;27(4):275-280. doi: 10.1111/ajr.12524.


Objective: Stepped care models are a possible solution to address service gaps in the provision of psychological therapies for anxiety and/or depression. The benefits may be particularly relevant for people in rural and remote areas and other under-serviced and/or hard to reach populations, such as older adults.

Design: Narrative literature review.

Participants: Narrative literature review of the PubMed, Medline, and Psycinfo databases for studies reporting on the results of stepped care psychological interventions for older adults with anxiety and/or depressive symptoms.

Main outcomes: Seventy-seven papers were identified for evaluation of which nine papers met the study criteria (reporting on four individual trials).

Results: We identified four controlled studies. Three of the four studies found stepped care intervention to be associated with significantly better clinical outcomes and cost-effectiveness compared to treatment as usual. Studies primarily targeted subthreshold symptoms, mostly in primary care. Various interventions and stepping models were used.

Conclusion: Stepped care has been associated with improved clinical outcomes and costs in older adults, particularly in primary care. There have been no rigorous studies of stepped delivery of psychological interventions to older depressed and anxious adults in alternative settings such as in specialist older adult mental health services or in private clinics. Although the evidence-base for stepped care interventions is growing, it is not clear what evidence-based treatment model should be adopted and in what services it could apply. More research is needed. However, the evidence to date is promising and suggests that stepped care approaches are feasible in older adults, and are likely to increase access to high quality interventions for older adults living in rural communities.

Keywords: allocation of psychological therapy resources; depression and anxiety care; elderly; narrative review; steps of evidence based practice.

Publication types

  • Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anxiety / psychology
  • Anxiety / therapy*
  • Cost-Benefit Analysis
  • Depression / psychology
  • Depression / therapy*
  • Evidence-Based Medicine
  • Geriatric Assessment
  • Humans
  • Primary Health Care* / economics