***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Depression accounts for the greatest burden of disease among all mental health problems , and is expected to become the second-highest amongst all general health problems by 2020 . By the age of 75 , 1 in 7 older people meet formal diagnostic criteria for depression . Efforts to ameliorate the burden of illness and personal suffering associated with depression in older people have focussed on those with more severe depressive syndromes . Less attention has been paid to those with mild disorders/sub-threshold depressive syndromes but these patients also suffer impairments in their quality of life and level of functioning . Methods / Design The CASPER study has been design ed to assemble an epidemiological cohort of people over 75 years of age ( the CASPER cohort ) , from which we will identify those eligible to participate in a trial of collaborative care for sub-threshold depression ( the CASPER trial).We aim to undertake a pragmatic r and omised controlled multi-centre trial evaluating the effectiveness and cost-effectiveness of collaborative care ; a low intensity psychological intervention in addition to usual general practitioner care versus usual general practitioner care alone .  General practitioners from practice s based in the North of Engl and will be asked to identify potentially eligible patients over the age of 75 years . Patients will be sent a letter inviting them to participate in the study .We aim to recruit approximately 540 participants for the CASPER trial . A diagnostic interview will be carried out to ascertain trial eligibility with the major depressive episode module of the Mini International Neuropsychiatric Interview ( M.I.N.I. ) , eligible participants r and omised to either the intervention or usual care . The primary outcome will be measured with the Patient Health Question naire-9 ( PHQ-9 ) and additional quality of life measures will be collected . Data will be collected at baseline , 4 and 12 months for both trial and cohort participants .Trial Registration IS RCT N : IS RCT BACKGROUND Thus far collaborative stepped care ( CSC ) studies have not incorporated self-help as a first step . AIMS To evaluate the effectiveness of CSC  in the treatment of common mental disorders . METHOD An 8-month cluster r and omised controlled trial comparing CSC to care as usual ( CAU ) ( Dutch Trial Register identifier NTR1224 ) . The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder , followed by cognitive-behavioural therapy in mental healthcare . RESULTS Twenty general practitioners ( GPs ) and 8 psychiatric nurses were r and omised to provide CSC or CAU . The GPs recruited 163 patients of whom 85 % completed the post-test measurements . At 4-month mid-test CSC was superior to CAU : 74.7 % ( n = 68 ) v. 50.8 % ( n = 31 ) responders ( P = 0.003 ) . At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well . CONCLUSIONS Treatment within a CSC model result ed in an earlier treatment response compared with CAU Background Psychological distress is common in cancer survivors . Although there is some evidence on effectiveness of psychosocial care in distressed cancer patients , referral rate is low . Lack of adequate screening instruments in oncology setting s and insufficient availability of traditional models of psychosocial care are the main barriers . A stepped care approach has the potential to improve the efficiency of psychosocial care . The aim of the study described herein is to evaluate efficacy of a stepped care strategy targeting psychological distress in cancer survivors . Methods / design The study is design ed as a r and omized clinical trial with 2 treatment arms : a stepped care intervention programme versus care as usual .  Patients treated for head and neck cancer ( HNC ) or lung cancer ( LC ) are screened for distress using OncoQuest , a computerized touchscreen system . After stratification for tumour ( HNC vs. LC ) and stage ( stage I/II vs. III/IV ) , 176 distressed patients are r and omly assigned to the intervention or control group . Patients in the intervention group will follow a stepped care model with 4 evidence based steps : 1 . Watchful waiting , 2 . Guided self-help via Internet or a booklet , 3 . Problem Solving Treatment administered by a specialized nurse , and 4 . Specialized psychological intervention or antidepressant medication . In the control group , patients receive care as usual which most often is a single interview or referral to specialized intervention . Primary outcome is the Hospital Anxiety and Depression Scale ( HADS ) . Secondary outcome measures are a clinical level of depression or anxiety ( CIDI ) , quality of life ( EQ-5D , EORTC QLQ-C30 , QLQ-HN35 , QLQ-LC13 ) , patient satisfaction with care ( EORTC QLQ-PATSAT ) , and costs ( health care utilization and work loss ( TIC-P and PRODISQ modules ) ) . Outcomes are evaluated before and after intervention and at 3 , 6 , 9 and 12 months after intervention . Discussion Stepped care is a system of delivering and monitoring treatments , such that effective , yet least re source -intensive , treatment is delivered to patients first . The main aim of a stepped care approach is to simplify the patient pathway , provide access to more patients and to improve patient well-being and cost reduction by directing , where appropriate , patients to low cost (self-)management before high cost specialist services . Trial registration Background Depressive and anxiety disorders are common in general practice but not always treated adequately . Introducing stepped care might improve this . In this r and omized trial we examined the effectiveness of such a stepped care model . Methods The study population consisted of primary care attendees aged 18 - 65 years with minor or major DSM-IV depressive and /or anxiety disorders , recruited through screening . We r and omized 120 patients to either stepped care or care as usual . The stepped care program consisted of ( 1 ) watchful waiting , ( 2 ) guided self-help , ( 3 ) short face-to-face Problem Solving Treatment and ( 4 ) pharmacotherapy and /or specialized mental health care . Patients were assessed at baseline and after 8 , 16 and 24 weeks . Results Symptoms of depression and anxiety decreased significantly over time for both groups . However , there was no statistically significant difference between the two groups ( IDS : P = 0.35 and HADS : P = 0.64 ) . The largest , but not significant , effect ( d = -0.21 ) was found for anxiety on T3 . In both groups approximately 48 % of the patients were recovered from their DSM-IV diagnosis at the final 6 months assessment . Conclusions In summary we could not demonstrate that stepped care for depression and anxiety in general practice was more effective than care as usual . Possible reasons are discussed . Trial Registration Current Controlled Trails : IS RCT N17831610 Hedges ( 2018 ) encourages us to consider asking new scientific questions concerning the optimization of adaptive interventions in education . In this commentary , we have exp and ed on this ( albeit briefly ) by providing concrete examples of scientific questions and associated experimental design s to optimize adaptive interventions , and commenting on some of the ways such design s might challenge us to think differently . A great deal of method ological work remains to be done . For example , we have only begun to consider experimental design and analysis methods for developing " cluster-level adaptive interventions " ( NeCamp , Kilbourne , & Almirall , 2017 ) , or to extend methods for comparing the marginal mean trajectories between the adaptive interventions embedded in a SMART ( Lu et al. , 2016 ) to accommo date r and om effects . These method ological advances , among others , will propel educational research concerning the construction of more complex , yet meaningful , interventions that are necessary for improving student and teacher outcomes Background Faced with a life-threatening illness , such as cancer , many patients develop stress symptoms , i.e. avoidance behaviour , intrusive thoughts and worry . Stress management interventions have proven to be effective ; however , they are mostly performed in group setting s and it is commonly breast cancer patients who are studied . We hereby present the design of a r and omized controlled trial ( RCT ) evaluating the effectiveness and cost-effectiveness of an individual stress-management intervention with a stepped-care approach in several cancer diagnoses . Method Patients ( ≥ 18 years ) with a recent diagnosis of breast cancer , colorectal cancer , lymphoma , prostate cancer or testicle cancer and scheduled for adjuvant/curative oncology treatment , will consecutively be included in the study . In this prospect i ve longitudinal intervention study with a stepped-care approach , patients will be r and omized to control , treatment as usual , or an individual stress-management intervention in two steps . The first step is a low-intensity stress-management intervention , given to all patients r and omized to intervention . Patients who continue to report stress symptoms after the first step will thereafter be given more intensive treatment at the second step of the programme . In the intervention patients will also be motivated to be physically active . Avoidance and intrusion are the primary outcomes . According to the power analyses , 300 patients are planned to be included in the study and will be followed for two years . Other outcomes are physical activity level , sleep duration and quality recorded objective ly , and anxiety , depression , quality of life , fatigue , stress in daily living , and patient satisfaction assessed using valid and st and ardized psychometric tested question naires . Utilization of hospital services will be derived from the computerized patient administration systems used by the hospital . The cost-effectiveness of the intervention will be evaluated through a cost-utility analysis . Discussion This RCT will provide empirical evidence of whether an individually administered stress-management programme in two steps can decrease stress as well as maintain or enhance patients ’ physical activity level , quality of life and psychological well-being . Further , this RCT , with a stepped-care approach , will provide knowledge regarding the cost-effectiveness of an individually administered stress-management programme whose aim is to help and support individual patients at the right level of care . Trial registration Clinical Trials.gov Identifier : NCT 01588262 Background This study compared the best available treatment for bulimia nervosa , cognitive – behavioural therapy ( CBT ) augmented by fluoxetine if indicated , with a stepped-care treatment approach in order to enhance treatment effectiveness . Aims To establish the relative effectiveness of these two approaches . Method This was a r and omised trial conducted at four clinical centres ( Clinical trials.gov registration number : NCT00733525 ) . A total of 293 participants with bulimia nervosa were r and omised to one of two treatment conditions : manual-based CBT delivered in an individual therapy format involving 20 sessions over 18 weeks and participants who were predicted to be non-responders after 6 sessions of CBT had fluoxetine added to treatment ; or a stepped-care approach that began with supervised self-help , with the addition of fluoxetine in participants who were predicted to be non-responders after six sessions , followed by CBT for those who failed to achieve abstinence with self-help and medication management . Results Both in the intent-to-treat and completer sample s , there were no differences between the two treatment conditions in inducing recovery ( no binge eating or purging behaviours for 28 days ) or remission ( no longer meeting DSM – IV criteria ) . At the end of 1-year follow-up , the stepped-care condition was significantly superior to CBT . Conclusions Therapist-assisted self-help was an effective first-level treatment in the stepped-care sequence , and the full sequence was more effective than CBT suggesting that treatment is enhanced with a more individualised approach BACKGROUND Exposure and response prevention ( ERP ) for obsessive-compulsive disorder ( OCD ) is underutilized , in part because of costs and time requirements . This study extends pilot work investigating the use of a stepped care ERP administration , in which patients are first given a low-intensity , low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention . METHODS Thirty adults with OCD were r and omized to receive stepped care ERP or st and ard ERP .  Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy ; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP ( 17 sessions twice weekly ) . Those receiving st and ard ERP received the therapist-administered ERP with no lower-intensity lead-in . RESULTS The two treatments were equally efficacious , with 67 % of stepped care completers and 50 % of st and ard treatment completers meeting criteria for clinical ly significant change at posttreatment . Similarly , no differences in client satisfaction ratings were obtained between the two groups . Examination of treatment costs , however , revealed that stepped care result ed in significantly lower costs to patients and third-party payers than did st and ard ERP , with large effect sizes . CONCLUSIONS These results suggest that stepped care ERP can significantly reduce treatment costs , without evidence of diminished treatment efficacy or patient satisfaction . Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD , and to examine the financial and therapeutic impact of implementing stepped care in community setting Background A life threatening illness such as breast cancer can lead to a secondary diagnosis of PTSD ( post traumatic stress disorder ) with intrusive thoughts and avoidance as major symptoms . In a former study by the research group , 80 % of the patients with breast cancer reported a high level of stress symptoms close to the diagnosis , such as intrusive thoughts and avoidance behavior . These symptoms remained high throughout the study . The present paper presents the design of a r and omized study evaluating the effectiveness and cost-effectiveness of a stress management intervention using a stepped-care design . Method Female patients over the age of 18 , with a recent diagnosis of breast cancer and scheduled for adjuvant treatment in the form of 
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Conclusions Trials of proportionate staged interventions are being used predominantly within the mental health field .