***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 Data on the duration of major depressive episodes ( MDE ) in the general population are sparse . AIMS To assess the duration of MDE and its clinical and socio-demographic determinants in a study group drawn from the general population with newly originated episodes of major depression . METHOD The Netherl and s Mental Health Survey and Incidence Study is a prospect i ve epidemiological survey in the adult population ( n=7076 ) , using the Composite International Diagnostic Interview . Duration of MDE over 2 years was assessed with a Life Chart Interview . RESULTS The median duration of MDE was 3.0 months ; 50 % of participants recovered within 3 months , 63 % within 6 months , 76 % within 12 months and nearly 20 % had not recovered at 24 months . Determinants of persistence were severity of depression and comorbid dysthymia . A recurrent episode predicted shorter duration . CONCLUSIONS Although half of those affected with MDE recovered rapidly , the risk of chronicity ( duration 24 months or more ) was considerable . This underlines the necessity of diagnosing and treating those at risk CONTEXT Given the public health significance of late-life depression and anxiety , and the limited capacity of treatment , there is an urgent need to develop effective strategies to prevent these disorders . OBJECTIVE To determine the effectiveness of an indicated stepped-care prevention program for  depression and anxiety disorders in the elderly . DESIGN R and omized controlled trial with recruitment between October 1 , 2004 , and October 1 , 2005 . SETTING Thirty-three primary care practice s in the northwestern part of the Netherl and s. PARTICIPANTS A total of 170 consenting individuals , 75 years and older , with subthreshold symptom levels of depression or anxiety who did not meet the full diagnostic criteria for the disorders . INTERVENTION Participants were r and omly assigned to a preventive stepped-care program ( n = 86 ) or to usual care ( n = 84 ) . Stepped-care participants sequentially received a watchful waiting approach , cognitive behavior therapy-based bibliotherapy , cognitive behavior therapy-based problem-solving treatment , and referral to primary care for medication , if required . MAIN OUTCOME MEASURES The cumulative incidence of DSM-IV major depressive disorder or anxiety disorder after 12 months as measured using the Mini International Neuropsychiatric Interview . RESULTS The intervention halved the 12-month incidence of depressive and anxiety disorders , from 0.24 ( 20 of 84 ) in the usual care group to 0.12 ( 10 of 86 ) in the stepped-care group ( relative risk , 0.49 ; 95 % confidence interval , 0.24 to 0.98 ) . CONCLUSIONS Indicated stepped-care prevention of depression and anxiety in elderly individuals is effective in reducing the risk of onset of these disorders and is valuable as seen from the public health perspective Abstract Objectives : To determine whether problem solving treatment combined with antidepressant medication is more effective than either treatment alone in the management of  major depression in primary care . To assess the effectiveness of problem solving treatment when given by practice nurses compared with general practitioners when both have been trained in the technique . Design : R and omised controlled trial with four treatment groups . Setting : Primary care in Oxfordshire . Participants : Patients aged 18 - 65 years with major depression on the research diagnostic criteria —a score of 13 or more on the 17 item Hamilton rating scale for depression and a minimum duration of illness of four weeks . Interventions : Problem solving treatment by research general practitioner or research practice nurse or antidepressant medication or a combination of problem solving treatment and antidepressant medication . Main outcome measures : Hamilton rating scale for depression , Beck depression inventory , clinical interview schedule ( revised ) , and the modified social adjustment schedule assessed at 6 , 12 , and 52 weeks . Results : Patients in all groups showed a clear improvement over 12 weeks . The combination of problem solving treatment and antidepressant medication was no more effective than either treatment alone . There was no difference in outcome irrespective of who delivered the problem solving treatment . Conclusions : Problem solving treatment is an effective treatment for depressive disorders in primary care . The treatment can be delivered by suitably trained practice nurses or general practitioners . The combination of this treatment with antidepressant medication is no more effective than either treatment alone . Key messages Problem solving treatment is an effective treatment for depressive disorders in primary care Problem solving treatment can be delivered by suitably trained practice nurses as effectively as by general practitioners The combination of problem solving treatment and antidepressant medication is no more effective than either treatment alone Problem solving treatment is most likely to benefit patients who have a depressive disorder of moderate severity and who wish to participate in an active psychological We evaluated , among depressed medical patients who are high utilizers of health care , whether improved vs unimproved depression is associated with differences in the course of functional disability . At baseline , 6 months , and 12 months , depression and disability were assessed among a sample of enrollees in health maintenance organizations ( N = 145 ) in the top decile of users of ambulatory health care who exceeded the 70th percentile of health maintenance organization population norms for depression . Improved depression was defined as a reduction of at least one third in depressive symptoms averaged across the two follow-up times . At the 12-month follow-up , persons with severe-improved depression experienced a 36 % reduction in disability days ( 79 days per year to 51 days per year ) and a 45 % reduction in disability score . Persons with moderate-improved depression experienced a 72 % reduction in disability days ( 62 days per year to 18 days per year ) and a 40 % reduction in disability score . In contrast , persons with severe-unimproved depression reported 134 disability days per year at baseline , while persons with moderate-unimproved depression reported 77 disability days per year at baseline . Neither group with unimproved depression showed improvement in either disability days or disability score during the 1-year follow-up period . High utilizers of health care with severe-unimproved depression were more likely to have current major depression and to be unemployed . Improved ( relative to unimproved ) depression was associated with borderline differences in the severity of physical disease and in the percent married . We conclude that depression and disability showed synchrony in change over time . However , depression and disability may show synchrony in change with disability because both depression and disability are controlled by some other factor that influences the chronicity of depression ( eg , chronic disease or personality disorder ) . The finding of synchronous change of depression and disability provides a rationale for r and omized controlled trials of depression treatments among depressed and disabled medical patients to determine whether psychiatric intervention might improve functional status in such patients . Such research is needed to determine whether there is a causal relationship between depression offset and reductions in functional disability BACKGROUND The current nonr and omized clinical trial explored changes over time in children with an anxiety disorder during stepped care , manual-based cognitive behaviour therapy ( CBT ) . METHODS Clinical ly anxious children ( 8 - 12 years , n = 133 ) and their parents participated in child focused CBT  ( 10 sessions ) . If assessment s indicated additional treatment was necessary , participants could step up to a second and possibly third treatment phase ( each 5 sessions ) including more parental involvement . RESULTS After the first treatment phase 45 % of the Intention-To-Treat sample was free of any anxiety disorder ; after the second and third phase an additional 17 % and 11 % respectively . In total , 74 % of the children no longer met criteria for any anxiety disorder following treatment . Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases , as well as child reported anxiety sensitivity and negative affect . Children participating in more treatment showed significant improvements during additional treatment phases , indicating that late change occurred for the subgroup that had not changed during the first phase . CONCLUSIONS Stepped care offers a st and ardized , assessment based , yet tailored treatment approach for children with anxiety disorders . A more intensive treatment is offered when initial CBT is insufficient , providing children additional opportunities to reach the desired outcome INTRODUCTION Worldwide , health systems are improving access to empirically supported psychological therapies for anxiety and depression . Evaluations of this effort are limited by the cross sectional nature of studies , short implementation periods , poor data completeness rates and lack of clinical ly significant and reliable change metrics . OBJECTIVE Assess the impact of implementing stepped care empirically supported psychological therapies by measuring the prospect i ve outcomes of patients referred over a two year period to one Improving Access to Psychological Therapies service in the UK . METHOD We collected demographic , therapeutic and outcome data on depression ( PHQ-9 ) and anxiety ( GAD-7 ) from 7859 consecutive patients for 24 months between 1st July 2006 and 31st August 2008 , following up these patients for a further one year . RESULTS 4183 patients ( 53 % ) received two or more treatment sessions . Uncontrolled effect size for depression was 1.07 ( 95 % CI : 0.88 to 1.29 ) and for anxiety was 1.04 ( 0.88 to 1.23 ) . 55.4 % of treated patients met reliable improvement or reliable and clinical ly significant change criteria for depression , 54.7 % for anxiety . Patients received a mean of 5.5 sessions over 3.5h , mainly low-intensity CBT and phone based case management .  Attrition was high with 47 % of referrals either not attending for an assessment or receiving an assessment only . CONCLUSIONS Recovery rates for patients receiving stepped care empirically supported treatments for anxiety and depression in routine practice are 40 to 46 % . Only half of all patients referred go on to receive treatment . Further work is needed to improve routine engagement of patients with anxiety and depression OBJECTIVES To determine the effects of implementing stepped care evidence -based psychological treatments for  anxiety and depression  in routine practice using a collaborative care implementation model . DESIGN Observational prospect i ve cohort study /Phase IV field trial . METHODS We collected data on depression and anxiety from a prospect i ve cohort of 3,994 consecutive patients referred to the UK Improving Access to Psychological Therapies demonstration site in Doncaster for 12 months from August 2006 using PHQ-9 and GAD-7 .  We collected demographic and process information including the type and methods of treatments received . We calculated effect sizes , remission , and recovery rates for patients competing treatment and those who dropped out or were considered to be unsuitable . RESULTS Two thous and seven hundred and ninety-five patients received an assessment , out of which 2,017 received two or more appointments . Out of these , 869 had completed treatment by the census date , 743 remained in treatment , 319 had dropped out , and 85 had been found to be unsuitable . Pre-post treatment effect sizes for anxiety and depression in those patients completing treatment were 1.39 and 1.41 , respectively , with post-treatment relative risks of depression and anxiety 0.29 and 0.34 . The combined remission and recovery rates were 76 % for depression and 74 % for anxiety . The mean number of treatment sessions was 5.15 in a mean time of 2 h and 45 min . On an average , patients received at least three of these contacts by telephone . Outcomes are comparable with benchmarked trials , review s , and routine data sets . CONCLUSIONS Combining low-intensity stepped care psychological treatment with a telephony-based collaborative care organizational system can deliver good clinical outcomes in routine practice OBJECTIVE To determine the clinical predictors and rate of relapse for major depression in primary care . DESIGN A cohort study of subjects in 2 r and omized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians . Baseline , 7-month , and 19-month assessment s were conducted . SETTING A large primary care clinic of a staff-model health maintenance organization . PATIENTS Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders , Revised Third Edition ( DSM-III-R ) criteria for major depression at 7 months . MAIN OUTCOME MEASURES Relapse was defined as ( 1 ) satisfying DSM-III-R criteria for major depression at 19 months , or ( 2 ) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months . Predictors examined included demographic characteristics , medical comorbidity , disability , and psychological symptoms . Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist . RESULTS Of the patients , 37.1 % reported relapse of depression in the 12-month relapse-risk period . The 2 major risk factors associated with relapse were ( 1 ) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy ( odds ratio , 3.3 ; 95 % confidence interval , 2.74 - 3.93 ) and ( 2 ) history of 2 or more episodes of major depression , or chronic mood symptoms for 2 years ( odds ratio , 2.1 ; 95 % confidence interval , 1.41 - 2.76 ) . Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither . CONCLUSIONS The relapse rate among primary care patients treated for depression approached that of specialty sample s , with more than one third reporting relapse in 1 year . Clinical characteristics can help target high-risk patients for relapse prevention efforts 
    Output:
    
Evidence suggested that stepped care interventions for depression are at least as effective as usual care .
However , the clinical and organisational superiority of stepped care is yet to be scientifically verified .
Differential benefits of stepped care may ultimately depend on service quality .