Commentary on Sawrikar et al.: Using Staged Care to Provide “Right Care First Time” to People With Common Affective Disorders

In their article, Vilas Sawrikar and colleagues (1) present staged care as a novel service delivery element for people with affective disorders, aiming to deliver “the right level of care the first time.” Extending a model developed for youths to children (5–11 years), youths and adults (12–54 years), and older adults (55 years and older), the authors engage with important aspects of health care, including decision making based on knowledge of typical clinical course, risk, and patient preference. The staging that Sawrikar et al. present includes secondary prevention, which is important because it often is overlooked, with acute care taking priority over prevention. For affective illness, a preventive focus is critical, considering that depression is prone to relapse and recurrence.

The authors identify issues and further directions for investigation. Reviewing work on staging in youths, Shah, as cited by Sawrikar et al., identified a need for “iterative feedback between concept and operationalization, supported by deep, enduring partnerships between researchers, clinicians, health planners, and young people themselves.” We suggest that this observation holds for the application of staging concepts across the age ranges; many of our comments converge with Sawrikar et al.’s suggestions for further work. Using Shah’s words as a framework may help extend these concepts or bring out further issues.

Feedback Between Concept and Operationalization

Common across dictionary definitions of “stage” is an idea of a process that has a typical course of identifiable steps, or stages. So, sets of items defining stages in a process, such as a typical progression from a healthy state to mental illness, should be observed to move together or in step along a continuum. A staging model may be less useful if people often are at one stage for one item in a process but are also at another stage for a different item in the process. A challenge to such a model is that early-stage descriptions are necessarily transdiagnostic where presentations often are undifferentiated. Time courses of depressive and anxiety disorders differ, as do time courses of comorbid states (2), so stage transition rates may vary across disorder categories. As the authors identified, further work is needed to clarify whether an underlying continuum or continua can be identified; a “clinimetric approach,” as they propose, would suggest application of elements of item-response theory, including, perhaps, Rasch modeling. We note that in the authors’ work based on prospective follow-up of clinic attenders in the youth domain, they have suggested multiple subtypes and trajectories; the adult model may need similar extension and validation of findings in population cohort studies.

Although the clinical staging model presented by Sawrikar et al. involves mainly clinical or functional observations, additional content from disability models also can be clinically relevant. For instance, in the World Health Organization International Classification of Functioning, Disability and Health, important influences on the course and outcome of a mental illness include activity, participation, environmental, and personal factors. When analytic models are introduced that can incorporate a wide range of variables, results may yield predictors that are more personal and environmental, for instance with prediction of nonresponse by “unemployment, depression severity, hostility, sleep problems, and lower positive emotionality at baseline” (3). The investigative agenda also might be furthered by using investigations to add more formally logical structures to the descriptors. Boolean logic may help with clarification of decision rules employing consistent use of the basic operators AND, OR, and NOT.

Partnerships among researchers, clinicians, and health Planners

The concept of stages has been widely used in oncology. Neoplasia commonly progresses with involvement of tumor and then lymph nodes and metastases, so the staging approach has been highly successful in supporting increasingly effective treatments. Clinical decision making (CDM), however, may need to guard against assuming that staging applied in mental health care necessarily implies similar underlying progressive properties, because targeted disorders may typically have episodic rather than progressive courses. Most people with depressive symptoms are not likely to progress to anything that would usefully fit a description of an end-stage disorder. Caution is especially needed here because the clinicians’ illusion creates bias toward viewing health outcomes as worse than is present in representative population samples. How staging is described and implemented may make a difference in whether these assumptions are activated unhelpfully.

Stepped care commonly (4) acknowledges that while some people may need, as it were, to toil “up the staircase” to receive more resources, given characteristics such as greater severity or risk, other people may effectively take an escalator or even an elevator to quickly access high-intensity services. But perhaps clinical staging may be seen as having a “CDM-trumping” role, suggesting stepped care elevation, where other assessment may not. Throughout is the challenge of remaining person centered, including incorporating patient preferences, thereby complementing the nomothetic with the idiographic.

Any rule-based criterion for transition between levels of care presents planning challenges. Resource levels vary internationally such that a level of care identified or implemented in one setting may be absent or limited in another. Even within countries described as having universal health care, such as Australia, patterns of access to mental health care can vary widely among locations (5). In many settings, level of insurance coverage will influence the service response two people at similar stages might receive; in many cases, better-resourced consumers will be able to “buy tickets for the escalator.” Where resource levels vary, questions will arise as to whether the properties of staging models used to guide level of care will be stable and equitable across settings. Post–COVID-19 pandemic, telehealth may be a widespread game changer. Simulation models including economic modeling may be useful here in scenario setting for differing service delivery contexts.

Partnerships With Consumers

Contemporary discourse regarding mental health care would call for consultation and perhaps codesign of a staged care approach with consumers. Although Sawrikar et al. do not reference clinician-consumer partnerships in their article, it could be a useful next stage. The concept of mental illness recovery, considered as personal recovery, is relevant here and takes into account personal progress even in the continued presence of a disorder. There is a parallel discourse along with some developed measures in stages of personal recovery (6). Terminology may be sensitive here; the article repeatedly refers to staging of patients, although consumers may prefer that the term be applied to their mental health problem, not to them as an entire person. So working with consumers on how staging concepts may be used collaboratively in shared decision making seems indicated. Involving patients and the public in research development has increasingly robust practice models to draw from.

A further aspect to consider would be quaternary prevention, or avoidance of iatrogenic harm, which we have argued can include a range of iatrogenic influences on consumer empowerment and activation in mental health care (5). Labeling a person as having a mental health problem at any stage has potential social and individual costs. Dialogue with consumers, clinicians, and health educators around terminology would be constructive.

Conclusions

Sawrikar and colleagues’ work has added significantly to the conversation around staging care. Additional research and discussion are needed to consider the acceptability of staging and its value to consumers; alignment with other influential models in the recovery and disability fields; and, through implementation science, its role in health service system design that seeks to maximize population mental health and equity.