Stepped care: doing more with less?

Several issues concerning stepped care are discussed: the constraints of using Diagnostic and Statistical Manual of Mental Disorders diagnoses in randomized clinical trials (RCTs), the importance of basic and process research, the unintended negative effects of exaggerated claims of effectiveness and efficiency, the limits of RCTs in evaluating improvement and deterioration, the self-correcting nature of stepped care, the link between stepped care and empirically supported treatments, clinical judgment in clinical work, the concept of the least restrictive alternative, the costs of using low-intensity but ineffective psychosocial treatments, and the costs of both ineffective and effective psychotropic drug therapy. An analysis of stepped care can lead to an appreciation that the dialectic operating between science and practice affords an opportunity to synthesize the seemingly irreconcilable standards and needs of researchers and clinicians.