STEPPED CARE VS BEST AVAILABLE CARE FOR BULIMIA NERVOSA

尽管现有的治疗研究文献表明，认知行为疗法（CBT）是治疗神经性贪食症的有效方法，但有证据表明，CBT通常不适用于研究协议之外的患者，而且大多数治疗师没有接受过提供这种技术的培训。这一观察结果很可能适用于许多形式的心理治疗，并说明了学术中心正在开发的基于手册的治疗方法与临床实践中可用的治疗方法之间越来越大的差异。本研究旨在探讨神经性贪食症的两种治疗方案。第一种包括认知行为疗法，结合氟西汀治疗那些单独对CBT没有反应的人，这是目前治疗这种疾病的最先进的治疗方案。第二个顺序将是一个潜在的具有成本效益的阶梯式治疗方法，包括使用有监督的自助治疗，然后使用抗抑郁药物（氟西汀），如果自助治疗没有达到缓解，最后再使用CBT，如果药物治疗没有达到缓解。前两步可以广泛应用于那些目前还无法获得针对神经性贪食症的CBT治疗的地区，并为治疗抵抗性更强的病例提供CBT治疗。我们建议的样本量为324名受试者。考虑到本研究的样本量要求，我们提出了一项多点研究，在4个治疗点招募患者并进行治疗，其中一个治疗点包括数据中心。所选择的治疗地点范围从大城市（如纽约市）到小城市（如法戈），后者广泛吸引农村地区的人。这一策略也将使我们能够以加强少数族裔招聘为目标。关注的结果包括两种干预策略的相对有效性，它们的成本效益，它们成功地使患者接受治疗并防止损耗的能力，以及它们防止成功治疗的患者需要进一步治疗的能力（复发预防）。

Although the available treatment research literature suggests that cognitive behavioral therapy (CBT) is an effective treatment for bulimia nervosa, there is evidence that CBT is often not available to patients outside of research protocols and that most therapists are not trained to deliver this technique. This observation may well hold true for many forms of psychotherapy, and speaks to a growing discrepancy between the manual based therapies that are being developed in academic centers and what is available in clinical practice. This study is designed to examine two treatment sequences to bulimia nervosa. The first includes cognitive behavior therapy, coupled to fluoxetine treatment for those who fail to respond to CBT alone, a treatment package that is currently the state-of- the-art treatment for this condition. The second sequence will be a potentially cost-effective stepped treatment approach comprising the use of supervised self-help followed by the use of antidepressant medication (fluoxetine) if remission isn't attained with self-help, and finally followed by CBT, if remission isn't attained with drug therapy. The first two steps could be made widely available in areas where patients currently have no ready access to CBT specific for bulimia nervosa, with referral for CBT for the more treatment resistant cases. We are proposing a sample size of 324 subjects. Considering the sample size requirements for this study, we are proposing a multisite study wherein patients will be recruited and treated at 4 treatment sites, one of which includes the data center. The treatment sites chosen range from large urban areas (e.g., New York City), to small city (e.g., Fargo) which draws extensively from rural areas. This strategy will also allow us to target enhanced minority recruitment. Outcomes of interest include relative effectiveness of the 2 intervention strategies, their cost-effectiveness, their ability to successfully hold patients in therapy and prevent attrition, and their ability to prevent the need for further treatment for those successfully treated (relapse prevention).