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通常不适用于研究方案以外的患者，而且大多数治疗师没有接受过提供这项技术的培训。这一观察结果很可能适用于许多形式的心理治疗，并说明学术中心正在开发的基于手册的疗法与临床实践中可用的疗法之间存在着越来越大的差异。本研究旨在探讨神经性暴食症的两种治疗方案。第一个包括认知行为治疗，加上对CBT无效的人的氟西汀治疗，这是目前治疗这种疾病的最先进的治疗方案。第二个序列将是一种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，如果自助无法缓解，则使用抗抑郁药物(氟西汀)，如果药物治疗无法缓解，则最后使用CBT。前两个步骤可以在患者目前无法立即获得针对神经性暴食症的CBT的地区广泛使用，对于更具治疗耐药性的病例可以转介CBT。我们建议样本大小为324名受试者。考虑到这项研究的样本量要求，我们建议进行一项多地点研究，在4个治疗地点招募患者并进行治疗，其中一个包括数据中心。选择的治疗地点从大城市地区(如纽约市)到小城市(如法戈)，后者大多来自农村地区。这一战略还将使我们能够针对加强的少数族裔招聘。令人感兴趣的结果包括两种干预策略的相对有效性、它们的成本效益、它们成功地让患者接受治疗和防止磨损的能力，以及它们防止那些成功治疗的人需要进一步治疗的能力(预防复发)。

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).