Stepped Care for Obsessive-Compulsive Disorder

描述(由申请人提供)：这项R34拨款申请的目标是开发和试点测试强迫症(OCD)的心理社会治疗的最佳实践模式，强迫症是一种慢性、虚弱和昂贵的精神疾病。目前，强迫症的心理社会治疗选择是认知行为疗法(CBT)，将暴露与仪式预防(EX/RP)相结合。尽管CBT的疗效得到了证实，但这种治疗方法很大程度上是难以获得、耗时、劳动密集型和昂贵的。因此，最有效的强迫症心理社会治疗的“现实世界”有效性是有限的。这项应用将开发和测试一种提供CBT(即阶梯式护理)的新治疗方法，试图增加这种治疗的可及性和成本效益。在CBT分级护理计划中，首先为患者提供一种成本更低、侵入性更小、更容易获得的类似于高质量社区护理的选择(即，自我管理的EX/RP结合咨询以解决药物问题、生活压力和激励增强)。对这一初步治疗无效的患者将进入更强化的治疗(即治疗师管理的EX/RP)。此应用程序的主要特定目标是：1)开发阶梯式护理方案；2)获得患者、研究临床医生和专家顾问的迭代反馈以修改方案；3)获得初步的试点数据，估计将用于R01拨款申请的功率分析的效果大小。这些目标将通过1)阶梯式护理计划的初始小规模开放试验来实现，该试验将提供修订手册所依据的数据，以及2)小型随机对照试验，比较修订后的阶梯式护理方案与“黄金标准”即刻CBT的有效性和成本。阶梯式护理是一种创新的治疗方法，有可能极大地提高强迫症患者护理的可及性和成本效益。然而，由于这种方法的新颖性，在该计划能够真正运作之前，需要通过这种R34应用程序进行广泛的协议开发和试点研究。

DESCRIPTION (provided by applicant): The goal of this R34 grant application is to develop and pilot-test a best practice model for the psychosocial treatment of obsessive-compulsive disorder (OCD), a chronic, debilitating, and costly psychiatric illness. Currently the psychosocial treatment of choice for OCD is cognitive-behavioral therapy (CBT) incorporating exposure with ritual prevention (EX/RP). Despite CBT's demonstrated efficacy, this treatment is largely inaccessible, time consuming, labor intensive, and expensive. Thus the "real world" effectiveness of the most validated psychosocial treatment for OCD is limited. This application will develop and test a novel treatment approach to delivering CBT (i.e., stepped care) in an attempt to increase the accessibility and cost-effectiveness of this treatment. In the CBT stepped care program, patients are first provided with a less expensive, less intrusive, and more accessible option that resembles quality community care (i.e., self-administered EX/RP combined with counseling to address medication issues, life stress, and motivational enhancement). Patients who fail to respond to this initial treatment progress to a more intensive treatment (i.e., therapist-administered EX/RP). The primary specific aims of this application are to 1) develop a stepped care protocol, 2) obtain iterative feedback from patients, study clinicians, and expert consultants to revise the protocol, and 3) obtain preliminary pilot data estimating an effect size that will be used in a power analysis for an R01 grant application. These aims will be accomplished in 1) an initial small open trial of the stepped care program that will provide data upon which to revise the manual, and 2) a small randomized controlled trial comparing effectiveness and cost of the revised stepped care protocol with "gold standard" immediate CBT. Stepped care is an innovative treatment approach that has the potential to greatly improve the accessibility and cost-effectiveness of care for patients with OCD. However, because of the novelty of this approach extensive protocol development and pilot research via this R34 application is needed before the program can be truly operational.