Stepped Care for Obsessive-Compulsive Disorder

描述（由申请人提供）：此R34补助金申请的目标是开发和试点测试强迫症（OCD）心理社会治疗的最佳实践模型，强迫症是一种慢性，衰弱和昂贵的精神疾病。目前，对强迫症的心理社会治疗的选择是认知行为疗法（CBT）结合暴露与仪式预防（EX/RP）。尽管CBT的疗效已得到证实，但这种治疗在很大程度上是无法获得的，耗时，劳动密集型和昂贵的。因此，在“真实的世界”中，最有效的强迫症心理社会治疗的有效性是有限的。本申请将开发和测试一种新的治疗方法来提供CBT（即，阶梯式护理），以增加这种治疗的可及性和成本效益。在CBT阶梯式护理计划中，首先为患者提供一种更便宜、侵入性更小、更容易获得的选择，类似于优质社区护理（即，自我管理EX/RP结合咨询，以解决药物问题，生活压力和动机增强）。对这种初始治疗没有反应的患者进展到更强化的治疗（即，治疗师施用的EX/RP）。本申请的主要具体目的是：1）制定阶梯式护理方案，2）从患者、研究临床医生和专家顾问处获得迭代反馈以修订方案，3）获得初步试点数据，估计将用于R 01资助申请的把握度分析的效应量。这些目标将通过以下方式实现：1）一项初步的小规模开放试验，该试验将为修订手册提供数据; 2）一项小规模随机对照试验，比较修订后的阶梯式护理方案与“金标准”即时CBT的有效性和成本。阶梯式护理是一种创新的治疗方法，有可能大大提高强迫症患者护理的可及性和成本效益。然而，由于这种方法的新奇，在该计划真正投入使用之前，需要通过R34应用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.