Two Stepped Care Models for PTSD among Cambodian Refugees in Primary Care

描述(由申请人提供)：NIMH已将非英语群体的治疗开发，特别是创伤后应激障碍(PTSD)的治疗，确定为研究所的主要优先事项，如卫生局局长的报告：精神健康：文化、种族和民族(美国卫生与公众服务部[USDHHS]，2001)。最近公布的NIMH战略计划(USDHHS，2008)作为其四个战略目标之一，是“开发新的、更好的干预措施，纳入精神疾病患者的不同需求和情况”(USDHHS，2008)，该计划强调需要个性化护理，以便适合不同的文化群体，以不同的方式提供 报告强调需要调查影响谁将从哪些治疗中受益的变量(另见，USDHHS，2010年)。对这些问题的调查导致了NIMH战略计划的另一个战略目标：“加强NIMH支持的研究对公共健康的影响。”只有一项研究探讨初级保健诊所对创伤后应激障碍的干预(Roy-Byrne等人，2010年)，没有关于初级保健中难民或少数民族群体的创伤后应激障碍治疗的研究。这是文献中的一个重大空白。目前的研究是对柬埔寨难民进行的一项混合效果-疗效研究，柬埔寨难民是一个创伤后应激障碍社区发病率极高的群体：在一项研究中社区患病率为62%(马歇尔等人，2005年)。这项研究利用了几种可供其他文化群体使用的方法，以使治疗更有效，包括增加初级保健医生开适当药剂的方法，增加药物依从性的方法，文化上适当的评估方法，以及对文化敏感的CBT。拟议的赠款将使我们能够调查是否可以在初级保健中为患有创伤后应激障碍的柬埔寨难民提供有效的治疗(包括所有治疗调整，例如，适用于所有难民和少数民族人口的文化适应的混合CBT)，并将比较两种护理模式。在第一步，所有患者接受为期12周的创伤后应激障碍药物治疗。在步骤1之后，仍有症状的患者将被随机分成两种强化策略之一。在药理强化分级护理模式中，步骤2是药理强化(添加另一种创伤后应激障碍药理制剂)。在CBT强化分级护理模式中，步骤2是一种文化适应的CBT(Hinton等人，2004,2005)。我们将研究个性化护理的各个方面：在步骤1中，变量 对初始药物治疗的适度反应(例如，性别、教育水平、愤怒程度)，以及在步骤2中，缓和对药物和CBT增强反应的变量(例如，在步骤1中评估的主持人、在步骤1中对药物的不良反应，以及治疗偏好，即，药理学或CBT)。 公共卫生相关性：NIMH已将为非英语群体，尤其是创伤后应激障碍(PTSD)的治疗开发确定为研究所的主要优先事项，如卫生局局长的报告：精神健康：文化、种族和民族(美国卫生与公众服务部[USDHHS]，2001)，以及最近公布的NIMH战略计划(USDHHS，2008)将其四个战略目标之一，“开发新的更好的干预措施，纳入精神疾病患者的不同需求和情况”(USDHHS，2008；另见，刚刚出版的NIMH报告：USDHHS，2010)。没有关于初级保健中难民或少数民族群体的创伤后应激障碍治疗情况的研究。拟议的赠款将使我们能够调查是否可以在初级保健中为患有创伤后应激障碍的柬埔寨难民提供有效的治疗(包括所有治疗调整，例如，适用于所有难民和少数民族人口的文化适应的混合CBT)，并将比较在这种情况下的两种分级护理治疗模式。

DESCRIPTION (provided by applicant): The NIMH has identified treatment development for non-English-speaking groups, particularly for posttraumatic stress disorder (PTSD), as a major Institute priority, as stated in the Surgeon General's report, Mental Health: Culture, Race, and Ethnicity (U.S. Department of Health and Human Services [USDHHS], 2001). The recently published NIMH Strategic Plan (USDHHS, 2008) has as one of its four strategic objectives to "Develop New and Better Interventions that Incorporate the Diverse Needs and Circumstances of People with Mental Illness" (USDHHS, 2008), and the plan emphasizes the need to personalize care so that it is appropriate for different cultural groups, for delivery in different contexts (primary care), and the report emphasizes the need to investigate the variables that influence who will benefit from which treatments (see too, USDHHS, 2010). Investigating these issues leads toward another of the NIMH Strategic Plan's strategic objectives: "Strengthen the Public Health Impact of NIMH-Supported Research." There is only one study examining an intervention for PTSD in a primary care clinic (Roy-Byrne et al., 2010), and there is no study of the treatment of PTSD among a refugee or ethnic minority group in primary care. This is a major gap in the literature. The current study is a hybrid effectiveness-efficacy study of Cambodian refugees, a group with an extremely high community rate of PTSD: a 62% community prevalence in one study (Marshall et al., 2005). The study utilizes several means to make the treatment more effective that can be utilized with other cultural groups, including the methods to increase the prescribing of adequate pharmacology by the primary care physician, the methods to increase medication adherence, the method of culturally appropriate evaluation, and the culturally sensitive CBT. The proposed grant would allow us to investigate whether effective treatment can be provided in primary care for Cambodian refugees with PTSD (with all the treatment adaptations, e.g., the hybrid culturally adapted CBT, applicable to all refugee and ethnic minority populations), and will compare two models of care. At step 1, all patients receive PTSD medication for 12 weeks. After step 1, patients who are still symptomatic will be randomized to one of two augmentation strategies. In the Pharmacology Augmentation Stepped Care Model, step 2 is pharmacologic augmentation (adding another PTSD pharmacological agent). In the CBT Augmentation Stepped Care Model, step 2 is a culturally adapted CBT (Hinton et al., 2004, 2005). We will investigate aspects of personalized care: in step 1, variables that moderate response to the initial pharmacological treatment (e.g., gender, education level, level of anger), and in step 2, variables that moderate the response to pharmacological and CBT augmentation (e.g., the moderators assessed for step 1, poor response to pharmacology in step 1, and treatment preference, viz., pharmacology or CBT). PUBLIC HEALTH RELEVANCE: The NIMH has identified treatment development for non-English-speaking groups, particularly for posttraumatic stress disorder (PTSD), as a major Institute priority, as stated in the Surgeon General's report, Mental Health: Culture, Race, and Ethnicity (U.S. Department of Health and Human Services [USDHHS], 2001), and the recently published NIMH Strategic Plan (USDHHS, 2008) has as one of its four strategic objectives, "Develop New and Better Interventions that Incorporate the Diverse Needs and Circumstances of People with Mental Illness" (USDHHS, 2008; see too, the just published NIMH report: USDHHS, 2010). There is no study of the treatment of PTSD among a refugee or ethnic minority group in primary care. The proposed grant would allow us to investigate whether effective treatment can be provided in primary care for Cambodian refugees with PTSD (with all the treatment adaptations, e.g., the hybrid culturally adapted CBT, applicable to all refugee and ethnic minority populations), and it will compare two models of stepped care treatment in that setting.