Stepped Care for Obsessive-Compulsive Disorder

描述（由申请人提供）：这项R34基金申请的目标是开发和试点测试强迫症（OCD）的社会心理治疗的最佳实践模型，强迫症是一种慢性的、使人衰弱的、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）结合暴露与仪式预防（EX/RP）。尽管CBT已经证明了疗效，但这种治疗在很大程度上是难以获得的、耗时的、劳动密集的、昂贵的。因此，最有效的强迫症心理治疗在“现实世界”的有效性是有限的。本应用程序将开发和测试一种新的治疗方法，以提供CBT（即阶梯式护理），试图增加这种治疗的可及性和成本效益。在CBT阶梯式护理项目中，首先为患者提供一种更便宜、更少干扰、更容易获得的选择，类似于高质量的社区护理（即，自我管理的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（即治疗师给药的EX/RP）。本申请的主要具体目标是：1)制定阶梯式护理方案；2)从患者、临床医生和专家顾问那里获得反复反馈，以修改方案；3)获得初步试验数据，估计将用于R01拨款申请的功效分析。这些目标将在以下方面实现：1)对阶梯式护理方案进行初步小型公开试验，为修订手册提供数据；2)进行小型随机对照试验，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。阶梯式治疗是一种创新的治疗方法，有可能大大提高强迫症患者的可及性和成本效益。然而，由于这种方法的新颖性，需要通过R34应用程序进行广泛的协议开发和试点研究，然后才能真正投入使用。

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.