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

描述（由申请人提供）：NIMH已将非英语人群的治疗开发，特别是创伤后应激障碍（PTSD）的治疗开发确定为主要的研究所优先事项，如外科医生报告《心理健康：文化、种族和民族》（美国卫生与公众服务部[USDHHS]，2001年）中所述。最近公布的《国家精神卫生战略计划》（USDHHS，2008年）的四个战略目标之一是“制定新的、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年），该计划强调需要个性化护理，以便适合不同文化群体，在不同国家和地区提供服务。 该报告强调，需要调查影响哪些人将从哪些治疗中受益的变量（另见美国卫生和公众服务部，2010年）。调查这些问题导致NIMH战略计划的另一个战略目标：“加强NIMH支持的研究的公共卫生影响。“只有一项研究在初级保健诊所检查PTSD的干预措施（Roy-Byrne等人，2010年），也没有研究在初级保健中治疗难民或少数民族群体的创伤后应激障碍。这是文献中的一个重大空白。目前的研究是对柬埔寨难民的混合有效性-有效性研究，柬埔寨难民是一个具有极高社区PTSD率的群体：在一项研究中有62%的社区患病率（马歇尔等人，2005年）。该研究采用了几种方法，使治疗更有效，可用于其他文化群体，包括增加初级保健医生处方适当药理学的方法，增加药物依从性的方法，文化适当评估的方法，以及文化敏感的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（所有治疗适应，例如，混合型文化适应性认知行为疗法，适用于所有难民和少数民族人口），并将比较两种护理模式。在第一步，所有患者接受PTSD药物治疗12周。第1步后，仍有症状的患者将随机接受两种加固策略之一。在药理学增强分步护理模型中，第2步是药理学增强（添加另一种PTSD药理学试剂）。在CBT增强分步护理模型中，步骤2是文化适应的CBT（欣顿et al.，2004年，2005年）。我们将研究个性化护理的各个方面：在步骤1中，变量 对初始药理学治疗的中度反应（例如，性别、教育水平、愤怒水平），以及在步骤2中，调节对药物和CBT增强的反应的变量（例如，对于步骤1、步骤1中对药理学的不良反应和治疗偏好，即，药理学或CBT）。 公共卫生相关性：国家精神卫生研究所已确定为非英语群体开发治疗方法，特别是创伤后应激障碍（PTSD），作为研究所的主要优先事项，如卫生部长的报告《精神卫生》所述：文化、种族和民族（美国卫生与公众服务部[USDHHS]，2001年），以及最近公布的NIMH战略计划（美国卫生和公众服务部，2008年）的四个战略目标之一是“制定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”（美国卫生和公众服务部，2008年;另见刚刚发表的国家精神卫生研究所报告：美国卫生和公众服务部，2010年）。目前还没有关于难民或少数民族群体在初级保健中治疗创伤后应激障碍的研究。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（所有治疗适应，例如，混合文化适应CBT，适用于所有难民和少数民族人口），它将比较在这种情况下的两种阶梯式护理治疗模式。

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.