Objective There are effective treatments of trichotillomania (TTM), but access to expert providers is limited. This study tested a stepped care model aimed at improving access. Method Participants were 60 (95% women, 75% Caucasian, 2% Hispanic) adults (M = 33.18 years) with TTM. They were randomly assigned to Immediate vs. Waitlist (WL) conditions for Step 1 (10 weeks of web-based self-help via StopPulling.com). After Step 1, participants chose whether to engage in Step 2 (8 sessions of in-person Habit Reversal Training). Results In Step 1 the Immediate condition had a small (d = .21) but significant advantage, relative to WL, in reducing TTM symptom ratings by interviewers (masked to experimental condition but not to assessment point); there were no differences in self-reported TTM symptoms, alopecia, functional impairment, or quality of life. Step 1 was more effective for those who used the site more often. Stepped care was highly acceptable: motivation did not decrease during Step 1; treatment satisfaction was high, and 76% enrolled in Step 2. More symptomatic patients self-selected into HRT, and on average they improved significantly. Over one-third (36%) made clinically significant improvement in self-reported TTM symptoms. Considering the entire stepped care program, participants significantly reduced symptoms, alopecia, and impairment, and increased quality of life. For quality of life and symptom severity, there was some relapse by 3-month follow-up. Conclusions Stepped care is acceptable, and HRT was associated with improvement. Further work is needed to determine which patients with TTM can benefit from self-help and how to reduce relapse.

Different studies of the treatment of trichotillomania (TTM) use varying standards to determine the proportion of patients who obtain clinically meaningful benefits, but there is little information on the similarity of results yielded by these methods or on their comparative validity. Data from a stepped care (1. Web-based self-help; 2. Individual behavior therapy) (N = 60) treatment study of TTM were used to evaluate seven potential standards: complete abstinence, >=25% symptom reduction, recovery of normal functioning, and clinical significance (recovery + statistically reliable change), each of the last three being measured by self-report (Mass. General Hospital Hair Pulling Scale; MGH-HPS) or interview (Psychiatric Institute Trichotillomania Scale; PITS). Depending on the metric, response rates ranged from 25 to 68%. All standards were significantly associated with one another, though less strongly for the 25% symptom reduction metrics. Concurrent (with deciding to enter Step 2 treatment) and predictive (with 3-month follow-up treatment satisfaction, TTM-related impairment, quality of life, and diagnosis) validity results were variable but generally strongest for clinical significance as measured via self-report. Routine reporting of the proportion of patients who make clinically significant improvement on the MGH-HPS, supplemented by data on complete abstinence, would bolster the interpretability of TTM treatment outcome findings.