Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: A preliminary study of efficacy and costs

Abstract

Background Exposure and response prevention (ERP) for obsessive–compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention. Methods Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in. Results The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes. Conclusions These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.

A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder

“…A possible explanation for the different findings could be that our participants had previous attempts with psychological therapies as well as prior medication trials. Newer stepped-care strategies utilizing self-help materials have obtained more promising results when therapist feedback and support is provided (Tolin, Diefenback, & Gilliam, 2011). The current study was not designed as a definitive test of self-help, but in this study the effects of access to self-help materials alone was not enough for a clinically significant result.…”

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005 guidelines from the British Association for Psychopharmacology

“…Cost-effectiveness studies in panic disorder provide evidence for the value of CBT (Heuzenroeder et al, 2004;Roberge et al, 2008) [II]; SSRI or tricyclic antidepressants (Heuzenroeder et al, 2004;McHugh et al, 2007); lifestyle approaches (Lambert et al, 2010) [III]; computerised interventions (Klein et al, 2009;McCrone et al, 2009;Mihalopoulos et al, 2005) and early intervention (Smit et al, 2009) (Francois et al, 2008). The costeffectiveness of treatments for obsessive-compulsive disorder has been investigated only rarely, with limited evidence for the greater cost-effectiveness of 'stepped care' compared to standard CBT [II] (Tolin et al, 2011) and group CBT in children and adolescents [III] (Farrell et al, 2012). In post-traumatic stress disorder, there is only modelled or limited evidence, for the cost-effectiveness of trauma-focused CBT in the treatment of sexually abused children, which may be enhanced when combined with an SSRI [III] (Gospodarevskaya and Segal, 2012); and for virtual reality graded exposure therapy in combat-related trauma [III] ).…”

Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: A case series

“…In an open trial of computerized self-help supplemented by an average of 86 min of telephone and instant messaging therapist support (Wootton et al, in press), 29% of OCD patients met criteria for recovery (Fisher & Wells, 2005). In an RCT of stepped care versus standard ERP, the patients given stepped care were given exercises in ERP to perform from a self-help book (Tolin, Diefenback, & Gilliam, 2011). In this step, an average of 105 min of additional therapist guidance was given to patients in three face-to-face sessions to aid in their completion of selfhelp book exercises, but no ERP was performed in-session.…”