Self-Directed and Stepped Care Models of OCD Treatment David F. Tolin Gretchen J. Diefenbach Christina M. Gilliam The Institute of Living Hartford, CT USA

Cognitive Behavioral Therapy is Effective for OCD… Foa et al., Am J Psychiatry 2005;162:151-161

…But CBT Is Underutilized Marques et al., Depress Anxiety 2010;27:470-475

Barriers to Receiving CBT Marques et al., Depress Anxiety 2010;27:470-475

Can Bibliotherapy Work? Tolin et al., Behav Ther. 2007;38:179-191

Rationale for Stepped Care 25% sustained response rate for bibliotherapy Not great on its own, but may be cost effective as a first step Stepped care allows for built-in self-correction by providing patients with the adequate level of treatment and no more Reduces the impact of the most common barriers: Cost Time Therapist availability Wanting to handle it on my own

When to “Step Up?” Failure to respond Absence of clinically significant change Significant worsening of symptoms CGI-I rating of “much worse” or “very much worse” Reliable change (worsening) on Y-BOCS or BDI Emergence of severe symptoms e.g., increased suicidal ideation

Study 1 (N = 11) Three steps Bibliotherapy Therapist-supported CBT (3 sessions, 20 min every 2 weeks) Therapist-directed CBT (12 sessions, 90 min twice per week) Tolin et al., Cog Behav Pract 2005;12:403-414

Results of Study 1 Total Study: 4 (36%) dropouts 6 (86%) responders Bibliotherapy: 1 (9%) dropout 2 (20%) responders d = 0.97 Therapist-supported CBT: 1 (12%) dropout 2 (29%) responders d = 0.07 Therapist-directed CBT: 2 (40%) dropouts 2 (67%) responders d = 2.82 Total Study: 4 (36%) dropouts 6 (86%) responders d = 2.28 Tolin et al., Cog Behav Pract 2005;12:403-414

Study 2 (N = 14) Two steps Bibliotherapy + therapist-supported CBT (3 sessions, 20 min every 2 weeks) Therapist-directed CBT (12 sessions, 90 min twice per week) Gilliam et al., Behav Res Ther 2010;48:1144-1149

Results of Study 2 Total Study: 5 (36%) dropouts 7 (88%) responders Bibliotherapy + therapist-supported CBT: 2 (14%) dropout 5 (36%) responders d = 1.26 Therapist-directed CBT: 3 (50%) dropouts 2 (67%) responders d = 2.22 Total Study: 5 (36%) dropouts 7 (88%) responders d = 1.99 Gilliam et al., Behav Res Ther 2010;48:1144-1149

Study 3 (N = 30) Randomized Controlled Trial Stepped care (n = 18) Bibliotherapy + therapist-supported CBT (3 sessions, 20 min every 2 weeks) Therapist-directed CBT (17 sessions, 90 min twice per week) Standard treatment (n = 12) Therapist-directed CBT (17 sessions, 90 min twice per week) Tolin et al., Depress Anxiety 2011;28:314-323

Results of Study 3 Stepped care: Standard treatment: 5 (28%) dropouts 9 (36%) responders dpost = 1.68 dFU = 1.79 Standard treatment: 2 (17%) dropouts 5 (50%) responders dpost = 2.00 dFU = 1.71 Tolin et al., Depress Anxiety 2011;28:314-323

Average Costs of Treatment (Direct + Indirect Costs) Stepped Care Standard Treatment d Fixed dose $3122 $5223 0.96 Flexible dose $2480 $4280 0.81 Tolin et al., Depress Anxiety 2011;28:314-323

What is the Cost of Delaying Effective Treatment? Calculated cost of illness Total number of lost productivity days Work loss days due to illness + (Work cutback days due to illness * 0.5) Multiplied by average daily wage in region Test-retest reliability r = 0.84 Kessler & Frank, Psychol Med 1997;27:861-873

Costs of Treatment + Illness Stepped Care Standard Treatment d Direct treatment cost $2446 $4162 0.96 Indirect treatment cost $998 $1583 0.78 Cost of illness $2522 $3796 0.29 Total cost $5966 $9540 0.66 Diefenbach & Tolin, J OCD Relat Disord 2013;2:144-148

Need for patient-treatment matching Identify patients more likely to respond to the initial (minimal) step Divert those unlikely to benefit into immediate treatment Reduce dropout Reduce indirect cost (illness burden)

Study 4: Internet-guided self-help Open trial 17 weeks Therapist support every 2 weeks 29% dropout rate 29% completer clinically significant change

Predictors of response * *

Summary Stepped care and standard treatment have comparable efficacy Stepped care has lower treatment costs (large effect) than standard treatment Dropout and cost of illness remain a concern Pre-treatment motivation and early attendance may be favorable signs

Thank you!