1. 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

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

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

4. Barriers to Receiving CBT
Marques et al., Depress Anxiety 2010;27:

5. Can Bibliotherapy Work?
Tolin et al., Behav Ther. 2007;38:

6. 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

7. 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

8. 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:

9. 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:

10. 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:

11. 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:

12. 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:

13. 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:

14. 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:

15. 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:

16. 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:

17. 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)

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

19. Predictors of response* *

20. 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

21. Thank you!