Stepped care for obsessive-compulsive disorder: A pilot study

Cognitive-behavioral therapy incorporating exposure and ritual prevention (EX/RP) is the first-line psychosocial treatment of choice for obsessive-compulsive disorder (OCD). However, several barriers to care prevent many OCD patients from receiving this treatment. Previous research has indicated that some OCD patients may benefit from less intensive treatment options, such as bibliotherapy; however, it is not clear how to assign patients to their appropriate level of treatment. We suggest that an optimal approach may be to use a stepped care protocol, in which patients begin with a low-intensity treatment and then progress to more costly (but perhaps more efficacious) treatments as needed. In this pilot study, 11 adults with OCD initially received bibliotherapy EX/RP treatment; 20% of patients completing this treatment met stringent responder criteria. The remaining patients were then assigned to a therapist who provided brief education and EX/RP advice but did not actually assist patients with exposure exercises. Twenty-nine percent of patients who completed this treatment were classified as responders. The remaining patients then received the more traditional therapist-administered EX/RP; 67% of patients completing this treatment were responders. Across the entire protocol, 86% of treatment completers and 80% of the intent-to-treat sample were rated as “much improved” or “very much improved.” Cost-effectiveness analyses, in which the total cost of treatment was divided by the degree of symptom reduction, showed that stepped care compared favorably to other forms of EX/RP delivery. We provide a detailed case discussion that illustrates the clinical decision-making process and one patient's response to different levels of treatment.