Videoconferencing-delivered psychotherapy for obsessive-compulsive disorder in low-resource settings: A pilot study from India

Abstract

BACKGROUND

Psychological treatments such as exposure and response prevention (ERP) or cognitive behavioral therapy are effective in obsessive-compulsive disorder (OCD), either on their own or in combination with medications. However, very few patients receive ERP or cognitive behavioral therapy. Digital-delivered psychotherapy can surmount many obstacles associated with conventional psychotherapy, but there are very few trials of videoconferencing (VC) delivered ERP for OCD, particularly from low-resource settings.

AIM

To examine the VC-delivered ERP’s feasibility, acceptability, efficacy, and long-term outcomes and compare its efficacy with inpatient ERP.

METHODS

This study compared VC ERP’s pre- and post-intervention efficacy (n = 20) with a matched group of patients who had undergone inpatient ERP (n = 17). The Yale-Brown Obsessive-Compulsive Scale (YBOCS) scores rated the efficacy of ERP. The feasibility outcomes for VC-delivered ERP included the operational capacity, treatment utilization, treatment engagement, use of other services, and adverse events. Treatment satisfaction and preferences among users determined acceptability. Long-term follow-up determined whether patients were in remission based on the YBOCS scores and other criteria.

RESULTS

The sample had 97 patients with OCD. The patients had severe (YBOCS score 27) and chronic (6 years) OCD with psychiatric comorbidity (51%). The refusal rate for VC-ERP was 11%, and the dropout rate was 19%. VC-ERP failed in 29% with treatment-resistant OCD. The 20 patients who completed VC-ERP had 85% reductions in the YBOCS scores and recovered completely. The two groups did not differ in the change in YBOCS scores with the treatment. Gains from VC-ERP persisted for more than 2 years. The VC platform could deliver ERP despite the fluctuating network connectivity and variable patient motivation. The VC treatment improved access to ERP for many more patients. Users found VC-ERP acceptable and appreciated its advantages over inpatient ERP.

CONCLUSION

Despite its methodological limitations, this study suggests that VC-delivered ERP is feasible, acceptable, and as efficacious as in-person ERP for OCD in the resource-constrained settings of low- and middle-income countries.

Key Words: Videoconferencing; Exposure-response prevention; Obsessive-compulsive disorder; Pilot study; Low-resource settings

Core Tip: Videoconferencing (VC) delivered exposure and response prevention (ERP) may be suitable for the treatment of obsessive-compulsive disorder (OCD) in low-resource settings, but there are no trials. This study examined the feasibility, acceptability, efficacy, and long-term outcomes of VC-delivered ERP in 97 patients with OCD and compared its efficacy with inpatient ERP. Despite its methodological limitations, this study suggests that VC-delivered ERP was feasible, acceptable, and as efficacious as in-person ERP. Gains from VC-ERP persisted for more than 2 years. VC-delivered ERP is a viable treatment option for OCD in the resource-constrained settings of low- and middle-income countries.

INTRODUCTION

Challenges in the global treatment of obsessive-compulsive disorder

Psychological treatments such as exposure and response prevention (ERP) or cognitive behavioral therapy (CBT) are effective in obsessive-compulsive disorder (OCD), either on their own or in combination with medications[1,2]. However, only a small proportion of patients with OCD receive ERP or CBT. Low rates of help-seeking and long delays of about 10 years in seeking treatment are standard globally[2-5]. In high-income countries, 60% of the patients remain untreated or receive inadequate treatment, and less than 10% receive ERP or CBT that meets minimum standards of care[5-7]. Treatment-seeking rates are much lower, and the treatment gap is larger in low- and middle-income (LAMI) countries, with only about 10%-15% of the patients having access to any treatment[8,9].

Provider and patient-related barriers to psychological treatment for OCD

Several provider- and patient-related barriers prevent patient access to psychotherapy for OCD. The major provider-related hurdle is the lack of clinicians trained in delivering psychological treatments[1,3,4,10,11]. The inequitable distribution of trained specialists means that access to these treatments is particularly limited for people from remote areas. Lack of adequate training also leads to non-recognition of OCD and negative perceptions of psychosocial treatments among clinicians[3,6]. For patients, the main barriers to treatment are inadequate awareness and negative attitudes, stigma, low expectations from treatment, high treatment costs, and the intensive involvement required for psychotherapy[2,4-6]. Other patient barriers are having to travel long distances to obtain care, problems with transportation, physical limitations such as illness, old age, and poor mobility, and social hurdles such as the inconvenience of hospital visits for working people or mothers with young children[2,6,10]. Moreover, poor motivation and treatment non-adherence are common among patients who start treatment, often leading to unsuccessful outcomes[2,10].

The role of digital interventions

Digital interventions can surmount many obstacles associated with conventional psychotherapy[1,3-6]. Digitally delivered psychotherapy saves costs and travel time, can prevent treatment delays, is more convenient for patients and therapists, and may improve motivation and treatment engagement because of frequent therapist contact. Thus, digital interventions are more efficient in delivering and disseminating psychotherapeutic treatments.

Digitally delivered psychotherapies for OCD

A wide range of digital interventions that deliver ERP or CBT using information and communications technologies are currently available to treat OCD[1,11-14]. Digital ERP or CBT can be delivered using telephones, computers, mobile devices, or internet-based platforms. The most commonly used digital psychotherapies for OCD are videoconferencing (VC) delivered ERP or CBT, and internet-delivered psychotherapy. The synchronous form of VC psychotherapy involves interactive and real-time communication between clinicians and patients. Internet-delivered treatments include internet-based CBT (ICBT), bibliotherapy, web-based self-help, smartphone interventions, and virtual-reality-based treatments (Supplementary Table 1).

Efficacy of VC-delivered ERP or CBT for OCD

Although VC-delivered ERP or CBT is commonly used, particularly in LAMI countries, the evidence for its efficacy is limited. Reviews[1,6,15-17] and meta-analyses[2-4,12,14] of digital interventions for OCD include very few studies of VC-delivered ERP or CBT. Correspondingly, reviews and meta-analyses of VC-delivered treatments for psychiatric disorders include very few studies of OCD[18-22]. Most studies and randomized-controlled trials (RCTs) involve therapist-guided and self-guided ICBT interventions, followed by computer-based and phone-based CBT treatments.

The number of VC-delivered ERP or CBT trials is relatively small[1,4,11,13]. Supplementary Table 2 includes a list of VC-delivered ERP trials. There are only 5 RCTs of VC-delivered ERP or CBT for OCD. These RCTs have shown that VC treatments are superior to control treatments and equal to in-person treatments in reducing OC symptoms, improving quality of life, patient satisfaction, treatment engagement, and working alliance. The number of open trials is greater. They have shown that VC-delivered treatments are feasible, acceptable, and safe. Additionally, VC-delivered ERP leads to a reduction in depressive and anxiety symptoms, improved functioning, more positive therapists’ attitudes, and is cost-effective. Recent naturalistic studies have indicated that VC-delivered treatments are also helpful in routine care settings. However, a convincing demonstration of the effectiveness of VC treatments for OCD will require more methodologically sound research.

The evidence base for the efficacy of ICBT is larger and more robust. Nevertheless, the two treatments seem equally effective. Only one meta-analysis suggested that high-intensity treatments such as VC might be more efficacious than low-intensity treatments such as ICBT[4].

The challenge of treating OCD in LAMI countries

The evidence suggests that the prevalence of OCD, its demographic and clinical correlates, and its impact are not different in LAMI countries[8,23-26]. The principal reason for the large treatment gap is the lack of specialist treatment facilities for OCD[9,27]. Although in-person ERP or CBT appears to be effective[28-31], the management of OCD relies heavily on medications because of the lack of specialists to deliver psychological treatments[27]. Unawareness, negative perceptions of treatment, and stigma among patients and families also contribute to the treatment gap.

Digital psychotherapies for OCD in LAMI countries

Digital interventions can potentially improve access to ERP or CBT for OCD[29]. However, there are substantial gaps in the delivery of digital interventions in India[32] and other LAMI countries[33-36]. Although these countries enhanced their digital services during the coronavirus disease 2019 (COVID-19) pandemic[37], considerable improvements in infrastructure, human resources, and regulations will be needed to catch up with high-income countries[36].

VC-delivered ERP or CBT for OCD in LAMI countries

Digital interventions are effective for psychiatric disorders in low-resource settings, but most of the studies have involved patients with depression, substance use disorders, post-traumatic stress disorder, and psychosis[33-35]. There are no studies of VC-delivered ERP or CBT for OCD from LAMI countries.

The limited research on the efficacy of ERP or CBT from these countries suggests that the traditional ERP or CBT format must be modified to overcome cultural barriers and improve acceptability and treatment engagement in these countries[29,38]. Moreover, the most suitable mode of delivery of digital interventions for OCD is uncertain. The advantages of VC-delivered treatment are its similarity to in-person treatment, ability to access people from remote and underserved areas, flexibility and adaptability that may lead to greater generalization of gains, and greater family involvement (Supplementary Table 1). These features make VC-based treatments more suitable for low-resource settings, where the primary concern is to reach patients in remote areas and to provide high-quality specialist treatment for those who do not have access to such care. VC treatment is still commonly used in LAMI countries[34]. Technological developments, inexpensive and easy-to-operate equipment, and the availability of several free platforms have ensured that it remains a viable form of treatment[20]. Moreover, there has been renewed interest in VC treatment since the COVID-19 pandemic, when clinicians used it extensively to treat OCD[2]. However, because of the intensive therapist involvement, VC-delivered ERP might not be suitable for wider dissemination of ERP or CBT for OCD[33]. On the other hand, there are few studies of ICBT in non-Western settings[39-41]. Therefore, an adequate examination of the effectiveness of ICBT for OCD in low-resource settings remains a challenge.

Aims and objectives of the current study

This study aimed to fill the gap in research on VC-delivered ERP for OCD from LAMI countries. The development of a VC-delivered ERP treatment and preliminary findings of its usefulness suggested that VC could be a viable option for delivering ERP in the low-resource settings of these countries[42]. The current study aimed to examine the feasibility, acceptability, efficacy, and long-term outcomes of the VC-delivered ERP in a larger group of patients than the earlier study. Additionally, this study compared the efficacy of VC-delivered and inpatient ERP.

MATERIALS AND METHODS

This report followed the STROBE guidelines for reporting observational studies.

Site of the study and a home-based VC service for delivering ERP

The site of this study was the psychiatry department of a multi-specialty hospital in northern India. The unit has a large patient load, with patients coming from distant locations. Visits to the hospital are usually complicated, time-consuming, and costly; therefore, outpatient ERP is less feasible.

The home-based VC service delivered a comprehensive ERP treatment[43]. The service provided medication management and psychotherapeutic treatment by utilizing free VC platforms such as Zoom or Google Meet and supplemented by landlines, smartphones, WhatsApp video calls, texts, and e-mails. The treatment also incorporated standard protocols for training, privacy, confidentiality, safety, and record-keeping, ensuring a high standard of care. The treatment protocol of the VC-delivered ERP intervention has been described in detail earlier[42]. Table 1 provides a summary of its features[44,45]. The consultant and qualified senior trainees supervised the trainee psychiatrists who conducted the treatment at weekly VC groups.

Table 1 Videoconferencing-delivered exposure and response prevention for obsessive-compulsive disorder.

Modules	Description
Diagnostic evaluation	ICD-10 diagnosis of OCD established by detailed evaluation
Management plan	Pharmacological and psychosocial interventions for treatment
Brief psychoeducation	1-2 sessions explaining OCD and its treatment. Agreement on medication and ERP treatment between patients, family members, and therapists
Scale-based evaluations	YBOCS screen for OC symptoms not reported initially. YBOCS rating of the severity of OCD
Functional analysis	Structured behavioral analysis following the “ABC” paradigm[44]
Pre-treatment symptom tracking	1-2 weeks of daily record of symptoms in structured formats by patients and family members. Exchanged with the clinician using Google sheets or WhatsApp text messages
Hierarchy of symptoms	Ascending hierarchy of symptoms/situations rated on a 0%-100% scale of subjective distress; jointly constructed by patients, family members, and therapists.
ERP constituents	Detailed psychoeducation, symptom tracking within and between ERP sessions, anxiety management (Benson’s Relaxation Training[45], exposure sessions, post-session processing
	Post-session processing includes discussions about patients’ and family members’ experience of ERP, learning about ERP, reality of the patient’s obsessions, neutralizing strategies, and adaptive coping
VC-delivered sessions	All sessions at home are attended by patients and family members and supervised by therapists. Minimum duration 30 minutes. Average 1 session every 7-14 days. Patients are actively engaged by therapists during sessions to avoid unnecessary interruptions or distractions. Patients are carefully monitored during the sessions for obsessional thoughts, compulsions, or neutralizing acts. Additional advice by phone calls or WhatsApp text messages
Homework assignments	Daily exposure sessions supervised by the family member who was chosen by the patient as a co-therapist
Hybrid treatment	Combination of VC and in-person sessions. Alternative modes of communication were used to minimize disruptions when the VC connection failed
Preventing relapse	Regular VC follow-ups, further education, and booster sessions of ERP if required
Supervision	VC groups for training and regular supervision of therapist carrying out ERP

ICD-10: International Classification of Diseases, 10^th version criteria; OCD: Obsessive-compulsive disorder; YBOCS: Yale-Brown Obsessive-Compulsive Scale; OC: Obsessive-compulsive; ABC: Antecedents, behaviour, consequences; ERP: Exposure and response prevention; VC: Videoconferencing.

Approval and consent

This study was part of a larger study on home-based VC services for all patients, including those with OCD. The institute’s ethics committee approved the protocol in 2020 and renewed it in 2024. The approval allowed for recorded verbal informed consent. The study included patients who gave such consent and also consented to engage in ERP. The study followed the guidelines of the Declaration of Helsinki for medical research involving human subjects.

Recruitment of participants

Participants included adult (> 18 years) patients with OCD accompanied by an adult family member who attended the psychiatric clinic either virtually or in person. Participants verbally consented to undertake ERP and completed at least one ERP session. The study excluded patients who were very severely depressed, at risk of self-harm, or with OCD secondary to medical conditions. The diagnoses of OCD and comorbid psychiatric conditions followed the International Classification of Diseases, 10th version criteria[46].

Assessments of outcome

Efficacy: The current investigation was a naturalistic, observational, and longitudinal study. It included a controlled comparison of ERP’s pre- and post-intervention efficacy and follow-up for over 2 years to determine the long-term outcome of VC-delivered ERP. The study compared the efficacy of VC-delivered ERP (n = 20) with a matched group of patients who had undergone inpatient ERP in 2016-2017 before the start of the VC treatment (n = 17). The Yale- Brown Obsessive-Compulsive Scale (YBOCS) scores rated the efficacy of VC-delivered ERP and inpatient ERP. Although monthly YBOCS ratings were available, the efficacy analysis included only pre- and post-ERP scores.

Feasibility: The feasibility outcomes for VC-delivered ERP included the operational capacity, treatment utilization, treatment engagement, use of other treatment services, and the frequency of adverse events. This study extracted the data on treatment engagement (refusal and dropout rates), treatment utilization (the additional use of emergency services), and the frequency of adverse events from the medical records.

Acceptability: Treatment satisfaction and treatment preferences among patients, caregivers, and therapists determined the VC treatment’s acceptability. Feasibility outcomes, such as the operational capacity (barriers and solutions) and acceptability outcomes (treatment satisfaction and preferences among users), were assessed using an unstructured questionnaire.

Follow-up assessments: After receiving VC-delivered ERP, patients were followed up by VC every 1-2 months. This study assessed whether patients met remission criteria during the last follow-up. Remitted patients met the criteria set out by Mataix-Cols et al[47] of a YBOCS score < 12 for a week. Recovered patients had YBOCS scores < 12 for 6-12 months. Relapsed patients had YBOCS scores of > 13 or met the criteria for OCD during follow-up.

Statistical analysis

Frequencies, means, and standard deviations described the sample characteristics. Loss to follow-up at any time was considered a dropout. Group comparisons used χ² and Student’s t-tests. Student’s t-tests examined the pre-and post-treatment comparisons.

RESULTS

Participant profile

The VC-delivered ERP treatment program started in July 2020. From July 2020 to July 2023, the sample included 97 patients with OCD advised to start VC-delivered ERP. Eleven patients refused ERP, and 86 patients started the treatment. Twenty patients completed the treatment, and 16 patients dropped out. Eight patients were hospitalized for inpatient ERP because VC-delivered ERP failed. Forty-two patients are continuing on VC-delivered ERP. The 86 patients were about 32 ± 9.36 years old, most were women (n = 50), married (n = 53), college graduates (n = 62), and urban-based (n = 70). About half of them (n = 44) had comorbid disorders, mostly depressive disorders (n = 34), followed by schizophrenia spectrum disorders (n = 7) and bipolar disorder (n = 3). The patients had suffered from OCD for about 6 years (6.44 ± 5.30). Their average YBOCS scores (27.46 ± 6.10) put them in the severe OCD category. All patients were on concomitant medications, which included selective serotonin reuptake inhibitors and clomipramine. The average dose was 40 mg/day of fluoxetine or its equivalent. The patients were on stable doses of medications and took them regularly during the ERP treatment. Although the details of medications and response to medications before ERP were unavailable, most patients had received multiple medication trials before commencing ERP. However, none of the patients had received psychotherapy before starting VC-delivered ERP.

Table 2 includes the demographic and clinical details of the patients who had completed the VC-delivered ERP and inpatient ERP treatment. There were no significant differences in the patient variables between the two groups.

Table 2 Participants of the videoconferencing-delivered and inpatient exposure and response prevention treatment groups.

Variables	VC-delivered ERP (from 2020-2023) (n = 20)	Inpatient ERP (from 2016 and 2017) (n = 17)	Comparisons
Age (year), mean ± SD	30.90 ± 8.10 (range 18-56)	31.71 ± 13.60 (range 16-61)	t = 0.22; df = 35; P = 0.82 - not significant
Gender			χ2 = 1.30; df = 1; P = 0.25 - not significant
Men	12	7
Women	8	10
Marital status			χ2 = 2.47; df = 1; P = 0.12 - not significant
Single	13	7
Married	7	10
Education			χ2 = 0.29; df = 1; P = 0.59 - not significant
College graduates	10	07
School education	10	10
Residence			χ2 = 0.50; df = 1; P = 0.48 - not significant
Urban	14	10
Rural	6	7
Comorbidity			χ2 = 1.96; df = 1; P = 0.16 - not significant1
Depressive disorders	5	8
Schizophrenia spectrum disorders	2	2
Bipolar disorder	3	0
Other disorders	0	2
Duration of OCD (years), mean ± SD	7.43 ± 6.51 (range 1-25)	9.00 ± 6.16 years (range 2-26)	t = 0.75; df = 35; P = 0.46 - not significant

¹Comparison of depressive vs combined comorbid bipolar, comorbid schizophrenia spectrum, and other comorbid disorders (trichotillomania and dissociative disorder).

VC: Videoconferencing; ERP: Exposure and response prevention; OCD: Obsessive-compulsive disorder.

VC-delivered and inpatient ERP

Table 3 includes the details of the ERP for both groups. The VC-delivered ERP treatment took significantly longer than inpatient ERP. Therapists supervised ERP sessions through VC every 7-14 days, whereas therapists conducted daily sessions for inpatients. Consequently, the number of supervised sessions for inpatient ERP was significantly greater than the VC-delivered ERP.

Table 3 Videoconferencing- delivered exposure and response prevention treatment for obsessive-compulsive disorder: Comparison with inpatient treatment.

Variables	VC-based ERP (from 2020-2023) (n = 20)	Inpatient ERP (from 2016 and 2017) (n = 17)	Comparisons
Duration of ERP (month), mean ± SD	5.5 ± 3.3 (range 3-9)	2.5 ± 2.4 (range 2-5)	t = 3.11; df = 35; P < 0.01
Frequency of sessions	Clinician supervised: Every 7-14 days	Daily sessions supervised by clinicians and attended by family members	-
	Family member supervised: Daily
Average number of clinician-supervised ERP sessions, mean ± SD	11 ± 5.4 (range 6-18)	63.5 ± 30.1 (range 45-90)	t = 7.67; df = 35; P < 0.001
Duration of ERP sessions	30-45 minutes	40-75 minutes	-
Average pre-treatment YBOCS scores, mean ± SD	27.45 ± 5.65 (range 17-38)	28.07 ± 7.84 (range 11-38)	t = 0.44; df = 35; P = 0.67 - not significant
Average post-treatment YBOCS scores, mean ± SD	4.02 ± 3.85 (range 0-13)	9.73 ± 8.11 (range 0-24)	t = 2.80; df = 35; P < 0.05
Pre-treatment vs post-treatment YBOCS scores	Significant change (P < 0.001)	Significant change (P < 0.001)	t = 2.0; df = 35; P = 0.05 - not significant
Change in YBOCS scores, mean ± SD	22.43 ± 7.79	17.36 ± 7.49
Cohen’s d values	4.85	2.30	-
Duration of follow-up	6-26 months	-	-
Outcome at last follow-up YBOCS and remission criteria1	YBOCS score at last follow-up: 3.55 ± 2.35	-	-
	All patients had remained in recovery and none had relapsed

¹Remission criteria according to Mataix-Cols et al[47].

VC: Videoconferencing; ERP: Exposure and response prevention; YBOCS: Yale-Brown Obsessive-Compulsive Scale.

Feasibility of VC-delivered ERP

It was possible to deliver the VC treatment using the home-based VC service. Poor network connectivity was the primary barrier for clinicians, patients, and family members. Poor connectivity was mitigated to some extent by additional WhatsApp video calls or phone calls. Patients also faced difficulties in scheduling sessions. For therapists, variable patient motivation presented a significant problem. Increasing the frequency of sessions, psychoeducation, and in-person visits was used to improve patients’ motivation. The refusal rate was 11% (11/97 patients). The dropout rate was 19% (16/86) at the last assessment, but this figure could change if some of the 42 patients with ongoing ERP were to drop out. The analysis of completers vs dropouts showed no significant differences in demographic and clinical parameters. Though the VC-based ERP failed in 8 patients (29%) with very severe and treatment-resistant OCD, none of the patients reported any adverse events during the treatment. Only five patients reported the additional use of emergency services. Comparisons with the inpatient-ERP group showed that twice as many patients were treated with VC-delivered ERP annually.

Acceptability of VC-delivered ERP

Patients, family members, and clinicians were satisfied with the treatment. Users reported that the main advantages were improved access, greater flexibility, and convenience compared to in-person treatment and the opportunity for closer contact between the patients and therapists. About half the patients and family members used hybrid care and felt it was beneficial.

Efficacy of VC-delivered ERP

Table 3 details the 20 patients who have completed their treatment. Although the severity of OCD and the rates of comorbidity were similar to the total sample, the patients who completed ERP were more likely to be men, single, and with lower educational levels compared with the total sample of patients.

VC-delivered ERP led to a significant reduction (85%) in the YBOCS scores. Cohen’s d estimations showed a large effect size. All patients had recovered by the end of treatment according to the response criteria[47]. Two of these 20 patients recovered following the initial psychoeducational and relaxation treatments. The treatment response did not differ between patients with or without additional comorbid disorders.

Treatment gains in these patients have been maintained from 6 months to over 2 years. At the most recent follow-up, the mean YBOCS scores were 3.55 ± 2.35 for the last week. All patients had remained in remission and recovery for the last 6-12 months. None of the patients had scored > 13 on the YBOCS or met criteria for OCD during follow-up.

The inpatient group also showed significant reductions in the YBOCS scores with ERP. The two groups did not differ in the change in YBOCS scores with the treatment. However, the post-treatment YBOCS scores were significantly lower in the VC group compared with the inpatient group. Cohen’s d estimations showed a smaller effect size for the inpatient than the VC-ERP group.

DISCUSSION

The VC-delivered ERP treatment of this study

The core constituents of the VC-delivered and inpatient ERP treatment were similar and based on standard ERP protocols[48-50]. However, the format was adapted to suit patients’ and families’ needs and delivery by VC. Post-session processing replaced cognitive restructuring because it is a more straightforward technique to address dysfunctional cognitions and neutralizations[6,49,51,52]. Before the start of treatment, brief psychoeducation allowed the patients and families to make decisions about treatment based on the evidence[50,53-55]. Brief psychoeducation also improved the patients’ and family members’ motivation for ERP and prepared them to tolerate the anxiety that arose from exposure. Stress management used a VC-adapted form of Benson’s Relaxation Training[45] to reduce distress, improve motivation for ERP, and cope with anxiety[48]. WhatsApp texts or Google Sheets for daily symptom monitoring by patients and family members were consistent with the substantial evidence demonstrating the accuracy and reliability of VC-based assessments for OCD[19]. Daily monitoring of symptoms through VC reduces recall biases, allows instant therapist feedback, and improves the quality of the VC-delivered ERP[1,16]. Prolonged exposure sessions by VC were less feasible and less acceptable to patients. Therefore, exposure lasted at least 30 minutes per session[42]. Family members were essential to the treatment because the family’s positive involvement is crucial to ERP’s success[50]. Hybrid care included alternative modes of communication to minimize disruptions in network connectivity and the blending of VC and in-person sessions. The use of multiple modes of communication makes the systems more versatile and ensures continuity of care[10,16,56]. Recent studies have suggested that multiple digital modes enhance the efficacy and acceptability of VC-delivered ERP[57,58]. Blending VC-delivered and in-person sessions helps improve access, saves costs, and enhances the treatment alliance[20,59]. A recent Indian study also found hybrid treatment to be effective in a young woman with OCD[60]. Patients had a range of treatment options, including brief psychoeducation and anxiety management for mild OCD, exclusive VC-delivered or hybrid treatment for moderate to severe OCD, and inpatient care for those with treatment-resistant OCD. Therefore, the treatment program could incorporate stepped care. In the context of digital interventions for OCD, stepped care refers to the initial use of low-intensity treatments for less severe OCD, followed by high-intensity or in-person treatment for more severe OCD[4,11,61]. Lastly, VC groups for training and supervising therapists facilitated the delivery of ERP through VC. However, VC-based psychotherapy supervision is an evolving area that has not been explored adequately[59,62].

Feasibility, acceptability, and efficacy of the VC-delivered ERP

The VC platform could deliver ERP despite the fluctuating network connectivity and variable patient motivation. The VC treatment substantially increased access to ERP for many patients. It was less demanding of the patients’, family members’, and therapists’ time. The VC-delivered ERP was successful in most patients except those with very severe and resistant OCD. It could be delivered safely. The refusal and dropout rates were consistent with earlier reports[3,10]. However, since many patients are still undergoing ERP, the dropout rates may increase. Patients, family members, and clinicians found VC-delivered ERP acceptable and appreciated its advantages compared to inpatient ERP. The hybrid care option was particularly helpful in improving treatment engagement. The VC treatment was efficacious in reducing OC symptoms and inducing remission. Although the patients treated had severe and chronic OCD with high rates of comorbidity, this did not seem to affect the efficacy of the VC treatment. The short-term efficacy of VC-delivered ERP was not significantly different from that of the more intensive inpatient ERP. However, post-treatment YBOCS scores were significantly lower and the effect sizes larger in the VC-delivered ERP group. The reasons for these differences were not clear. They could be due to the longer duration of VC-delivered ERP or the methodological issues relating to the comparisons. It was not possible to compare long-term outcomes between VC and inpatient ERP, but the VC-delivered ERP led to persisting gains for long periods. Despite the small number of patients involved, these results were very similar to the evidence regarding the efficacy of VC-delivered ERP treatment in OCD, especially from the recently conducted naturalistic studies (Supplementary Table 2). The efficacy of the VC-delivered ERP was also similar to in-person ERP in studies from India and other LAMI countries[28-31].

Limitations

This pilot, naturalistic, observational study of VC-delivered ERP for OCD had some obvious limitations. The number of patients was small, but the recommendations for sample sizes of pilot studies were met[63,64]. There are no clear recommendations for sample sizes for pilot studies[63,64]. An ideal sample size would be about 30 patients in each group, but a minimum of 8-12 patients is also acceptable[63,64]. Although the estimation of sample sizes is not necessary for pilot studies, RCTs of VC delivered ERP should carry out a sample size calculation derived from earlier studies.

Nevertheless, the small sample size limits statistical power, increases the risk of type II errors, and may lead to overestimating treatment effects. Therefore, conclusions about efficacy or equivalence of efficacies are not always accurate in pilot studies[63].

The inpatient control group was similar to the VC group in terms of ERP treatment. Moreover, the two groups had similar demographic and clinical profiles. However, inpatient ERP was more intensive because therapists supervised sessions daily. Other differences, such as selection biases or the effect of medications, could have influenced the efficacy comparisons between VC and inpatient ERP.

Another limitation was that follow-up status was determined at the last follow-up assessment since prospective data on YBCOS scores were unavailable. Examining operational capacity (barriers and solutions) and acceptability outcomes using unstructured qualitative analysis and not scale-based assessments limits the generalization of the findings of this pilot study.

Finally, this observational study could not control for biases arising from medications and comorbid conditions. It was not possible to separate the effects of medications from the effects of combined treatment with medications and ERP. The inability to determine independent effects of ERP has also been a common failing of RCTs of ERP for OCD, since patients with severe OCD are invariably treated with a combination of medications and ERP[2]. In this study, the average dose of 40 mg/day of fluoxetine or its equivalent for medications was adequate, the doses remained stable during ERP, and patients adhered to the medication treatment. Although the details of medications and response to medications before ERP were unavailable, most patients had received multiple medication trials before commencing ERP.

In contrast, none of the patients had received psychotherapy before starting VC-delivered ERP. The severity and chronicity of their OCD indicate that medications were not very effective before patients received ERP as a part of their treatment. Nevertheless, it is impossible to attribute the 85% reduction in YBOCS scores to ERP alone. Medications may have contributed to the reductions in YBOCS scores, but this cannot be determined precisely.

CONCLUSION

Despite its limitations, this study suggests that VC-delivered ERP is feasible, acceptable, and as efficacious as inpatient ERP. It can improve access to evidence-based ERP. VC-delivered ERP could be suitable for the treatment of OCD in LAMI countries, where specialist treatment resources are limited, and the treatment gap for OCD is greater than in high-income and resource-rich countries. However, a more rigorous examination of the efficacy of VC-delivered ERP is needed. Further efforts are required to improve access for women, homemakers, the less literate, and those from rural areas. Large-scale and methodologically adequate trials will also be needed to make VC-delivered treatments for OCD a part of mainstream care in low-resource countries.