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©The Author(s) 2023.
World J Psychiatry. Feb 19, 2023; 13(2): 60-74
Published online Feb 19, 2023. doi: 10.5498/wjp.v13.i2.60
Published online Feb 19, 2023. doi: 10.5498/wjp.v13.i2.60
Table 1 The treatment protocol for videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder
| Components | Details |
| Detailed assessment | Establishing the diagnosis based on history and mental state examination |
| Relevant investigations. Formulating a management plan consisting of medications and psychosocial treatment. The decision to start ERP was made following this assessment | |
| Introductory psychoeducation1 | Brief introductory education sessions with patients and designated caregivers with the help of a two-page written information leaflet for them |
| Standardized assessments | (1) YBOCS screening |
| (2) YBOCS rating | |
| (3) Standardized behavioral analysis, e.g., by Hawton et al[40] | |
| (4) Construction of ascending hierarchy of symptoms (according to the subjective units of distress on a 0%-100% scale) | |
| Five-step ERP2 | Psychoeducation, symptom monitoring, relaxation exercises, exposure and response prevention, and processing |
| Conduct of VC sessions3 | All VC-ERP sessions were conducted at home, supervised by the clinician, and attended by the caregiver. WhatsApp messages or phone calls were used to convey advice regarding details of sessions, investigations, and medications |
| Additional strategies | Incorporation of additional techniques, e.g., thought stopping with ERP for those with predominant obsessions |
| Relapse prevention | Continued follow-up through VC with constant re-emphasis on all components of the ERP. Booster sessions, if required upon completion of the initial VC-ERP treatment |
| Caregiver involvement | A family member designated as the primary caregiver was involved in the entire process of the VC-ERP treatment. The caregiver conducted homework sessions |
| Hybrid care | Hybrid treatment had two components |
| (1) Employing a combination of VC-ERP sessions at home and in-person ERP sessions at the outpatient department | |
| (2) Employing multiple modes of patient-clinician communication such as VC, mail, text messages, and phones to augment in-person care |
Table 2 Content of the brief introductory education session for videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder
| Content |
| 1 What is OCD? What are obsessions and compulsions in OCD? |
| 2 How common is OCD? |
| 3 How does the patient feel while experiencing the symptoms of OCD? |
| 4 Why do patients develop OCD? |
| 5 What are the types of treatment available? |
| 6 What is the role of medications in treating OCD? |
| 7 What is ERP and how does it work? |
| 8 What is the need for ERP? |
| 9 How will the VC-ERP sessions be conducted? |
| 10 How long will the treatment take? |
Table 3 Problems with videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder and in-person and proposed solutions
| Difficulties with VC-ERP | Suggested solutions | |
| Understanding and motivation of patients and caregivers | It was harder to explain the procedure to patients/caregivers. Motivation to engage in VC-ERP was often low. As a result, treatment engagement was variable | Early initiation of psychoeducation and the more frequent use of hybrid treatment |
| Difficulties faced during the assessment | The initial assessment took longer. Frequent interruptions due to poor network connectivity and the need to restart the process several times were common. Patients/caregivers often complained about the long period of assessment. Some patients became more anxious during the process | Educate patients/caregivers about the likely timeframes for assessment and treatment during the introductory psychoeducation sessions. Additional in-person sessions and administering benzodiazepines for short periods could help control anxiety |
| Conducting ERP sessions-patient-related and caregiver-related difficulties | These included variable cooperation, discomfort and hesitation, worry about confidentiality, indulging in neutralization strategies during sessions, preference for in-person visits, and problems with the timing and duration of the sessions | Shorter VC-ERP sessions (minimum of 30 min) and flexible scheduling of sessions (every 7-14 d). Ongoing education of patients and caregivers to ensure realistic expectations from VC-ERP |
| Conducting ERP sessions-clinician-related difficulties | Clinicians faced problems in sustaining their motivation, dealing with the additional burden of VC sessions and the need to adjust to a new medium | Training, supervision, and support for clinicians through regular group meetings |
| Technological difficulties | Poor connectivity, unavailability of proper equipment, user’s unfamiliarity with technology, and time constraints | Modifications to the ERP procedure to make it more compatible with VC |
| Disadvantages | Group members conducting VC-ERP sessions rated it about three times as difficult compared to in-person ERP because of the problems encountered | A structured treatment package incorporating modifications in the treatment, ongoing education, and support for all users |
| Advantages | Group members agreed that VC-ERP had advantages such as greater access, convenience of carrying out sessions at home, and lesser likelihood of late disengagement if motivation could be ensured | The consensus was that though conducting VC-ERP may be more difficult than in-person ERP, the basic procedures and their implementation were similar |
Table 4 Modifications in technique required for conducting videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder
| VC-ERP components | Modifications made to the VC-ERP |
| Detailed psychoeducation | Carried out using manuals in English and the local language for clinicians, patients, and caregivers. The content was simple, brief, and provided clear explanations. Psychoeducation sessions continued throughout the treatment |
| Monitoring of symptoms and progress | Simultaneous monitoring was carried out by the patients, caregivers, and clinicians through VC sessions, Google sheets, or WhatsApp messages that were regularly updated. Constant feedback about the progress of treatment was provided to the patient |
| Relaxation exercises | Benson’s relaxation technique was preferred because of its brief and simple format. Autogenic training or modified Jacobson’s progressive muscular relaxation exercises were taught if required. Written instructions in English and the local language and audio-visual aids for teaching were available for clinicians, patients, and caregivers |
| Duration of VC-ERP sessions | Though prolonged exposure is the goal because of its greater efficacy, it was quite difficult to have VC sessions of more than 30 min. Thus, the minimum duration was set at 30 min with the opportunity to prolong the sessions according to the patient’s convenience |
| Frequency of VC-ERP sessions | The frequency of sessions varied from weekly sessions to one session every 10-14 d. Flexibility was essential in deciding the duration and frequency of sessions. Several other factors were considered, particularly patient/caregiver preferences, the stage of ERP, the severity of symptoms, and the availability of clinicians |
| Supervision of VC-ERP sessions | The patient’s camera was not only focused on the patient but also covered a significant portion of the room so that clinician could detect any surreptitious compulsions or neutralizing acts. The camera was never switched off during the sessions |
| Engaging patients during the VC-ERP sessions | Clinicians, patients, and caregivers were all actively involved during the VC-ERP sessions. Every effort was made to minimize distractions. Neutralizing acts were noted and discussed later during processing. The clinician engaged with the patients at regular intervals to make sure that they were focusing on the treatment and to check the level of anxiety during sessions. However, constant talking was avoided because this might distract the patient |
| Ensuring patients’ tolerance of anxiety | Patient comfort with the level of exposure and their ability to tolerate anxiety was of overriding importance. They were never forced to engage in something that made them uncomfortable during the ERP sessions. Rather, each step was undertaken after proper education and fully ensuring the patient’s agreement and cooperation |
| The slower pace of VC-ERP | VC-ERP was expected to progress at a much slower pace than in-person ERP. This was explained to the patients and caregivers and usually did not present a problem |
| Privacy and confidentiality | Privacy was essential, and patients were informed about the people present in the room (e.g., technicians) when the session was being conducted. The patient was only accompanied by the designated caregiver at home. Any recording was done only with the patient’s explicit consent. All material relating to the treatment was stored securely |
| Safety | Patients were required to be accompanied by caregivers during the sessions. Anxiety levels were constantly monitored, and sessions were terminated if the patient was uncomfortable. If there were other concerns about the safety of the patient (e.g., risk of self-harm or violence), closer monitoring was instituted for such highrisk situations. Caregivers were also educated to manage such high-risk situations. For persisting safety concerns including symptom exacerbations during VC-ERP, patients and family members were helped to attend outpatient or emergency services |
| Treatment of comorbidities | Other modalities such as medications or occasionally ECT were used to treat primary or secondary comorbidities. The VC-ERP was adapted to meet the needs of patients with comorbid symptoms. Techniques utilized included temporarily suspending the sessions when comorbid symptoms increased, offering increased support at this time using the VC platform, promoting greater involvement of caregivers, and combining VC sessions with in-person sessions |
| Using hybrid modes of treatment | Hybrid care involved conducting some of the initial ERP sessions on an in-person basis and the later sessions by utilizing VC. Similarly, for each new step of the hierarchy, the initial session was an in-person one followed by VC sessions. This often mitigated the problems of poor understanding and variable motivation noted in exclusive VC-ERP treatment. Requests from patients and caregivers for in-person sessions were catered to as far as possible |
| Self-exposure | In exceptional instances when caregivers were not available, therapist-guided self-exposure was tried. A greater level of patient motivation was required for self-exposure and the pace of ERP was slower |
Table 5 Details of videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder
| Patients | Number | Comments/details |
| Patients with OCD attending the home-based TMH services during the study-period | 115 | This was 3% of all new outpatients and represented an increase in the number of such patients compared to the period before the pandemic |
| Patients available for analysis | 78 | ERP not considered (n = 17; 15%); improved with medications and did not require ERP (n = 2); refused ERP (n = 3); VC-ERP yet to be initiated (n = 13) |
| Patients in whom VC-ERP was initiated/early dropouts | 43 | Six patients dropped out from VC-ERP treatment. (Dropout rate 14%) |
| Improvement after initial treatment | 1 | One patient improved after initial psychoeducation and regular relaxation exercises and was not required to complete the entire VC-ERP treatment |
| Transition to hybrid care | 20 | Hybrid care became easier once the outpatient services resumed in December 2021 |
| Transition to inpatient ERP | 3 | VC-ERP was followed by inpatient-based ERP because of severe OCD and non-response to VC-ERP. |
| Patients who have undergone/are undergoing VC-ERP | 33 | VC-ERP has been completed in 11 patients and is ongoing in 22 patients |
Table 6 Efficacy of videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder
| Age | Sex | Marital status | Residence | Comorbidity | Duration of OCD | Baseline YBOCS score | YBOCS score at completion |
| Mean: 31.27 (SD: 9.65) yr, range: 22-56 yr | Men: 9; Women: 2 | Single: 8; Married: 3 | Urban: 9; Rural: 2 | OCD primary disorder: 7 (depressive disorder: 2); OCD secondary disorder: 4 (schizophrenia: 3; bipolar disorder: 1) | Mean: 6.90 (SD: 6.48) yr, range: 1-25 yr | Mean: 25.45 (SD: 5.63), range: 17-36 | Mean: 4.27 (SD: 4.22)1, range: 0-13 |
- Citation: Kathiravan S, Chakrabarti S. Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic. World J Psychiatry 2023; 13(2): 60-74
- URL: https://www.wjgnet.com/2220-3206/full/v13/i2/60.htm
- DOI: https://dx.doi.org/10.5498/wjp.v13.i2.60