HIGHLIGHTS

  • Digital health technologies such as videoconferencing could increase access to evidence-based treatments for obsessive-compulsive disorder (OCD).

  • This column describes five potential strategies for integrating videoconferencing into OCD treatment, as illustrated by a clinical case series.

  • Videoconferencing can enable remote exposure and response/ritual prevention, psychopharmacology, or support groups for OCD and could support clinical training and supervision.

Obsessive-compulsive disorder (OCD), a disabling psychiatric illness affecting 2% of adults, produces substantial societal burden. Effective treatments exist, including serotonin reuptake inhibitors and cognitive-behavioral therapy (CBT) with exposure and response/ritual prevention (EX/RP). Yet many people with OCD go untreated, and those who receive treatment often wait years between symptom onset and initial appointment. Barriers to accessing treatment include cost, stigma, clinician availability, and location (1).

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Increasing evidence suggests that digital health technologies, including videoconferencing and other approaches (e.g., online platforms, websites, and mobile applications), can circumvent these barriers (2). Since the 1980s (3), remote OCD treatment development has focused on EX/RP, a standardized treatment that is easily adaptable to telehealth formats (i.e., telephone, text, and videoconferencing). EX/RP clinicians teach patients to confront situations that trigger obsessive fears (i.e., exposure) while refraining from performing compulsions (i.e., ritual/response prevention). Patients gradually approach feared stimuli through real-life (in vivo) and imagined exposures, learning through repetition to apply these skills independently (4). A meta-analysis including 18 remote OCD treatment studies found large effect sizes for CBT delivered via telephone, text, and videoconferencing (3). Remote psychopharmacology for OCD has not been studied systematically (5).

Technological innovations and the COVID-19 pandemic have increased interest in using digital health technologies for OCD treatment. At the Center for OCD and Related Disorders, we have studied different digital health approaches (6, 7); for over a decade, we have also clinically used telehealth, specifically videoconferencing and telephone, to ensure continuity of care when patients could not visit onsite. However, when New York City became the pandemic’s epicenter, telehealth via videoconferencing became the de facto standard of care. In this column, we draw from these experiences to describe strategies for integrating videoconferencing into traditional OCD treatment. These include hybrid treatment combining in-person and videoconferencing-assisted EX/RP, fully remote EX/RP, remote psychopharmacology treatment, virtual support groups, and videoconferencing-assisted training for frontline clinicians. Through a clinical case series, we identify advantages, challenges, and practical considerations relevant to each strategy, highlighting topics requiring further study. (A table showing strategies, advantages, and potential challenges is available as an online supplement to this column.)

Videoconferencing-Assisted OCD Treatment: Potential Strategies

Hybrid EX/RP.

EX/RP can be delivered in a hybrid format that includes in-person and videoconferencing-assisted sessions. One approach is illustrated by case 1A (Table 1), in which EX/RP was delivered primarily in person. However, the therapist used videoconferencing to conduct home visits (recommended by EX/RP manuals but not always done in clinical practice), thereby eliminating travel burden for the therapist and patient. Videoconferencing also helped the therapist tailor exposures to the patient’s real-life context.

TABLE 1. Case studies illustrating videoconferencing-assisted OCD treatment strategiesa

Case and background Presentation Treatment courseb Patient comments
1A. 34-year-old woman requesting EX/RP Primary obsessions: fear of illness, disgust following perceived contamination. Primary compulsions: ritualized showering, avoiding contact with most surfaces. Pretreatment YBOCS: 32. Patient completed 12 in-person EX/RP sessions and two videoconferencing-assisted home visits. Exposures: touching toilet seats in office restrooms, imagining strangers’ urine. Midtreatment YBOCS: 19. Transitioned to fully remote to reduce patient’s burden of arranging child care. Patient completed five videoconferencing-assisted sessions, modifying exposures as needed (e.g., touching toilet seats at home, including possible dried urine). Posttreatment YBOCS: 10. “Scheduling was much easier without having to find a sitter.”
1B. 22-year-old woman requesting EX/RP Primary obsessions: fears of contracting STIs and causing fires. Primary compulsions: researching STI symptoms, reassurance-seeking, checking appliances. Pretreatment YBOCS: 28. Patient completed 10 in-person EX/RP sessions. Exposures: reading health-related articles, leaving appliances plugged in, imagining contracting STIs. Midtreatment YBOCS: 11. Transitioned to fully remote during COVID-19. Patient completed six videoconferencing-assisted sessions including similar exposures heightened by using home environment (e.g., leaving stove on). Posttreatment YBOCS: 6. “Doing exposures at home felt more real because that’s where my fears usually came up.”
2A. 30-year-old woman requesting remote EX/RP Primary obsessions: fear of self-harm, “just-right” concerns. Primary compulsions: repeating behaviors (e.g., entering/exiting doorways). Pretreatment YBOCS: 24. Patient completed 16 videoconferencing-assisted sessions. Exposures: reading articles about suicide, writing the word “suicide,” removing objects from “just-right” positions. Posttreatment YBOCS: 3. “I live upstate, 2 hours from the closest EX/RP therapist. Teletherapy has been lifesaving.”
2B. 28-year-old man requesting remote EX/RP during COVID-19 Primary obsessions: fear of homosexuality, perfectionism. Primary compulsions: mental reviewing, reassurance-seeking, rereading/rewriting. Pretreatment YBOCS: 21. Patient completed 16 videoconferencing-assisted sessions. Exposures: writing “I’m gay,” reading articles about gay celebrities, intentionally making typographical errors. Posttreatment YBOCS: 8. “I was nervous about being judged for these thoughts. Teletherapy seemed less intimidating.”
3. 30-year-old man requesting remote medication treatment during COVID-19 Primary obsessions: fears about dirt and germs, disgust following perceived contamination. Primary compulsions: excessive handwashing, showering. Medications: Escitalopram 20 mg/day, previously prescribed. Pretreatment YBOCS: 33. Escitalopram titrated to 40 mg/day, maintained for 6 weeks. Midtreatment YBOCS: 27. Patient reported reduced libido and minimal benefit, prompting cross-titration to sertraline 400 mg. Over subsequent 8 weeks, low libido resolved, and OCD symptoms improved. Posttreatment YBOCS: 15. “I couldn’t do weekly meetings, and with COVID, exposures felt unsafe. Thankfully, remote medication treatment was an option.”
4. 37-year-old woman requesting OCD treatment after voluntary hospitalization for OCD Primary obsessions: fears of developing incurable illnesses, being a pedophile, and harming herself/family. Primary compulsions: body-scanning, mental reviewing, reassurance-seeking. Medications (started in hospital 30 days prior): sertraline 100 mg/day, aripiprazole 5 mg/day, N-acetylcysteine 2,400 mg/day. Pretreatment YBOCS: 33. Patient completed eight in-person EX/RP/psychopharmacology sessions. Sertraline increased to 200 mg/day and N-acetylcysteine to 3,600 mg/day; aripiprazole discontinued because of akathisia. Exposures: watching television shows featuring children, reading about patients with neurological illnesses. Midtreatment YBOCS: 22. Patient completed eight additional in-person treatment sessions. She also joined a weekly videoconferencing-assisted OCD support group, comprising patients from several countries with diverse OCD symptoms. Posttreatment YBOCS: 14. “Hearing that I wasn’t alone made me feel less ashamed and more self-confident.”
5. 22-year-old man requesting EX/RP at no cost Primary obsessions: fears of causing harm to himself and to others. Primary compulsions: checking ovens/outlets, avoiding self-harm–related stimuli (rooftops, knives). Pretreatment YBOCS: 19. Patient completed eight in-person EX/RP sessions with a trainee, who met weekly with a supervising psychologist. Exposures: approaching cliffs/rooftops, holding knives. Midtreatment YBOCS: 17. Treatment and weekly supervision transitioned to videoconferencing during COVID-19. With patient consent, the supervisor occasionally provided live in-session feedback. Modified exposures included approaching patient’s open seventh-floor window. Posttreatment YBOCS: 10. “I already use [software] for work, so tele-meetings with different people felt normal.”

aEX/RP, exposure with response/ritual prevention; OCD, obsessive-compulsive disorder; STI, sexually transmitted infection

b60-minute, once-weekly sessions; assessments performed pretreatment, midtreatment (session 8), and posttreatment (session 16). YBOCS, Yale-Brown Obsessive-Compulsive Scale, a validated measure of OCD symptom severity. Scores ≥16 reflect clinically significant OCD.

TABLE 1. Case studies illustrating videoconferencing-assisted OCD treatment strategiesa

Enlarge table

Another approach, also described in case 1A, is to start EX/RP onsite, with a planned transition to videoconferencing if treatment is going well. Beginning treatment in person enables therapists to develop the therapeutic alliance while closely supervising early sessions to ensure that patients successfully complete exposures before practicing them independently. Subsequently, transitioning to videoconferencing reduces the travel burden to the patient and can greatly facilitate scheduling. In case 1A, the patient’s young children made coordinating onsite appointments challenging. Integrating videoconferencing eliminated this barrier and helped her complete the full treatment course.

When moves, illnesses, or other unexpected life events interrupt ongoing EX/RP, rapid conversion to videoconferencing can maintain continuity of care. Our staff took this approach during the COVID-19 pandemic, given concerns that abruptly halting onsite treatment would adversely affect patient well-being. As case 1B illustrates, this transition can be accomplished quickly and seamlessly while maintaining efficacy.

When considering hybrid EX/RP, it is important to assess patients’ alliance with their therapist, adherence during in-person sessions, motivation to attend in-person and remote sessions, and overall progress. When transitioning to remote treatment, reviewing the treatment model (e.g., revisiting the fear hierarchy and redesigning ongoing exposures for remote contexts), providing an orientation to the videoconferencing software, and obtaining informed consent (with documentation) are also key. Licensure issues may occur with relocations, requiring clinicians to obtain limited permits or arrange local referrals.

Fully remote EX/RP.

Videoconferencing can also facilitate fully remote EX/RP, a cost-effective approach for patients (3) that enables expert care for individuals who are homebound, rurally located (as illustrated by case 2A), or lack access to OCD treatment facilities. As illustrated by case 2B, patients with substantial shame about their symptoms might find videoconferencing more tolerable than office-based care and may more readily seek remote treatment. Finally, all exposures during videoconferencing-assisted EX/RP are conducted in patients’ home environments, which could promote independent skill development and generalization of learning to real-life contexts.

Challenges related to fully remote EX/RP include difficulty identifying subtle mental status changes over videoconferencing. A therapist might observe a patient’s engagement in safety behaviors onsite, but these may be less obvious over videoconferencing, limiting opportunities for corrective feedback. Certain exposures depend on a therapist’s physical presence (e.g., sitting next to a patient with harm-related obsessions while they hold a knife). Fully remote treatment may be inappropriate when patients struggle with adherence, have certain comorbid conditions (e.g., psychosis, severe personality disorders), or face immediate safety concerns (e.g., suicidality).

Videoconferencing-assisted psychopharmacology.

Videoconferencing can be used to deliver pharmacotherapy for OCD (as illustrated by case 3), expanding expert pharmacological consultation and treatment beyond metropolitan centers (where most specialty programs are located). Because patients with OCD have strong treatment preferences (6), the option to pursue EX/RP, medications, or a combination of the two may increase satisfaction. Medications may be first-line therapies in certain situations (e.g., when depression limits EX/RP adherence). During COVID-19, the European College of Neuropsychopharmacology recommended psychopharmacology over EX/RP for patients with predominant handwashing or contamination fears, given challenges implementing appropriate exposures under pandemic-related restrictions (8).

Limitations of videoconferencing-assisted psychopharmacology include inability to perform physical examinations (e.g., brief neurological exam for patients endorsing medication-induced tremor). Licensure or medication supply could present challenges in some locations. Finally, although evidence generally supports telehealth-assisted psychopharmacology (5), this approach has not yet been studied with OCD specifically (2).

Virtual support groups.

Alongside psychopharmacology and EX/RP, the patient described in case 4 attended a virtual (videoconferencing-assisted) OCD support group. Organizations such as the International OCD Foundation now offer support groups that historically have been hosted via phone or in person via videoconferencing, often at no cost. Although OCD support groups remain untested in controlled trials, participant surveys suggest they can reduce loneliness, isolation, and stigma while reinforcing CBT techniques (9). By allowing participants to see one another, virtual groups may be more engaging and thus achieve these benefits more readily than phone-based groups; compared with in-person groups, virtual groups may be more accessible. We recommend groups with trained moderators to ensure that treatment does not inadvertently reinforce accommodation of symptoms or avoidance. Some groups involve 12-step models that are untested in OCD and incorporate religious themes that may or may not be acceptable to patients.

Videoconferencing-assisted clinical supervision.

A dearth of experienced clinicians also limits access to evidence-based OCD treatments (1). As illustrated by case 5, videoconferencing can be used to facilitate and increase access to clinical supervision. Similar to traditional supervision, online software allows supervisors to view trainees’ recorded treatment sessions and provide retrospective feedback. Supervisors can also passively view sessions with video or audio disabled, activating video or audio at key moments to provide real-time feedback (e.g., when trainees are stuck or when patients experience urgent symptoms). Although models for telehealth-based supervision are emerging, it is important to consider trainee, supervisor, and patient experience with treatment and supervision via videoconferencing and to discuss and document informed consent (5).

Discussion and Future Directions

Videoconferencing can be integrated into evidence-based OCD treatments, including EX/RP and psychopharmacology; it can also facilitate support groups to bolster these treatments and clinical supervision to ensure trainees deliver them with fidelity. Videoconferencing may improve accessibility and, in some contexts, offer clinical advantages in comparison with in-person treatment approaches. Moreover, although some treatments may be difficult to conduct remotely (e.g., dynamic/relational therapies), skill-focused treatments such as EX/RP may be well suited to videoconferencing.

There are several important considerations. First, technical difficulties (e.g., poor Wi-Fi signal, low-bandwidth connections), lack of private space, transmission lags, and increased reliance on verbal communication may limit effectiveness (5). Second, equipment and Internet costs could be problematic, although videoconferencing software is generally free, and >90% of American adults now have Internet access through computers or mobile devices (6). Finally, coordinating emergency care remotely is difficult, making comprehensive risk assessments critical when using videoconferencing.

Even when videoconferencing treatment is technically feasible, state-by-state differences in licensure laws and uncertainty regarding reimbursement may limit access. Many states are exploring ways to streamline telehealth models, which may eventually position telehealth technologies like videoconferencing as key elements in treatment delivery (10). Examples include using other digital tools (e.g., text, computer or smartphone applications, social media assets) alongside videoconferencing. These approaches are beginning to be studied with OCD (7). Alternatively, web-based CBT platforms (e.g., OCD-NET.com), validated in preliminary studies, could augment or even substitute for videoconferencing-assisted treatment.

Outstanding issues remain. There is limited research on outcomes from fully remote EX/RP for OCD and none for videoconferencing-assisted psychopharmacology. Virtual support groups and remote clinical supervision, also promising videoconferencing applications, need refinement and testing before being implemented broadly. Finally, researchers should explore how to incorporate videoconferencing with emerging technologies, including virtual reality-based EX/RP (2) and mobile applications (7). Although digital health technologies such as videoconferencing are unlikely to replace in-person OCD treatment, they are quickly becoming important tools to increase access and improve care for this debilitating, undertreated condition.

Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, and Research Foundation for Mental Hygiene, New York State Psychiatric Institute, New York City. Dror Ben-Zeev, Ph.D., is editor of this column.
Send correspondence to Dr. Kayser ().

This work was supported by a National Institute of Mental Health (NIMH) T32 training grant in mood, anxiety, and related disorders and an NIMH loan repayment award (grants T32MH15144 and L30MH120715, both to Dr. Kayser).

Dr. Simpson has received research support from Biohaven Pharmaceuticals, royalties from Cambridge University Press and UpToDate, and a stipend from the American Medical Association for her role as associate editor at JAMA Psychiatry. The other authors report no financial relationships with commercial interests.

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