Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic

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

¹Details in Table 2.

²These five steps of exposure and response prevention (ERP) were based on standard protocols of ERP or cognitive behavior therapy[1,39,41-43]. Psychoeducation imparted more detailed information about obsessive-compulsive disorder (OCD) including a cognitive-behavioral model of OCD. Apart from providing basic information about OCD, it attempted to correct common misconceptions. Psychoeducation also involved providing a clear rationale for ERP, information about the components and procedure for ERP, conduct of videoconferencing-based ERP sessions, and how ERP was expected to help. Patients and caregivers were taught to objectively monitor symptoms, thoughts, and distress during sessions and during the course of treatment. Standard formats for monitoring during videoconferencing sessions were developed. Google sheets or text messages that could be regularly updated were exchanged between clinicians and patients. The clinician carried out his/her own assessments, and feedback about progress of treatment was provided to the patient. Relaxation exercises, preferably using Benson’s relaxation technique[44] were taught. It involved muscle relaxation, deep breathing, and the use of relaxation as a coping strategy. It was used to reduce anxiety and improve motivation for treatment. Standard techniques of ERP were used with certain modifications as explained in Table 4. During processing, the patients’ experience of the sessions was discussed to enhance their understanding of ERP, examining the reality of their beliefs, and discussing more adaptive ways of coping[13,42].

³More details in Table 4.

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