Commentary

When and for whom is telehealth OCD treatment appropriate?


 

It is no secret that the COVID-19 pandemic resulted in widespread disruptions in health care services. While providers and resources were limited and many patients were apprehensive to present to health care settings out of concern of disease contraction, telehealth services did offer some relief.

Compared to other specialty care services, mental health care providers were well equipped to handle the expansion of telehealth services, as extensive treatment literature provides strong support for the use of psychotherapeutic interventions over telehealth mediums.1 This holds true in the context of obsessive-compulsive disorder (OCD), where an impressive literature supports the use of telehealth delivery for the gold-standard psychotherapeutic, exposure and response prevention (ERP).2,3,4

Dr. Andrew D. Wiese, Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, Houston, Texas

Dr. Andrew D. Wiese

Through ERP, patients work with a clinician to systematically expose themselves to anxiety-providing triggers while actively resisting compulsive behaviors to learn the distress does go away with time and/or the distress is within their ability to cope. This intervention is conceptually similar to repeatedly watching a scary film, by which continued exposure results in less pronounced emotional reaction with subsequent viewings.

Fortunately for patients and providers, the expansion of telehealth ERP across different treatment settings has had many unintended benefits, including increased access to care, lower no-show rates due to the ease of attending appointments, and the ability to offer higher levels of care, including intensive outpatient programs, over telehealth mediums. Anecdotally, our clinic has been able to increase patient reach by providing telehealth ERP to those who historically would not have been able to access care due to geography. Even for those living within driving distance to our clinic, the ease of joining a video visit for a 45-minute appointment far outweighs driving into the clinic, in many circumstances. With these benefits, the delivery of ERP over telehealth appears likely to stay, although OCD providers delivering ERP will need to consider when and for whom this medium may not be appropriate.

To this end, we recently conducted a study examining ERP providers perceptions of telehealth and in-person ERP, patient characteristics best suited for telehealth services, and provider ability to identify and address factors that adversely impact the course of treatment (e.g., substance use, limited symptom insight, distractions during ERP, etc.).5 Providers reported lower feasibility ratings for telehealth compared to in-person ERP for younger patients (aged under 13 years), and patients with more severe OCD presentations. Providers also reported more difficulty identifying and addressing ERP interfering factors over telehealth relative to in-person. The findings from our research do not necessarily speak to the effectiveness of telehealth ERP, which has repeatedly been documented in treatment literature, but rather our findings highlight that ERP providers endorse reservations about the feasibility of ERP for certain OCD patient profiles, and that telehealth ERP may not be appropriate for all patients with OCD.

Mental health care providers, including those delivering ERP, should consider when telehealth is and is not appropriate. Importantly, telehealth offers a limited field of view compared to in-person, and providers can only observe what is captured by the camera. In the context of telehealth ERP, patients may engage in subtle avoidant behaviors that are more difficult to observe, which may prevent them from experiencing necessary anxiety during exposure practice. Many providers may have firsthand experience with this, or patients who appear distracted over telehealth mediums because of environmental factors that can be controlled for during in-person services.

As telehealth treatment options appear increasingly likely to stay, ERP providers and intervention researchers should continue identifying patient characteristics that are more and less appropriate for telehealth settings in order to maximize treatment outcomes. Providers should share concerns with patients when delivering telehealth ERP and work to address interfering factors impacting the course of treatment. In circumstances where this is not possible, such as when the patients age or symptom severity prevents effective telehealth ERP, or when treatment progress stalls, providers should speak with patients to determine if it would be beneficial to transition to in-person services.

Both in-person and telehealth ERP are fundamentally the same, however it does appear that subtle differences across these modalities may have differential impacts on treatment outcomes for certain OCD patient presentations. Telehealth ERP, and more broadly telehealth psychotherapy, offers many benefits for patients and providers, however appropriate caution should be exhibited, and providers should use clinical judgment when offering telehealth services.

Dr. Wiese is a clinical psychologist in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, Texas. He is primarily focused on conducting research on OCD and related disorders and providing empirically supported treatments to individuals diagnosed with these conditions.

References

1. Fernandez E et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment. Clin Psychol Psychother. 2021 Nov;28(6):1535-49. doi: 10.1002/cpp.2594.

2. Storch EA et al. Preliminary investigation of web-camera delivered cognitive-behavioral therapy for youth with obsessive-compulsive disorder. Psychiatry Res. 2011 Oct 30;189(3):407-12. doi: 10.1016/j.psychres.2011.05.047.

3. Fletcher TL et al. A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans. Mil Psychol. 2021 Oct 28;34(1):83-90. doi: 10.1080/08995605.2021.1970983.

4. Wootton BM. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: a meta-analysis. Clin Psychol Rev. 2016 Feb;43:103-13. doi: 10.1016/j.cpr.2015.10.001.

5. Wiese AD et al. Provider perceptions of telehealth and in-person exposure and response prevention for obsessive–compulsive disorder. Psychiatry Res. 2022 Jul;313:114610. doi: 10.1016/j.psychres.2022.114610.

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