New Guidance to Help Manage OCD During COVID-19

Batya Swift Yasgur, MA, LSW

June 15, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Two international specialty societies have jointly released new guidance on management of obsessive-compulsive disorder (OCD) during the COVID-19 pandemic.

"Individuals with OCD, particularly those with contamination concerns or hypochondriacal kinds of worries associated with OCD, people who have perfectionistic type of rituals, or who worry about transmitting COVID-19 [to others] might be particularly vulnerable to this pandemic," statement co-author Michael Van Ameringen, MD, professor, McMaster University, Department of Psychiatry and Behavioral Neurosciences, Hamilton, Ontario, Canada, told Medscape Medical News.

The guidance, issued by the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive and Related Disorders Research Network (OCRN) of the European College of Neuropsychopharmacology, emphasizes the importance of using pharmacotherapy as a first-line approach, suspending or reducing exposure and response prevention (ERP), and offering psychoeducation.

The statement was published in the July issue of Comprehensive Psychiatry.

Confirm OCD Diagnosis

A diagnosis of OCD should be confirmed, and it is important to clarify whether the current symptoms are a "rational or exaggerated response to recent highly stressful events" or a worsening of obsessive-compulsive symptomatology, the statement notes.

Some patients may experience an exacerbation of comorbid conditions such as anxiety disorder, depression, bipolar disorder, or posttraumatic stress disorder (PTSD), which may need to be managed separately.

The authors recommend consulting the World Health Organization (WHO) guidelines regarding mental health and psychosocial considerations during the COVID-19 outbreak.

"Several suicidal patients with OCD have come to the clinic during the pandemic," reported Van Ameringen, who is also director of the MacAnxiety Research Centre in Hamilton. "They felt overwhelmed and that they were contaminating themselves with everything they did, including breathing."

The authors encourage clinicians to assess suicidal risk, using validated instruments, such as the Columbia Suicide Severity Rating Scale, and hospitalize patients if necessary.

Pharmacotherapy is "the most efficacious first-line treatment modality" for adults and children with OCD and contamination, washing, or cleaning symptoms during the pandemic, the authors note.

They recommend a stepwise pharmacotherapeutic approach.

Type of medication

  • Selective serotonin reuptake inhibitor (SSRI) as first choice

  • Another SSRI if no response to first SSRI

  • Clomipramine as third choice

Dosage

  • Gradually increase suboptimal dose, paying attention to contraindications, adverse effects

SSRI resistance

  • Low-dose adjunctive antipsychotic (eg, aripiprazole, risperidone, quetiapine, olanzapine), for incomplete response, especially if tic is present.

Adherence

  • Ensure patient can obtain an adequate supply of medication and is taking it regularly

  • Involve family/caregivers if adherence is problematic

  • Pill organizers and reminder apps may be helpful

A Role for CBT?

Under ordinary circumstances, CBT is considered a first-line intervention for OCD. However, there are risks associated specifically with ERP during the pandemic.

"In ERP, people are being exposed to things that trigger their OCD, so those with contamination fears may be asked to touch things in public places, then resist washing their hands, which would counter public health recommendations," Van Ameringen said.

In vivo exposure should be paused, but some ERP interventions can be adapted or modified "on a case-by-case basis," the authors state. For patients whose exposure is unrelated to contamination, other ERP treatment plans can be continued.

The authors recommend using therapy time to "prevent patients from deteriorating" by encouraging them to engage in activity scheduling and structuring the day to include physical activity, enjoyable activities, practices that enhance sleep, and mindfulness.

Limit News Exposure

A central component of managing OCD during the pandemic is providing "balanced information" about the known risks and impact of COVID-19, the authors state.

Van Ameringen recounted that he has seen patients who have washed their hands for hours and bleached or even boiled their hands.

"Some [patients with OCD] wonder if it's safe to touch a newspaper or if they can catch the virus if they go outside, even if no one is around," he reported. "Some wonder if they should 'quarantine' a package or wear gloves to bed."

It has been helpful, for example, to show them the public health guidance of the WHO or CDC advising that 20 seconds of handwashing is adequate, he said.

"We have also seen that some of the sources of information about COVID-19 haven't been factually correct and that people were watching the news all day and being bombarded with information from every source, which was making their symptoms a thousand time worse," Van Ameringen reported.

Therefore, patients should be advised to limit news viewing to half an hour twice daily, the authors suggest. The authors also advise clinicians to "take a compassionate, calming" and culturally sensitive approach to inform all interventions.

Unique Anchor

Commenting on the statement for Medscape Medical News, Debanjan Banerjee, MD, geriatric psychiatry senior resident, National Institute of Mental Health and Neurosciences, Bangalore, India, said that this "comprehensive guideline, based on expert experience, will serve as a guiding framework for physicians and psychiatrists globally."

In the "absence of systemic data so far, this guideline can provide a unique anchor of a global consensus on how to take care of those with pre-existing OCD or newly emergent cases" said Banerjee, who was not involved in authoring the statement.

Also commenting on the statement for Medscape Medical News, Jonathan Abramowitz, PhD, professor of psychology and neuroscience, University of North Carolina at Chapel Hill, said that he "generally agrees" with these guidelines but disagrees with the "apparent recommendations to scale back" ERP.

"The fact is that effective and safe ERP is possible, even during this time, even following the scientific guidance," stated Abramowitz, who is also the editor-in-chief of the Journal of Obsessive-Compulsive and Related Disorders and was not involved in the statement.

He noted that the International OCD Foundation offers educational programs for clinicians regarding the safe use of ERP during this time.

The authors acknowledge that their guideline is "largely based on empirical evidence" and should be regarded as "preliminary." The guidance "will be updated as new information arises."

No specific source of funding for the statement listed. Van Ameringen reports being on the advisory boards of Allergan, Almatica, Brainsway, Janssen, Lundbeck, Myriad Neuroscience, Otsuka, and Purdue Pharma (Canada); is on the speaker's bureau for Allergan, Lundbeck, Otsuka, Pfizer, Purdue Pharma (Canada) and Takeda; and has received research support from Janssen, Purdue Pharma (Canada), the Canada Foundation for Innovation, and Hamilton Academic Health Sciences Organization (HAHSO). The other authors' disclosures are listed on the original paper. Banerjee and Abramowitz have disclosed no relevant financial relationships.

Compr Psych. 2020;100:152174. Full text

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