Two international specialty societies have jointly released new guidance on management of obsessive-compulsive disorder (OCD) during the COVID-19 pandemic.
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“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 coauthor Michael Van Ameringen, MD, professor, of the department of psychiatry and behavioral neurosciences, McMaster University, Hamilton, Ont., said in an interview.
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 Dr. Van Ameringen, 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 suicide 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 (for example, 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,” Dr. 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.