How to manage obsessive-compulsive disorder during the COVID-19 pandemic– a guide for clinicians and advanced amateurs

EM of sars-cov-2 budding from apoptotic (dying) cells–NIAID

This article comes from Science Direct — Comprehensive Psychiatry for July 2020.  It is titled “How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician’s guide from 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” and the article is almost as long as the title.  It is available without a paywall under a Creative Commons license.

Here is the first paragraph:

The rapid advance of the coronavirus COVID-19 pandemic has significantly increased mortality but also has demonstrated considerable potential to negatively impact mental health, including in the young. From a public mental health perspective, guidelines for responding to mass trauma and disaster emphasize the importance of focusing on resilience. In the immediate and ongoing response, consensus guidelines emphasize the importance of interventions that maintain calm, build community, and sustain hope.

The article is a consensus statement from the ICOCS and OCRN on how to manage patients with obsessive-compulsive disorder (OCD) during the pandemic.  It recommends temporizing measures to control symptoms rather than any attempt to perform insight-oriented psychiatry (what we normally associate with psychiatric treatment– breaking down barriers and rebuilding a healthier psyche.)  The rationale is that any attempt at insight will only make symptoms worse– albeit temporarily– and what is needed now is to keep patients calm while we await “rescue” in the form of a vaccine, or at least abatement of the current emergency situation.

The article recommends, first, to take a calming, compassionate approach to the patient to reduce symptoms.  Use telemedicine, that is , phone calls and video calls, to reach out to patients who are isolated by the quarantine.  Take a careful history to confirm the diagnosis of obsessive-compulsive disorder and any associated conditions, particularly hypochondriasis.  Clarify whether the symptoms represent a rational response to current events or a worsening of previous OCD symptoms.

Establish the patient’s level of insight into her condition– does she feel that her symptoms are irrational or excessive?  Are there tics?  Are contamination fears being exacerbated by directions to wash hands and avoid fomites?  Are there idiosyncratic fears, such as fear of sexually transmitted disease or of antibiotic-resistant bacteria?  Comorbid conditions may be exacerbated by the stress, such as anxiety, depression, bipolar disorder, or post-traumatic stress disorder.  If other conditions are the primary presenting problem, see also general recommendations here.  (These are general psychosocial recommendations for everyone, suffering from mental disorders or not, in dealing with the pandemic.)

Assess suicidal risk.  OCD doesn’t usually present a high risk for suicide, but comorbid conditions do, particularly bipolar disorder, substance abuse disorder, and even latent schizophrenia.  People with a recent increased severity of OCD, people who are experiencing the illness of close relatives or associates, and people who are feeling extreme stress from isolation in quarantine are at increased risk for suicidal ideation.  Use a rating scale and specific questions to assess risk; here is one scale you can use, the Columbia Suicide Severity Rating Scale.  Here is a gateway to using the scale in multiple settings: the Lighthouse Project.

Provide balanced information about what to do to keep from catching the virus and what is known about it currently.  It is important to have the patient recognize that the situation may persist for a long time, and they need to manage their stress levels over a long period.  Tell them to set up a routine that they can continue indefinitely that will help to keep a manageable stress level.

Find out how much TV and internet they are consuming.  Ask them to limit themselves to a reasonable amount of this– say, half an hour in the morning and a half hour in the evening.  Recommend health education websites, like CDC, (hand sanitizer) WHO, and Johns Hopkins.  Or this hand-washing video.

If OCD symptoms are the main problem, assess the effectiveness of medication treatment or start medications.  The first choice is a selective serotonin reuptake inhibitor (SSRI)– there are several drugs available and if one doesn’t work, another should be tried.  As a third choice, clomipramine is effective but it may require evaluation for safety with an electrocardiogram (ECG).  Start the SSRI at a low dose and gradually increase it to reduce side effects.  If the SSRI is really not working, an antipsychotic drug like olanzapine, aripiprazole, or quetiapine might be added in severe cases, especially if the patient has a tic.

The patient should be evaluated for adherence to treatment.  It is very important to be sure that she is taking the medication regularly as it takes time to work.  Using a pill organizer box with slots for each day is helpful to keep the patient on track.  If she is not sleeping well, this needs to be treated too; make sure she is going to bed at the same time, avoiding night-time disturbances, not watching TV late at night, and not eating or exercising right before bedtime.

Enlist help from anyone staying with the patient to keep her taking medicine and not watching too much TV.  Support from a significant other is necessary, especially for patients who are confused or agitated.

Ordinarily, cognitive behavioral therapy is used for OCD, but during the pandemic this may not be possible and exposure could be dangerous.  If symptoms are distressing to the patient during this time, medication is preferable to exposure-based or cognitive behavioral treatment.

A new form of treatment, deep brain stimulation, is available for patients with severe symptoms.  If the patient has deep brain electrodes implanted and battery-powered, they should be checked for battery failure if symptoms return.  Unfortunately, new patients can’t have electrodes put in when elective surgery has been put on hold due to isolation.

Finally, maintenance of routines, with regular morning arising and evening bedtimes, and social interaction with frequent contact by phone or video, are very important to keep the patient from feeling too isolated.  The article recommends morning physical activity under bright lights to help keep up the circadian rhythm.  It also advises against late night meals just before bedtime.

Here is a particularly useful quote:

Offer guidance regarding a rational amount of time spent listening to news as a distraction to occupational or preferred activities, provide acknowledgement of fear but also a balanced perspective on risk, address grief and loss of control and recommend hedonic activities especially those that involve children, such as baking, cooking, gardening, inventing a new game or watching a movie.

Help the isolated patient to overcome loneliness and build stability by increasing communication with friends, family members and loved ones, even if at a distance via the multiple online platforms including Facetime; Skype and Zoom. Learning to use these can be a helpful experience in terms of the acquisition and mastery of new skills as well as the pleasure of social contact. In the case of those with a poor social network, telephone helplines such as those run by OCD charities are particularly useful, especially if managed by qualified trained professionals.

There is much more in this long article, but the most important guidance is that patients who are undergoing or considering cognitive behavioral therapy and exposure response prevention (graded exposure to stimuli that induce anxiety) should have their treatment re-evaluated and/or paused during the pandemic because of potential risks.  The consensus of these experts is that patients with OCD will need to be more or less cocooned during the pandemic.