Investigating the effectiveness of using a telemental health approach to manage obsessive-compulsive disorder: a systematic review

Background Obsessive-compulsive disorder is a mental disorder that leads to impairment in various cognitive functions. Telemental health is applied in providing several telemental health and psychiatric services. It can provide health and psychological care, such as counseling, diagnosis, and treatment. Therefore, this study systematically examines the effectiveness of using a telemental health approach to manage obsessive-compulsive disorder. Methods We searched PubMed, Web of Science, and Scopus using the keywords telepsychiatry, telemental health, telemedicine, telehealth, videoconferencing, obsessive-compulsive disorder, and OCD up to November 2023. In addition to searching the mentioned databases, references to related articles were also examined. Results In this study, based on the search strategy, we identified 130 articles, 4 duplicate articles were removed, and the title and abstract of 126 articles were reviewed. Considering the selection criteria, 104 articles were excluded and 22 articles were included in the study. In 77.27% of the articles, videoconference telecommunication methods were used for communication. In 8 articles, the participants were children and adolescents. Reviewing these studies indicates mentions concerning the effectiveness of this method in most of them. Conclusions In general, telemental health interventions increase access to treatment and can be promising for patients with certain conditions. This systematic review contributes to the expanding literature indicating that delivering CBT through telemental health methods, particularly videoconference-based approaches, is a feasible substitute for in-person treatments.


Introduction
Obsessive-compulsive disorder (OCD) is a mental disorder that leads to impairment in various cognitive functions.This disorder is associated with repetitive thoughts and behaviors that cause disability and impairment in daily functioning.The symptoms of this disorder include compulsive activities and obsessive thoughts [1] that start in childhood and adolescence [2].More women suffer from this disorder in adulthood and men in childhood [2,3].Intrusive thoughts are usually associated with a feeling of not being complete and not right and lead to compulsive behaviors such as frequent checking [4].Several factors such as genetics, childhood injuries, complications of pregnancy and childbirth, and stressful events can be effective in causing and aggravating the disease [5].Many people suffer from this mental disorder worldwide [6].OCD is considered one of the diseases that affects and severely reduces the quality of life [7].Cognitive behavioral therapy (CBT) is among the basic methods of treating obsessions.This method emphasizes exposure and response prevention (ERP) and is the most extensively validated psychosocial treatment for individuals of all ages with OCD.Meta-analyses have demonstrated significant positive outcomes of this method concerning its effectiveness [8,9].This method aims at changing habits and rebuilding thoughts and minds.As a result, the patient can face his fear in stressful situations and reduce his compulsive behaviors [10].However, there are many obstacles to accessing this type of treatment, such as the limitation of therapists, high treatment costs, stigmatization, and embarrassment for patients [11].
Telemedicine is a method to provide medical services through telecommunications technologies.This technique is mainly applied to provide services to remote and geographically distant areas.One of the most widely used technologies in telemedicine is videoconferencing, which makes it easy for therapists to see patients and give them advice in real-time.Cost-effectiveness and providing quality treatment are among the advantages of telemedicine [12].Telemedicine can provide health and psychological care, such as counseling, diagnosis, and treatment [13].However, the use of telemedicine still involves challenges such as patient privacy, confidentiality aspects, technical issues, and training of doctors and patients [14].Telemental health is applied in providing several telemental health and psychiatric services [15].Various studies [16][17][18][19][20] have investigated the use of telemental health for disease management of patients with OCD.Integrating telemental health technology with evidence-based treatments and drug therapy can facilitate the management and treatment of the disease and promote clinical benefits.Despite potential problems in this field, using communication technology in telemental health can be effective by focusing on an ERP method [21].Therefore, this study systematically examines the effectiveness of using a telemental health approach to manage obsessivecompulsive disorder.

Methods
This systematic review study investigates the effectiveness of using a telemental health approach to manage OCD in 2023 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist [22].Figure 1 shows the process of selecting articles.

Data sources
We searched PubMed, Web of Science, and Scopus using the keywords telepsychiatry, telemental health, telemedicine, telehealth, videoconferencing, obsessive-compulsive disorder, and OCD up to November 2023.In addition to searching the mentioned databases, references to related articles were also examined.

Study selection
Two researchers independently retrieved relevant articles based on titles and abstracts.Then, the full text of the articles was reviewed, and the most relevant articles were selected considering the inclusion and exclusion criteria.The disagreement between the two authors was resolved by reaching a consensus with the third author.In the last step, data was extracted from the articles and organized in tables.
The inclusion criteria were (1) original articles and reports, (2) articles in English, and (3) articles related to the purpose of the study.Also, exclusion criteria were (1) review articles, systematic reviews, letters to the editor, and protocols, (2) articles not related to the purpose of the study, and (3) lack of access to the full text of the articles.

Data extraction
Two researchers reviewed the articles, extracted the desired data, and entered the tables.Data included authors, year, country, study objective, telecommunication method, participants, and outcome.

Results
In this study, based on the search strategy, we identified 130 articles, 4 duplicate articles were removed, and the title and abstract of 126 articles were reviewed.Considering the selection criteria, 104 articles were excluded and 22 articles were included in the study.

Discussion
OCD is a severe neurobehavioral condition that often leads to significant impairments in various aspects of a person's life, persisting throughout their lifespan [40].Improving access to evidence-based therapy can be accomplished by implementing more efficient therapy delivery models that maximize outreach while maintaining integrity and effectiveness [19].Telemental health has long been extensively employed by medical professionals to efficiently treat behavioral disorders [34,41,42].The objective of this systematic review was to evaluate the effectiveness of using a telemental health approach to manage obsessive-compulsive disorder.
After completing the search strategy, we obtained a total of 130 results.Of these studies, 22 unique papers were identified and included.The dissemination of more than 50% of the studies conducted in the last 2 years indicates that this type of care delivery is at the forefront of current research in OCD therapy.Overall, the studies aimed to assess the feasibility [16,18,24,26,[29][30][31][32]   The use of video teleconferencing as a combined method reduced the severity of obsessive-compulsive disorder.
Baer et al. [17] 1995 USA Investigating the effect of using telemedicine and comparing it with face-to-face treatment for patients with OCD.

Videoconference
Patients with OCD (n = 16) The effectiveness of using telemedicine for OCD symptoms was evident in the results.
Comer et al. [18] 2014 USA Investigating the treatment of early symptoms of OCD using video conferencing.

Videoconference
Children with OCD (n = 5), ages of 4 and 8 years The improvement of symptoms and severity of the disease was determined using videoconferencing.
Farrell et al. [19] 2022 Australia Investigating the effectiveness of telehealth education for the treatment of OCD.

Videoconference
Children with OCD and parents (n = 9), ages 8 to 14 years Providing education through telehealth for the management of OCD was partially effective.

Video teletherapy
Patients with OCD, ages ≥ 18 years The results showed that the use of online video teletherapy reduces the symptoms of the disease.
Fitt and Rees [23] 2012 Australia Investigating the effect of cognitive therapy through video conferencing for OCD.

Videoconference
Adults with OCD (n = 4), ages 34 to 66 years The effectiveness of the video conference to reduce the symptoms of OCD was evident in the results.
Fletcher et al. [24] 2022 USA/Texas Investigating the effectiveness of telehealth for exposure prevention and response of rural veterans with OCD.
Videoconference Veterans (n = 11) with OCD, mean age 47.2 years Telehealth videos were effective in reducing disease symptoms.
Gittins Stone et al. [25] 2023 USA Investigating the effect of using cognitive behavioral therapy using videoconferencing to treat children with obsessive-compulsive disorder during the COVID-19 pandemic.

Videoconference
Children and adolescents with OCD (n = 130), ages 8-19 years The results showed that the use of videoconferencing to treat children reduces their symptoms.
Goetter et al. [26] 2014 USA Investigating the effectiveness of videoconferencing for the treatment of OCD.

Videoconference
Adults with OCD (n = 15), mean age of 32.2 years The use of videoconferencing improves the symptoms of OCD and can be an alternative to face-toface methods.

Videoconference
Patients with OCD (n = 3), ages 19 to 39 years The treatment using video conference was effective and resulted in patient satisfaction.
Hollmann et al. [28] 2022 Germany Investigating the effectiveness of internet-based treatment for patients with OCD.

Videoconference
Children and adolescents with OCD (n = 60), ages 6 to 18 years Symptom improvement in patients with OCD using the telemedicine method was high.Matsumoto et al. [33] 2020 Japan Investigating the effect of using videoconferencing for patients with OCD in Japan.

Videoconference Adults with OCD (n = 25), ages 20 to 54 years
The results showed that the use of videoconferencing is an effective and cost-effective method for treating patients with OCD.
Milosevic et al. [34] 2022 Canada Comparison of face-to-face and telemedicine methods for managing anxiety and mental disorders.

Videoconference
Patients with anxiety disorders (n = 413), ages ≥ 18 years The use of videoconferencing for the management of anxiety and mental disorders was promising and is considered an alternative to the face-to-face method.
Pinciotti et al. [35] 2022 USA Investigating the effectiveness of telehealth for the treatment of OCD in the COVID-19 pandemic.

Computerized platform
Patients diagnosed with OCD (n = 468), ages 18 to 75 years Treatment via telehealth was as effective as face-to-face treatment.
Storch et al. [36] 2011 USA Investigating the effectiveness of treating OCD using a web camera.Online program (using a webcam) Youth with OCD (n = 31), ages

7-16 years
Using the web camera-based method improved symptoms in young people with OCD.
Turner et al. [37] 2014 Australia Evaluation of the effectiveness of treatment of OCD over the phone for adolescents.

Call
Adolescents with OCD (n = 72), ages 11 to 18 years The results showed that the treatment using the phone can be as effective as the face-to-face method and is associated with patients' satisfaction.
Vogel et al. [38] 2012 Norway Treatment of OCD using video conferencing and mobile phones.

Videoconference
Patients with OCD (n = 6), ages 24 to 44 years OCD symptoms decreased by 50% with the use of mobile phone video conferencing.

Table 1 (continued)
Author Year Country Objective Telecommunication method

Outcome
Vogel et al. [39] 2014 Norway Investigating the effectiveness of cognitive behavioral therapy using video conferencing for the treatment of OCD.

Videoconference
Patients with OCD (n = 30) The treatment through video conference reduced the symptoms.
Regarding the feasibility and effectiveness, the studies provide promising evidence that delivering CBT through telemental health approaches is feasible [16,18,24,26,[29][30][31][32] and has the potential to be equally effective as inperson treatment across different age groups [25,26,28,34,35,37,39].The results of the randomized clinical trial study showed that the CBT method using the computer is accepted by young people with mental problems [43].
The majority of the studies demonstrated effectiveness in terms of alleviating symptoms of depression, anxiety, and stress [16, 18-20, 24-26, 28, 30, 32, 34-36] and improving quality of life [20,24,26,28,32,33,35].Studies also offer proof of effectiveness by demonstrating improvements in recovery rates and reductions in treatment duration [16,19,27,28,30,32,33,36]. Furthermore, some studies provide evidence of effectiveness by highlighting the advantages of cost and time savings [18-20, 29, 30, 33].The estimated timeframe for this improvement is predicted to be less than 50% of the total therapist time and less than 50% of the duration of a typical once-weekly in-person CBT session [20].The results of a meta-analysis study have also emphasized the effectiveness of telemental health interventions and pointed to conducting more trial studies to investigate this method's effectiveness, feasibility, and acceptability [44].
The coronavirus disease 2019 (COVID-19) pandemic and the need for physical separation accelerated the adoption and using of telemental health services for various behavioral disorders [45][46][47][48][49]. Telemental health practitioners have substantially augmented their daily use of telehealth to handle their patient workload, which has nearly doubled since the initiation of the COVID-19 pandemic [45].Our research has discovered four papers that specifically investigated the effectiveness of telemental health strategies for delivering CBT during the global pandemic.These studies have highlighted the favorable impact of this technique in this specific context.Overall, these works have determined that telemental health services are effective and appropriate alternatives for inperson care, especially during the pandemic.By enabling convenient access to psychiatric care, they can overcome different barriers linked to traditional services, augment user satisfaction, and empower the underserved population residing in remote regions [25,29,31,35].
Most of the studies identified in our research apply videoconferencing [16-20, 23-29, 32-34, 38, 39] as a central telemental health strategy for delivering CBT.In addition to this method, online and computer platforms [30,31,35,36] and calls [30,37] were also used to manage the disease However, videoconferencing is a highly valuable technique to deliver telemental health services, as it closely resembles well-accepted in-person therapy [27].Besides, this service is highly accessible [20].Recent experiments have introduced supplementary functionalities to videoconferencing, including chat features, a virtual whiteboard for material presentation, an online data cloud system for assignment and progress restoration, and a physiological wristband for setting timestamps for different events [18,28].
In general, to manage OCD, it is possible to use a telemental health approach.Moreover, as a therapeutic support tool, it can improve OCD.Since it is possible to practice at home using the telemental health method, the effectiveness of the method will increase, thereby providing the therapists with more opportunities to understand and pay attention to the patient's behavior [24].Paying attention to the mental health of special age groups such as children and youth and integrating their treatment with available methods (e.g., telemental health) are points that future research should pay attention to.
One of the limitations of this study is the non-inclusion of articles that did not have access to their full text.A common limitation of any systematic review is that not every relevant study may be found.This issue was considered during the peer review process when another relevant study was revealed.

Conclusion
Telemental health interventions increase access to treatment and can be promising for patients with certain conditions.This systematic review contributes to the expanding literature indicating that delivering CBT through telemental health methods, particularly videoconference-based approaches, is a feasible substitute for in-person treatments.These approaches enhance the availability of state-of-the-art treatment and provide potential relief to individuals who would otherwise lack access to high-quality mental health care.This issue is especially crucial during a global pandemic.

Fig. 1
Fig. 1 The flow diagram of the selection of articles

Table 1
Main characteristics of the included studies