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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 104-112

Use of self-help manual for the management of obsessive–compulsive disorder: Effectiveness in Indian context


1 Department of Psychology, Jesus and Mary College, University of Delhi, New Delhi, India
2 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication22-Jul-2020

Correspondence Address:
Sneh Kapoor
Department of Psychology, Jesus and Mary College, University of Delhi, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_38_18

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  Abstract 


Background: The past few decades have seen great strides in the field of psychotherapy. With the advancement in technology, alternative modes of therapy dissemination such as computers, telemental health, and manuals are being explored. Obsessive–compulsive disorder (OCD) has increasingly come under the purview of these modes, particularly for the delivery of self-directed exposure and response prevention. The current study explores the effectiveness of self-help manuals (SHMs) in the management of OCD. Methods: The study employed a pre- and post-experimental design. Participants were randomly assigned to one of the three conditions (independent variable) – Therapist-directed Intervention, SHM, and Control Group. Outcome measures used (Dependent Variables) were symptom severity scores as assessed on Yale–Brown Obsessive Compulsive Scale (Y-BOCS). Sixty participants between the ages of 15–45 years were screened and assigned to one of the three conditions. The therapist-directed group received exposure and response prevention (ERP) delivered by the therapist in weekly sessions, while self-help group received the manual with progress updates on a fortnightly basis, and control group received only pharmacotherapy. Outcome assessment was conducted postintervention at 15 weeks. Results: Both therapist-directed as well as SHM groups showed significant improvement from pre- to post-intervention while was not seen for the control group. No significant difference was seen in improvements for the groups using therapist-directed or SHM approach; however, both showed significantly greater improvement on Y-BOCS scores as compared to controls. Conclusion: SHMs produce improvements comparable to that of traditional therapist-directed approaches. The findings raise important implications for the use of manuals as adjuncts or independent therapy models.

Keywords: Exposure-response prevention, obsessive–compulsive disorder, self-help manual


How to cite this article:
Kapoor S, Mehta M, Sagar R. Use of self-help manual for the management of obsessive–compulsive disorder: Effectiveness in Indian context. J Mental Health Hum Behav 2019;24:104-12

How to cite this URL:
Kapoor S, Mehta M, Sagar R. Use of self-help manual for the management of obsessive–compulsive disorder: Effectiveness in Indian context. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Oct 28];24:104-12. Available from: https://www.jmhhb.org/text.asp?2019/24/2/104/290516




  Introduction Top


Despite the high level of disability and burden, obsessive–compulsive disorder (OCD) is highly treatable, with response rates with cognitive behavioral therapy (CBT) reported as high as 75%.[1] Efficacy of CBT and its variants are well established in the treatment of OCD,[2],[3] and exposure and response prevention (ERP) is advised as the treatment of choice for OCD.[4],[5],[6]

However, treatment seeking for OCD continues to be low. A number of barriers exist not only for seeking treatment but also for dissemination of therapy. Among these, paucity of therapists is a well-established fact,[7] and the situation is no different in India where, particularly, lack of trained personnel for treatment continues to be a challenge.[8] With numbers for psychiatrists, psychiatric nurses, and psychologists ranging between 0.03 and 0.2 per 100,000 people,[8] availability of therapists, as well as mounting therapist- and health-care worker burden are important considerations in the field of mental health care. In a developing setup such as India, where a number of barriers – geographical, economic, and among others – already exist to hamper help-seeking, it is important that alternative modes of therapy dissemination be explored so as to increase availability and outreach of therapy.

In the global context, newer technology has been explored as an avenue to address some of these barriers to therapy,[9] and hence, the area of self-guided therapy came into shape. Lucock[10] has defined guided self-help (GSH) as a structured treatment method with which the patients can help themselves with some support from another person. Varying forms of GSH are being explored in the realm of psychotherapy – self-help manuals (SHMs) one among them.

There are many advantages to SHMs over traditional psychotherapy such as the ability to self-pace, allowing individuals who are unable to receive mental health services due to geographical or transportational barriers receive treatment, cost-effectiveness for those who cannot afford psychotherapy or pharmacotherapy, providing individuals with privacy that can lessen stigmatization or labeling, and providing individuals with coping skills available after treatment has ended.[11] Manuals also seek to increase people's insight into their disorder, and by providing information that can be shared, they provide a more inclusive model of therapy.

The rationale for the present study was, thus, to extend this work in the Indian context, where currently work on SHMs is scarce, especially for OCD.


  Methods Top


The present study aimed at assessing the effectiveness of a SHM approach in the treatment of OCD. Sixty participants, between the ages of 15 and 45 years, diagnosed with OCD as per Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria[12] were recruited from a tertiary care, public hospital in India. All procedures and participation were cleared by the institute ethics committee. It was essential that participants have average intellectual ability, and at least primary level education as well as basic reading and writing ability in Hindi or English, for inclusion. Participants included those stabilized on SSRI use for at least 4 weeks. Participants with comorbid Axis I disorders, as well as those having received previous psychotherapy, were excluded from the study.

Sociodemographic information for the participants is presented in [Table 1]a.


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All participants were screened using the State-Trait Anxiety Inventory,[13] Mini-International Neuropsychiatric Inventory version 5.0,[14] and Hamilton Depression Rating Scale[15] to rule out any concurrent diagnosis. This was particularly important – keeping in mind the self-directed nature of the intervention – where conditions such as anxiety or depression may impact compliance. In addition to the scales, a feedback form was constructed for the purpose of the study, to gain feedback regarding manual use and contents. Two subsets – one for the patient (self-report) and the other for a family member/cotherapist – were developed. The form also contained a section on perceived improvement in various psychosocial domains – interpersonal and professional.

The study employed a pre- and post-experimental design, where participants were compared on measures at baseline, and postintervention. Following informed consent and screening, subjects were randomly assigned to one of the three conditions (independent variable) – Therapist-directed Intervention (TDI), SHM Group, and Control Group. Outcome measures used (Dependent Variables) were symptom severity scores as assessed on Yale–Brown Obsessive Compulsive Scale (Y-BOCS),[16] and self-rated improvement as a part of Feedback form.

Intervention

The therapist-directed group was placed in standard ERP. Participants in this group received weekly sessions of 45–60 min each for the first 4 sessions and fortnightly afterward. Salient features of the intervention included psychoeducation about OCD, familiarization with the CBT model, therapist-directed ERP, and evaluation.

The self-help group was familiarized with manual use, and mode of follow-up was established along with assigning a family member as cotherapist, wherever possible. This was done to increase accountability and ensure compliance of the participants to manual use. Participants were instructed not to use any part of the manual without consulting the therapist first or if instructions to ERP were unclear. The manual chapters were issued in part to the participants – and they would be required to report progress at each contact – either in person, over phone or E-mail. No active intervention was carried out in these meetings – barring progress check, as well as clarification of any queries pertaining to manual use.

The control group, which received standard pharmacological treatment, received no active psychological intervention following the assessment, barring familiarity with the study.

Manual

An extensive review of the current advances in the practice of ERP was carried out, along with a study of the existing barriers to carrying out psychotherapy, particularly ERP. This was followed by an insight into the use of SHMs by reviewing some of the manuals currently in use and empirically tested either in an open trial or independent cases. Combined with the expertise of the guide and co-guide in the management of obsessive–compulsive disorder, this literature and material review guided the development of the first draft of the SHM for the present study. The first draft was then sent out to three experts in the field of ERP and management of OCD across the country, for feedback and content validation. The manual was then pilot tested, which yielded encouraging results with a mean reduction of 46.06% in symptom severity for the manual-using group.[17] Based on the feedback from this pilot, the manual underwent final revisions.

The manual contained five sections – psychoeducation, self-monitoring, self-directed ERP, self-directed cognitive therapy techniques, and self-evaluation. The sections are not presented as chapters and are not mutually exclusive. Each section may overlap with other parts of the manual and may be used independently at different stages of treatment. Psychoeducation for parents or caregivers, as well as tips for increasing efficacy of ERP, are included as well.

The first chapter, psychoeducation, contains information regarding OCD, symptoms, demographic features, causal factors, and possible treatment approaches. The chapter clarifies and distinguishes between obsessions and compulsions, delineates the common types of both, and gives examples and case vignettes to further clarify their symptomatology. In addition, the section also contains information for parents regarding appropriate involvement and anxiety management. This is important in light of the cultural context in India, where family involvement at every stage from diagnosis to treatment is very common. Psychoeducation, particularly in the context of the manual, serves to provide not only information but a sense of normalization and validation; both of which have been identified as important ingredients of change (Schrank and Engles, 1981).

The sections on self-directed techniques, as well as self-evaluation, serve to facilitate a sense of self-efficacy. Self-directed ERP and cognitive techniques serve as a guide to direct the individual toward the process of ERP, starting from the listing of target symptoms, construction of hierarchy and then gradual ERP, using principles of habituation and extinction. Self-monitoring as a part of self-evaluation helped the individual monitor progress over the course of their manual use.

Analysis

The three groups were compared at the baseline and the posttreatment assessment using one-way analysis of variance. Intent to treat analysis was done; the last observation was carried forward for those who completed at least five sessions. Those that did not complete at least five sessions were considered dropouts, and not considered for the purpose of analysis. The final number of participants for whom data were analyzed is presented in [Figure 1]. All tests were two-tailed tests, and statistical significance was set at 0.05 levels for interpretation of the obtained data.
Figure 1: Participant profile

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Data were reported for within and between group analyses. Within-group analysis was done to assess for improvement in each of the three arms of the study; while between-group comparisons were done to compare the two treatment conditions (TDI and SHM) against controls, and with each other.

Where data were found to be skewed in distribution, nonparametric tests were used. Kruskal–Wallis test was conducted to compare for improvements in outcomes across the three groups, while Mann–Whitney U-test was done where within group comparisons or comparisons between two treatment means was required.


  Results Top


Comparison of baseline sociodemographic and clinical data is presented in [Table 1]a, [Table 1]b, [Table 1]c and [Table 1]d. There were no significant differences noted in the three groups on baseline Y-BOCS score (P = 0.10). As shown in [Table 2], both therapist-directed as well as self-help group reported a significant reduction in Y-BOCS scores postintervention (P < 0.001). The mean percentage change in Y-BOCS score reported for the self-help group was found to be 36.62%, while that for TDI was reported at 41.67%.
Table 2: Comparison of Yale–Brown Obsessive Compulsive Scale score pre- and post-intervention: T-test (two-tailed) paired, for P<0.05 (t crit=2.093)

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Comparison of groups

Mean change in Y-BOCS scores for the three groups presented a skewed distribution of the data, and hence median (and interquartile range) has been reported, and Kruskal–Wallis test for independent means was used for nonparametric comparison of the groups. On overall comparison [Table 3], significant difference in means was found for the three groups (χ2 = 13.079, P = 0.001). Further analysis was conducted to ascertain actual group differences, using Mann–Whitney U-test.
Table 3: Comparison of groups using Kruskal–Wallis test

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On comparison with controls [Table 4], the TDI showed significantly greater mean improvement on Y-BOCS scores (U = 90, Z = 3.16, P = 0.001).
Table 4: Comparison of therapist-directed intervention and self-help manual with controls (U critical=127)

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On comparison of the two treatment conditions, no significant difference between mean improvement for therapist-directed and SHM groups was found (U = 127, Z = 0.77, P = 0.44). There was, however, greater mean improvement in the TDI group (41.67%), reflecting in superior gains as compared to self-help group (36.62%).

In addition to the mean improvement reported, the clinical significance of improvement (35% or more reduction in Y-BOCS scores) was also assessed. While 50% (n = 10) of the participants in the TDI group showed clinically significant improvement, the same held for 60% (n = 12) participants in the SHM group and 5% (n = 1) in the control group. Comparing TDI and SHM, the difference in clinically significant participants was not found to be significant (χ2 = 0.404, P = 0.52).


  Discussion Top


The study aimed at assessing the effectiveness of a SHM-based approach for the management of OCD. To this end, the following discussion looks at a reduction in symptom severity of OCD with manual use and compares it with a similar reduction in the group assigned to traditional TDI as well as a control group on solely pharmacotherapy.

The reduction in symptom severity in the present study is greater than that reported by both Robinsonet al.[18] and Tolin et al.[19] Robinson, in her clinical trial with 8 adolescents over 10 weeks, reported a mean CY-BOCS reduction of 18.6%, while Tolinet al.,[19] in the randomized controlled trial, reported mean reduction of 17% for SHM group in a sample of 20 adult outpatients. One important reason for this difference may be attributed to the amount of therapist contact in the three conditions – in the earlier studies of Robinson and Tolin, therapist contact was only available at the assessment and orientation sessions, and then at postintervention or follow-up assessments; or in case of worsening of symptoms. However, in the present study, the amount of therapist contact was significantly greater, in the form of regular follow-up for clarification of manual use, motivation for adherence, and even one session for the demonstration of technique by participant and cotherapist. Therapist contact and training have been demonstrated to be important variables in treatment outcomes. While earlier work showed no significant relationship between therapist contact and effectiveness of self-help treatments,[20] more recent attempts have diverse findings.[21] Kobak etal.[22] reported that adding human element was effective in motivating patients to use the prescribed techniques and to confront their fears, while also motivating them to complete the homework tasks. Studies have also found that introducing therapist contact – even minimally-caused greater treatment gains – even if contact was limited to psychoeducation and monitoring.[23] These findings are supported across literature, where the addition of therapist contact has been associated with better outcomes, increased adherence, and patient satisfaction.[21],[24],[25],[26] Currently, however, the level of human contact or support necessary for greater treatment gains have not been empirically tested or reported.[21]

Another possible reason for the greater gains in the present study could be the assignment of a cotherapist. Wherever possible, as was in most cases, a family member or significant other was assigned as cotherapist to help the participant maintain motivation, adherence and to facilitate the practice of ERP techniques. This was particularly essential in adolescent cases where parents guided the adolescents in completing the tasks and oversaw correct execution; maintained participant motivation and ensured timely follow-up. Assigning a family member as cotherapist has shown to enhance treatment gains and produce better outcomes than CBT carried out alone.[27],[28] Mehta[27] reported greater gains for family-based intervention in the domains of anxiety, depression, obsessive symptoms, and social adjustment. Assigning a family member serves the dual task of reducing family members' anxiety, as well as helping manage the family members' expectations in consonance with the ongoing progress, thereby reducing pressure and stress on the participants.

Comparison of groups

The finding of no greater gains in both therapists assisted as well as SHM group in comparison to controls is in concordance with existing evidence for ERP (standalone or combination) as treatment of choice for OCD, with greater gains when compared with pharmacotherapy alone. Eddy et al.,[3] in a meta-analysis of different combinations of psychotherapy for OCD, reported larger effect sizes for combined therapies, higher than pharmacotherapy alone (1.72 as compared to 1.18), as well as higher than those reported for psychotherapy alone.

Not only in the TDI group, but also in the SHM group, differed significantly from the controls (P = 0.003). This indicates that the SHM approach can be said to be more effective for symptom reduction as compared to treatment as usual/only pharmacological treatment (SSRIs). While controlled trials for the comparison of SHMs for OCD in comparison with treatment as usual have not been carried out, treatment gains have been reported for any form of CBT as compared to pharmacotherapy. Gava et al.[29] reported significantly greater gains for variants of cognitive or behavioral therapy when compared with treatment as usual. The efficacy of CBT/ERP in reducing OCD symptoms is already well established;[2],[30] and hence, it is safe to assume that the manual, by employing particularly ERP, would lead to favorable outcomes.

The treatment groups (TDI and SHM) were also compared against each other [Table 5] for better understanding of relative effectiveness of each, as well as the utility of SHMs in comparison to therapist-directed traditional approaches. No significant difference was reported between the two. There is paucity of comparative research in literature for the use of SHMs in comparison with TDI. In a randomized controlled trial of 41 adult outpatients, Tolin et al.[19] compared the efficacy of self-directed ERP (n = 20) with that of TDI (n = 21) and reported that patients in both treatment conditions showed statistically and clinically significant symptom reduction. No significant differences were found between the two groups for mean improvement on Y-BOCS scores (F [1,39] =1.52, P = 0.225). This is in concordance with the present study. Similar to the present study, superior gains were reported for those receiving TDI. On an ITT analysis, participants in the therapist-directed group reported 35% improvement as compared to 17% for the self-help group, which was found to be 46% and 20% for completers in both groups, respectively. The present improvement in the TDI group for the study lies in the range reported by Tolin; however, gains in SHM group are much larger when compared with either ITT or completers.
Table 5: Comparison of improvement for therapist-directed intervention and self-help manual groups using two-tailed Mann–Whitney test

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The findings are also consistent with those by Greist et al.[26] who reported superior gains for clinician-delivered therapy as compared to self-directed therapy, albeit by a computer (mean change on Y-BOCS of 8 vs. 5.6). As in the present study, both groups showed greater change than the control group (1.7). An important finding that brings the present study more in alignment with the findings of Greistet al.,[26] is that if participants completed even one ERP session, the difference in mean improvement did not remain significant.

In addition to the reasons for greater gains discussed in the previous section (therapist contact, assignment of cotherapist), other possible explanations for the lower gap between gains in therapist-directed versus self-help groups as compared to previous studies can be the nature of self-help interventions in the previous studies, and the relative benefits of TDIs perceived. According to Tolin and Hannan,[31] TDI showed greater gains in comparison to self-help interventions owing to the functions served by the therapist in TDI interventions. First, therapist-directed approaches include a component of education, which ensures thorough understanding of OCD and ERP, as well as rationale for the study; as well as that of modeling and consultation, where the therapist not only displays an intent and motivation to carry out ERP tasks but also clarifies and provides corrective feedback on the techniques associated with ERP. In addition, the presence of a therapist provides much-needed motivation and support, by providing an accepting and collaborative environment for the participant to work in. In addition, accountability is ensured where therapist contact is available.

Looking at the protocol of the present study, while the approach in SHM group was essentially self-directed, it allowed for a higher degree of therapist contact than in the previous studies. Hence, even in brief fortnightly sessions or follow-up over E-mail or phone, the patients were accountable to the therapist. Assignment of a family member as cotherapist further strengthened accountability in completion of ERP tasks. The current protocol was also educative in nature, as the follow-up after psychoeducation chapter involved clarification of its materials and addressing doubts of the participants regarding any aspect of OCD or the treatment program. Where modeling and consultation is concerned, this aspect was taken care of in two ways: By mandating one follow-up session in person after assigning the ERP chapter, for demonstration of the technique by the participant; as well as by the cotherapist to clarify the technique and correct for any inconsistencies or errors. This ensured that the participant was carrying out the technique in the prescribed way and had a feedback mechanism at home for correction and clarification if need be. Since these six factors – education, consultation, modeling, motivation, support, and accountability – are in part hypothesized to be a major factor in the superior treatment gains for TDIs, and were adequately addressed in the protocol for self-help groups in the present study, this may have been a factor in the reduced gap between the two approaches where treatment gains in this study are concerned.

Looking at the clinically significant improvement, no significant differences were found between the two intervention groups. These findings are inconsistent with those of Tolin (2007), where at posttreatment, 47.6% of the TDI group showed clinically significant improvement, while 15% of the SHM did; and the difference was found to be significant (χ2 = 5.03, P = 0.025). However, the difference at 6 months of follow-up was not significant (P = 0.116) where 42.9% of the TDI participant continued to show clinically significant improvement, while the SHM group increased to 20% participants showing the same.

In addition to the above findings, it was noted that 30% (n = 6) participants in both groups, TDI and SHM, did not meet criteria for OCD on Y-BOCS (Score <8), while one participant (5%) showed such improvement in the control group. These findings are consistent with those reported in the meta-analysis by Eddy et al.,[3] who reported that about one-third (range: 27%–47%) of participants undergoing any variant of CBT met criteria for recovery.

Self-rated improvement

The visual analog scale was constructed as part of the feedback form for participants only in the SHM group, to assess for perceived improvement in domains of vocation (work/study), interpersonal relationships (family/friends/others), feelings of anxiety, psychological distress, and negative thinking. To assess for overall perceived improvement by family members/cotherapists, a rating scale consisting of four categories – no improvement, some improvement, moderate improvement, and vast improvement – was made part of the family/cotherapist feedback form.

Overall, mean self-rated improvement ranged from 46% to 70%. The National Comorbidity Survey Replication[32] reported maximum impairment in the domains of relationships and social functioning for those suffering from OCD; and it is possible that the return to normal activities and interaction may have been perceived as “more” improvement owing to the earlier higher level of dysfunction in the said domains. A lot of the ERP tasks that address avoidance, in particular, also involved interacting with other individuals, friends, and social settings; and hence, this may also have contributed to the perceived improvement in this domain. Improvements in social and occupational domains following CBT are reflected in the existing literature[33],[34] as in the present study. Improvements in social functioning reported in the present study are consistent with findings of Kobak et al.,[22] who reported improvement in functioning after CBT delivered by a computer.

On the family form, most family members/cotherapists reported changes tending toward “Moderate” Improvement (67%), followed by “Some” improvement (33%). These scores may also be reflective of the fact that family members and cotherapists viewed “improvement” as extending beyond just the obsessive–compulsive symptomatology. Many parents often complained, during follow-up assessment, that though the patient did not demonstrate any noticeable compulsions or complain of obsessions, his/her daily activities were not up to expectations, or that he/she would be lazy. Hence, they reported that though there was an improvement, they could not rate it at “vast” or great improvement, as they felt that the patient needed to be fully functioning at par with their perception of how others (or “normal”) people would perform.

To summarize, looking at data from all outcome measures, it can be said that the SHM approach is effective in the reduction of obsessive–compulsive symptoms, and stands well in comparison against controls, as well as produces similar effects as that of traditional TDIs.

Implications

Manual use circumvents the glaring barriers of increased costs of seeking therapy, as well as long waiting periods associated with health care in the relatively more inexpensive public sector, particularly in the Indian context. It increases possibilities for patients seeking treatment beyond the two options of inexpensive but delayed treatment, and rapid but expensive therapy. Economic factors play an important role in help-seeking in India, particularly for the lower socioeconomic strata, and even for the middle strata as most insurance does not account for prolonged psychiatric care. Self-help approaches also help in overcoming barriers of distance, by removing the necessity for the patient to travel. It allows for follow-up by phone or E-mail, thereby further reducing effort and costs involved in traveling. By allowing individuals to practice at home, SHMs reduce the burden of stigma that the patients otherwise perceive, as well as allow for self-pacing of therapy, and reducing undue pressure on the patient to conform to a particular pace. It also increases the outreach of therapy, by giving access to treatment to those who do not wish to seek consultations, or bring their disorders “to light.” By taking their treatment into their own hands, patients gain a sense of responsibility[35] and self-efficacy and can sustain gains for longer periods as the treatment protocol is available to them whenever they need, and is already tailored to their needs from their previous experience with it.

SHMs can prove to be an important step in reducing the burden on therapist time and resources. By employing a stepped care approach, or using SHMs in the early stages of treatment, burden on therapist time and resources would be greatly reduced. In addition, research has shown that therapists, in the face of lesser time, may choose not to give ERP due to its time-consuming nature thereby reducing the proportion of people receiving standard treatment of choice;[36] manual use and the time, it affords may allow more therapists to employ standard treatment procedures as opposed to more generalized packages. Manuals may also strengthen and increase treatment gains, if used as adjuncts at the beginning of therapy[35] for psychoeducation and later, posttermination for continued use, instead of frequent booster sessions.

In addition to use in mental health-care setups or psychiatric settings in primary health-care, manuals may have important uses in the community. Research has reported the occurrence of obsessions and compulsions, as well as associated distress, in community samples with individuals that are not diagnosed with a mental illness. Fullana,[37] in a community study, reported rates as high as 31%–42% of individuals who are not diagnosed with a mental disorder but are distressed by obsessions for over 2 weeks. 25% of the 972 participants reported having obsessions for more than an hour a day; while those that were emotionally upset by them formed 15% of the sample. Similar rates were found for compulsions, where 33%–45% of the sample reported experiencing compulsions for over 2 weeks, and 11%–12% of these reported being upset by them. Ruscio et al.[37] has also supported the findings that OCD symptoms may affect individuals that do not have the full OCD syndrome, and expressed concern regarding the increased public health burden as compared to what the prevalence data implies currently.

These findings raise important implications for the use of manuals, even in cases where a full diagnosis of OCD cannot be made. In the community, the use of SHMs for the proportion of individuals that report even one obsession or compulsion may act as an aid in reducing distress, and help terminate symptoms at an early stage. With increased awareness of the disorder that the manual brings about, even treatment seeking may increase if individuals are able to identify themselves as having certain symptoms and unable to find gains with manual use alone. In addition, SHMs can be used by early career psychologists with basic training to aid in dealing with obsessions and compulsions, or milder forms of OCD, where full-blown, intensive treatment is not immediately available.

Manual use in the Indian context also has implications for adopting a stepped care approach to therapy. Such approaches essentially involve starting with the “lowest intensity” treatment and moving on to higher levels only for those patients who do not respond to lower levels of intervention. Stepped care approaches are gaining increasing value across the world, and have been successfully incorporated as part of the “Increasing Access to Psychological Therapy” program by the National Health Scheme in the United Kingdom. These stepped care programs have been associated with higher treatment gains and increased outcome.[38],[39],[40],[41] In a novel attempt in India, MANAS (Goa) is a project that is making an attempt to integrate evidence-based treatments for common mental disorders in routine primary care.[42] An important finding of the project was that while interpersonal therapy was initially planned to be delivered face to face, this was not possible for a number of patients owing to cost and time barriers, as well as issues of travel.[43] These findings further strengthen the case for the use of SHMs, where patients would not have to forego treatment due to paucity of therapist time, neither for economic- and travel-related concerns. In a burdened health-care setup like India, projects such as these that employ a stepped care approach could have far-reaching implications for increasing therapy outreach.

Strengths and limitations

The study is the first of its kind in the Indian setting, to develop a SHM-based treatment for OCD, as well as to test one empirically. The study compares the use of SHMs with both therapist-directed approach as well as a pharmacotherapy control group, which appears to be the most commonly used choice in the setup. Another strength of the protocol lies in the distributed assignment of the manual, this approach ensured that the participants proceeded in the right order, and reverted with feedback at each stage before being assigned the next section.

Looking at the limitations, the small sample size in each of the treatment conditions is an important concern. While this suited the needs of the present study and took care of time constraints, for findings to be more generalizable the study may be replicated on larger samples. The current protocol mandated exclusion of individuals diagnosed with a comorbid Axis I condition. However, the occurrence of “pure” OCD is highly limited, as it is associated with high rates of comorbidity. Exclusion of such cases, therefore, limits the generalizability of results; and calls for an extension of the present work on more representative samples. In addition, detailed data on pharmacotherapy compliance was not sought. However, it was ensured that the participants were stabilized on optimum dosage and were instructed to report on any drastic changes in medication regime. A minimum of 4 weeks of drug use was designed for inclusion, which may have been inadequate in some cases. Furthermore, since some degree of therapist contact existed, conclusions about the effectiveness of manual use in the complete absence of therapist cannot be made. In addition, the inclusion of “co-therapist” in some cases of the SHM group has not been explored fully. While the role of such individuals in the current study was limited to monitoring and motivation, further research may explore the impact of having an involved cotherapist for the self-help group.


  Conclusion Top


The results from the present study confirm the effectiveness of the given SHM on the reduction of severity of obsessive–compulsive symptoms. Findings suggest significant treatment gains with the use of the manual, with results comparable to those with TDIs; and significantly greater gains than control groups receiving only pharmacotherapy. The findings are encouraging for the use of such manuals as adjuncts to treatment, or as treatment modalities in their own right, comparable to therapist-delivered intervention. However, further research with larger sample sizes in multiple centers would strengthen the inferences, and provide for more conclusive evidence.

Financial support and sponsorship

This study was supported by University Grants Commission.

Coflicts of interest

There are no conflicts of interest.



 
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