(PS3-C64) A Pilot Study of “BOLD”: A Text-message Based App to Support Homework Adherence in Exposure and Response Prevention for Obsessive-compulsive Disorder

Exposure and ritual prevention (ERP) is an effective, first-line treatment for obsessive-compulsive disorder (OCD). However, 30-40% of individuals do not respond to ERP. Poor adherence to exposure homework is an important predictor of worse ERP outcome; in fact, clinicians frequently cite patients’ inability to work in between sessions as a significant barrier to OCD treatment progress. Mobile health (mHealth) adjuncts to ERP may be useful in promoting homework adherence by 1) prompting patients with reminders at times when they are most likely to complete exposure homework, 2) offering a support tool outside of typical business hours when therapists are not available, 3) improving the quality of homework by guiding patients through questions informed by inhibitory learning principles (e.g., expectancy violation) after an exposure to solidify learning, and 4) optimizing behavior change by leveraging the behavioral economics principles of pre-planning and pre-commitment, prompting patients to plan exposures in advance. While research supports the utility of incorporating text-message adjuncts into standard treatments, no such apps have been created to supplement ERP for OCD specifically.

This seven-month pilot tested the feasibility and utilization of BOLD (Break through Obstacles and Learn Digitally), a text-message app that incorporates principles of behavioral economics, nudging, and inhibitory learning to augment homework adherence in standard ERP for OCD. Participants (n = 24) included patients diagnosed with OCD engaged in ERP at an OCD and anxiety specialty clinic. ERP was delivered by 10 masters and doctoral-level therapists. Patients received daily text-message reminders to complete exposure homework assigned by their therapists. Text messages gave patients the option to do an exposure immediately, plan future exposures, or log already completed exposure homework. Once an exposure was completed, BOLD then prompted patients to answer exposure processing questions informed by inhibitory learning.

Participants sent a total of 3,779 text responses, with substantial variability in how often patients interacted with the app (M = 130 texts over the pilot period, SD = 214). Of responses related to exposure homework (n = 531), 46% were to log a previously completed exposure, 37% to do an exposure immediately, and 17% to plan a future exposure. Of note, the majority (2,434; 64%) of text responses were submitted outside of working hours (i.e., on weekends or before or after 9am-5pm on weekdays). In addition, qualitative feedback obtained from participating therapists indicated that therapists found the app useful and timesaving.

Results from this pilot indicate it is feasible to leverage mHealth technology to assist with exposure therapy. OCD patients were interested in using the BOLD app, utilized it frequently, and were more likely to use it outside of working hours. Text message-based apps may be beneficial to pair with standard ERP as a means of enhancing exposure homework quality and adherence for some patients with OCD. Future studies should identify individuals most likely to benefit from mHealth technology and the effectiveness of interventions that increasingly utilize mHealth technology to deliver exposure therapy.