Obsessive-compulsive disorder

Clinical GuidelinePublished: November 2005

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NICE clinical guidelines

• Recommendations for good practice based on best available evidence of clinical and cost effectiveness

• DH document ‘Standards for better health’ expects organisations will work towards implementing clinical guidelines

• Healthcare Commission will monitor compliance with NICE guidance

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Rationale for the guideline

• OCD is a potentially life-long disabling disorder and is poorly recognised and under-treated

• Individuals in some studies report waiting an average of 17 years before the correct management is initiated

• Treatment occurs in a wide range of NHS settings – provision and uptake is varied

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What does this guideline cover?

• Children, young people and adults with OCD/BDD – mild, moderate and severe functional impairment

• A stepped-care approach to recognition, assessment, treatment interventions, intensive treatment and inpatient services, discharge and re-referral

Who is it aimed at?• Healthcare professionals who share in the treatment

and care of people with OCD/BDD • Commissioners of services• Service users, families/carers

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What is OCD?

• Obsessive-compulsive disorder (OCD): characterised by the presence of either obsessions (repetitive, distressing, unwanted thoughts) or compulsions (repetitive, distressing, unproductive behaviours) – commonly both. Symptoms cause significant functional impairment/distress

• Diagnostic criteria:

ICD-10/DSM-IV – must include the presence of either compulsions or obsessions

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How common is OCD?• Estimated UK prevalence 1-2% of adult population -

fourth most common mental disorder after depression, alcohol and substance abuse, and social phobia

• 1% of young people – adults often report experiencing first symptoms in childhood

• Onset can be at any age. Mean age is late adolescence for men, early twenties for women

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Recommendations identified as key priorities

• All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology

• CBT (including ERP) should be offered in a variety of formats

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Recommendations identified as key priorities

• PCTs, mental healthcare trusts and children’s trusts that provide mental health services should have access to a specialised OCD multidisciplinary healthcare team

• Anyone who has relapsed and has been re-referred should be seen as soon as possible

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Stepped-care model

• The model provides a framework in which to organise the provision of services in order to identify and access the most effective interventions

• Stepped care attempts to provide the most effective but least intrusive treatments appropriate to a person’s needs

• The recommendations in the NICE guidance are structured around the stepped-care model

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Who is responsible for care?

STEP 6 Inpatient care or intensive treatment programmes. CAMHS Tier 4

STEP 5 Multidisciplinary teams with specific expertise in management of OCD. CAMHS Tiers 3 and 4

STEP 4 Multidisciplinary care in primary or secondary care.CAMHS Tiers 2 and 3

STEP 3 GPs and primary care team, primary care mental health worker, family support team. CAMHS Tiers 1 and 2

STEP 2 GPs, practice nurses, school health advisors, general health settings. CAMHS Tier 1

STEP 1 Individuals, public organisations, NHS

STEPPED CARE MODEL

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STEP 1 Awareness and recognition

PCTs, mental healthcare trusts and children’s trusts that provide mental health services should:• have access to a specialist OCD multidisciplinary team offering age- appropriate care

Specialist mental healthcare professionals/teams in OCD should:• collaborate with local and national voluntary organisations to increase awareness and understanding of the disorders and improve access to high quality information about them• collaborate with people with the disorders and their family/carers to provide training for all mental health professionals

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Step 2 Recognition and assessment

Routinely consider and explore the possibility of comorbid OCD for people:• at higher risk of OCD, such as those with symptoms of:

- depression- anxiety- alcohol or substance abuse- BDD- an eating disorder

• attending dermatology clinics

Ask direct questions about possible symptoms

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Step 2 Recognition and assessment

For any person diagnosed with OCD:• assess risk of self-harm and suicide (particularly if depression already

diagnosed)• include impact of compulsive behaviours on patient and others in risk

assessment• consider other comorbid conditions or psychosocial factors that may

contribute to risk• consult mental health professional with specific expertise in OCD if

uncertain about risks associated with intrusive sexual, aggressive or death-related thoughts. (These themes are common in OCD and are often misinterpreted as indicating risk.)

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Steps 3~5 Treatment options for adults with OCD

Mild functional Moderate functional Severe functional impairment impairment impairment

Brief CBT (+ERP)< 10 therapist hours

(individual or groupformats)

Offer choice of:more intensive CBT

(+ERP)>10 therapist hours

orcourse of an SSRI

Patient cannot engage in/CBT (+ERP) is inadequate

Offer combinedtreatment ofCBT (+ERP)and an SSRI

Inadequate response at 12 weeks

Multidisciplinary review

Please refer to QRG for full overview of treatment pathway

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Steps 3~5Treatment options for adults

Offer either: a different SSRI or clomipramine

Refer to multidisciplinary team with expertise in OCD

Consider:• additional CBT (including ERP), or cognitive therapy• adding an antipsychotic to an SSRI or clomipramine• combining clomipramine and citalopram

Severe functional impairment:• offer combined treatment with CBT (including ERP) and an SSRI

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Steps 3~5 Treatment options for children and young people with OCD

Mild functional Moderate to severe impairment functional impairment

Ineffective or refused

Consider guidedself-help

support andinformation forfamily/carers

Offer CBT (+ERP)involve family/

carers(individual or

group formats)

Ineffective or refused

Consider an SSRI

(with careful monitoring)

Please refer to QRG for full overview of treatment pathway

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Steps 3~5Treatment options for children and young people

Consider an SSRI (e.g. use licensed medication) and carefully monitor for adverse events

Multidisciplinary review

SSRI + ongoing CBT (including CBT)• Consider use in 8-11 year age group• Offer to 12-18 year age group• Carefully monitor for adverse events, especially at start of treatment

Consider either (especially if previous good response to):• a different SSRI• clomipramine

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Step 6 - Intensive treatment and inpatient services

• People with severe/chronic problems should have continuing access to multidisciplinary teams with specialist expertise in OCD

• Inpatient services are appropriate for a small proportion of people with OCD

• A small minority of adults will need suitable accommodation in a supportive environment in addition to treatment

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Discharge after recovery

• When in remission, review regularly for 12 months by a mental health professional – frequency to be agreed between the healthcare professional and person with OCD

• At the end of the 12-month period if recovery is maintained the person can be discharged to primary care

• If relapse – see as soon as possible

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Psychological interventions - adults

CBT (including ERP) is the mainstay of psychological treatment

• Consider CBT (including ERP) for patients with obsessive thoughts without overt compulsions

• Consider cognitive therapy adapted for OCD:

- as an addition to ERP to enhance long-term symptom reduction

- for people who refuse or cannot engage with treatments that include ERP

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Psychological interventions - adults

• If a family member/carer is involved in compulsive behaviours, avoidance or reassurance seeking, treatment plans should help them to reduce their involvement in a supportive way

• The intensity of intervention is dependent upon the degree of functional impairment and patient preference

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Psychological interventions – children and young people

• Guided self-help, CBT (including ERP) recommended• Work collaboratively and engage the family or carers• Identify initial and subsequent treatment targets

collaboratively with the patient• Consider the wider context including other

professionals involved with the child• Maintain optimism in child and family or carers• Consider including rewards to enhance motivation

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How to use pharmacological treatments - adults

Starting treatment • address common concerns about taking medication with the

patient e.g. potential side effects including worsening anxiety• explain that OCD responds to drug treatment in a slow and

gradual way and that improvements may take weeks or months

Choice of drug • initial pharmacological treatment should be an SSRI• if drug treatment effective, consider continuing for 12 months to

prevent relapse and then review with the patient• consider prescribing a different SSRI if prolonged side effects

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How to use pharmacological treatments - adults

Monitoring risk • Monitor closely on a regular basis particularly:

- during the early stages and during dose changes of SSRI treatment

- adults younger than 30

- people who are depressed or considered to present an

increased suicide risk • Consider prescribing limited quantities of medication and

enlisting others e.g. other carers may contribute to the monitoring until the risk is no longer significant

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How to use pharmacological treatments- adults

Poor response to initial treatment

• if symptoms not responded adequately within 12 weeks to treatment with an SSRI or CBT (including ERP) - conduct multidisciplinary review

• consider offering combined treatment of CBT (including ERP) and an SSRI

• consider offering a different SSRI or clomipramine if symptoms not responded to combined treatment

• then if not responded, consider referral to multidisciplinary team with specific expertise in OCD for comprehensive assessment and further treatment planning

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How to use pharmacological treatment - adults

Discontinuing treatment

• taper the dose gradually when stopping treatment in order to minimise potential discontinuation/withdrawal symptoms

• encourage people to seek advice if they experience significant discontinuation/withdrawal symptoms

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When to use pharmacological treatments – children and young people

• If CBT ineffective or refused - carry out a multidisciplinary review and consider adding an SSRI

• Sertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCD*

• Monitor carefully and frequently• If successful, continue for 6 months post remission • Withdraw slowly with monitoring

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Special issues for children and families• Symptoms are similar in children, young people and

adults and they respond to the same treatments• Stressful life events may worsen symptoms or

relapse may occur:

- school transitions

- examination times

- relationship difficulties

- transition from adolescence to adult life• Parents may feel guilty and anxious• Increase in severity if left untreated

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Needs of people with OCD

• Early recognition, diagnosis and effective treatment• Information about the nature of OCD and treatment

options• Respect and understanding• What to do in case of relapse• Information about support groups• Awareness of family/carer needs

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Implementation for cliniciansDiagnosis:• Increase your awareness and recognition of symptoms

of OCD - be aware of those at higher risk and how difficult initial disclosure is for many people with OCD

• Ask the ‘right’ questions – assessment

Treatment:• Involve patients and when appropriate, family/carers,

fully in treatment options • Offer CBT (including ERP)• If pharmacological treatment is required, regularly

monitor side effects of SSRIs (self-harm and suicide)

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Implementation for clinicians

Access to services:• Be aware of how to access specialist teams• Ensure you have access to local protocols

Training:• Identify your training needs in the use of CBT

(including ERP) for OCD• Less therapist-intensive interventions have a role to

play, particularly in primary care

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Implementation for managers• Actively disseminate the guidance• Carry out a baseline assessment• Develop and implement an action plan • Ensure CBT and specialist teams can be accessed

appropriately• Identify professionals that require training or updating in

CBT (including ERP) – less-therapist intensive interventions have a role to play, particularly in primary care

• Include OCD within local education planning e.g. PTIs• Monitor and review

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Four implementation tools support this guidance• Costing tools

- a local costing template

- a national costing report• Implementation advice• Audit criteria• This slide set

• The tools are available on our website:

www.nice.org.uk/implementation

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Where is further information available?• Quick reference guide: summary of recommendations for health

professionals- www.nice.org.uk/cg031quickrefguide

• NICE guideline- www.nice.org.uk/cg031niceguideline.pdf

• Full guideline: all of the evidence and rationale behind the recommendations- www.nice.org.uk/cg031fullguideline.pdf

• Information for the public: plain English version for people with OCD, carers and the public- www.nice.org.uk/cg031publicinfo

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www.nice.org.uk

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