Obsessive-compulsive disorder

Clinical Guideline
Published: November 2005

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Recommendations identified as key priorities

All people with OCD should have access to evidencebased treatments: CBT including exposure and response prevention (ERP) and/or pharmacology CBT (including ERP) should be offered in a variety of formats

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Recommendations identified as key priorities

PCTs, mental healthcare trusts and childrens 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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 persons needs The recommendations in the NICE guidance are structured around the stepped-care model
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

STEPPED CARE MODEL 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

STEP 1 Awareness and recognition

PCTs, mental healthcare trusts and childrens trusts that provide mental health services should: have access to a specialist OCD multidisciplinary team offering ageappropriate 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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 deathrelated thoughts. (These themes are common in OCD and are often misinterpreted as indicating risk.)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Steps 3~5 Treatment options for adults with OCD

Mild functional impairment Moderate functional impairment Severe functional impairment

Brief CBT (+ERP) < 10 therapist hours (individual or group formats)

Offer choice of: more intensive CBT (+ERP) >10 therapist hours or course of an SSRI

Inadequate response at 12 weeks

Multidisciplinary review

Offer combined treatment of CBT (+ERP) and an SSRI

Patient cannot engage in/CBT (+ERP) is inadequate Please refer to QRG for full overview of treatment pathway
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Steps 3~5
Treatment options for adults
Severe functional impairment: offer combined treatment with CBT (including ERP) and an SSRI

*
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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Steps 3~5 Treatment options for children and young people with OCD
Mild functional impairment Moderate to severe functional impairment

Consider guided self-help support and information for family/carers

Ineffective or refused

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Steps 3~5
Treatment 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
Intro Clinical background Treatment Implementation

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

Implementation for clinicians

Diagnosis: 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)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

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
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info

www.nice.org.uk

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Intro Clinical background Treatment Implementation More Info