Obsessive-compulsive disorder

1. Obsessive-compulsive disorder Support for education and learning: slide set 2nd. Edition: March 2012 NICE clinical guideline 31

2. Guideline review • Guideline issue date: 2005 • First review : 2007 • Second review : 2011 • 2011 review recommendation: • The guideline should not be updated at this time and should be reviewed again in due course

3. What this presentation covers • Background • Epidemiology • Scope • Key priorities for implementation • Stepped care • Psychological and pharmacological treatments • Costs • NHS Evidence and NICE pathway • Find out more

4. Scope Children and adults who meet the standard diagnostic criteria of obsessive-compulsive disorder and body dysmorphic disorders Care provided in primary and secondary care and that provided by health care professionals who have direct contact with and make decisions concerning the care of patients with OCD • The interface between health care services and social services, the voluntary sector and education

5. Background • OCD is a potentially life-long disabling disorder and is poorly recognised and under-treated • People in some studies report waiting an average of 17 years before the correct management is started • Treatment occurs in a wide range of NHS settings – provision and uptake is varied

6. 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

7. Epidemiology • 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

8. Key priorities for implementation The key priorities for implementation are grouped in three areas: • all people with OCD or BDD • adults with OCD or BDD • children and young people with OCD or BDD

9. All people with OCD or BDD: 1 • Each trust that provides mental health services should have access to a specialist OCD/BDD multidisciplinary team offering age-appropriate care. This team would: • increase the skills of mental health professionals in assessment and treatment • provide high-quality advice and understand family and developmental needs • conduct expert assessment and specialist cognitive-behavioural and pharmacological treatment

10. All people with OCD or BDD: 2 • Condition may be fluctuating or episodic, relapse may occur after successful treatment • See previously discharged people as soon as possible if re-referred with further occurrences of OCD or BDD • Use care coordination at the end of a treatment programme to identify continuing support needs and appropriate services

11. Adults with OCD: 1 • Offer low intensity psychological treatments initially if functional impairment is mild and/or the person prefers a low intensity approach • Low intensity treatments include: • brief individual cognitive behavioural therapy (CBT) (including exposure and response prevention [ERP]) using structured self-help materials • brief individual CBT (including ERP) by telephone • group CBT (including ERP)

12. Adults with OCD: 2 • For mild functional impairment, if low intensity treatment is inadequate or unsuitable, offer: • a selective serotonin re-uptake inhibitor (SSRI) or • more intensive CBT

13. Adults with OCD or BDD • For OCD with moderate functional impairment offer: • a course of an SSRI, or • more intensive CBT • For BDD with moderate functional impairment offer: • a course of an SSRI, or • more intensive individual CBT (including ERP) that addresses key features of BDD

14. Children and young people with OCD • For OCD with moderate to severe functional impairment, or mild functional impairment for which guided self-help has been ineffective or refused, offer CBT (including ERP) that involves the family or carers and is adapted to the developmental age of the child • Offer group or individual formats depending on the preference of the child or young person and their family or carers

15. Children and young people with OCD or BDD • For moderate to severe functional impairment and an adequate response to CBT, carry out multidisciplinary review, then: • for a young person (aged 12-18 years) offer to add an SSRI to ongoing psychological treatment • for a child (aged 8-11 years) consider adding an SSRI to ongoing psychological treatment • Monitor carefully, particularly at the beginning of treatment

16. Children and young people with BDD • For BDD offer CBT (including ERP) that involves the family or carers and is adapted to suit the developmental age of the child or young person as first-line treatment

17. 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

18. Stepped care model Who is responsible for care? STEP 6Inpatient care or intensive treatment programmes. CAMHS Tier 4 STEP 5Multidisciplinary teams with specific expertise in management of OCD. CAMHS Tiers 3 and 4 STEP 4Multidisciplinary care in primary or secondary care. CAMHS Tiers 2 and 3 STEP 3GPs and primary care team, primary care mental health worker, family support team. CAMHS Tiers 1 and 2 STEP 2GPs, practice nurses, school health advisors, general health settings. CAMHS Tier 1 STEP 1Individuals, public organisations, NHS

19. 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

20. Step 2 Recognition and assessment of OCD: 1 • 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 misuse • - BDD • - an eating disorder • attending dermatology clinics Ask direct questions about possible symptoms

21. Step 2 Recognition and assessment of OCD: 2 • 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.)

22. Step 2 Recognition and assessment of BDD: 1 • Routinely consider and explore the possibility of comorbid BDD for people: • at higher risk of BDD, such as those with symptoms of: • - depression • - social phobia • - alcohol or substance misuse • - OCD • - an eating disorder • attending dermatology clinics Ask direct questions about possible symptoms

23. Step 2 Recognition and assessment of BDD: 2 • For any person diagnosed with OCD: • Those seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional • Assess risk of self-harm and suicide (particularly if depression already diagnosed) • Specialist mental health professionals in BDD should work in partnership with cosmetic surgeons and dermatologists to ensure a screening system is in place

24. Steps 3 to 5 treatment options for adults with OCD or BDD: 1 Mild functional Moderate functional Severe functional impairment impairment impairment Inadequate response at 12 weeks 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 Multidisciplinary review Offer combined treatment of CBT (+ERP) and an SSRI Patient cannot engage in/CBT (+ERP) is inadequate Next slide See the QRG for full overview of treatment pathway

25. Steps 3 to 5 treatment options for adults with OCD or BDD: 2 • Severe functional impairment: • offer combined treatment with CBT (including ERP) and an SSRI inadequate response or the patient cannot engage Offer either: a different SSRI or clomipramine inadequate response or the patient cannot engage Refer to multidisciplinary team with expertise in OCD inadequate response or the patient cannot engage • Consider: • additional CBT (including ERP), or cognitive therapy • adding an antipsychotic to an SSRI or clomipramine • combining clomipramine and citalopram

26. Steps 3 to 5 for children and young people with OCD or BDD: 1 Mild functional Moderate to severe impairment functional impairment Consider guided self-help support and information for family/carers Offer CBT (+ERP) involve family/ carers (individual or group formats) Consider an SSRI (with careful monitoring) Ineffective or refused Ineffective or refused Next slide Please refer to QRG for full overview of treatment pathway

27. Steps 3 to 5 for children and young people with OCD or BDD: 2 Consider an SSRIand carefully monitor for adverse events inadequate response or the patient cannot engage Multidisciplinary review inadequate response or the patient cannot engage • 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 inadequate response or the patient cannot engage • Consider either (especially if previous good response to): • a different SSRI • clomipramine

28. Psychological interventions adults: 1 • 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

29. Psychological interventions adults: 2 • 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

30. 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 rewards to enhance motivation

31. Pharmacological treatmentsadults: starting treatment • Address common concerns about taking medication with the patient, such as 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

32. Pharmacological treatments adults: 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

33. Pharmacological treatments adults: monitoring risk • Monitor closely on a regular basis particularly: • early stages and 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 • Consider enlisting others, for example carers, to contribute to monitoring until risk is no longer significant

34. Pharmacological treatmentsadults: response to treatment • Symptoms not responded adequately within 12 weeks to SSRI or CBT (including ERP)? Conduct multidisciplinary review • Consider combined treatment of CBT (including ERP) and an SSRI • Not responded to combined treatment? Consider different SSRI or clomipramine • Still not responded? Consider referral to OCD multidisciplinary team for assessment and treatment planning

35. Pharmacological treatments 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

36. Pharmacological treatments: children and young people • CBT ineffective or refused, carry out 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

37. 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

38. 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

39. Special issues for children and families • Symptoms are similar in children, young people and adults and they respond to the same treatments • Stress may worsen symptoms or cause relapse: • school transitions • examination times • relationship difficulties • transition from adolescence to adult life • Parents may feel guilty and anxious • Increase in severity if left untreated

40. 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

41. Recurrent annual net cost for England Costs correct at Dec. 2005. Costs not updated for 2nd edition

42. NICE pathway • The NICE obsessive-compulsive disorder (OCD) pathway covers core interventions in the treatment of OCD and body dysmorphic disorder (BDD) Click here to go to NICE pathways website

43. NHS Evidence To be added- the latest NHS evidence image Visit NHS Evidence for the best available evidence on all aspects of OCD Click here to go to the NHS Evidence website

44. Find out more • Visit www.nice.org.uk/guidance/CG31 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing report and template • implementation advice • NICE pathway for OCD and BDD

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