Obsessive-compulsive disorder Clinical Guideline Published: November 2005 NOTES FOR PRESENTERS You can add your own organisation’s logo alongside the NICE logo DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. Although the guideline covers the core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder, the slide set focuses on obsessive compulsive disorder.

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 NOTES FOR PRESENTERS 2

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 NOTES FOR PRESENTERS Refer to Scope section 3.0 3

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 NOTES FOR PRESENTERS THE SLIDE SET IS FOCUSED ON OBSESSIVE COMPULSIVE DISORDER – PLEASE REFER TO FULL GUIDELINE, NICE GUIDELINE AND NICE QRG FOR MORE INFORMATION RELATING TO BODY DYSMORPHIC DISORDER Target audience: psychiatrists, clinical psychologists, mental health nurses, community psychiatric nurses, social workers, practice nurses, secondary care medical staff, paramedical staff, occupational therapists, pharmacists, paediatricians, other physicians, GPs, family/other therapists. For commissioners and service planners. The guideline covers: Children = age 8 – 11 years Young people = 12 – 18 years Adults 4

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 NOTES FOR PRESENTERS Refer to full guideline – section 2.1.2 and Appendix 15 gives a comparison of diagnostic criteria from ICD-10 and DSM-IV) The diagnostic criteria ICD-10 (included within the broad category of Neurotic, Stress-related and Somatoform disorders) and DSM-IV (classified as an anxiety disorder) are virtually identical and must include the presence of either obsessions or compulsions. The obsessions must cause marked distress or significantly interfere with the patient’s occupational and / or social functioning, usually by wasting time. Section 2.1.5 It may take individuals between 10-15 years or longer to seek professional help. Recurrent compulsions and obsessions interfere with work/educational, home, family and social functioning. OCD is often complicated by depression. 5

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 NOTES FOR PRESENTERS 6

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 NOTES FOR PRESENTERS CBT and ERP can be delivered in a variety of formats: Low intensity Less than 10 therapist hours brief individual CBT (including ERP) using structured self-help materials Brief individual CBT (including ERP) by telephone Group CBT (including ERP) (more than 10 hours of therapy) More intensive More than 10 hours of therapy 7

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 NOTES FOR PRESENTERS Refer to QRG and NICE guideline – - Section key priorities Access to specialised team – help to increase the skills of mental health practitioners in the assessment and evidence-based treatment of children and adults with OCD Provide high quality advice Understand family and developmental needs Conduct expert assessment and specialist cognitive-behavioural and pharmacological treatment when appropriate. Children, young people and adults who have been successfully treated, discharged but re-referred after a first episode of OCD should be seen as soon as possible rather than placed on a routine waiting list 8

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 NOTES FOR PRESENTERS Refer to NICE guideline and full guideline – Section 2.5 The guideline suggests that a stepped care model could prove useful if applied to UK settings to encourage access to intensive treatment when severity or risk indicate less intensive treatment would be inappropriate. Each step introduces additional interventions: the higher steps normally assume interventions in the previous step have been offered/attempted but there are situations when an individual may be referred to any appropriate level. The guidance follows the steps in the figure on slide 10 9

STEP 6 Inpatient care or intensive treatment 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 NOTES FOR PRESENTERS Refer to QRG (page 7) NICE guideline – Section 1.2 Each step introduces additional interventions: the higher steps normally assume interventions in the previous step have been offered and/or attempted but there are situations where an individual may be referred to any appropriate level. The guidance follows the steps in the figure STEP 1 Individuals, public organisations, NHS 10

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 NOTES FOR PRESENTER Step 1 applies to any age group 11

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 NOTES FOR PRESENTER Step 2 applies to any age group Refer to QRG (page 9)and NICE guideline – Sections 1.4.1.1 to 1.4.1.3 People at higher risk of OCD – ask direct questions about possible symptoms, such as: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you’d like to get rid of but can’t? Do your daily activities take a long time to finish? Are you concerned about putting things in a special order or are you very upset by mess? Do these problems trouble you? Ask direct questions about possible symptoms 12

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.) NOTES FOR PRESENTER Refer to QRG (page 9) Step 2 is applicable to any age group 13

Patient cannot engage in/CBT (+ERP) is inadequate 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 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 NOTES FOR PRESENTER Please refer to the NICE guideline and QRG (pages 10 and 11) for the full overview of treatment pathway Mild functional impairment: if the patient cannot engage in CBT (with ERP) or CBT (with ERP) is inadequate, consider: Moderate functional impairment: if inadequate response at 12 weeks, multidisciplinary review and consider: Severe functional impairment: if inadequate response at 12 weeks, or no response to SSRI or patient has not engaged in CBT, consider: (refer to next slide 15) Refer to QRG (page 10) and NICE guideline – Section 1.5.1 to 1.5.1.7 The intensity of psychological treatment has been defined as the hours of therapist input per patient. By this definition, most group treatments are defined as low intensity treatment (less than 10 hours of therapist input per patient), although each patient may receive a much greater number of hours of therapy. CBT and ERP can be delivered in a variety of ways e.g. individual / group therapy, telephone, books and self-help. Patient cannot engage in/CBT (+ERP) is inadequate Please refer to QRG for full overview of treatment pathway 14

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 NOTES FOR PRESENTER This slide continues from the previous slide (slide 14) * If there has been inadequate response or the patient cannot engage – move to the next step Do not routinely initiate treatments such as combined antidepressant and antipsychotic augmentation in primary care 15

Steps 3~5 Treatment options for children and young people with OCD 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 NOTES FOR PRESENTERS Please refer to NICE guideline and QRG (page 12) for full overview of treatment pathway for children and young people OCD – use licensed medication, either: Sertraline Fluvoxamine * * At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people. Please refer to QRG for full overview of treatment pathway 16

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 NOTES FOR PRESENTER This slide continues from the previous slide (16) Refer to QRG (page 12) Mild functional impairment: If guided self-help ineffective or refused, consider: Moderate to severe functional impairment: If patient cannot engage with or declines CBT (with ERP), consider: Consider an SSRI and carefully monitor for adverse events. If SSRI prescribed, use in combination with concurrent CBT (with CBT) SSRIs should only be used after assessment and diagnosis by a child/adolescent psychiatrist who should be involved in decisions about dose changes and discontinuation. Use low starting dose, especially for young children OCD – use licensed medication, either: Sertraline Fluvoxamine * * At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people. * Consider either (especially if previous good response to): a different SSRI clomipramine 17

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 NOTES FOR PRESENTERS Refer to QRG (page 21) and NICE guideline – Section 1.6.1.1, 1.6.1.2 and 1.6.1.3 OCD can usually be managed in the community and in primary care. However, inpatient services, with specific expertise in OCD, may be appropriate for a small proportion of people with OCD when: There is risk to life There is severe self-neglect There is extreme distress or impairment A person has not responded to adequate trials of pharmacological/psychological/combined treatments over long periods of time in other settings A person has additional diagnoses, such as severe depression, anorexia nervosa or schizophrenia, that make outpatient treatment more complex A person has a reversal or normal night/day patterns that make attendance at any day-time therapy impossible The compulsions and avoidance behaviour are so severe or habitual, normal activities of daily living cannot be undertaken In addition to treatment, suitable accommodation in a supportive environment may be necessary for some adults with long-standing and disabling obsessive compulsive symptoms that interfere with daily living, in order to enable them to develop life skills for independent living. Children and young people with severe OCD / BDD with high levels of distress and/or impaired functioning and who have not responded to adequate treatment in outpatient settings or those with significant self-neglect or risk of suicide should be offered assessment for intensive inpatient treatment. People re-referred should not be placed on a routine waiting list. 18

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 NOTES FOR PRESENTERS Refer to QRG page 22 19

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 NOTES FOR PRESENTERS Refer to QRG (page 14) and NICE guideline – Section 1.5.2.1 ERP = exposure to obsessive thoughts and response prevention of mental rituals and neutralising strategies Psychological treatment is aimed at improving coping skills and reducing symptoms. All healthcare professionals offering treatments for OCD to people of any age should: receive appropriate training in these interventions and there should be on-going clinical supervision in line with recommendations in Organising and Delivery Psychological Therapies (Department of Health 2004). Available from www.dh.gov.uk/ Refer to NICE guideline – Sections 1.5.2.3, 1.5.2.7 and 1.5.2.10 CBT and ERP can be delivered in a variety of ways: individual / group, telephone, books and self-help. Consider involving a family member or carer as co-therapist in ERP. The intensity is dependent upon the degree of functional impairment and patient preference. For people with significant functional impairment, access to appropriate support for travel and transport may be necessary to allow them to attend for treatment. 20

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 NOTES FOR PRESENTERS 21

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 NOTES FOR PRESENTERS Refer to QRG (page 15) – Consider offering one or more additional sessions after completion of CBT, if needed, at review appointments. Refer to NICE guideline – Section 1.5.2.1 All healthcare professionals offering treatments for OCD to people of any age should: Receive appropriate training in these interventions and there should be on-going clinical supervision in line with recommendations in Organising and Delivery Psychological Therapies (Department of Health 2004). Available from www.dh.gov.uk/ Sections 1.5.1.8, 1.5.1.9 and 1.5.1.11 Things to consider in the cognitive-behavioural treatment of children and young people with OCD or BDD - Section 1.5.2.12 22

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 NOTES FOR PRESENTERS Starting the treatment – refer to NICE guideline section 1.5.3.1 Choice of drug treatment – refer to NICE guideline section 1.5.3.8 to 1.5.3.19 Initial SSRI should be one of the following: Fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram. Apart from SSRIs and clomipramine, other anti-depressants are generally not helpful. Drugs not recommended for OCD: The following should not normally be used without comorbidity – Tricyclic antidepressants (except clomipramine) Tricyclic-related antidepressants SNRIs (including venlafaxine) MAOIs Anxiolytics (except cautiously for short periods to counter early activation of SSRIs) Antipsychotics as monotherapy should not normally be used for OCD 23

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 NOTES FOR PRESENTERS Refer to NICE guideline – Sections 1.5.3 Current published evidence suggests that SSRIs are effective in treating adults with OCD. However, SSRIs may increase the risk of suicidal thoughts and self-harm in people with depression and in younger people. It is currently unclear whether there is an increased risk for people with OCD. Regulatory authorities recommend caution in the use of SSRIs until evidence for differential safety has been demonstrated. Monitoring risk – refer to NICE guideline section 1.5.3.2 24

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 NOTES FOR PRESENTERS Poor response to initial treatment for adults Refer to NICE guideline – Section 1.5.4 How to use clomipramine for adults Section 1.5.4.11 25

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 NOTES FOR PRESENTERS Poor response to initial treatment for adults Refer to NICE guideline – Section 1.5.4 26

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 NOTES FOR PRESENTERS Refer to QRG (page 13) – If SSRI prescribed, use in combination with concurrent CBT (with CBT) SSRIs should only be used after assessment and diagnosis by a child/adolescent psychiatrist who should be involved in decisions about dose changes and discontinuation. Use low starting dose, especially for young children OCD – use licensed medication, either: Sertraline Fluvoxamine * * At the date of publication (November 2005) the following do not have a UK Marketing Authorisation: fluvoxamine for use in OCD in children younger than aged 8 years, fluoxetine for OCD in children and young people. Refer to NICE guideline – Section 1.5.5 Current published evidence suggests that SSRIs are effective in treating children and young people with OCD. The only SSRI licensed for use in children and young people with OCD is sertraline. When used as a treatment for depression, SSRIs can cause significant adverse reactions including increased suicidal thoughts and risk of self-harm but it is not know whether this same risk occurs with their use in OCD. SSRIs may be safer in depression when combined with psychological treatments (see the NICE guide Depression in children and young people – www.nice.org.uk/CG 028). Given that the UK regulatory authority has advised that similar adverse reactions cannot be ruled out in OCD, appropriate caution should be observed, especially in the presence of comorbid depression. Section 1.5.6.1 If an SSRI is to be prescribed to children and young people with OCD, it should only be following assessment and diagnosis by a child and adolescent psychiatrist who should also be involved in decisions about dose changes and discontinuation. Section 1.5.6.3 Children and young people with OCD started on SSRIs should be carefully and frequently monitored and seen at an appropriate and regular basis agreed by the patient, his or her family or carers an the healthcare professional and this should be recorded in the notes. Section 1.5.6.8 The starting dose of medication for children and young people with OCD should be low, especially in younger children. A half or quarter of the normal starting dose may be considered for the first week. For recommendations on how to use clomipramine in children and young people and how to stop or reduce SSRIs and clomipramine – refer to NICE guideline – sections 1.5.6.12 to 1.5.6.18. 27

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 NOTES FOR PRESENTERS Refer to full guideline 28

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 NOTES FOR PRESENTERS Refer to Full guideline 29

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) NOTES FOR PRESENTERS Ensure continuity of care and minimise the need for multiple assessments by different health care professionals Co-ordination of care across primary / secondary care interface Initial disclosure difficult for many people with OCD Recognition and assessment - co-morbidities – depression is common 30

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 NOTES FOR PRESENTERS 31

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 NOTES FOR PRESENTERS This slide is intended as a discussion tool. See NICE OCD implementation advice – www.nice.org.uk/ Multidisciplinary Protected Time Initiatives (PTIs) / Protected Leaning Time (PLTs) / GP lunchtime education sessions Seamless transition between services – age related Co-ordination of care – clear agreement who is responsible for patient and treatment (possibly CPA) 32

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 33

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 NOTES FOR PRESENTERS The slides do not replace the full version of the guideline and should be used in conjunction with the Quick Reference Guide or Full guideline – links are displayed above. What other NICE guidance should be considered? Depression: management of depression in primary and secondary care - www.nice.org.uk/CG023niceguideline Anxiety: management of anxiety in adults in primary, secondary and community care - www.nice.org.uk/CG022niceguideline Depression in children: identification and management of depression in children and young people in primary care and specialist services - www.nice.org.uk/CG0 Computerised cognitive behaviour therapy (CCBT) for the treatment of depression and anxiety – Publication expected September 2005) - www.nice.org.uk/ 34

www.nice.org.uk NOTES FOR PRESENTERS You can find more information on NICE and our work by visiting the website at www.nice.org.uk 35