Obsessive-compulsive disorderSupport for education and learning: slide set

2nd. Edition: March 2012NICE clinical guideline 31

Guideline review Guideline issue date: 2005First review : 2007Second review : 2011

2011 review recommendation:The guideline should not be updated at this time and should be reviewed again in due course

What this presentation coversBackgroundEpidemiologyScope Key priorities for implementationStepped carePsychological and pharmacological treatments Costs NHS Evidence and NICE pathwayFind out more

ScopeChildren 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 OCDThe interface between health care services and social services, the voluntary sector and education

BackgroundOCD is a potentially life-long disabling disorder and is poorly recognised and under-treatedPeople in some studies report waiting an average of 17 years before the correct management is startedTreatment occurs in a wide range of NHS settings provision and uptake is varied

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/distressDiagnostic criteriaICD-10/DSM-IV must include the presence of either compulsions or obsessions

EpidemiologyEstimated UK prevalence 12% of adult populationFourth most common mental disorder after depression, alcohol and substance abuse, and social phobia1% of young people adults often report experiencing first symptoms in childhoodOnset can be at any age; mean age is late adolescence for men, early twenties for women

Key priorities for implementation The key priorities for implementation are grouped in three areas:all people with OCD or BDDadults with OCD or BDDchildren and young people with OCD or BDD

All people with OCD or BDD: 1Each 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 treatmentprovide high-quality advice and understand family and developmental needsconduct expert assessment and specialist cognitive-behavioural and pharmacological treatment

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

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

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

Adults with OCD or BDDFor 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

Children and young people with OCDFor 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 childOffer group or individual formats depending on the preference of the child or young person and their family or carers

Children and young people with OCD or BDDFor 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

Children and young people with BDDFor 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

Stepped care modelThe model provides a framework in which to organise the provision of services in order to identify and access the most effective interventionsStepped care attempts to provide the most effective but least intrusive treatments appropriate to a persons needsThe recommendations in the NICE guidance are structured around the 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 4STEP 4 Multidisciplinary care in primary or secondary care.CAMHS Tiers 2 and 3STEP 3 GPs and primary care team, primary care mental health worker, family support team. CAMHS Tiers 1 and 2STEP 2 GPs, practice nurses, school health advisors, general health settings. CAMHS Tier 1STEP 1 Individuals, public organisations, NHSStepped care model

STEP 1 Awareness and recognitionPCTs, mental healthcare trusts and childrens trusts that provide mental health services should:have access to a specialist OCD multidisciplinary team offering age-appropriate careSpecialist 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 themcollaborate with people with the disorders and their family/carers to provide training for all mental health professionals

Step 2 Recognition and assessment of OCD: 1Routinely 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 clinicsAsk direct questions about possible symptoms

Step 2 Recognition and assessment of OCD: 2For 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 assessmentconsider other comorbid conditions or psychosocial factors that may contribute to riskconsult 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.)

Step 2 Recognition and assessment of BDD: 1Routinely 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 clinicsAsk direct questions about possible symptoms

Step 2 Recognition and assessment of BDD: 2For any person diagnosed with OCD:Those seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professionalAssess 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

Mild functional Moderate functional Severe functional impairment impairment impairmentSteps 3 to 5 treatment options for adults with OCD or BDD: 1 Brief CBT (+ERP)< 10 therapist hours(individual or groupformats)Offer choice of:more intensive CBT (+ERP)>10 therapist hoursorcourse of an SSRIPatient cannot engage in/CBT (+ERP) is inadequateOffer combinedtreatment ofCBT (+ERP)and an SSRIInadequate response at12 weeksMultidisciplinary reviewSee the QRG for full overview of treatment pathwayNext slide

Offer either: a different SSRI or clomipramineRefer 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

inadequate response or the patient cannot engage Steps 3 to 5 treatment options for adults with OCD or BDD: 2inadequate response or the patient cannot engage inadequate response or the patient cannot engage

Steps 3 to 5 for children and young people with OCD or BDD: 1 Mild functional Moderate to severe impairment functional impairmentIneffective or refused

Consider guidedself-help support andinformation forfamily/carers

Offer CBT (+ERP)involve family/carers(individual or group formats)

Ineffective or refusedConsider an SSRI(with careful monitoring)

Please refer to QRG for full overview of treatment pathwayNext slide

Consider an SSRI and carefully monitor for adverse events

Multidisciplinary reviewSSRI + 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 treatmentConsider either (especially if previous good response to): a different SSRI clomipramineinadequate response or the patient cannot engage inadequate response or the patient cannot engage inadequate response or the patient cannot engage Steps 3 to 5 for children and young people with OCD or BDD: 2

Psychological interventions adults: 1CBT (including ERP) is the mainstay of psychological treatmentConsider CBT (including ERP) for patients with obsessive thoughts without overt compulsionsConsider cognitive therapy adapted for OCD:as an addition to ERP to enhance long-term symptom reductionfor people who refuse or cannot engage with treatments that include ERP

Psychological interventions adults: 2If 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

Psychological interventions children and young peopleGuided self-help, CBT (including ERP) recommendedWork collaboratively and engage the family or carersIdentify initial and subsequent treatment targets collaboratively with the patientConsider the wider context including other professionals involved with the childMaintain optimism in child and family or carersConsider rewards to enhance motivation

Pharmacological treatmentsadults: starting treatmentAddress 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

Pharmacological treatments adults: choice of drugInitial pharmacological treatment should be an SSRIIf drug treatment effective, consider continuing for 12 months to prevent relapse and then review with the patientConsider prescribing a different SSRI if prolonged side effects

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 medicationConsider enlisting others, for example carers, to contribute to monitoring until risk is no longer significant

Pharmacological treatments adults: monitoring risk

Symptoms not responded adequately within 12 weeks to SSRI or CBT (including ERP)? Conduct multidisciplinary reviewConsider combined treatment of CBT (including ERP) and an SSRINot responded to combined treatment? Consider different SSRI or clomipramine Still not responded? Consider referral to OCD multidisciplinary team for assessment and treatment planningPharmacological treatments adults: response to 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

Pharmacological treatments adults: discontinuing treatment

Pharmacological treatments: children and young peopleCBT ineffective or refused, carry out multidisciplinary review and consider adding an SSRISertraline and fluvoxamine are the only SSRIs licensed for use in children and young people with OCDMonitor carefully and frequentlyIf successful, continue for 6 months post remissionWithdraw slowly with monitoring

Step 6: intensive treatment and inpatient services

People with severe/chronic problems should have continuing access to multidisciplinary teams with specialist expertise in OCDInpatient services are appropriate for a small proportion of people with OCDA small minority of adults will need suitable accommodation in a supportive environment in addition to treatment

Discharge after recoveryWhen in remission, review regularly for 12 months by a mental health professional frequency to be agreed between the healthcare professional and person with OCDAt the end of the 12-month period if recovery is maintained the person can be discharged to primary careIf relapse see as soon as possible

Special issues for children and familiesSymptoms are similar in children, young people and adults and they respond to the same treatmentsStress may worsen symptoms or cause relapse:school transitionsexamination timesrelationship difficultiestransition from adolescence to adult lifeParents may feel guilty and anxiousIncrease in severity if left untreated

Needs of people with OCD Early recognition, diagnosis and effective treatmentInformation about the nature of OCD and treatment optionsRespect and understandingWhat to do in case of relapseInformation about support groupsAwareness of family/carer needs

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

Current cost 000sProposed cost 000s Change 000sAdult interventionsCurrent medication13,809Current therapy35,149Future interventions74,600Net cost: adult25,643Child and young person interventionsCurrent medication978Current therapy2,893Future interventions9,878Net cost: child and young person6,007 TOTAL NET COST52,82884,47931,650

NICE pathwayThe 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

NHS EvidenceVisit NHS Evidence for the best available evidence on all aspects of OCD

Click here to go to the NHS Evidence websiteTo be added- the latest NHS evidence image

Find out moreVisit www.nice.org.uk/guidance/CG31 for:the guideline the quick reference guideUnderstanding NICE guidancecosting report and templateimplementation adviceNICE pathway for OCD and BDD

What do you think?Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice?We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form.If you are experiencing problems accessing or using this tool, please email implementation@nice.org.ukTo open the links in this slide set right click over the link and choose open link

*This slide set was updated in March 2012 and includes details of NHS Evidence and the NICE pathway. The NICE clinical guideline has not changed.ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. This guideline has been written for professional groups who share in the treatment and care of people diagnosed with obsessive-compulsive disorder (OCD) or body dysmorphic disorder (BDD); professionals in other health and non-health sectors who may have direct contact with or are involved in the provision of health and other public services for those diagnosed with OCD or BDD; and those with responsibility for planning services for people diagnosed with OCD or BDD and their carers.The guideline covers OCD and BDD; the slide set focuses mainly on OCD.The guideline is available in several formats, including a quick reference guide, which are available from www.nice.org.uk. You may wish to print a copy of the NICE guideline to use during your presentation. You can add your own organisations logo alongside the NICE logo. We have included notes for presenters, broken down into key points to raise, which you can highlight in your presentation, and additional information that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. 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.PROMOTING EQUALITY: Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

NOTES FOR PRESENTERS: This guideline was first issued in 2005 and has been reviewed twice, in line with routine NICE practice.Factors influencing the decisionLiterature search1. From initial intelligence gathering and a high-level randomised control trial (RCT) search, clinical areas were identified to inform the development of clinical questions for focused searches. Twenty relevant studies were identified. These were related to the clinical effectiveness of psychological therapies such as cognitive behavioural therapy, motivational interviewing and thought mapping.2. One review question about psychological therapies was developed, based on qualitative feedback from other NICE departments and the views of the Guideline Development Group (GDG), for more focused literature searches. In total, 13 studies relevant to this review question were identified. There is insufficient evidence to potentially change the current recommendations.Guideline Development Group and National Collaborating Centre perspective3. A questionnaire was distributed to GDG members and the National Collaborating Centre about the need for an update of the guideline. Four GDG members responded. Two highlighted that there is insufficient variation in current practice supported by adequate evidence to warrant an update. The respondents highlighted limited access to good psychological services, improving access to psychotherapy roll out and variation in practice in stepped care approach particularly access to specialist care services. Other areas with potential new evidence were pharmacological augmentation therapies among treatment resistant groups, and treatment strategies for hoarding. Potential new areas suggested were deep brain stimulation, transcranial magnetic stimulation and different delivery formats of psychotherapies.4. Feedback from the GDG and NCC contributed to the development of clinical questions for the focused searches. Full details of the review are on the website, http://guidance.nice.org.uk/CG31/ReviewDecision/pdf/English **NOTES FOR PRESENTERS: In this presentation we will start by providing some background information and epidemiology. The scope of the guideline will be set out. We will then present the key priorities for implementation. The NICE guideline contains ten key priorities for implementation, which you can find on page 3 of the quick reference guide. Next, we will summarise the costs that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.Following this we will highlight the NICE pathway and look at NHS Evidence and how this resource may help with keeping up to date with the latest evidence base. Finally, we will end the presentation with further information about the support provided by NICE.

*NOTES FOR PRESENTERSKey points to raise: This guideline is relevant to children, young people and adults diagnosed with OCD or BDD, to their families and carers, and to all healthcare professionals involved in the help, treatment and care of people with OCD or BDD. These include the following: Professional groups who treat and care for people with OCD or BDD, including 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 and general medical professionals. Professionals in other health and non-health sectors who may have direct contact with or provide health and other public services for people with OCD or BDD. These may include prison doctors, the police and professionals who work in the criminal justice and education sectors. Those with responsibility for planning services for people with OCD or BDD and their carers, including directors of public health, NHS trust managers and managers in primary care trusts.

The guidance does not specifically address care and treatment not normally available on the NHS. The scope for the guideline covered: a) The full range of OCD care routinely made available by the NHS. b) Clarification and confirmation of current diagnostic criteria and diagnostic factors that trigger the use of this guideline, and assessment and instruments that might be used in this process. c) Pathways to treatment. d) Psychological interventions including type, format, frequency, duration and intensity. This includes computerised cognitive behavioural therapy (CCBT). e) Pharmacological treatments, including type, dose and duration. f) Appropriate use of combined pharmacological and psychological interventions. g) Psychosurgery and deep brain stimulation. h) Self-care. i) Sensitivity to cross-cultural and religious factors. j) The role of the family in the treatment and support of patients.

* *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 patients occupational and / or social functioning, usually by wasting time.

Section 2.1.5It 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.

*NOTES FOR PRESENTERS:According to some studies, OCD is the fourth most common mental disorder after depression, alcohol and substance misuse, and social phobia. It has a lifetime prevalence in community surveys of about 23%. However, the instruments used have been criticised and may have over-diagnosed OCD, so the true prevalence may be somewhat lower.There is remarkable consistency in the lifetime and annual prevalence of OCD from studies conducted across the world. The mean age of onset is in late adolescence for men and early twenties for women, although onset may occur in a wide range of ages. However, it may take individuals between 1015 years or longer to seek professional help. There is often comorbidity with a range of disorders, especially depression, anxiety, alcohol or substance misuse, BDD, or an eating disorder.*NOTES FOR PRESENTERS: The NICE clinical guideline contains 124 recommendations about how care can be improved. The experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care, and are the most important priorities for implementation. They are divided into three areas of key priority; within these there are ten recommendations that we will consider in turn. Key priorities for implementation are highlighted in this slide set by [KPI].

NOTES FOR PRESENTERS: Recommendation in full :Each PCT, mental healthcare trust and childrens trust that provides mental health services should have access to a specialist OCD/BDD multidisciplinary team offering age-appropriate care. This team would perform the following functions: increase the skills of mental health professionals in the assessment and evidence-based treatment of people with OCD or BDD, provide high-quality advice, understand family and developmental needs, and, when appropriate, conduct expert assessment and specialist cognitive-behavioural and pharmacological treatment. [1.3.1.1] [KPI]Additional information:Although the more common forms of OCD are likely to be recognised when people report symptoms, less common forms of OCD and many cases of BDD may remain unrecognised, sometimes for many years. Relatively few mental health professionals or GPs have expertise in the recognition, assessment, diagnosis and treatment of the less common forms of OCD and BDD.

*NOTES FOR PRESENTERS:Recommendation in full :OCD and BDD can have a fluctuating or episodic course, or relapse may occur after successful treatment. Therefore, people who have been successfully treated and discharged should be seen as soon as possible if re-referred with further occurrences of OCD or BDD, rather than placed on a routine waiting list. For those in whom there has been no response to treatment, care coordination (or other suitable processes) should be used at the end of any specific treatment programme to identify any need for continuing support and appropriate services to address it. [1.7.1.2] [KPI]*NOTES FOR PRESENTERS: ERP = exposure to obsessive thoughts and response prevention of mental rituals and neutralising strategiesRecommendation in full:In the initial treatment of adults with OCD, low intensity psychological treatments (including ERP) (up to 10 therapist hours per patient) should be offered if the patients degree of functional impairment is mild and/or the patient expresses a preference for a low intensityapproach. Low intensity treatments include: brief individual CBT (including ERP) using structured self-help materials brief individual CBT (including ERP) by telephone group CBT (including ERP) (note, the patient may be receiving more than 10 hours of therapy in this format). [1.5.1.1] [KPI]

*NOTES FOR PRESENTERS: Recommendation in full :Adults with OCD with mild functional impairment who are unable to engage in low intensity CBT (including ERP), or for whom low intensity treatment has proved to be inadequate, should be offered the choice of either a course of a selective serotonin re-uptake inhibitor (SSRI) or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious. [1.5.1.2] [KPI]*NOTES FOR PRESENTERS: Recommendations in full :Adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious. [1.5.1.3] [KPI]

Adults with BDD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive individual CBT (including ERP) that addresses key features of BDD. [1.5.1.6] [KPI]

*NOTES FOR PRESENTERS: Recommendation 1.5.1.9 in full :Children and young people with OCD with moderate to severe functional impairment, and those with OCD with mild functional impairment for whom guided self-help has been ineffective or refused, should be offered CBT (including ERP) that involves the family or carers and is adapted to suit the developmental age of the child as the treatment of choice. Group or individual formats should be offered depending upon the preference of the child or young person and their family or carers. [1.5.1.9] [KPI]*NOTES FOR PRESENTERS: Recommendations in full :Following multidisciplinary review, for a child (aged 811 years) with OCD or BDD with moderate to severe functional impairment, if there has not been an adequate response to CBT (including ERP) involving the family or carers, the addition of an SSRI to ongoing psychological treatment may be considered. Careful monitoring should be undertaken, particularly at the beginning of treatment. [1.5.5.2] [KPI]

Following multidisciplinary review, for a young person (aged 1218 years) with OCD or BDD with moderate to severe functional impairment, if there has not been an adequate response to CBT (including ERP) involving the family or carers, the addition of an SSRI to ongoing psychological treatment should be offered. Careful monitoring should be undertaken, particularly at the beginning of treatment. [1.5.5.3] [KPI]*NOTES FOR PRESENTERS: Recommendation in full :All children and young people with BDD should be offered 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. 1.5.1.10 [KPI]

**This recommendation is not a KPI but forms part of the care of people with OCD. NOTES FOR PRESENTERS:The stepped-care model draws attention to the different needs of people with OCD and BDD, depending on the characteristics of their disorder, their personal and social circumstances, their age, and the responses that are needed from services. It provides a framework in which to organise the provision of services in order to identify and access the most effective interventions (see figure 1, p12 NICE clinical guideline).Stepped care attempts to provide the most effective but least intrusive treatments appropriate to a persons needs. It assumes that the course of the disorder is monitored and referral to the appropriate level of care is made depending on the persons difficulties. 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 in which an individual may be referred to any appropriate level. The guidance follows the steps in the figure.At all stages of assessment and treatment, families or carers should be involved as appropriate. This is particularly important for children and young people with OCD or BDD, where it may also be helpful to involve others in their network, for example teachers, school health advisors, educational psychologists, and educational social workers.

Additional information:For further information refer to section 1.2 on pages 12-13 of the NICE clinical guideline.*This recommendation is not a key priority for implementation but forms part of the care of people with OCD. NOTES FOR PRESENTERS:Refer to section 1.2 on pages 12-13 of the NICE clinical guideline.

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

*NOTES FOR PRESENTERS:Key points to raise:Step 1 applies to any age group.Recommendations in full:Each PCT, mental healthcare trust and childrens trust that provides mental health services should have access to a specialist OCD/BDD multidisciplinary team offering age-appropriate care. This team would perform the following functions: increase the skills of mental health professionals in the assessment and evidence-based treatment of people with OCD or BDD, provide high-quality advice, understand family and developmental needs, and, when appropriate, conduct expert assessment and specialist cognitive-behavioural and pharmacological treatment. [1.3.1.1] [KPI]

Specialist mental healthcare professionals in OCD or BDD 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. Such information should also be made available to primary and secondary healthcare professionals, and to professionals from other public services who may come into contact with people of any age with OCD or BDD. [1.3.1.2]

Specialist OCD/BDD teams should collaborate with people with OCD or BDD and their families or carers to provide training for all mental health professionals, cosmetic surgeons and dermatology professionals. [1.3.1.3]*This slide is based on a recommendation that is not a KPI but forms part of the care of people with OCD. NOTES FOR PRESENTERS:Key points to raise:Step 2 applies to any age group.Recommendation in full:For people known to be at higher risk of OCD (such as individuals with symptoms of depression, anxiety, alcohol or substance misuse, BDD or an eating disorder), or for people attending dermatology clinics, healthcare professionals should routinely consider and explore the possibility of comorbid OCD by asking direct questions about possible symptoms such as the following: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but can not? 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? [1.4.1.1 ]

*This slide is based on recommendations that are not KPIs but form part of the care of people with OCD. NOTES FOR PRESENTERS:Recommendations in full:In people who have been diagnosed with OCD, healthcare professionals should assess the risk of self-harm and suicide, especially if they have also been diagnosed with depression. Part of the risk assessment should include the impact of their compulsive behaviours on themselves or others. Other comorbid conditions and psychosocial factors that may contribute to risk should also be considered. [1.4.1.2] If healthcare professionals are uncertain about the risks associated with intrusive sexual, aggressive or death-related thoughts reported by people with OCD, they should consult mental health professionals with specific expertise in the assessment and management of OCD. These themes are common in people with OCD at any age, and are often misinterpreted as indicating risk. [1.4.1.3] *This slide is based on recommendations that are not a KPIs but form part of the care of people with BDD. NOTES FOR PRESENTERS:Step 2 applies to any age group.Recommendations in full:For people known to be at higher risk of BDD (such as individuals with symptoms of depression, social phobia, alcohol or substance misuse, OCD or an eating disorder), or for people with mild disfigurements or blemishes who are seeking a cosmetic or dermatological procedure, healthcare professionals should routinely consider and explore the possibility of BDD. [1.4.2.1]

In the assessment of people at higher risk of BDD, the following five questions should be asked to help identify individuals with BDD: Do you worry a lot about the way you look and wish you couldthink about it less? What specific concerns do you have about your appearance? On a typical day, how many hours a day is your appearance onyour mind? (More than 1 hour a day is considered excessive.) What effect does it have on your life? Does it make it hard to do your work or be with friends? [1.4.2.2]*This slide is based on recommendations that are not KPIs but form part of the care of people with BDD. NOTES FOR PRESENTERS:Recommendations in full:People with suspected or diagnosed BDD seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional with specific expertise in the management of BDD. [1.4.2.3]

In people who have been diagnosed with BDD, healthcare professionals should assess the risk of self-harm and suicide, especially if they have also been diagnosed with depression. Other comorbid conditions and psychosocial factors that may contribute to risk should also be considered. [1.4.2.4]

All children and young people who have been diagnosed with BDD should be assessed for suicidal ideation and a full risk assessment should be carried out before treatment is undertaken. If risks are identified, all professionals involved in primary and secondary care should be informed and appropriate risk management strategies put into place. [1.4.2.5]

Specialist mental health professionals in BDD should work in partnership with cosmetic surgeons and dermatologists to ensure that an agreed screening system is in place to accurately identify people with BDD and that agreed referral criteria have been established. They should help provide training opportunities for cosmetic surgeons and dermatologists to aid in the recognition of BDD. [1.4.2.6]*NOTES FOR PRESENTERS:Refer to pages 16-19 of the NICE clinical guideline 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)

Refer to NICE clinical guideline, recommendations 1.5.1.1 to 1.5.1.7The 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, for example individual or group therapy, telephone, books and self-help.

*NOTES FOR PRESENTERS:This slide continues from the previous slide 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.

Refer to NICE clinical guideline, recommendations 1.5.1.1 to 1.5.1.7

*NOTES FOR PRESENTERS:Refer to NICE clinical guideline (recommendations 1.5.1.8-12 on page 19 of the NICE guideline for a full overview of the treatment pathway).

*NOTES FOR PRESENTERS:This slide continues from the previous slide.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: [is there text missing here, or does this go on to Consider an SSRI on the line below?] If so, I suggest deleting one consider: and running the line on for clarity.]Consider an SSRI and carefully monitor for adverse events.

If an SSRI is prescribed, use in combination with concurrent CBT (with CBT)SSRIs should be used only 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 did 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.

*These recommendations are not key priorities for implementation but form part of the care of people with OCD or BDD. NOTES FOR PRESENTERS:Refer to NICE guideline recommendation 1.5.2.1.

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 recommendations 1.5.2.3, 1.5.2.7 and 1.5.2.10CBT and ERP can be delivered in a variety of ways: individual or 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.

*NOTES FOR PRESENTERS:This recommendation is not a KPI but forms part of the care of people with OCD or BDD. Recommendation in full: When family members or carers of people with OCD or BDD have become involved in compulsive behaviours, avoidance or reassurance seeking, treatment plans should help them reduce their involvement in these behaviours in a sensitive and supportive manner. [1.5.2.9]*NOTES FOR PRESENTERS:These recommendations are not KPIs but form part of the care of people with OCD or BDD. Consider offering one or more additional sessions after completion of CBT, if needed, at review appointments.Recommendations in full:All healthcare professionals offering treatments for OCD to people of any age should receive appropriate training in the interventions they are offering and should receive on-going clinical supervision in line with recommendations in Organising and Delivery Psychological Therapies (Department of Health 2004). Available from www.dh.gov.uk [1.5.2.1]

In the cognitive-behavioural treatment of children and young people with OCD or BDD, particular attention should be given to: developing and maintaining a good therapeutic alliance with the child or young person, as well as their family or carers maintaining optimism in both the child or young person and their family or carers collaboratively identifying initial and subsequent treatment targets with the child or young person actively engaging the family or carers in planning treatment and in the treatment process, especially in ERP where, if appropriate and acceptable, they may be asked to assist the child or young person encouraging the use of ERP if new or different symptoms emerge after successful treatment liaising with other professionals involved in the child or young persons life, including teachers, social workers and other healthcare professionals, especially when compulsive activity interferes with the ordinary functioning of the child or young person offering one or more additional sessions if needed at review appointments after completion of CBT. [1.5.2.12]

In the psychological treatment of children and young people with OCD or BDD, healthcare professionals should consider including rewards in order to enhance their motivation and reinforce desired behaviour changes. [1.5.2.13] See also recommendations 1.5.1.8, 1.5.1.9 and 1.5.1.11

*NOTES FOR PRESENTERS:This recommendation is not a KPI but forms part of the care of people with OCD or BDD. Recommendation 1.5.3.1 in full:Common concerns about taking medication for OCD or BDD should be addressed. Patients should be advised, both verbally and with written material, that: craving and tolerance do not occur there is a risk of discontinuation/withdrawal symptoms on stopping the drug, missing doses, or reducing the dose there is a range of potential side effects, including worsening anxiety, suicidal thoughts and self-harm, which need to be carefully monitored, especially in the first few weeks of treatment there is commonly a delay in the onset of effect of up to 12 weeks, although depressive symptoms improve more quickly. taking medication should not be seen as a weakness. [1.5.3.1]*NOTES FOR PRESENTERS: These recommendations are not KPIs but form part of the care of people with OCD or BDD. Key points to raise: Choice of drug treatment refer to NICE guideline recommendations 1.5.3.8 to 1.5.3.19Recommendations in full:For adults with OCD, the initial pharmacological treatment should be one of the following SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram*.[1.5.3.8]

The following drugs should not normally be used to treat OCD or BDD without comorbidity: tricyclic antidepressants other than clomipramine tricyclic-related antidepressants serotonin and noradrenaline re-uptake inhibitors (SNRIs), including venlafaxine monoamine oxidase inhibitors (MAOIs) anxiolytics (except cautiously for short periods to counter the early activation of SSRIs).[1.5.3.20]

Antipsychotics as a monotherapy should not normally be used for treating OCD.[1.5.3.21]

Additional information: Current published evidence suggests that SSRIs are effective in treating adults with OCD or BDD, although evidence for the latter is limited and less certain. 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 or BDD. Regulatory authorities recommend caution in the use of SSRIs until evidence for differential safety has been demonstrated.Footnote: * Citalopram did not have a UK Marketing Authorisation for use in OCD in adults at the date of publication (November 2005)

*NOTES FOR PRESENTERS:These recommendations are not KPIs but form part of the care of people with OCD or BDD. Key points to raise: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.Recommendations in full:Adults with OCD or BDD started on SSRIs who are not considered to be at increased risk of suicide or self-harm should be monitored closely and seen on an appropriate and regular basis. The arrangements for monitoring should be agreed by the patient and the healthcare professional, and recorded in the notes. [1.5.3.2 ]

Because of the potential increased risk of suicidal thoughts and self harm associated with the early stages of SSRI treatment, younger adults (younger than age 30 years) with OCD or BDD, or people with OCD or BDD with comorbid depression, or who are considered to be at an increased risk of suicide, should be carefully and frequently monitored by healthcare professionals. Where appropriate, other carers as agreed by the patient and the healthcare professional may also contribute to the monitoring until the risk is no longer considered significant. The arrangements for monitoring should be agreed by the patient and the healthcare professional, and recorded in the notes.[1.5.3.3]*NOTES FOR PRESENTERS:These recommendations are not KPIs but form part of the care of people with OCD or BDD. Poor response to initial treatment in adults. Refer to NICE guideline section 1.5.4Recommendations in fullFor adults with OCD or BDD, if there has not been an adequate response to treatment with an SSRI alone (within 12 weeks) or CBT (including ERP) alone (more than 10 therapist hours per patient), a multidisciplinary review should be carried out. [1.5.4.1]

Following multidisciplinary review, for adults with OCD or BDD, if there has not been an adequate response to treatment with an SSRI alone (within 12 weeks) or CBT (including ERP) alone (more than 10 therapist hours per patient), combined treatment with CBT (including ERP) and an SSRI should be offered. [1.5.4.2]

For adults with OCD or BDD, if there has not been an adequate response after 12 weeks of combined treatment with CBT (including ERP) and an SSRI, or there has been no response to an SSRI alone, or the patient has not engaged with CBT, a different SSRI or clomipramine should be offered. [1.5.4.3]

Clomipramine should be considered in the treatment of adults with OCD or BDD after an adequate trial of at least one SSRI has been ineffective or poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it. [1.5.4.4]

For adults with OCD or BDD, if there has been no response to a full trial of at least one SSRI alone, a full trial of combined treatment with CBT (including ERP) and an SSRI, and a full trial of clomipramine alone, the patient should be referred to a multidisciplinary team with specific expertise in the treatment of OCD/BDD for assessment and further treatment planning. [1.5.4.5 ]

*NOTES FOR PRESENTERS:This recommendation is not a KPI but forms part of the care of people with OCD or BDD.

See recommendation 1.5.4.15.*NOTES FOR PRESENTERS: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 See section 1.5.5 of the NICE guideline Current published evidence suggests that SSRIs are effective in treating children and young people with OCD.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 guideline Depression in children and young people www.nice.org.uk/guidance/CG28). 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.Recommendations in full: An SSRI should only be prescribed to children and young people with OCD or BDD following assessment and diagnosis by a child and adolescent psychiatrist who should also be involved in decisions about dose changes and discontinuation. [1.5.6.1]Children and young people with OCD or BDD starting treatment with SSRIs should be carefully and frequently monitored and seen on an appropriate and regular basis. This should be agreed by the patient, his or her family or carers and the healthcare professional, and recorded in the notes. [1.5.6.3]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. [1.5.6.8]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 recommendations 1.5.6.12 to 1.5.6.18.*These recommendations are not KPIs but form part of the care of people with OCD or BDD. NOTES FOR PRESENTERS:Refer to NICE guideline recommendations: 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 lifethere is severe self-neglectthere is extreme distress or impairmenta person has not responded to adequate trials of pharmacological/psychological/combined treatments over long periods of time in other settingsa person has additional diagnoses, such as severe depression, anorexia nervosa or schizophrenia, that make outpatient treatment more complexa person has a reversal or normal night/day patterns that make attendance at any day-time therapy impossiblethe 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.*NOTES FOR PRESENTERS:Recommendations in full:When a person of any age with OCD or BDD is in remission (symptoms are not clinically significant and the person is fully functioning for 12 weeks), he or she should be reviewed regularly for 12 months by a mental health professional. The exact frequency of contact should be agreed between the professional and the person with OCD or BDD and/or the family and/or carer and recorded in the notes. At the end of the 12-month period if recovery is maintained the person can be discharged to primary care. [1.7.1.1]

OCD and BDD can have a fluctuating or episodic course, or relapse may occur after successful treatment. Therefore, people who have been successfully treated and discharged should be seen as soon as possible if re-referred with further occurrences of OCD or BDD, rather than placed on a routine waiting list. For those in whom there has been no response to treatment, care coordination (or other suitable processes) should be used at the end of any specific treatment programme to identify any need for continuing support and appropriate services to address it. [1.7.1.2 ] [KPI]*This slides covers suggestions from the full guideline (p73-4). These are not NICE recommendations.NOTES FOR PRESENTER:Key points to raise:There is little evidence that life-events cause OCD, but in people vulnerable to the condition, times of stress may be when symptoms worsen or relapses occur. In childhood this can particularly be around events that affect the family, school transitions, exams or difficulties with friendships or other relationships. Children experiencing learning problems, which may have been undetected or their needs may not have adequately met, may be vulnerable to exacerbations of OCD.The transition from adolescence to adult life, with increasing independent living demands, can be an especially challenging time, particularly for anxious people. Young people with OCD are often more than usually dependent on their parents, more cautious about exploring new experiences out of the home or with friends, or may have symptoms that make aspects of life difficult (for example, sharing a rented house/bathroom).In the UK, mental health services for young people usually stop at age 16 or 18 and people transfer to general adult mental health services. For a young person with OCD at a vulnerable stage of their development, continuity of services at this stage is essential. Child and adolescent mental health services should link with the appropriate adult service well before discharge from child services occurs, to enable the young person to meet the new team, have joint appointments and so on. Whatever the age of the person with OCD, clinicians need to give time and attention to family members and carers. The younger the child the more responsibility and decision making will rest with the adults, but even young children need to feel involved in the treatment, able to express preferences and to take charge of aspects of their therapy. Young people need to develop autonomy, so for older children and teenagers the therapist should assess sensitively and collaboratively the degree to which parents need to be involved, and negotiate at each stage what information to share. Parents can be invaluable in ensuring therapy is successful, and involvement is essential if they are closely involved in their childs rituals.Many parents feel guilty about their childs OCD, and therapists need to take active steps to remove the parents sense of blame. It can be helpful for parents to understand that they do not cause OCD but can inadvertently become involved in it. Most importantly, they need to understand that that they can be helpful in the recovery process and in maintaining good mental health in future.Parents of children with OCD can sometimes be anxious themselves, perhaps because of their own nature but also because their child is distressed, has difficulty coping, or has changed markedly. Parental anxiety needs to be understood by therapists and dealt with sensitively and actively. Treatment for OCD always involves understanding anxiety, and often helping the child confront and deal with it, rather than ritualising or running away. The anxious parent may find it challenging to help their child learn to deal with anxiety in this way, and may need help themselves to learn effective strategies.*This slide covers suggestions from the full guideline (p.57). These are not NICE recommendations.NOTES FOR PRESENTER:Key points to raise:The full guideline (section 3.3) includes personal testimonies illustrating the experience over the past 40 years of a number of people with OCD and one with BDD and also of family members and carers of people with OCD. The testimonies were chosen to demonstrate a range of experience and should not be taken as representative. These narratives express the experience of OCD and BDD over a lifetime, the effect on family and carers, the process of obtaining treatment and the response to treatment. The testimonies suggest that the following are useful for people suffering from OCD and BDD: Early recognition and diagnosis, particularly in people presenting with depression, anxiety or somatic complaints. Respect and understanding from healthcare professionals. Awareness and understanding from public sector services, including educational establishments, local authorities, police and emergency services. Healthcare professionals being aware of the condition and effective treatment. Full information about the nature of OCD and treatment options. Psychological treatment that directly addresses OCD. Group therapy sessions and the possibility of working with more than one therapist. That all aspects of the OCD are treated. Information about what to do in case of relapse. Information about support groups.*ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.

NOTES FOR PRESENTERS: NICE has worked closely with people within and outside the NHS to look at the major costs and savings related to implementing this guideline.

The estimated net national annual changes in costs arising from implementing the guideline on Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder are 31,3650,00

NICE has produced a costing report that provides detailed estimates of the national costs and savings associated with implementing this guideline. NICE has also developed a costing template to calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.

For further information please refer to the costing template and costing report for this guideline on the NICE website.NOTES FOR PRESENTERS: NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. NICE pathways are simple to navigate, and allow you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.

*NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for obsessive-compulsive disorder. For the home page go to www.evidence.nhs.uk**NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website.The NICE guideline all the recommendations. This document also includes audit criteria.A quick reference guide a summary of the recommendations for healthcare professionals.Understanding NICE guidance information for patients and carers.The full guideline all the recommendations, details of how they were developed, and reviews of the evidence they were based on.

NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing report gives the background to the national savings and costs associated with implementation, and the costing template allows you to estimate the local costs and savings involved.Implementation advice on how to put the guidance into practice and national initiatives that support this locally. *NOTES FOR PRESENTERS: Additional information: The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated.

To open the links in this slide set right click over the link and choose open link.