Transcript Slide set

Obsessive-compulsive
disorder
Support for education and learning: slide set
2nd. Edition: March 2012
NICE clinical guideline 31
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
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
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
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
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
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
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
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
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
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)
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
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
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
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
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 firstline treatment
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
Stepped care model
Who is responsible for care?
STEP 6 Inpatient care or intensive treatment
programmes. CAMHS Tier 4
STEP 5 Multidisciplinary teams with specific expertise in
management of OCD. CAMHS Tiers 3 and 4
STEP 4 Multidisciplinary care in primary or secondary care.
CAMHS Tiers 2 and 3
STEP 3 GPs and primary care team, primary care mental health
worker, family support team. CAMHS Tiers 1 and 2
STEP 2 GPs, practice nurses, school health advisors, general health
settings. CAMHS Tier 1
STEP 1 Individuals, public organisations, NHS
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
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
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.)
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
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
Steps 3 to 5 treatment options
for adults with OCD or BDD: 1
Mild functional
impairment
Brief CBT (+ERP)
< 10 therapist hours
(individual
or group
formats)
Moderate functional
impairment
Offer choice of:
more intensive CBT
(+ERP)
>10 therapist hours
or
course of an SSRI
Patient cannot engage in/CBT
(+ERP) is inadequate
See the QRG for full overview of treatment pathway
Severe functional
impairment
Inadequate
response at
12 weeks
Multidisciplinary
review
Offer combined
treatment of
CBT (+ERP)
and an SSRI
Next slide
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
Steps 3 to 5 for children and
young people with OCD or BDD: 1
Mild functional
impairment
Consider guided
self-help
support and
information for
family/carers
Moderate to severe
functional impairment
Ineffective
or refused
Please refer to QRG for full overview of
treatment pathway
Offer CBT (+ERP)
involve family/
carers
(individual or
group formats)
Ineffective
or refused
Consider an
SSRI
(with careful
monitoring)
Next slide
Steps 3 to 5 for children and
young people with OCD or BDD: 2
Consider an SSRI and 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
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
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
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
Pharmacological treatments
adults: 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
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
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
Pharmacological treatments
adults: 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
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
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
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
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
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
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
Recurrent annual net cost for England
Current
cost £000s
Proposed
cost £000s
Change £000s
Adult interventions
Current medication
13,809
Current therapy
35,149
Future interventions
74,600
Net cost: adult
25,643
Child and young person interventions
Current medication
978
Current therapy
2,893
Future interventions
9,878
Net cost: child and young person
TOTAL NET COST
Costs correct at Dec. 2005.
Costs not updated for 2nd edition
6,007
52,828
84,479
31,650
NICE pathway
The NICE obsessivecompulsive 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 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
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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