Obsessive-Compulsive Disorder (OCD)
NICE CKS Obsessive-compulsive disorder. Last revised: Feb 2024.
Guidelines
Management
Disclaimer: This article is mainly based on NICE CKS article on OCD, which was last revised in 2024 (NICE guideline was published in 2005 with no further revision or updates).
Referral Criteria
Referral for specialist assessment is indicated in:
- Severe OCD
- At risk of suicide or risk to life due to OCD symptoms (urgent same-day referral to crisis team if at high-risk of suicide)
- Severe self-neglect
- Presence of a significant comorbidity (e.g. substance misuse, severe depression, anorexia nervosa, or schizophrenia)
- Initial treatment has not led to an inadequate response
- <18 y/o irrespective of OCD severity (referred to CAMHS)
Management Approach
Management depends on the degree of functional impairment caused by OCD.
Mild Functional Impairment
1st line: Offer low-intensity CBT, including exposure and response prevention (ERP)
Options include:
- Individual CBT with ERP with self-help material
- Individual CBT with ERP by phone
- Group CBT with ERP
2nd line: Treat as moderate functional impairment
Moderate Functional Impairment
Offer either:
- Intensive CBT, including exposure and response prevention (ERP) OR
- Drug treatment
- 1st line: SSRI
- 2nd line: clomipramine (esp. if there is a previous good response to it)
SSRI counselling:
- Symptoms may worsen in the first week
- If <30 y/o → review the patient 1 week after starting the drug (due to risk of suicidal thinking and self-harm)
- In OCD, benefits usually take at least 12 weeks to be noted
- Continue treatment for at least 1 year after clinical response achieved (to prevent relapse)
- Advise the patient not to stop the medication themselves
Severe Functional Impairment
Refer to secondary care
While awaiting assessment offer combined therapy with:
- Intensive CBT, including exposure and response prevention (ERP), and
- Drug treatment
- 1st line: SSRI
- 2nd line: clomipramine (esp. if there is a previous good response to it)