Dr John Hague discusses how the NICE guideline will help GPs to recognise and treat obsessive-compulsive disorder and body dysmorphic disorder

The NICE guideline on obsessive- compulsive disorder, published in November 2005,1 covers two of the ‘lesser known’ common mental health disorders – obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD).

OCD is the fourth most common mental health disorder after depression, alcohol and substance abuse, and social phobia, with a lifetime prevalence of around 1-2% (although some studies suggest 2-3%).1 One per cent of children and young adults suffer from OCD.2

The WHO ranks OCD in the top 10 disabling illnesses by loss of income and reduced quality of life. It is thought that 0.5-0.7% of the population suffers from the related disorder BDD.1

Despite this OCD is often only diagnosed some 7-12 years after its onset. The situation is compounded by the fact that there are too few professionals with the training to help patients with OCD.1

Obsessive–compulsive disorder

OCD sufferers exhibit obsessions or compulsions, and commonly both, and these can lead to functional impairment and/or distress. Obsessions are repeated unwanted thoughts, images or urges; compulsions are repetitive behaviours or mental acts (which can be covert or overt) that the person feels they must perform.

Body dysmorphic disorder

Patients with BDD are preoccupied with an imaginary defect or are excessively concerned over a minor physical imperfection. Typical signs include consuming behaviours (prolonged mirror gazing), excessive camouflaging to hide the defect, skin picking, comparing features with those of others and reassurance seeking.

Developing the guideline

NICE commissioned the National Collaborating Centre for Mental Health to develop this guideline.The centre established a multi-disciplinary guideline development group which reviewed the evidence and developed the recommendations.The guideline development group followed standard NICE methodology to develop the guideline, and the evidence was considered using the standard NICE grading system (Figure 1, below).

Figure 1: Evidence and recommendations grading scheme
Reproduced by kind permission of the National Institute for Health and Care Excellence

An overwhelming number of the recommendations are graded as C or GPP with very few being graded A or B. (This explains the section in the guideline which suggests further research studies.)

Key priorities for implementation

The wide ranging nature of the key priorities for implementation (Figure 2, below) presents a substantial challenge to ‘usual practice’.

Figure 2: Priorities for implementation
Reproduced by kind permission of the National Institute for Health and Care Excellence

Setting up a specialist OCD/BDD team is a laudable aim; however, this team is going to have to compete for funding and personnel with all the other specialist teams and therapies that the NSF and other NICE guidelines have recommended. These services include comprehensive cognitive behavioural therapy (CBT) and family therapy services for those suffering from schizophrenia,3 CBT for those with generalised anxiety disorder,4 CBT for those with panic disorder,4 CBT for those suffering from depression,5 and the recommended services for those with post traumatic stress disorder.6

The next priority, rapid re-referral on relapse, is more easily achievable by GPs changing their practice so that they rapidly re-refer patients who relapse rather than treating them in primary care.

The key recommendations for adults present a real challenge to commissioners and providers, as they also involve setting up CBT services (with exposure response prevention, referred to here as CBT).

Currently, in primary care in most areas of the country, it is not possible to refer someone for up to 10 hours of therapy immediately after initial diagnosis. This is partly because patients with serious mental illness take priority under the NSF and also because of financial constraints.

I suspect that in many areas the recommendations involving therapy will remain aspirational for some time, and those involving medication, which are clear and easy to follow, will remain the main way in which treatment is delivered.

Children and young people

Once more these key priorities (Figure 2, above) represent a step up from the usual care that is currently available in many areas.They correctly reflect the fact that treating this group of patients is usually the preserve of specialists in child and adolescent mental health, and is not often undertaken in primary care.

Principles of care

As in previous mental health guidelines these principles are very sensible, and should form the bedrock of primary care. They are all based on ‘good practice points’:

  • Providing accurate information in an appropriate format for the patient is relatively easy to do, and yet very effective, as is sensitively exploring the hidden distress of the disorders.
  • Ensuring continuity of care, thus minimising re-assessment, and providing seamless handovers between professionals, with written agreements about monitoring and treatment is again relatively easy to achieve, yet immensely effective if correctly implemented.
  • Consider, with consent, the boundary between religious or cultural practice and OCD, with an appropriate religious or community leader.

Shared decision making is emphasised, as in other guidelines.

Stepped care

The principle of stepped care first appeared in the depression and anxiety guidelines.4,5 The steps used in the OCD/BDD guideline are slightly different and there are six steps, rather than the five used in the first two guidelines.

Figure 3, below, gives a clear plan of action from initial diagnosis, with the treatment escalating in complexity if it has not been successful at a particular step.

Figure 3: The stepped-care model
Reproduced by kind permission of the National Institute for Health and Care Excellence

Step 1 – Awareness and recognition

This is a collection of good practice points, mainly centred around setting up an OCD/BDD team, then ensuring that it has access to the best information at a national level, thereby acting as the anchor for all the other steps.

Step 2 – Recognition and assessment

People known to be at higher risk of OCD include those attending dermatology clinics, and also those with symptoms of:

  • Depression
  • Anxiety
  • Alcohol or substance misuse
  • BDD
  • An eating disorder.

For OCD, Step 2 includes six questions, based on level C evidence,to be routinely asked to patients in the higher risk groups:

  • 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?

Risk assessment is also covered, with a good practice point to consult mental health professionals if the practitioner is unsure of level of risk posed, for example by sexual, aggressive or death-related thoughts.

Bearing in mind that about one-third of primary care workload involves common mental health problems,7 adding an extra six questions to every
10-minute consultation with patients attending with these very common conditions may not be realistically achievable, even if the questions are just asked every few years.

To help identify BDD, the following questions should be asked:

  • Do you worry a lot about the way you look and wish you could think about it less?
  • What specific concerns do you have about your appearance?
  • On a typical day, how many hours a day is it on your mind? (Consider >1 excessive)
  • What effect does it have on your life?
  • Does it make it hard to do your work or be with your friends?

For BDD the evidence level is that of good practice points.There is advice on assessing risk, as well as the recommendation that people suspected of suffering from BDD who seek cosmetic surgery or dermatological treatment should be referred for assessment by a mental health professional.

This disorder is both less common than OCD and less recognised in primary care, so adding the extra 5 questions to the 6 recommended for OCD, in every depressed patient is, I suspect, going to prove a tall order.

Steps 3-5 – Treatment options

These three steps are grouped together into one. This reflects the fact that the same interventions are used but the experience of the professional and the intensity of the treatment escalates as higher steps are attained. The first step is offering CBT as a ‘low-intensity approach’ before any drugs are used (level C evidence for OCD, level B evidence for BDD). Following this practitioners have a choice of more intensive CBT or medication (level B evidence states they are equally effective in OCD).1

The use of selective serotonin reuptake inhibitors (SSRIs) is covered in some detail, with clear advice about initiation and discontinuation issues, and use in children. There is level A evidence for use of SSRIs in OCD, and level B evidence for their use in BDD.

Finally a multidisciplinary review is recommended if either treatment fails.

Clear advice about other medications to use and to avoid is also given.

Step 6 – Intensive treatment and inpatient services

This step is entirely beyond the remit of primary care and covers very specialised services to patients who have not responded at step 5.

Implementation

A large change in practice is needed to‘raise the game’ of every practitioner, in order that patients may be identified early and treated effectively. This guideline is going to be costly to implement, because of the emphasis on psychological therapies.

Appendix D in the guideline contains suggested audits, which will aid implementation and monitoring.

NICE has also produced an implementation guide for the guideline, a slide set, a document on the national cost impact (estimating that it will cost an extra £31.6 million annually to implement), and a template for localities to use to estimate costs (see box below).

Implementation tools

NICE has developed the following tools to support implementation of its guideline on obsessive-compulsive disorder.They are now available to download from the NICE website:www.nice.org.uk.

Slide set
The slides are aimed at supporting organisations to help implement the guideline recommendations at a local level.They do not try to cover all the recommendations from the guideline but contain key messages and should be used in conjunction with the quick reference guide.

Costing tools
National cost reports and local cost templates for the guideline have also been produced. Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice and predictions of how it might change following implementation of the guideline. Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates and quickly assess the impact the guideline may have on local budgets.

The estimated number of extra staff required by each PCT of 152,000 is 2.5 full-time equivalents.8

Impact on primary care

The guideline states that ‘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.’

The largest impact on primary care is going to be that of the recommendations for screening for OCD/BDD during routine consultations, followed by those on the general principles of care, then those concerning medication.

Undoubtedly these points all promote best practice in the care of OCD/BDD, but because of the large potential impact on the time taken to perform‘usual care’ it is likely that their implementation will be gradual.

Take up will be encouraged by commissioners who will ensure that GPs have a reason to change their practice by providing a specialist multidisciplinary team and rapid access to CBT (including exposure response prevention). Until these two facets of care are commissioned there will be little reward for patients or practitioners who discover more cases by screening.

Very few GPs will be skilled enough to be able to offer the psychological interventions themselves, and these parts of the guideline will have less impact on primary care, beyond the need to refer for therapy.

I look forward to the day when these guidelines are fully implemented as it will indicate the dawn of a truly comprehensive mental health service for all.

Copies of the full guideline and the quick reference guide can be downloaded from the NICE website: www.nice.org.uk

Guidelines in Practice, January 2006, Volume 9(1)
© 2006 MGP Ltd
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  1. NICE Clinical Guideline 31. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London: NICE, 2005.
  2. Robins LN, Helzer, JE, Weissmann MM et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984; 41: 949-958.
  3. NICE Clinical Guideline 1.Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE, 2002.
  4. NICE Clinical Guideline 22. Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in primary, secondary and community care. London: NICE, 2004.
  5. NICE Clinical Guideline 23. Depression: management of depression in primary and secondary care. London: NICE, 2004.
  6. NICE Clinical Guideline 26. Post-traumatic stress disorder. The management of PTSD in adults and children in primary and secondary care. London: NICE, 2005.
  7. Primary Solutions: an independent policy review on the development of primary care mental health services. London: The Sainsbury Centre for Mental Health, 2002.
  8. www.nice.org.uk