UK guidelines urge improved recognition of obsessive-compulsive disorder

Considerable efforts should be made to improve the detection and management of people with obsessive-compulsive disorder (OCD) or body dysmorphic disorder, say UK guidelines published by the National Institute for Health and Clinical Excellence (NICE) this week. The guidelines warn that the current average time between first onset of symptoms of obsessive-compulsive disorder and the provision of treatment is 17 years.

The guidelines recommend that all health professionals, including GPs, should routinely consider and explore the possibility of OCD for people at higher risk of the condition. OCD is characterised by the presence of obsessions (unwanted intrusive thoughts, images, or urges) or compulsions (unwanted, unnecessary behaviours).

People at risk include those with symptoms of depression, anxiety, alcohol or substance misuse, body dysmorphic disorder (a preoccupation with an imagined or minor defect in appearance), eating disorders, and people attending dermatology clinics with conditions that could be related to the condition. The guidelines suggest asking patients direct questions about possible symptoms, such as, “Do you wash or clean a lot?” or “Do you check things a lot?” or “Is there any thought that keeps bothering you that you'd like to get rid of but can't?”

Tim Kendall, the joint director of the National Collaborating Centre for Mental Health, said, “It is a terrible indictment of current services that it currently takes 17 years, on average, from the first onset of symptoms before someone with OCD gets effective treatment. This is probably the worst delay in any mental illness.”

He suggested that part of the delay was associated with the sense of guilt and shame that many people with OCD feel about their symptoms. “But health services haven't done our part in helping to detect the condition,” he said. The centre developed the guidelines for the National Institute for Health and Clinical Excellence, which is responsible for providing national guidance on treatment in the NHS, with the aim of improving the management of OCD.

Once diagnosed, the guidelines suggest that adults with OCD should be offered psychological therapies as first line treatment, with drug treatment (selective serotonin reuptake inhibitors) being considered only in people with more severe OCD or people who do not want, or respond to, psychological approaches.

Children and young people with mild OCD should be offered guided self help as first line treatment, and, if that fails or if they have more severe OCD, they should be offered cognitive behaviour therapy. Medication may be appropriate only if a child does not respond to psychological therapies, the guidelines suggested.

Dr Kendall explained that the emphasis on using psychological therapies before drug treatments was based on an analysis of risks versus benefits. “In children with OCD, even those with severe OCD, psychological therapies should be used first because of the risks associated with drug treatments. In adults with severe OCD, the evidence there is indicates that drugs and psychological treatments are probably equally effective.”

The guidelines also stressed the importance of improving the organisation of services, requiring that every primary care trust, mental healthcare trust, and children's trust that provides mental health services should have access to a specialist OCD and body dysmorphic disorder multidisciplinary team, offering age appropriate care. This team should play a central role in training and improving the skills of mental health and other healthcare professionals in the assessment and in the evidence based treatment of people with these conditions.

The guidelines, Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder, are available at http://www.nice.org.uk/.