COMBINED INTERVENTIONS AND INTENSIVE INTERVENTIONS

National Collaborating Centre for Mental Health (UK)

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National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society (UK); 2006. (NICE Clinical Guidelines, No. 31.)

Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder.

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7COMBINED INTERVENTIONS AND INTENSIVE INTERVENTIONS

7.1. INTRODUCTION

There have been many advances in the treatment of OCD over the past 35 years, with the development of effective pharmacological and psychological treatments for a disorder that was previously considered extremely refractory to treatment (Black, 1974). Despite the overall success of these treatments, the situation is far from ideal (Foa et al., 2000). The acute efficacy of SRI-based pharmacotherapy is still moderate both in terms of the proportion of people who respond and their average response; a significant number report adverse effects, and many relapse on discontinuing medication. Likewise, the acute efficacy of ERP-based treatments is also moderate both in terms of the proportion of people who respond and their average response. The long-term maintenance of gains is unknown, and a significant number refuse treatment or do not complete it. Given the moderate efficacy of both treatment types, their differential and combined effects become a question of obvious interest. From the point of view of the person with OCD, the ability to make informed choices depends on information on the relative efficacies, possible adverse effects, durability of effects and availability of treatments and their combinations. From the point of view of healthcare providers, knowledge of efficacy and effectiveness is required in order to make decisions about which resources to provide.

7.2. PSYCHOLOGICAL VERSUS PHARMACOLOGICAL INTERVENTIONS

7.2.1. Introduction

There have been at least five English language meta-analyses addressing the comparison but some of these have contrasted arms from different studies, in some cases using different measures, in order to address this question (Abramowitz, 1997; Christensen et al., 1987; Cox et al., 1993; Kobak et al., 1998; van Balkom et al., 1994). These reviews have not reached any consistent conclusions. Although there has been a keen debate between proponents of psychological and biological approaches to understanding OCD and its treatment, as yet there is no unified theory that can readily accommodate the key elements of both approaches of OCD. However, a broad biopsychosocial framework is accepted by many, at least for the treatment of OCD. Beyond its academic interest, the question of differential efficacy has important implications for people with OCD, their families and carers, and health care professionals.

7.2.2. Current practice

With the advent of SSRIs that are generally better tolerated than clomipramine and better known by medical practitioners given their use for a range of disorders, pharmacotherapy has become more widely available. People are often offered pharmacotherapy in primary care, whether or not they are referred on to secondary or tertiary care. Despite the fact that many professionals are trained each year in cognitive behavioural therapies, there is an increasing demand on therapists as CBT becomes indicated for a greater range of disorders and waiting lists for psychological services are common (Lovell & Richards, 2000). Although there is increasing provision of mental health resources in primary care, there are relatively few professionals who have currently received training to provide the focused and structured treatments that are required for OCD. Consequently, many people do not have ready access to CBT of any type. Although some people are at least eventually able to choose when they obtain access to both, in a proportion of cases the treatment received may be determined more by referral patterns and availability of resource rather than by informed choice.

7.2.3. Studies considered¹³

The review team conducted a new systematic search for RCTs that assessed the efficacy of alternative (psychological versus pharmacological) or combination interventions among adults and children/young people with OCD. Six studies were identified, of which two studies (HEMBREE2003; OCONNOR1999) did not meet inclusion criteria. Of the four included studies, two studies were on adults with OCD (FOA2005; MARKS1980), while two studies were on children and young people with OCD (DEHAAN1998; POTS2004). The studies on adults with OCD provided efficacy data on 104 patients and tolerability data on 84 participants (FOA2005). The studies on children and young people with OCD provided efficacy and tolerability data on 79 participants (DEHAAN1998; POTS2004).

The studies involving adults compared ERP with clomipramine (FOA2005) and ERP and placebo with relaxation and clomipramine (MARKS1980). The studies involving children compared CBT with clomipramine (DEHAAN1998) and CBT with sertraline (POTS2004).

The included studies were 12 weeks long, except MARKS1980, which was 10 weeks long though data from this study was extracted at the 7-week time-point when all patients receiving relaxation were switched to exposure. In the adult studies, the average age of the participants was 35 years and the mean duration of illness was 14 years. The studies did not report the mean final dosage.

In the studies on children and young people, participants were classified as outpatient. Participants received a maximum dosage of the drug of 200 mg per day and a mean final dosage of the drug of 196 mg per day. The average age of the participants ranged from 12–18 years across studies. Comorbid conditions included anxiety disorder, eating disorder and tic disorder.

Full details of the studies included in the guideline and the reasons for excluding studies are given in Appendix 16.

7.2.4. Behaviour therapy versus clomipramine

7.2.4.1. Clinical evidence statements¹⁴

Efficacy ¹⁵	Included studies
There is limited evidence suggesting a difference favouring ERP over clomipramine on reducing obsessive-compulsive symptoms as measured on the Y-BOCS or the Compulsive Checklist (K = 2; N = 68; SMD = 20.67; 95% CI, 21.16 to 20.17). I	FOA2005 MARKS1980
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between ERP and clomipramine on the likelihood of leaving the study early (K = 1; N = 84; RR = 1.02; 95% CI, 0.62 to 1.67). I	FOA2005

7.2.5. CBT versus clomipramine (children and young people)

7.2.5.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT and clomipramine on the efficacy of treatment.	DEHAAN1998
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT and clomipramine on the likelihood of leaving the study early (K = 1; N = 23; RR = 2.36; 95% CI, 0.11 to 52.41). I	DEHAAN1998

7.2.6. CBT versus sertraline (children and young people)

7.2.6.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT and sertraline on the efficacy of treatment.	POTS2004
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT and sertraline on the likelihood of leaving the study early (K = 1; N = 56; RR = 1.5; 95% CI, 0.27 to 8.3). I	POTS2004

7.2.7. Clinical summary

Based on the two head-to-head comparisons for adults with OCD reviewed here, there is some evidence for greater efficacy of ERP over clomipramine. The results on tolerability were inconclusive. There are no comparisons for SSRIs. These results would argue for ERP being offered to all adults with OCD, although ultimately it will depend on patient preference.

The evidence for children and young people is inconclusive for both efficacy and tolerability based on the two studies reported here. Given concerns about the safety of SSRIs and clomipramine for children and young people, CBT should be offered as initial treatment. When CBT is not available or when the young person and their family prefer, SRIs may be considered.

7.3. COMBINATION INTERVENTIONS

7.3.1. Introduction

Despite numerous studies of both CBT and SRIs, there are relatively few that have investigated the combination of both. This is somewhat surprising given that both are only partially effective, many people relapse on discontinuing SRIs, and some people cannot tolerate CBT, especially the ERP component because of anxiety. Consequently it is important to investigate whether the combination can increase efficacy and overcome some of the limitations of each treatment.

7.3.2. Current practice

The Expert Consensus Panel for OCD (March et al., 1997) compiled guidelines with recommendations on a comprehensive range of issues relating to pharmacological and psychological treatments. They concluded that CBT should be the first line treatment for mild OCD for adults and young people and for children (regardless of severity). Combined SRI and CBT should be the first line treatment for moderate to severe OCD for both adults and young people, but not children. However, it is not clear at present what the optimal timing should be for introducing each treatment (Foa et al., 2002a).

It is likely that in the UK many people with OCD do indeed receive combined treatment, especially for moderate to severe OCD, but due to availability of CBT this may be offered sequentially and may happen in a relatively unplanned manner rather than by explicit decision and careful planning. In some cases there may be little coordination between the various professionals involved in care who may be in different services with different levels of experience and knowledge of the treatment of OCD, particularly of the other treatment modality. In other cases, especially in integrated multidisciplinary teams who can provide both treatments, the combined treatment is more likely to be explicitly planned and better coordinated.

7.3.3. Studies considered

The review team conducted a new systematic search for RCTs that assessed the efficacy and tolerability of combination interventions among adults and children with OCD. Eighteen studies were identified, of which eleven did not meet the eligibility criteria of the GDG. Five studies had no extractable data (KASVIKIS1988A; MARKS1988; MAWSON1982; OSULLIVAN1991; PETER2000), three studies were based on analyses from other studies (COTTRAUX1993; KASVIKIS1988; LAX1992), one study included patients with phobic neurosis (AMIN1977), one study was not an RCT (HEMBREE2003) and in another study patients were not properly randomised to treatment groups (OCONNOR1999). The seven included studies (COTTRAUX1990; FOA2005; HOHAGEN1998; MARKS1980; NEZIROGLU2000; POTS2004; VANBALKOM1980) provided efficacy data on 470 participants and tolerability data on 469 participants.

All five included studies on adults featured behaviour therapy (BT) and serotonin reuptake inhibitor (SRI) combinations (COTTRAUX1990; HOHAGEN1998; MARKS1980; FOA2005; VANBALKOM1998). One study also featured a cognitive therapy (CT) and fluvoxamine combination (VANBALKOM1998). Of the two studies on children and young people, one study (NEZIROGLU2000) featured a behaviour therapy and fluvoxamine combination intervention, while the other study (POTS2004) featured a CBT and sertraline combination intervention.

Six studies were between 8 and 24 weeks long (mean length = 13 weeks), while one study was 1 year long (NEZIROGLU2000). In four studies participants were classified as outpatient, in one study as inpatient, in one study as mixed and in one study it was unclear. In the adult studies, the mean age of the participants was 35 years. The duration of illness based on four studies on adults was 13 years. The average age of the participants in the studies on children and young people was 13 years. Three studies were conducted in the US, one each in the UK, France, Germany and the Netherlands. Participants receiving fluvoxamine received up to 300 mg per day and participants receiving clomipramine received a mean final dose of 180 mg per day. Participants in the children study received up to 200 mg of the drug per day.

Full details of the studies included in the guideline and the reasons for excluding studies are given in Appendix 16.

7.3.4. BT + SRIs versus BT

7.3.4.1. Clinical evidence statements

Efficacy	Included studies
There is limited evidence suggesting a difference favouring multimodal BT + fluvoxamine over multimodal BT + placebo on the likelihood of treatment response, defined as a 35% or greater reduction on the Y-BOCS (K = 1; N = 49; RR = 0.31; 95% CI, 0.10 to 1.00). I	HOHAGEN1998
There is limited evidence suggesting a difference favouring BT + SRIs over BT on reducing obsessive-compulsive symptoms as measured by the Y-BOCS (K = 3; N = 126; SMD = 20.37; 95% CI, 20.72 to 20.01). I	HOHAGEN1998 FOA2005 VANBALKOM1998
There is limited evidence suggesting a difference favouring BT + SRIs over BT on reducing compulsive symptoms as measured by the Compulsive Activity Checklist (K = 2; N = 51; SMD = 20.55; 95% CI, 21.12 to 0.01). I	COTTRAUX1990 MARKS1980
There is limited evidence suggesting a difference favouring BT + SRIs over BT on reducing the time spent performing rituals (K = 2; N = 51; SMD = −0.81; 95% CI, −1.38 to −0.23). I	COTTRAUX1990 MARKS1980
There is limited evidence suggesting a difference favouring BT + SRIs over BT on reducing depressive symptoms (K = 4; N = 137; SMD = 20.73; 95% CI, 21.08 to −0.38). I	COTTRAUX1990 HOHAGEN1998 MARKS1980 VANBALKOM1998
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between BT + SRI combinations and BT on the tolerability of treatment.	COTTRAUX1990 FOA2005 VANBALKOM1998

7.3.5. BT + clomipramine versus clomipramine

7.3.5.1. Clinical evidence statements

Efficacy	Included studies
There is limited evidence suggesting a difference favouring ERP and clomipramine over clomipramine on reducing obsessive-compulsive symptoms as measured by the Y-BOCS (K = 1; N = 45; SMD = 20.63; 95% CI, −1.23 to −0.03). I	FOA2005
There is limited evidence suggesting a difference favouring ERP plus clomipramine over clomipramine on the likelihood of response, defined as CGI ‘much improved’ or ‘very much improved’ (K = 1; N = 80; RR = 0.53; 95% CI, 0.33 to 0.87). I	FOA2005
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between ERP + clomipramine and clomipramine on the tolerability of treatment.	FOA2005

7.3.6. ERP + fluvoxamine versus anti-ERP + fluvoxamine

7.3.6.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between ERP + fluvoxamine and anti-ERP + fluvoxamine on the efficacy of treatment.	COTTRAUX1990
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between ERP + fluvoxamine and anti-ERP + fluvoxamine on the tolerability of treatment.	COTTRAUX1990

7.3.7. CT + fluvoxamine versus CT

7.3.7.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CT + fluvoxamine and CT on the efficacy of treatment.	VANBALKOM1998
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CT + fluvoxamine and CT on the likelihood of leaving the study early (K = 1; N = 49; RR = 1.74; 95% CI, 0.75 to 4.03). I	VANBALKOM1998

7.3.8. BT + fluvoxamine versus CT + fluvoxamine

7.3.8.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between BT + fluvoxamine and CT + fluvoxamine on the efficacy of treatment.	VANBALKOM1998
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between BT + fluvoxamine and CT + fluvoxamine on the likelihood of leaving the study early (K = 1; N = 52; RR = 0.86; 95% CI, 0.43 to 1.70). I	VANBALKOM1998

7.3.9. BT + fluvoxamine versus fluvoxamine (children and young people)

7.3.9.1. Clinical evidence statements

Efficacy	Included studies
There is limited evidence suggesting a difference favouring BT + fluvoxamine over fluvoxamine on reducing obsessive-compulsive symptoms as measured by the Children's Y-BOCS 52 weeks after beginning the treatment (K = 1; N = 10; SMD = 21.50; 95% CI, 23.00 to 0.00). I	NEZIROGLU2000

7.3.10. CBT + sertraline versus sertraline (children and young people)

7.3.10.1. Clinical evidence statements

Efficacy	Included studies
There is limited evidence suggesting a difference favouring CBT + sertraline over sertraline on the likelihood of relapse, defined as a score of less than or equal to 10 on the Children's Y-BOCS (K = 1; N = 56; RR = 0.59; 95% CI, 0.38 to 0.92). I	POTS2004
There is limited evidence suggesting a difference favouring CBT + sertraline over sertraline on reducing the severity of obsessive-compulsive symptoms as measured by the Children's Y-BOCS (K = 1; N = 56; SMD = 20.59; 95% CI, 21.13 to 20.05). I	POTS2004
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT + sertraline and sertraline on the likelihood of leaving the study early (K = 1; N = 56; RR = 1; 95% CI, 0.22 to 4.54). I	POTS2004

7.3.11. CBT + sertraline versus CBT (children and young people)

7.3.11.1. Clinical evidence statements

Efficacy	Included studies
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT + sertraline and CBT on the efficacy of treatment.	POTS2004
*Tolerability*
The evidence is inconclusive and so it is not possible to determine if there is a clinically important difference between CBT + sertraline and CBT on the likelihood of leaving the study early (K = 1; N = 56; RR = 1; 95% CI, 0.22 to 4.54). I	POTS2004

7.3.12. Clinical summary

The evidence from five studies suggests that there is greater improvement for OCD symptoms from combined SRIs and ERP when compared with ERP alone. There is also evidence from a single study that the combination may be better than SRI alone (clomipramine in this case). These results suggest that adults with OCD should be offered the possibility of combined treatment. However, the evidence to date is from simultaneous combined treatment and we do not know whether this is the best way of using the two treatments together.

For children and young people, one study found greater improvement in OCD symptoms with the combination of sertraline and CBT over sertraline alone but not over CBT alone. For children and young people, one small study found some superiority for the combination of CBT and fluvoxamine over fluvoxamine alone after 52 weeks. These results suggest for children and young people, especially given the concerns about safety of SRIs in young people, CBT should be offered first, but that combined treatment may also be offered.

7.3.13. Combinations of an SRI and CBT in BDD

No RCTs have been conducted that compare an SRI or any other medication with CBT or a combination of the two. There are a few case reports of combination treatments highlighted in the psychological interventions but they do not assist in guiding clinical practice.

7.4. CLINICAL PRACTICE RECOMMENDATIONS

7.4.1. Initial treatment options

Adults

7.4.1.1.: 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 an SSRI or more intensive CBT (including ERP) (more than 10 therapist hours per patient) because these treatments appear to be comparably efficacious. [C]
7.4.1.2.: 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. [B]
7.4.1.3.: Adults with OCD with severe functional impairment should be offered combined treatment with an SSRI and CBT (including ERP). [C]
7.4.1.4.: 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. [B]
7.4.1.5.: Adults with BDD with severe functional impairment should be offered combined treatment with an SSRI and CBT (including ERP) that addresses key features of BDD. [C]

7.4.2. Poor response to treatment

Poor response to initial treatment for adults

If initial treatment does not result in a clinically significant improvement in both symptoms and functioning, other treatment options should be considered. When additional treatment options also fail to produce an adequate response, multidisciplinary teams with specific expertise in OCD/BDD should become involved, including supporting and collaborating with those professionals already involved in an individual's care.

7.4.2.1.

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), a multidisciplinary review should be carried out. [GPP]

7.4.2.2.

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. [C]

7.4.2.3.

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. [C]

7.4.2.4.

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. [C]

7.4.2.5.

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. [GPP]

7.4.2.6.

The assessment of adults with OCD and BDD referred to multidisciplinary teams with specific expertise in OCD/BDD should include a comprehensive assessment of their symptom profile, previous pharmacological and psychological treatment history, adherence to prescribed medication, history of side effects, comorbid conditions such as depression, suicide risk, psychosocial stressors, relationship with family and/or carers and personality factors. [GPP]

7.4.2.7.

Following multidisciplinary review, for adults with OCD 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 following treatment options should also be considered (note, there is no evidence of the optimal sequence of the options listed below):

additional CBT (including ERP) or cognitive therapy [C]
adding an antipsychotic to an SSRI or clomipramine [C]
combining clomipramine and citalopram. [C]

7.4.2.8.

Following multidisciplinary review, for adults with 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 following treatment options should also be considered (note, there is no evidence of the optimal sequence of the options listed below):

additional CBT or cognitive therapy by a different multidisciplinary team with expertise in BDD [GPP]
adding buspirone to an SSRI. [C]

7.4.2.9.

For adults with BDD, if there has been no response to treatment, or the patient is not receiving appropriate treatment, more intensive monitoring is needed because the rate of suicide is high in people with BDD. [GPP]

7.4.2.10.

Treatments such as combined antidepressants and antipsychotic augmentation should not be routinely initiated in primary care. [GPP]

Poor response to initial treatment in children and young people

If CBT (including ERP) involving the family has not produced an adequate response in terms of a clinically significant reduction in symptoms and increase in functioning within 12 sessions, then review and consider further options according to the age of the child as described below.

Current published evidence suggests that SSRIs are effective in treating children and young people with OCD. The only SSRIs licensed for use in children and young people with OCD are fluvoxamine and sertraline. However, with depression SSRIs can cause significant adverse reactions, including increased suicidal thoughts and self-harm, although they may be safer when combined with psychological treatments. The UK regulatory authority has contraindicated all SSRIs in paediatric depressive illness, except fluoxetine. Although the risk associated with the use of SSRIs in children and young people with OCD is unclear, appropriate caution should be observed, especially in the presence of comorbid depression.

7.4.2.11.: For a child or young person with OCD or BDD, if there has not been an adequate response within 12 weeks to a full trial of CBT (including ERP) involving the family or carers, a multidisciplinary review should be carried out. [GPP]
7.4.2.12.: Following multidisciplinary review, for a child (aged 8 to 11 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. [C]
7.4.2.13.: Following multidisciplinary review, for a young person (aged 12 to 18 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. [B]
7.4.2.14.: For a child or a young person with OCD or BDD, if treatment with an SSRI in combination with CBT (including ERP) involving the family or carers, is unsuccessful or is not tolerated because of side effects, the use of another SSRI or clomipramine with careful monitoring may be considered, especially if the child or young person has had a positive response to these alternatives in the past. This should also be in combination with CBT (including ERP). [C]

7.4.3. Intensive treatment services and inpatient services for people with OCD or BDD

OCD and BDD can usually be treated and managed in the community and in primary care. However, people with severe and/or chronic problems that have not responded adequately to treatment should be referred to multidisciplinary teams with specialist expertise in the treatment of OCD/BDD. Occasionally inpatient treatment may be needed for children, young people or adults who are at particular risk or whose ability to function is severely impaired. Special support may be needed, especially for young adults with impaired autonomy and personal functioning as a result of severe OCD with onset in childhood or adolescence.

7.4.3.1.

People with severe, chronic, treatment-refractory OCD or BDD should have continuing access to specialist treatment services staffed by multidisciplinary teams of healthcare professionals with expertise in the management of the disorders. [C]

7.4.3.2.

Inpatient services, with specific expertise in OCD and BDD, are appropriate for a small proportion of people with these disorders, and may be considered when:

there is risk to life
there is severe self-neglect
there is extreme distress or functional impairment
there has been no response to adequate trials of pharmacological/psychological/combined treatments over long periods of time in other settings
a person has additional diagnoses, such as severe depression, anorexia nervosa or schizophrenia, that make outpatient treatment more complex
a person has a reversal of normal night/day patterns that make attendance at any daytime therapy impossible
the compulsions and avoidance behaviour are so severe or habitual that they cannot undertake normal activities of daily living. [GPP]

7.4.3.3.

A small minority of adults with long-standing and disabling obsessive-compulsive symptoms that interfere with daily living and have prevented them from developing a normal level of autonomy may, in addition to treatment, need suitable accommodation in a supportive environment that will enable them to develop life skills for independent living. [GPP]

7.4.3.4.

For children and young people with severe OCD or BDD with high levels of distress and/or functional impairment, if there has been no response to adequate treatment in outpatient settings, or there is significant self-neglect or risk of suicide assessment for intensive inpatient treatment in units where specialist treatment for children or young people with OCD or BDD is available should be offered. [GPP]

7.4.4. Discharge after recovery

After full recovery, children, young people and adults with OCD or BDD should be followed up for a year. After discharge, those re-referred should be seen quickly and should not be placed on a routine waiting list.

7.4.4.1.: When a person of any age with OCD or BDD is in remission (symptoms that 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. [C]

Footnotes

13: Here and elsewhere in the guideline, each study considered for review is referred to by a study ID (primary author and date of study publication in capital letters, except where a study is in press or only submitted for publication, then a date is not used).
14: The full list of all evidence statements generated from meta-analyses (and the associated forest plots) are available on the CD-ROM that accompanies the guideline (see Appendix 17 and Appendix 18). Where a meta-analysis was not possible (or not appropriate), a summary of the results from each study used to generate a statement can be found in Appendix 18.
15: In the case of SMD or WMD, negative effect sizes favour the treatment group.

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