Jump to content

NICE recommedations about treatment and CHOICE


Recommended Posts

This question came up about medication on another thread, so I thought it might be more useful for the forum if I respond in a separate thread about what NICE recommend for patients (adults) with OCD (BDD may be slightly different).

I'd need to re-read the guidelines but doesn't it say somewhere that to be eligible for "specialist referral" sufferers should have tried at least 2 SSRI medications?


I vaguely recall reading that somewhere too, Caramoole, that to get referred to one of the specialist treatment centres you've either got to have been tried on 2 courses of SSRI (or the equivalent) or have been under secondary care (a hospital psychiatrist). Secondary care (whether as an inpatient or an outpatient) almost always involves trying medication, so in my opinion that's using medication as a gateway to filter numbers of patients referred rather than a recommendation for medication.

I could be wrong about the referral criteria, but it stuck in my mind because it seemed strange to say 'our specialist CBT is the best treatment available for OCD...' while implying... [but you can only access it if you've tried the less effective methods first and failed with them at least twice.] :dry:


In short you are partly right, although the current requirements are not a NICE recommendation but a NHS England for those accessing the clinics through the HSS route (highly specialised service). I did manage to get them to stipulate that the medication requirement is flexible for those who are unable to take meds because of other medication reasons. But, if your CCG is making a referral then there is no minimum criteria other than what the CCG want (sometimes they will follow NICE, sometimes they will insist on the HSS criteria sometimes none at all). I will come back to this shortly, but for now I will discuss what NICE state.

NICE recommendations for treatment of OCD
NICE are a set of guidelines adopted in England and Wales that all NHS services providing mental health services are meant to adhere to, or have a good reason why they are not adhering.

Initially when you approach the GP
In practice sometimes medication may be offered by GPs where there are long waiting lists for CBT. If that happens then it is your choice if you accept or choose to wait for CBT without the meds. You can also request the GP to make a prescription for a self-help book through the 'Books on prescription' scheme. The three OCD books available through the scheme are: Overcoming Obsessive Compulsive Disorder (Veale and Willson), Understanding Obsessions and Compulsions (Tallis) and Break Free from OCD (Challacombe, Oldfield and Salkovskis). There are also books available for anxiety and depression.

But none of these should be instead of CBT or to try first, they should be offered whilst waiting for CBT!!!

NICE make the following recommendations using a stepped care approach:
Stepped care aims to provide the most effective but least intrusive treatment appropriate to an individual’s needs. It assumes that the course of the disorder is monitored and referral to the appropriate level of care is made depending on the person’s difficulties. Each step introduces additional interventions; the higher steps normally assume interventions in previous steps have been offered and/or attempted. However, there may be situations where an individual may be referred to any appropriate care level.

Initially...
In the initial treatment of adults with OCD, low intensity psychological treatments (including exposure and response prevention [ERP]) (up to 10 therapist hours per patient) should be offered if the patient’s degree of functional impairment is mild and/or the patient expresses a preference for a low intensity approach. Low intensity treatments include:

– brief individual cognitive behavioural therapy (CBT) (including ERP) using structured self-help materials
– brief individual CBT (including ERP) by telephone
– group CBT (including ERP) (note, the patient may be receiving more than 10 hours of therapy in this format).


then...
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 a selective serotonin re-uptake inhibitor (SSRI) or more intensive CBT (including ERP) (more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious.

or...
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.

Notice I have highlighted the fact medication should be a choice. In practice these guidelines are not always adhered to, so you may need to point them out to your health professional when seeking treatment.

then...
At this point patients should be usually be referred up the ladder to local mental health secondary care services. In practice IAPT services will discharge the patient and fail to step them up. If that happens go back to your GP and ask to be referred to local secondary care services, for example in Nottingham that is run by Nottinghamshire Healthcare NHS Foundation Trust, in Liverpool it would be Mersey Care NHS Trust. What NICE recommend at this level is:

Step 4
OCD or BDD with comorbidity or poor response to initial treatment - Assess and review, discuss options For adults: CBT (including ERP), SSRI, alternative SSRI or clomipramine, combined treatments.


Step 5
OCD or BDD with significant comorbidity, or more severely impaired functioning and/or treatment resistance, partial response or relapse - Reassess, discuss options
For adults: SSRI or clomipramine, CBT (including ERP), or combination of SSRI or clomipramine and CBT (including ERP); consider care coordination, augmentation strategies,
admission, social care.



Step 6
OCD or BDD with risk to life, severe self-neglect or severe distress or disability - Reassess, discuss options, care coordination SSRI or clomipramine, CBT (including ERP),
or combination of SSRI or clomipramine and CBT (including ERP), augmentation strategies; consider admission or special living arrangements.


then...
Many local services sadly don't have the specialist skills to access or treat severe OCD at step 6, we need to change this but until then you may need to seek a referral to the national specialist OCD treatment clinics. Many local services may not know or be aware of the national specialist clinics so you may have to tell them about them.

Referral to the specialist national treatment clinics
These are:

  • Anxiety Disorders Residential Unit (ADRU)
  • Bristol Centre for Specialist Psychological Treatments of Anxiety and Related Problems *not yet part of HSS*
  • Centre for Anxiety Disorders and Trauma (CADAT)
  • Springfield Hospital national OCD/BDD Service
  • Hertfordshire OCD Service (national service)

This brings us full circle to the questions raised by Caramoole and Snowbear above. There are two routes (no order, it can be by either) to most of these specialist services (Prof Salkovskis's clinic is not part of the HSS programme, so the only route is CCG funding).

Route 1 - Funding is approved by the Highly Specialist Service (HSS) direct from NHS England, rather than local NHS trusts having pay for the patients referral. This scheme was set up to treat only the most severe patients and funds a couple of hundred patients a year (or used to, I am not sure on current overall funding). Because this is reserved for the most severe patients there is a strict requirement that the patient must have:

  • Yale Brown Obsessive Compulsive score >30/40;
  • Failed to respond to two previous trials of SSRI drugs at British National Formulary recommended doses for a minimum of three months each (or be unable to take this by virtue of their disorder or side-effects);
  • Failed to respond to augmentation of above with one trial of either a dopamine-blocking agents; a mood stabiliser; supranormal SRI doses or addition of clomipramine (or be unable to take this by virtue of their disorder or side-effects);
  • Failed to respond to two previous trials of CBT including exposure and response prevention.

In summary, you must have had two courses of CBT, two SSRI's and one attempt at augmenting SSRI with anti-psychotic.

If a patient meets this criteria, then this is likely to be the fastest route to treatment. However if the patient does not meet that criteria then they can still be referred to the specialist clinics, but they must get their local NHS Clinical Commissioning Group (CCG) to fund the referral.

Route 2 - Funding is approved by the local Clinical Commissioning Group (CCG). You will need to get your local GP or ideally a mental health professional to write to your local CCG and recommend they approve a funding referral to the relevant specialist clinic. This can take 2-3 months (or longer) to get the funding approved, and often I end up arguing with CCGs to help patients. Sometimes they agree straight away, sometimes they may want you to go through more local therapy first. But eventually we can get them to say yes. Remember NO is not a final definitive NO! There should not be any clinical criteria from the specialist clinics, provided the CCG fund the patient, then they are likely to accept.

I could be wrong about the referral criteria, but it stuck in my mind because it seemed strange to say 'our specialist CBT is the best treatment available for OCD...' while implying... [but you can only access it if you've tried the less effective methods first and failed with them at least twice.] :dry:


Exactly. I think it is a little bit political Snowbear. The HSS panel is made of the clinical leads from the various specialist clinics, and of course they all have different views on medication. So, sadly for HSS referral there is a strict referral process, I remember Paul once told me he's not concerned if a patient is on meds or not usually, provided they are stable either on or off when referred to his clinic. I don't agree with the strict med clinical criteria, but on the other hand because there is a limited number of patients the HSS funding can treat, there does need to be a clinical requirement.


In all cases, remember not all local NHS services will be familiar with the guidance or recommendations so don't be afraid to show them this thread, or quote the NICE Guidelines for the treatment of OCD.

Finally, NICE also recommend the following for people who have success with CBT but relapse:

If a person needs to be re-referred because of further occurrences of OCD or BDD after successful treatment and discharge, the person should be seen as soon as possible and not placed on a routine waiting list.

Link to comment

The choice of treatment provider at local level is still relatively new, and this week I have been speaking to NHS England to clarify. Sadly, it won't benefit those of us already accessing treatment, but will be beneficial for people new to treatment and yet to seek a referral. Once I have clarified the legislation I will post. Nobody seems to understand it at the moment, I sat around a table with three specialists last month and all four of us had different interpretations.

Link to comment

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...