Obsessive-compulsive disorder

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

Assess the risk of self-harm/suicide in people with OCD (especially if there is comorbid depression), and the impact of OCD behaviours on them/others (including risk to others).

• Consider other psychosocial factors/comorbid conditions that may contribute to risk.

• If uncertain about risks associated with intrusive sexual, aggressive or death-related thoughts, consult mental health professionals with OCD expertise (these themes are common in OCD at any age and are often misinterpreted as indicating risk).

The stepped-care model should be followed, offering the most effective but least intrusive treatments appropriate to the person’s needs. See the NICE guideline for more information on use of the model and how to use treatments (e.g., psychological interventions, selective serotonin-reuptake inhibitors [SSRIs], clomipramine) described in this summary (including cautions, monitoring, dose changes, discontinuation/withdrawal and patient advice).

• At all stages of care, involve family/carers as appropriate (this is particularly important in the treatment of children/young people). Assess the degree to which family/carers are involved in supporting/carrying out behaviours (e.g., compulsions, avoidance or reassurance seeking), and ensure this is addressed.

Refer to a multidisciplinary team with specialist expertise in OCD if there is risk to life, severe self-neglect, severe distress or more severely impaired functioning, significant comorbidity, treatment resistance or relapse.

In adults:

• Antipsychotics as monotherapy should not normally be used to treat OCD

• The following drugs should not normally be used to treat OCD without comorbidity:

  • Tricyclic antidepressants (other than clomipramine); tricyclic-related antidepressants; serotonin and noradrenaline reuptake inhibitors (e.g., venlafaxine); monoamine oxidase inhibitors; anxiolytics (except cautiously for short periods to counter the early activation of SSRIs).

In children/young people:

• Tricyclic antidepressants (other than clomipramine) and other antidepressants (monoamine oxidase inhibitors; serotonin and noradrenaline reuptake inhibitors) should not be used to treat OCD

• Antipsychotics as monotherapy should not be used in routine treatment of OCD, but may be considered by a specialist as an augmentation strategy.

Treatment for adults with OCD and mild functional impairment

Offer low intensity psychological treatments for adults with OCD if functional impairment is mild and/or the patient expresses a preference for a low intensity approach. These include:

• Brief individual cognitive behavioural therapy (CBT; including exposure and response prevention [ERP]) either using structured self-help materials or via telephone

• Group CBT (including ERP).

Treatment for adults with OCD and moderate functional impairment

Offer a choice of SSRI or more intensive CBT (including ERP) for adults with OCD, if functional impairment is moderate or if low intensity CBT has been inadequate (or they are unable to engage with it). Both appear comparably efficacious.

Be aware when prescribing SSRIs of the potential increased risk of suicidal thoughts/behaviour and self-harm, particularly at the beginning of treatment, and especially in people under 30 years and those with comorbid depression.

• Advise patients starting an SSRI of these risks and to seek help urgently if they experience any of the above symptoms or if symptoms are at all distressing.

• Closely monitor and see patients on an appropriate and regular basis (actively seeking out akathisia/restlessness, suicidal ideation and increased anxiety/agitation) following initiation of an SSRI. Carefully and frequently monitor people who are under 30 years, have comorbid depression, or are considered at higher risk of suicide.

• If there is a high risk of suicide, a limited quantity of medication should be prescribed and the use of additional support (e.g., more frequent direct contacts) considered.

Initial SSRI should be one of the following: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram.

• If marked and/or prolonged akathisia, restlessness or agitation develops: review use of the SSRI, and if the patient prefers, change to a different SSRI.

• If there has been no response to a full course of SSRI treatment: check adherence and that there is no interference from alcohol or substance use.

• If response is inadequate after 4 to 6 weeks of a standard dose SSRI and there are no significant side effects: a gradual dose increase should be considered.

• If SSRI treatment is effective, it should be continued for at least 12 months to prevent relapse and allow for further improvements.

Treatment for adults with OCD and severe functional impairment or poor response to initial treatment

If functional impairment is severe in adults with OCD, or if there has not been an adequate response to an SSRI alone (within 12 weeks) or CBT (including ERP) alone (>10 therapist hours per patient), a multidisciplinary review should be carried out, after which:

• Combined CBT (including ERP) and SSRI treatment should be offered

• If there is inadequate response after 12 weeks of combined treatment (or no response to SSRI alone, or no CBT engagement), a different SSRI or clomipramine should be offered (clomipramine should be considered after adequate trial of at least one SSRI has been ineffective/poorly tolerated, if the patient prefers clomipramine or has had a previous good response to it).

If there has been no response to full trials of at least one SSRI alone, combined CBT and SSRI treatment, and clomipramine alone, the patient should be referred to a multidisciplinary team with specific expertise in the treatment of OCD for assessment and consideration of further management (e.g., antipsychotic augmentation, antidepressant combinations).

Treatment for children and young people with OCD

For children and young people with OCD who have functional impairment that is:

• Mild: guided self-help may be considered (with support/information for family/carers)

• Moderate to severe (or guided self-help is ineffective/refused): group or individual (depending on child/young person and family/carer preference) age-appropriate CBT (including ERP) involving the family/carers should be offered as treatment of choice.

The coexistence of comorbid conditions, learning disorders, persisting psychosocial risk factors (e.g., family discord) or parental mental health problems may be factors if OCD is not responding to any treatment, and additional/alternative interventions should be considered.

• If there is significant comorbid depression, this should be appropriately treated and there should be specific monitoring for suicidal thoughts/behaviours.

If a child or young person does not adequately respond within 12 weeks to a full trial of CBT (or they were unable to engage with psychological treatment, or this was declined), a multidisciplinary review should be carried out, after which:

• A child and adolescent psychiatrist may prescribe an SSRI (or, if an SSRI is unsuccessful/not tolerated, clomipramine), preferably in combination with CBT; this specialist should be involved in any dose change or discontinuation decisions.

© NICE (2005) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.