National Commissioning for Treatment Refractory Obsessive Compulsive Disorder and Body Dysmorphic Disorder

Many people suffering from OCD find their lives completely dominated by this problem and are unable to access appropriate treatment because of funding issues. For the most severely affected individuals there is now a system for referral to national specialist centres which does not require approval by local funding agencies such as the primary care trust. Because funding is provided centrally, patients who meet criteria (outlined below) will automatically be accepted for relatively rapid treatment for the obsessive compulsive disorder. This specifically means that people who are accepted by the National Specialist Service will be offered evidence based treatment including cognitive behaviour therapy, medication and possibly a combination. In these web pages we give details of the services on offer and some of the details about how they can be accessed.

The National Commissioning Group for Highly Specialist Services (NCGHSS) of the Department of Health has commissioned a service for the treatment refractory Obsessive Compulsive Disorder (OCD) or Body Dysmorphic Disorder (BDD). The funding for such patients is by the Department of Health. Patients who do not meet such criteria can still be referred by the normal process and funded by their PCTs. The referral pathways and criteria which they have to meet are described below.

  1. Adults with OCD
  2. Children and adolescents with OCD
  3. Adults and adolescents with BDD

Adults with OCD

Procedure for adults with OCD

Patients can be referred by existing routes to individual units as follows. All referrals must be made from local community mental health teams (CMHTs). It is helpful if the referral letter could indicate if the referrer believes the patient may fulfil the treatment refractory criteria described below

Adults with OCD
Service Contact person
Centre for Anxiety Disorders and Trauma, NCG Out-Patients service
(Adult out-patients)		 Dr. Blake Stobie
Maudsley Hospital, Centre for Anxiety Disorders and Trauma
NCG Out-Patients Service
99 Denmark Hill
London SE5 8AZ
Anxiety Disorders Residential Unit, Bethlem Hospital
(Adult residentail unit) 		Dr. David Veale
The Bethlem Royal Anxiety Disorders Residential Unit (ADRU)
Alexandra House
Monks Orchard Road
Beckenham
Kent BR3 3BX
Priory Hospital North London
(Adult or adolescent in-patients)		 Dr. David Veale
The Priory Hospital North London
Grovelands House
The Bourne
Southgate
London N14 6RA
Springfield Hospital OCD/BDD service
(Adult outpatients or inpatients) 		Dr. Lynne Drummond
Springfield University Hospital
Teak Tower and Heather Ward
61 Glenburnie Road
Tooting
London SW17 7DJ
National and Specialist CAMHS - Obsessive Compulsive Disorder Clinic
(Adolescents with OCD/BDD and significant co morbidity)		 Dr. Isobel Heyman
The Maudsley Hospital
Michael Rutter Centre for Children and Adolescents
Maudsley Hospital
Denmark Hill
London SE5 8AZ
Queen Elizabeth II Hospital
(medication reviews)		 Professor Naomi Fineberg
OCD Specialist Service
Queen Elizabeth II Hospital
Howlands
Welwyn Garden City
Hertforshire AL7 4HQ

Treatment refractory criteria

Patients will need to fulfil treatment refractory criteria:

  1. Have a Yale Brown Obsessive Compulsive Scale (YBOCS) score of 30 or more.
  2. Unsatisfactory response to previous therapy in primary and secondary care or a specialist regional service (where available). Recommended treatments are an offer of either pharmacotherapy and/or cognitive behaviour therapy according to patient choice In-patients are required to fulfil the criteria for admission and in some cases may not fulfil all the treatment refractory criteria listed below (e.g. if there is a risk to life or severe self-neglect but has had not yet had two courses of CBT as an out-patient)

Pharmacotherapy

a) Offer of treatment with at least two serotonin reuptake inhibiting drugs (SRIs) including clomipramine and/or an SSRI. Each trial should be for a minimum of 12 weeks and at optimal British National Formulary* doses. Recommended drugs are:

*or for some patients up to maximally tolerated dose levels.

b) Offer of augmentation of SRI treatment either with first or second generation antipsychotic drugs including haloperidol, trifluoperazine, risperidone, olanzapine, quetiapine, aripirazole, sulpiride or amisulpride, administered at maximally tolerated doses (usually below that for psychotic illness) or by extending the SSRI dose beyond normal formulary limits (usually suitable for SSRIs, but not for clomipramine without special precautions).

Cognitive Behaviour Therapy

Offer of two trials of cognitive behaviour therapy (CBT that includes exposure and response prevention (E+RP). A trial of therapy is defined as at least 10 hours of therapist time or discharged early. Therapy should have been performed under the guidance of a therapist who is accredited by the British Association for Behavioural and Cognitive Psychotherapists (BABCP) or has had equivalent training.

Outcome of Assessment Process in Adults with OCD

Patients assessed will be either

  1. routinely allocated for treatment at the centre where the assessment occurred
  2. discussed in more detail if there are questions about meeting criteria for eligibility or location of treatment. If patients do not meet the referral criteria for treatment refractory service, then alternative treatments and funding will be discussed with the patient and referrer. Alternatively patients who have been referred to the treatment refractory service but have not yet been assessed will be discussed and allocated to a unit for assessment.

The treatment outcome may be:

  1. The Maudsley Hospital, Centre for Anxiety Disorders and Trauma

    2. a) Out-patient CBT with or without pharmacotherapy
    b) Intensive CBT over 1-2 weeks and follow up with or without pharmacotherapy
  2. Anxiety Disorders Residential Unit, The Royal Bethlem Hospital

    3. a) Admission to residential unit for standard CBT with or without pharmacotherapy
    b) Admission to residential unit for intensive CBT over 1 week with or without pharmacotherapy

    The residential unit is especially suitable if more frequent CBT is required or if there are additional diagnoses (e.g. depression) or a family situation which makes out-patient treatment more complex; the person is housebound; or severe obsessional slowness so that attendance as an out-patient has become almost impossible.

  3. Admission to the Behavioural Cognitive Psychotherapy Unit (BCPU) at SW London and St George's Mental Health NHS Trust. Criteria for admission include:-
    4. a. Patient is a danger to self either by nature of suicidal tendencies or due to severe self neglect ( e.g. drinking restriction leading to possible acute renal failure; becoming so overwhelmed by rituals that becomes "stuck" in one place and unable to move despite danger e.g. in traffic etc.)
    b. Extreme impairment of activities of daily living requiring nursing care in initial stages e.g. incontinence of urine or faeces; inability to eat without assistance etc.
    c. Additional diagnosis such as schizophrenia or anorexia nervosa requiring extra monitoring of the effect of treatment and additional nursing care
    d. Reversal of night/day activity levels to such an extent that they make it impossible for a patient to get up in the morning.
    e. Extreme rituals of in excess of 3 hours per morning meaning that engagement in Community/OP treatment would be impossible.
    f. Failure to respond to treatment at one of the other NSCAG Units and the general opinion that a more intensive approach is appropriate.
    g. Occasionally patient may be admitted when there is diagnostic doubt about the condition and 24 observation would be helpful to this process.

    Note patients may not be admitted to Springfield under the Mental Health Act. If a patient is referred while under the Mental Health Act, management is discussed with them. They will be admitted if they are prepared to accept treatment and can remain a voluntary patient for the duration of therapy. Any patient who becomes an immediate risk to self or others during Inpatient treatment and who is not prepared to remain a voluntary patient will be transferred back to their Team of origin if requiring retention under the MHA. In patient treatment is for an average 3.5 months and a maximum 6 months. Decisions about length of stay are made subject to progress.

    Following inpatient stay, patient may receive one of the following approaches:-

    a. Discharge to local CMHT with FU at BCPU ( telephone or in person)
    b. Post discharge joint working with BCPU and local CMHT staff
    c. Further Community/OP sessions with BCPU.

  4. Community/ Out Patient treatment in SW London and St George's Mental Health NHS Trust, Behavioural and Cognitive Psychotherapy Unit (BCPU)

    5. Patients are accepted for OP/Community treatment if they fulfil the general severity criteria listed above and either live in an area where commuting for OP appointments or a member of the BCPU commuting to their home is a realistic option (i.e. Within 100 miles of London or on an electrified rapid rail link taking less than 2 hours one way). In addition a member of BCPU may occasionally travel further afield for intensive input. The types of treatment available all involve work with the CMHT as outreach. Treatment may consist of:-

    a) Intensive Home-based therapy ( in conjunction with Key worker of local CMHT) >6 hours in one week
    b) Less intense home-based therapy < 6hours per week
    c) Telephone monitoring and treatment
    d) OP treatment
    All of the above is conducted along with a full review of medication.

  5. Queen Elizabeth II Hospital
    6. a) Out-patient pharmacotherapy with or without individual/ group CBT
    b) Admission to in-patient unit for pharmacotherapy and CBT if under Mental Health Act for a reason other than OCD but requires nursing care (see in-patient criteria for Springfield).

  6. The Priory Hospital North London

    7. Admission to in-patient unit for CBT with or without pharmacotherapy if under the Mental Health Act for a reason other than OCD but requires nursing care (see in-patient criteria for Springfield).

    If accepted for in-patient or residential unit treatment at any of the units, referrals will be expected to have a full risk assessment and description of ongoing Care Programme under the Care Programme Approach (CPA). The referrer will be expected to confirm commitment from the local CMHT (as far as possible) to collaborate with care plans drawn up by the service including to continue therapy and consolidate treatment gains during periods of home leave or following discharge from the Service.

Children and adolescents with OCD

Procedure in children and adolescents with OCD

Patients will be referred to Dr Isobel Heyman at the Maudsley Hospital. In exceptional urgent cases potential in-patients may be referred direct to Dr David Veale at the Priory or Dr Heyman may discuss the referral on the telephone beforehand. All referrals must be made from local child and adolescent mental health teams (CAMHT). It is helpful if the referral letter could indicate if the referrer believes the patient may fulfil the treatment refractory criteria described below

Refractory treatment criteria in children and adolescents with OCD

Patients will need to fulfil treatment refractory pathway:

  1. (i) Have a Child Yale Brown Obsessive Compulsive Scale score of 30 or more
  2. (ii) Unsatisfactory response to previous therapy in primary and secondary care. Recommended treatments are either an offer of pharmacotherapy and/or cognitive behaviour therapy as for adults according to patient choice.

Outcome of Assessment Process in children and adolescents with OCD

If they fulfil treatment refractory criteria, they will either be allocated to

(a) Maudsley out-patient service for CBT with or without pharmacotherapy or
(b) Priory adolescent in-patient unit for CBT with or without pharmacotherapy

In-patient criteria are similar to those for adult in-patient treatment (e.g. suicide risk; severe self-neglect or functional impairment) or additional diagnoses (e.g. depression, schizophrenia, or disordered eating) or a family situation which makes out-patient treatment more complex; the person is housebound; there is a reversal of sleep pattern or severe obsessional slowness so that attendance as an out-patient has become almost impossible.

If they do not meet the referral criteria for treatment refractory service, then alternative treatments and funding will be discussed with the patient and referrer.

Referrals to the Priory in-patient unit will be expected to have a full risk assessment and description of ongoing Care Programme under the Care Programme Approach (CPA). The referrer will be expected to confirm commitment from the local CAMHT to collaborate with care plans drawn up by the service including continuation of therapy and to consolidate treatment gains during periods of home leave or following discharge from the Service.

Adults and adolescents with BDD

Procedure for referral

All referrals must be made from a local community mental health team (CMHTs or CAMHS) to either:

Service Contact person
Centre for Anxiety Disorders & Trauma
(Adult out-patients) 		Dr. David Veale
The Centre for Anxiety Disorders and Trauma
99 Denmark Hill
London
SE5 8AZ
Anxiety Disorders Residential Unit, Bethlem Hospital
(Adult residentail unit) 		Dr. David Veale
The Bethlem Royal Anxiety Disorders Residential Unit (ADRU)
Alexandra House
Monks Orchard Road
Beckenham
Kent BR3 3BX
Priory Hospital North London
(Adult or adolescent in-patients)		 Dr. David Veale
The Priory Hospital North London
Grovelands House
The Bourne
Southgate
London N14 6RA
Springfield Hospital OCD/BDD service
(Adult outpatients or inpatients) 		Dr. Lynne Drummond
Springfield University Hospital
Teak Tower and Heather Ward
61 Glenburnie Road
Tooting
London SW17 7DJ
National and Specialist CAMHS - Obsessive Compulsive Disorder Clinic
(Adolescents with OCD/BDD and significant co morbidity)		 Dr. Isobel Heyman
The Maudsley Hospital
Michael Rutter Centre for Children and Adolescents
Maudsley Hospital
Denmark Hill
London SE5 8AZ

If after assessment, patients fulfil treatment refractory criteria, they will be discussed at a monthly teleconference. Patient will be either (a) routinely allocated for treatment at the centre where assessment occurred (b) discussed in more detail if there are questions about meeting criteria for eligibility or location of treatment. If they do not meet the referral criteria for treatment refractory service, then alternative treatments and funding will be discussed with the patient and referrer. It is helpful if the referral letter could indicate if the referrer believes the patient may fulfil the treatment refractory criteria described below.

Treatment refractory criteria

Patients will need to fulfil treatment refractory pathway

(i) Have a Yale Brown Obsessive Compulsive Scale (YBOCS) for BDD score of 30 or more
(ii) Unsatisfactory response to previous therapy in primary and secondary care. Recommended treatments are an offer of either pharmacotherapy and/or cognitive behaviour therapy according to patient choice.

Pharmacotherapy

Offer of treatment with at least two serotonin reuptake inhibiting drugs (SRI's) including clomipramine and/or an SSRI. Each trial should be for a minimum of 12 weeks and at optimal British National Formulary* doses. Recommended drugs are:

Cognitive Behaviour Therapy

Offer of two trials of cognitive behaviour therapy (CBT that includes exposure and response prevention (E+RP). A trial of therapy is defined as at least 10 hours of therapist time. Therapy should have been performed under the guidance of a therapist who is accredited by the British Association for Behavioural and Cognitive Psychotherapists (BABCP) or has had equivalent training.

Outcome of Assessment Process in Adults or Adolescents with BDD

The treatment outcome may be:

  1. The Maudsley Hospital (Centre for Anxiety Disorders and Trauma) (Adults or Adolescents) for out-patient CBT with or without pharmacotherapy
  2. Springfield University Hospital (Behavioural Cognitive Psychotherapy Unit) (Adults only) for out-patient CBT with or without pharmacotherapy
  3. Springfield University Hospital (Behavioural Cognitive Psychotherapy Unit) for home based CBT with or without pharmacotherapy (only for residents in SW London)
  4. Bethlem Hospital (Anxiety Disorders Residential Unit) (Adults only) Admission to residential unit for CBT with or without pharmacotherapy
  5. The Priory Hospital North London (Adult or Adolescents in-patients) for CBT with or without pharmacotherapy
  6. Springfield University Hospital (Behavioural Cognitive Psychotherapy Unit). Adults only - Admission to in-patient unit for CBT with or without pharmacotherapy

In-patient criteria are similar to those for OCD (suicide risk; severe self-neglect or functional impairment or additional diagnoses (e.g. depression, schizophrenia, or disordered eating) or a family situation which makes out-patient treatment more complex; the person is housebound; there is a reversal of sleep pattern or severe slowness so that attendance as an out-patient has become almost impossible.

Patients may also be admitted under the Mental Health Act at the Priory Hospital if they are willing to engage in CBT but need to be detained for another reason (e.g. treatment of psychosis or risk of self-harm).

If accepted for in-patient or residential unit treatment, referrals will be expected to have a full risk assessment and description of ongoing Care Programme under the Care Programme Approach (CPA). The referrer will be expected to confirm commitment from the local CMHT (as far as possible) to collaborate with care plans drawn up by the service including to continue therapy and consolidate treatment gains during periods of home leave or following discharge from the Service.

Outcome

The main outcome measure that will be measured at each unit according to diagnosis (OCD and BDD) and population served (Adult or Child & Adolescent) will be:

  1. YBOCS or child YBOCS or YBOCS for BDD
  2. Clinical Global Improvement scale
  3. Obsessive Compulsive Inventory (adult OCD only)
  4. Sheehan Disability Scale (Work, Relationships, Social)

Expected outcomes for all services include:-

a) Discharged improved.

Patient offered 1 month; 3 month, 6 month and 1 year out-patient follow-up treatments to ensure continuation of gains. Consultation with local CMHT including and case-based training opportunities for key individual CMHT staff to equip CMHT for the ultimate care of the patient following discharge.

b) Premature discontinuation of inpatient or residential unit CBT.

Patient may be offered

  1. Pharmacological treatment at QEII Hospital
  2. Out-patient follow up and motivational interviewing
  3. Referred back to CMHT until ready to engage in CBT

c) Refractory patient

Ongoing outpatient psychopharmacological treatment over 2 years at QEII Hospital before referral back to CMHT and available options discussed as per NICE guidelines on OCD and BDD.

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