25 - NICE guidelines for the assessment and treatm

NICE guidelines for the assessment and treatment of OCD and BDD

588 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 5 not recommended. Research in adult patients shows that BDD patients with delusional intensity appearance beliefs are as likely to respond to SSRI monotherapy as are non-­ delusional patients.9 Prescribing SSRIs in children In 2004, the UK MHRA cautioned against the use of SSRIs in children and young people owing to a possible increased risk of suicidal ideation.10 Careful re-­analysis of treatment data suggests that SSRIs are clearly more efficacious in OCD than they are in moderate depressive episodes in children and young people.6 Investigators concluded that within the paediatric OCD group, the pooled risk for suicidal ideation and attempts was less than 1% across all studies. This of course is an important risk and should be explained and carefully monitored. Nonetheless, the naturalistic course of untreated OCD and BDD is that patients tend not to spontaneously remit, and they have tremendous associated morbidity. It is also known that untreated OCD and BDD are associated with a 10-­fold increased risk of completed suicide compared with the general population in OCD.9,11 The risk of suicide in BDD is higher, with roughly one in three patients with BDD attempting suicide.12 These factors need to be carefully considered and discussed with the patient and their carers or family in making informed choices about treatment. On occasion, medications other than sertraline and fluvoxamine may be used ‘off-­label’ with the appropriate and suitable cautions. NICE guidance13 for the treatment of OCD recommends the use of maximum tolerated dose strategies of two SSRIs before the use of clomipramine, owing to the latter drug’s greater propensity for side effects and need for cardiac monitoring. The alternative to clomipramine is augmentation with a low-­dose antipsychotic. Factors guiding the choice of other medications may include issues such as the presence of other disorders; response to a certain drug in other family members; and cost and availability. Compliance with medication can be an issue with some young people, which can guide the choice of preparation. For instance, young people with poor compliance may be better suited to treatment with fluoxetine considering its long half-­life compared with other SSRIs. A 2020 meta-­analysis showed fluoxetine and sertraline to be more effective in OCD treatment than fluvoxamine.8 Some children can find tablets or capsules hard to swallow and the availability of licensed liquid formulations is limited in most countries. NICE guidelines for the assessment and treatment of OCD and BDD NICE published guidelines in 2005 on evidence-­based treatment options for OCD and BDD for young people and adults.13 NICE recommends a ‘stepped care’ model, with increasing intensity of treatment according to clinical severity and complexity.13 Assessment of the severity and impact of OCD or BDD can be aided by the use of the Children’s Yale-­Brown Obsessive Compulsive Scale (CY-­BOCS) or BDD-­YBOCS questionnaires, respectively, or other quantitative measures, both at baseline and as a helpful monitoring tool.14 The summary treatment algorithm from the NICE guideline is shown in Figure 5.1.