# 25 - NICE guidelines for the assessment and treatm

# NICE guidelines for the assessment and treatment of OCD and BDD

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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.