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Gold, incentives and meh

Calls to GP helplines rising

A recent study showed that obsessive compulsive disorder is the most common mental health disorder after depression, affecting one in 100 people. Dr Richard Bowskill advises how to make a diagnosis and treat patients

Twenty per cent of OCD sufferers are unable to lead normal lives

OCD is under-diagnosed and under-treated because people are secretive about their symptoms. There is a general lack of insight into the illness and health care providers aren't familiar with it or equipped to deliver the appropriate treatments. Many people lack access to treatment resources.

Severity ranges from mildly inconvenient to totally incapacitating, with approximately 20 per cent of those afflicted unable to lead normal lives. The cardinal features of this illness are obsessive ruminations and associated behavioural rituals that the patient knows are irrational yet are irresistible; there may be a mixture of different obsessions and compulsions or one may predominate.

Depression and OCD

GPs can usually identify an OCD sufferer by asking the questions in the box below. There are important differences between a primary OCD patient who, as a consequence of the illness, suffers from depression or anxiety and a patient who presents with OCD symptoms as a result of depression. Once the latter have been successfully treated for depression, their obsessions usually disappear.

Similarly, people who are labelled ‘compulsive' because they are perfectionists should not be confused with OCD sufferers; the former's compulsiveness frequently serves a valuable purpose by contributing to the individual's self-esteem and to success in many facets of life.

People with OCD are often reassured that obsessional thoughts and rituals are a normal experience, but the frequency and intensity define their difficulties.

Patient relationships

A 2002 study at Trinity College Dublin showed that people with OCD have higher-than-average intelligence.

Working with OCD patients can be difficult because they are frequently pedantic, demanding patience and abundant human kindness. OCD sufferers initially appear to be ideal patients; however, they are usually ashamed of their thoughts and rituals and so reluctant to talk about their real problems and may be highly controlling.

Patients often have a preference for either medication, psychological therapy or both. Given the NHS's long waiting lists for psychological therapies, most patients are initially prepared to try medication. It is sensible for GPs to start an SSRI while the patient waits for specialist assessment.


Large studies have shown that more than 75 per cent of patients are helped by medication that diminishes the frequency and intensity of their obsessions and compulsions.

The SSRIs (fluoxetine, sertraline, paroxetine and citalopram) are effective in the treatment of OCD and are usually the first choice due to their tolerability and safety.

Many studies have examined the efficacy of sertraline, paroxetine and fluoxetine on OCD patients; these SSRIs are generally thought to have a favourable risk-to-benefit ratio allied with long-term safety and tolerability.

Clomipramine, a combined SSRI and noradrenaline reuptake inhibitor, was the first medication proven to be effective for OCD in the 1970s; today, many still view it as the gold standard, particularly for resistant


Additionally, there is increasing evidence that co-prescribing atypical antipsychotic agents like risperidone, olanzapine and quetiapine may encourage positive responses.

Selection depends on the side-effect profile and how well each individual drug is tolerated. Long-term treatment protects against relapse, which is common when patients stop medication.

Patients with OCD respond very differently to SSRIs than when they are prescribed for depression – neither the dosage nor the timetable for depression will get a result for OCD. The dose for OCD must be significantly higher – say 80mg of fluoxetine daily – and given for 12 to 16 weeks to reach maximum response.

Because GPs are used to treating depression, they don't prescribe high enough doses to get the job done and tend to give up after three or four weeks. They then change the patient to another drug and repeat the cycle, with the result that the patient gets fed up, believes that drug therapy won't work and remains ill.

Cognitive behaviour therapy

Many patients are successfully treated with just CBT, which modifies the beliefs that lead to the misinterpretation of the obsessional thoughts and of the compulsive or avoidant behaviours that maintain these beliefs – and helps the sufferer construct a new, more positive attitude toward their symptoms.

It generally takes between 10 and 20 hours of treatment by a skilled therapist for patients to become symptom-free. There are also advocate groups (see above) and good self-help manuals such as Brain Lock by Jeffrey Schwartz that may be beneficial.

Some studies have looked at computerised CBT, but the software can be costly and results are equivocal.

‘Much higher doses of antidepressants are needed to treat OCD effectively'


• Because patients are so reluctant to discuss their symptoms, it may be appropriate for the GP to ask for urgent specialist help in clarifying the diagnosis

• Formal, non-directive counselling is not an appropriate treatment for patients with OCD

• Cognitive behaviour therapy can be very helpful and it is worth getting the patient referred, even if they have to wait for treatment

• Patients who fail to respond to treatment in primary care should be referred to a psychiatric consultant at a hospital where they can receive specialist treatment

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