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Primary level healthcare involves all services that are available directly to you as a first point of contact. For OCD this includes your GP surgery and the primary care mental health team. The NICE guidelines recommend this step for support around management or initial treatment of OCD for individuals with mild to moderate symptoms.
At this level
A GP would usually be a first point of contact for someone looking for support for their OCD, although this isn’t strictly necessary. Your GP should find and provide information about OCD and signpost to any relevant services or organisations, including the local primary care mental health team. Your GP should also discuss medication options and can prescribe an anti-obsessional tablet if you are interested in taking medication.
In Northern Ireland, Scotland, and Wales, many local areas have a primary care mental health team, which can offer you CBT with ERP. Your GP should be able to give information on the local team and how to access their services, which might require a referral.
In England, a service called Improving Access to Psychological Therapies (IAPT) has streamlined what is available in primary care for mental health. Every area should be offering the same support. IAPT services are often called ‘Wellbeing’ centres or ‘Talking Therapies’, but no matter the name each local area will have at least one IAPT service. Your GP can provide contact details for local options or you can find them yourself on the NHS IAPT search page. You can either self-refer or ask your GP to refer you.
Recommended by NICE
Remember that whether to try medication, therapy, or a combination of both is always an individual decision. Recommendations outline what should be available, but you always have a choice about your care.
- Low intensity
This is recommended for individuals with ‘mild functional impairment’, meaning people whose symptoms only partly get in the way of day to day life.
A brief course of CBT with ERP. Brief means up to ten hours of therapist time. This can be done using self-help resources, over the phone, online, or in a group. If in a group, therapist time is split evenly between members, so a 2 hour group session with 4 people will mean 30 minutes of therapist time per patient. - High intensity
This is recommended for individuals with ‘moderate functional impairment’, meaning people whose symptoms noticeably get in the way of day to day life. It is also recommended for people who didn’t improve with low intensity CBT.
A more intensive course of CBT with ERP and/or a course of SSRI medication. More intensive means more than 10 hours of a therapist’s time. - Involving family/carers
No matter what level of ‘functional impairment’ you are experiencing, the service should also consider involving your carers or loved ones in your ERP plan, so that they can best support you with it at home. This should only happen if you are comfortable with it.
Primary care mental health teams in other UK areas might have a similar process
- Initial screening
This is often done over the phone and is an initial conversation with a professional in which they will ask you about what has brought you there. It might be quite brief. The aim of this conversation is to make sure that IAPT is an appropriate place for your treatment. The main things they will be screening for are low moods and high anxiety. - Assessment for treatment
An assessment is a more formal appointment that is more often attended in person for a full session length, which is usually 50 minutes. The assessor will get a full picture of what you are experiencing and discuss treatment options. At this stage, if something different is offered, it can help to remember that CBT with ERP is the most effective treatment for OCD and what is recommended by the NICE guidelines.
IAPT centres do not typically offer a diagnosis, but they can recognise OCD symptoms and provide you with treatment for them. - Low intensity therapy with a Psychological Wellbeing Practitioner (PWP)
PWP’s are trained practitioners who provide CBT-based support or guided self-help. A PWP can work through self-help books and worksheets with you individually or in a group. While a PWP can’t take you through ERP or make an individual treatment plan, they can support and encourage you if you’re able to do these for yourself. - High intensity therapy
A high intensity therapist is a qualified CBT practitioner who can offer CBT themselves and guide you through your ERP work.
For most people with OCD in primary care, this will be the more appropriate option.
The primary care mental health team will provide a certain number of sessions with a therapist, after which you will usually be discharged from that service. Once these are finished, they should assess your mental health and discuss whether treatment was successful. This doesn’t always happen, though, so it can be helpful to know in advance what to do if the sessions offered weren’t enough.
The NICE guidelines state:
“For those in whom there has been no response to treatment, care coordination (or other suitable processes) should be used at the end of any specific treatment programme to identify any need for continuing support and appropriate services to address it.”
To put it simply, if you’ve had the recommended treatment and your OCD is still impacting on your quality of life, the situation should be reviewed so that the appropriate next step in support can be explored. This is often referred to as ‘stepping up’ to more specialised or intensive support. The primary care mental health team might be able to assess you and make a recommendation for next steps themselves. Otherwise, they should contact your GP when discharging you, to ask them to arrange this, ideally in writing.
If you tried low intensity therapy, the next step would be high intensity therapy. If you have not responded to either high intensity therapy or a round of medication, a multidisciplinary review should be carried out – this means getting a recommendation from a team with a mix of professionals, usually in secondary care at the Community Mental Health Team (CMHT).