NICE draft guideline replaces the OCD treatment ladder with matched care
- In its draft guideline for consultation (September 2026), NICE recommends for adults with OCD a matched care approach (recommendation 1.9.4): treatment options are matched to the person's clinical needs, treatment history and informed preferences, in place of a traditional stepped care model.
- Table 1 of the draft orders the options as individual therapist-administered CBT or cognitive therapy, self-administered CBT with therapist support, group CBT, an SSRI and clomipramine. If more than one option is appropriate, they are offered in that order.
- Typical delivery in the draft: 12 to 14 weekly sessions for individual CBT or CT, 8 to 12 for self-administered CBT with therapist support, 10 to 12 for group CBT with 6 to 8 participants. An SSRI is continued for at least 12 weeks to evaluate response and typically taken for at least 12 months.
- Before psychological treatment starts, the draft asks clinicians to discuss the likely number of sessions, the time needed between sessions and the temporary distress (recommendation 1.10.1), and to tell a person on a waiting list how long the wait is likely to be (recommendation 1.10.2). The consultation runs from 17 September to 21 October 2026.
NICE has opened a consultation on a new guideline for obsessive compulsive disorder and body dysmorphic disorder, which will partially update CG31 from 2005. For adults with OCD, recommendation 1.9.4 sets out steps: identify which options in table 1 fit the person's clinical needs and treatment history, discuss them against the person's informed preferences, and offer the appropriate treatment. The committee writes that this allows decisions to be tailored "rather than following a fixed sequence of interventions or basing decisions on service capacity or availability". The final guideline is expected on 16 February 2027.
Ordered by evidence, chosen by the person
The table ranks treatments by clinical and cost-effectiveness evidence and safety. Individual therapist-administered CBT or cognitive therapy comes first, and the committee calls it likely to be the most appropriate option for many adults. Self-administered CBT with therapist support is described as particularly suitable for less severe functional impairment. SSRIs and clomipramine stay in the table and may be combined with therapy when both are appropriate. The committee did not review evidence for people whose current episode has not responded to an adequate trial of a table 1 option.
The first session without a ladder
Under a stepped model, the first offer followed from a person's place in the sequence and in the queue. Under this draft, the first conversation is about fit. Recommendation 1.10.1 lists what to cover: the reasons for the treatment, how it can be delivered, the likely number of sessions and duration, the possible benefits, and the possible challenges, including time outside sessions and temporary distress with active support.
For a practitioner, the promise that follows is about the process. A client can be told how many sessions to expect, what discomfort exposure brings, and, if there is a wait, how long it is likely to be and whom to contact meanwhile. The draft itself notes that services organised around stepped care will need adjusting.
The draft does not promise a shorter queue. It asks that the first offer be decided by the person's clinical picture and preference, and that the wait be explained.
This is a draft for consultation, and recommendations and wording may change before the final guideline, expected in February 2027. The note covers OCD in adults only and summarises recommendations 1.9.4, 1.10.1, 1.10.2 and table 1 of the draft; it does not cover treatment after non-response or relapse prevention, which the guideline excludes. The reading of what to tell a client in the first session is the author's, not a statement in the draft.