Ninewells Hospital & Medical School, Dundee, DD1 9SY

Frequently-Asked Questions (FAQ)

This page contains some of the common questions that people often ask about being referred and being assessed. We have grouped the questions by whether you are a patient or carer (wanting to find out more about the service) or a clinician (thinking about making a referral), but the questions are likely to be relevant to all.

There are five sections:

  1. Questions for patients and carers;
  2. Questions for clinicians;
  3. Questions about referring patients with OCD;
  4. Questions about other conditions;
  5. Other treatments.

If your particular question is not answered, please get in touch with us so that we can try to help.

1. Questions for patients and carers

These are questions that may be commonly asked by patients and/ or carers.

 

Referrals need to be made either by a consultant psychiatrist, or from another psychiatrist who is treating you. We will need to be provided with the name of the consultant in overall charge of your care, and there is an expectation that a more junior psychiatrist will have reviewed the case, looked at other treatments that could/ should be tried, and discussed it with a more senior consultant.

We are unable to accept referrals from GPs or psychiatrists/ psychologists in the private sector. More information on this (including advice on transferring care) can be found below.

If you do not have a psychiatrist, or are not being seen by specialist (secondary care) mental health services, we would advise you to discuss a referral to a Community Mental Health Team with your GP.

Like other specialist services in the UK, there is an expectation that treatments normally available in secondary care will already have been tried. In short, people usually need to have tried (and failed to respond to) the following before we are able to offer an assessment:

  1. Two trials of serotonergic antidepressants (this includes all SSRIs and also Clomipramine), at doses appropriate for OCD, and for suitable durations (usually around three months). A trial of Clomipramine is desirable, but not essential.
  2. At least one trial of an augmentation strategy for OCD. This will usually be an antipsychotic medication such as Risperidone or Aripiprazole.
    • If someone has had a trial of a different drug (such as Olanzapine or Quetiapine), we may make suggestions about trials of better-evidenced drugs, but will assess each case on an individual basis.
    • Other evidence-based augmentation strategies (such as Lamotrigine) would also be accepted.
  3. At least one trial of CBT/ ERP, with a total duration of at least 12 hours, and targeted at the core symptoms.
  4. Relevant psychoeducation and support for the family/ home environment.

Due to the nature of how our service is funded (via the NHS), we unable to accept self-referrals. Also, individuals cannot fund their own assessment/ treatment. The AIS works within the NHS, which has, at its core, a different method of funding than many other countries' systems.

More importantly, in order to deliver the highest levels of service we believe that individuals must receive any treatment we offer with the support of -- and in the context of -- an ongoing package of care from their local services and this could not be guaranteed if we accepted private patients.

You can, but funding will be required from your local NHS Trust or Clinical Commissioning Group (CCG). We are unable to offer an appointment until funding is confirmed.

However, in England there are specialist services for OCD and regional centres for depression, and someone will usually only be referred to us if they have been seen by a specialist service and an opinion on suitability for neurosurgery is being requested. Patients in England should be able to get intensive treatment (if required) via these specialist services, if they meet any relevant criteria. OCD Action has information on these specialist services on their website.

We can still accept referrals but funding will need to be agreed from your local health provider. Please speak to your psychiatrist or community nurse about whether they will be willing to seek funding and make a referral.

Details on our waiting times can be found on our homepage.

Briefly, around 50% of people are seen within 8 weeks (two months) of us receiving the referral. It can sometimes be quicker than this, however. Once we have accepted the referral we will be in touch with you and the psychiatrist who referred you with details about the assessment.

Before you go home, we will discuss our thoughts on diagnosis and likely treatment recommendations. We will send a more detailed report within 2-3 weeks after assessment to you, your psychiatrist, and your GP.

For most people, we will usually make some suggestions about drug treatment and/ or psychological treatment. Your local mental health services should be able to work through these with you. We can often help them to structure a treatment plan that suits you.

If you have completed all the treatments that people have usually completed before entering an intensive treatment programme, then we will talk to you about options for intensive treatment. For some people, we will arrange inpatient assessment that can guide the types of future treatment.

There's much more about this on our 'being assessed' page. We would typically aim to conduct a full-day assessment, usually in Dundee, with the involvement of any family.

Yes, of course. We will often suggest that people are re-referred if they have tried the suggested treatments and haven't got any better. It may be the case that they need to try a few more things before we can be confident that all the treatments in secondary care have been tried and that more specialist treatment is necessary. It is for this reason that we will usually ask your local team to provide more treatment and then get back in touch with us if things aren't any better.

2. Questions for clinicians

These are questions that will be most relevant to clinicians who are wanting information about how to make a referral or to contact the service.

 

Please see our referral page for more information on making a referral. This contains all the information that clinicians should need in order to make a referral.

Not currently, because all patients are different and it's hard to capture all the most useful information in a single 'one-size-fits-all' form. We have, however, developed a referral checklist for patients with OCD. This is available on our 'how to refer' page, along with additional guidance on the most useful information to include in any referral letter.

No, we are not able to accept GP referrals. All referrals need to come from secondary care (i.e. specialist) mental health services. Ideally, it will be a consultant psychiatrist making the referral but there are some circumstances where a referral from a non-consultant psychiatrist will be accepted.

However, all patients need to be currently under the care of secondary care MH services and have a named consultant psychiatrist overseeing their care.

We sometimes have enquiries from psychiatrists working within the private sector about referring a patient for treatment. Such a route of referral may be possible if a designated NHS consultant psychiatrist agrees to take over formal care of the patient; not just for the referral for but for any follow-up care as well.

How to Transfer Care

  1. It may be the case that the patient is already being seen by an NHS consultant and the patient is only receiving additional services (such as therapy) within the private sector. In this case, we would advise that you discuss the matter with the patient's NHS consultant who should make the referral.
  2. If the patient is not in contact with NHS psychiatric services, then a referral should be made by the General Practitioner (GP) to the local community mental health team (CMHT). This ensures that the GP remains 'in the loop' and makes sure the patient is within NHS services.
  3. Finally, if you are an NHS consultant psychiatrist but are seeing the patient privately, we would suggest that the referral is made via the NHS part of the patient's care and that their ongoing care is delivered by the NHS.

Not necessarily. However, we do require all patients to have a named NHS consultant who is in charge of their care and we expect any referrals to have already been discussed with the consultant.

Yes...most of the time. We recognise that locum psychiatrists make up a significant proportion of the NHS workforce and we will accept referrals from locums.

However, we normally expect that locums who are making referrals will have seen the patient on several occasions previously and have a reasonable expectation that they will continue to provide ongoing care after assessment and treatment recommendations. This is to ensure that appropriate assessments and case reviews have been done, that the locum is familiar with the case, and that there is appropriate continuity of care after any assessment.

If these conditions are not met, we would advise you to get in touch with us before making a referral.

No. Although most people we see are between the ages of 18 and 65, we will see people under the age of 18 and over the age of 65. In most cases, however, we would invite the referrer to get in touch before making a referral so that we can make sure a referral to our service is the best option.

In some circumstances (e.g. onset of first episode of depression in later life) we might ask for additional investigations (such as an MRI and neuropsychological testing) to be completed before making a referral.

We assess the majority of people in Dundee. However, where people cannot travel (perhaps because they are too unwell or in hospital), we will discuss the best place to assess the patient with the referring clinician.

If you feel that your patient cannot be seen for assessment in Dundee, we would be grateful if you could indicate this in the referral letter. We will then explore alternative arrangements with the referrer and the patient.

We encourage psychiatrists to get in touch with us if they have any queries about suitability of their patients, or the referral process. Our telephone number is on the contacts page. We also have a specific email address for general enquiries.

If you do contact us, it is extremely helpful for us to have some details of the patient you are calling about. We acknowledge that some doctors may be wary of giving details when making a 'casual' enquiry but having a name allows us to track individuals through the referral and assessment process and to make sure that there are no preventable delays. For example, it is useful to know if it takes 3-6 months after an initial enquiry before we receive a referral. Long delays might reflect funding applications which are happening in Primary Care Trusts outwith Scotland.

In most cases, where the patient is detained under the Mental Health Act, we will arrange to visit the patient in their locality. All additional costs of assessment will need to be funded by the referring NHS organisation.

If the patient remains subject to compulsory powers, and the patient is to be seen in Dundee, the host Primary Care Trust will need to contact the Department of Health (who will liaise with the Scottish Government) to ensure that the same (or equivalent) compulsory powers remain in place once the patient crosses the border. Information, and the relevant forms, can be obtained from the Department of Health's webpage on Cross-border transfers of patients under the Mental Health Act.

When the patient is being transferred back to England/ Wales, we will liaise with the Health Division of the Scottish Government to ensure that the transfer takes place with continuity of the compulsory powers.

We would be happy to provide estimates on the costs of multidisciplinary local assessment.

In most cases, where the patient is detained under the Mental Health Act, we will arrange to visit the patient in their locality (usually a hospital).

Before offering an appointment, we will try to discuss the best place to see people with the referrer. We are able to visit hospitals in Scotland where this is the preferred option.

3. Questions about referring patients with OCD

These are some questions that are specific to OCD referrals.

 

Yes, and they are generally the same as those for similar specialist services for OCD throughout the UK. In order to be suitable for assessment, people usually need to have tried (and failed to respond to) the following:

  1. Two adequate trials of serotonergic antidepressants (this includes all SSRIs and also Clomipramine), at doses suitable for OCD, and for suitable durations (usually around three months). A trial of Clomipramine is desirable, but not essential. See below for target doses.
  2. At least one trial of an augmentation strategy for OCD. This will ideally be an antipsychotic medication such as Risperidone or Aripiprazole. If someone has had a trial of a different drug (such as Olanzapine or Quetiapine), we may make suggestions about trials of better-evidenced drugs, but will assess each case on an individual basis.
  3. At least one trial of CBT/ ERP, with a total duration of at least 12 hours.
  4. Psychoeducation and support for the family.

For OCD referrals, we ask that you also complete our referral checklist so that we also have key information that allows us to make a quick decision about referral. Having these details (most of which will presumably have been included in the referral letter) means that we don't have to ask for further information which can delay decisions about care and treatment. The checklist is downloadable in MS Word format so it can be completed electronically, or printed out and filled in manually. Either is fine.

Target doses of SRIs for treating OCD

In principle, each trial should be at the maximum or maximum-tolerated dose for at least 10-12 weeks.

Drug Target dose
Fluoxetine ≥ 40mg/ day
Sertraline ≥ 200mg/ day
Citalopram ≥ 40mg/ day (please note relevant warnings about high dose Citalopram)
Escitalopram ≥ 20mg/ day
Paroxetine ≥ 40mg/ day
Fluvoxamine ≥ 200mg/ day
Clomipramine ≥ 200mg/ day

 

The NICE guidelines on OCD are a good place to start, but like most NICE guidelines they only deal with the first few steps. We've put together some thoughts and suggestions about a whole range of treatments in our guide to treating OCD. We cover: a) choice of antidepressant; b) augmentation strategies; c) psychological treatment; and d) include information on making a referral to us.

We recognise that it can often be difficult to access the kind of psychological therapy that is often recommended by guidelines. Patients with more severe and more chronic OCD will often need longer sessions, for more time, and treatment often has to be delivered at home. Most services struggle to deliver treatment outside of an office-based environment.

We would advise getting in touch to discuss things with us. We can often liaise with local services to help support delivery of treatment (a.k.a. 'outreach'), and to look at options for ensuring that people don't get caught in a catch-22 where they need more treatment, but can't get that treatment locally.

This can be very difficult to untangle and often it's a complex combination of both. We fully recognise that mapping out complicated symptoms can be challenging and can take a lot of time. Over the years, we have developed a range of tools that can be helpful for trying to understand which symptoms might respond to treatment. Please get in touch if you'd like more information.

Our general advice is where someone has only compulsive behaviours with a well-established diagnosis of ASD, it's not clear that we would have much to offer. However, where there is significant diagnostic uncertainty, and where someone has clear symptoms of OCD along with other behaviours that are more autistic, we would suggest that you get in touch to discuss the patient. Whilst we cannot guarantee that we would be able to offer treatment within the AIS, we often suggest that a comprehensive diagnostic assessment and recommendations for further treatment can be helpful in moving care forward.

Again, overlaps between OCD and OCPD can be complex, and both can often co-exist. It's probably worth bearing in mind that with the introduction of ICD-11 a distinct diagnosis of OCPD will no longer exist (although 'anankastia' as a type of personality disorder will still exist).

The transition to a different way of approaching personality disorder in ICD-11 is likely to be a slow one, but there is no reason why someone cannot have both OCD and 'anankastic' personality disorder/ personality difficulties. It is unlikely that someone will have symptoms of OCD that are very similar to those of personality disorder - it will usually be possible to separate them out.

Where there is diagnostic uncertainty, we would suggest that the clinician gets in touch with us to discuss further. Further discussions about previous treatment, and current symptoms may be helpful in understanding if it would be helpful for us to see someone for further assessment.

4. Questions about other conditions

These questions relate to other conditions that we are able to see (and those that we can't).

 

Sometimes. Although we are not commissioned to provide assessment and treatment of bipolar disorder, we are able to assess patients with bipolar disorder if:

  1. The prevailing pattern is one of chronic or recurrent depression, rather than a more unstable or rapid-cycling pattern;
  2. The current episode is chronic depression (i.e. symptoms persisting for at least two years);
  3. Guideline-based treatment for bipolar depression has been followed and the patient has not responded to treatment.

We would advise clinicians to get in touch with us to discuss these (and other) presentations.

We are not commissioned to see patients with primary body dysmorphic disorder (BDD). Unfortunately, there are no specialist services for BDD in Scotland.

However, where the BDD is occurring as a symptom within comorbid OCD, or where there is significant diagnostic uncertainty we would advise the referrer to discuss the case with us prior to referral. We may be able to advise on whether referral to us is the preferred option, or if a referral to specialist BDD services in England would be recommended.

There is more information on specialist BDD services in England on the BDD Foundation website.

Please note that any assessment and/ or treatment for BDD outwith Scotland will require funding from the referring NHS Board. A recommendation/ assessment from us should not be required in order for NHS Boards to make a referral for such services.

 

Again, overlaps between OCD and OCPD can be complex, and both can often co-exist. It's probably worth bearing in mind that with the introduction of ICD-11, a distinct diagnosis of OCPD will no longer exist (although 'anankastia' as a type of personality disorder will still exist).

The transition to a different way of approaching personality disorder in ICD-11 is likely to be a slow one, but there is no reason why someone cannot have both OCD and 'anankastic' personality disorder/ personality difficulties. It is unlikely that someone will have symptoms of OCD that are very similar to those of personality disorder - it will usually be possible to separate them out.

Where there is diagnostic uncertainty, we would suggest that the clinician gets in touch with us to discuss further. Further discussions about previous treatment, and current symptoms may be helpful in understanding if it would be helpful for us to see someone for further assessment.

Although many of the people we see have a concurrent diagnosis of ASD, we cannot provide assessment or treatment for individuals with autism alone. If a clinician is referring someone who has ritualised behaviour but few obvious obsessions, we would normally have a discussion with the referrer about whether it is more likely that the patient has a primary diagnosis of autism. If it is unclear, we might suggest a more detailed diagnostic assessment for ASD prior to referral to us.

We are happy to offer general advice to clinicians who are treating someone with a diagnosis of both OCD and ASD as any psychological/ behavioural therapy needs to be mindful of the similarities and differences between the diagnoses. For example, exposure-based therapy is the preferred treatment for OCD but may make anxiety and distress much worse for someone with ASD; so understanding which symptoms are related to which diagnosis is important.

5. Other treatments

We are often asked about other types of treatment. Some of these questions (and links to more information) are found below.

 

No, we do not provide this treatment. However, we have a blog article about rTMS here. The article covers the evidence for rTMS as a treatment for depression and offers some guidance on how patients in Scotland might access this form of treatment.

No. We do have some advice in our blog post about (es)ketamine and we are happy to discuss how a trial of ketamine could be delivered with consultants in Scotland. However, since it is unlicensed for depression we cannot provide more information here.


Last Updated on 24 November 2023 by David Christmas
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