Frequently-Asked Questions (FAQ) - Referral

You can, but funding will be required from your local Trust or Clinical Commissioning Group (CCG). 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. You are likely to be able to get intensive treatment (if required) via these specialist services.

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.

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

1. Two trials of serotonergic antidepressants (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.
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.
3. At least one trial of CBT/ ERP, with a total duration of at least 12 hours.
4. Psychoeducation and support for the family.

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

Briefly, around 50% of people are seen within 10 weeks of us receiving the referral. It can 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.

There's much more about this on our 'being assessed' page. Please note that COVID-19 will have changed much of this and we describe some of the key changes we've made because of COVID-19.

We will discuss the options with you once assessment is complete. You will be the first to know.

For most people, we will usually make some additional suggestions about drug treatment 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. At the moment, this is being delivered remotely via videoconferencing.

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.

Due to the nature of the service, we unable to accept self-referrals and 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 treatment 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.

1. Our address is given here. It is helpful to have as much information as possible regarding clinical history and previous treatments. Whilst the patient may be referred for assessment of suitability for a particular treatment, we focus on assessment as being the initial contact.
2. We would aim to acknowledge your referral within a week or two and would hope to be able to give you an approximate time when the patient would be seen. For patients outside of Scotland, this is dependent on funding being available and the casenotes being sent for review.
3. If funding is required, we will not be able to see the patient until we have written confirmation of funding for the assessment.

• Although we prefer referrals to come from consultant psychiatrists, we will accept referrals from other senior clinicians. However, referrals need to have a named consultant psychiatrist who will retain overall responsibility for the patient during the assessment process.
• Referrals are accepted on the understanding that the referring consultant retains overall clinical responsibility for the ongoing care of the patient, including the implementation of any treatment recommendations made by the service.
• Referrals are accepted from throughout the UK and Ireland. We would recommend that referrals from outside of the UK are only made following prior discussion.
• All referrals require a formal letter detailing current circumstances, clinical history, a summary of previous treatments, and the current treatment plan.
• Although we welcome enquiries via email, we prefer a letter rather than an email. A formal referral letter (in Word or PDF format) can, of course, be sent via email.
• We will be pleased to discuss any preliminary queries about referral by telephone, or by e-mail.
• To facilitate the assessment process, we require timely access to all relevant clinical case records (psychiatric / general medical / clinical psychology). All case records should be with us at least 2 weeks before the patient is seen (see below). Copies of contemporary case records are fine.
• Treatment recommendations are usually based on a detailed understanding of previous treatments. Where case records cannot be reviewed in advance of assessment, we may be forced to postpone an assessment appointment until we have had the opportunity to review the notes. We believe that it is more acceptable for patients to attend when all relevant information is available.
• Please note that we aim to provide a comprehensive, multidisciplinary, assessment service and to generate the most suitable, evidence-based and effective treatment recommendations tailored for each individual patient. This may, or may not, involve neurosurgical treatment methods.
• Accordingly, we generally discourage referrers and patients from assuming in advance they are being considered for any one specific therapy.
• For referrals originating within one of the Scottish Health Board areas, there is no requirement to seek financial authorisation for assessment.
• For referrals originating from elsewhere in the UK, we can only proceed with assessment following receipt of written confirmation that funding has been authorised by the relevant local body (Primary Care Trust, Mental Health Trust, Clinical Commissioning Group, etc.).
• We aim to acknowledge and to respond to your referral within 10 working days of receipt.

No, because all patients are different and it's hard to capture all the most useful information in a single 'one-size-fits-all' form.

Instead, please write us a letter with all the most relevant information and also include other information (such as treatment summaries).

We anticipate that patients will normally be able to travel to Dundee for assessment. However, it is acknowledged that there are clinical circumstances where it is better for us to travel to conduct the assessment:

• Where the patient is currently a hospital inpatient and travel to Dundee may be impractical.
• Where the patient cannot attend for reasons such as: infirmity, risks related to mental state, legal status, or inability to leave home.
• Where it is considered of additional importance to assess the patient at home. For example, in the case of severe obsessive-compulsive disorder.

If you feel that your patient would be unable to attend Dundee, or that a local assessment would be preferable, please indicate this in the referral letter. We would normally make arrangements to visit the patient at the most appropriate location for them.

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, and email addresses for the staff are also available. 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 assesment process and 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.

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.

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

We will usually discuss the best place to see people with the referrer. We are able to visit hospitals in Scotland where this is the preferred option.

Briefly, no. All referrals to the service need to come from the NHS. Psychiatrists working in the private sector should read the information on transfer of care.

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 trials of serotonergic antidepressants (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.
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.
3. At least one trial of CBT/ ERP, with a total duration of at least 12 hours.
4. Psychoeducation and support for the family.

You can read more details on typical criteria for different tiers of the service by reading our operational framework/ downloading the criteria for service provision.

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. In people with more severe and more chronic OCD, they will often need longer sessions, for more time, and usually 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, and 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.

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 a lot of 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 assesment 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 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.