Anxiety Disorder and OCD Clinical Pathway - Outpatient Behavioral Health and Primary Care

Description of BH Therapies / Definitions

Definitions

Active Monitoring
  • Active Monitoring emphasizes all of the important things that can occur BEFORE initiating a formal psychotherapeutic or pharmacological treatment to address a patient’s suicide risk.
  • The following list contains some of the elements of active monitoring
    • Schedule frequent visits to assess for changes in clinical presentation
    • Prescribe regular exercise and leisure activities, such as extracurricular clubs, hobby, arts and crafts, playing an instrument, etc.
    • Recommend a peer support group within community
    • Review self-management goals and engage in problem solving strategies
    • Follow up with patients via telephone in between sessions
    • Provide patients and families with patient educational materials
  • Pediatricians may utilize active monitoring at every visit, including AFTER treatment has started. During active monitoring, pediatricians track progress of psychotherapy, medication use, health choices, social life, activities, assess behavior change, self-care, sleep hygiene, family dynamic, and school progress.
Clinical Response
  • At least a 50 percent reduction in psychiatric symptoms
Cognitive Behavioral Therapy (CBT)
  • A skills-based psychotherapy treatment that conceptualizes the onset and maintenance of clinical symptoms within the context of cognitive vulnerabilities and negative psychosocial events. It focuses on the ways that a person’s thoughts, emotions, and behaviors are interconnected and how they each affect one another. A CBT approach teaches behavior and thinking skills to promote positive mood and coping with negative life events. CBT is indicated for children and adolescents ages and above.
Consult or Refer with Mental Health Specialist
  • Referring youth for treatment and making sure they receive proper follow-up care is a crucial step for primary care providers. Making sure youth don’t fall through the cracks always requires careful planning and clear communication between primary care and mental health providers. Once either a consultative relationship has been established or a referral has been made, primary care physicians and mental health practitioners should carefully define and discuss follow-up roles and continue to coordinate patient care until presenting problems are resolved.
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  • Pediatricians treating Pennsylvania families with Medical Assistance, can use the Pennsylvania Telephonic Psychiatric Consultation Service Program (TiPS) program.
Continuation Treatment
  • A type of Cognitive Behavior Therapy specific to the treatment of OCD. Involves exposure to a obsession provoking feared stimuli and simultaneous prevention of the compulsive ritual that is typically performed in the face of the anxiety-provoking stimuli.
Exposure and Response Prevention (ERP)
  • Used when a youth has achieved complete remission of psychiatric symptoms to consolidate the treatment response and avoid relapse. Should occur every 2-4 weeks for a duration of 6-12 months. Frequency can be determined by multiple factors including clinical status, functioning, existing support systems, environmental stressors, motivation, and co-morbidity.
Family Therapy
  • A psychotherapy intervention that recognizes the relationship between family interaction and the onset and course of pediatric psychiatric disorders. This type of approach specifically targets family processes and stresses, and often emphasizes fostering positive and supportive parent-child interactions and enhancing family and child coping and problem solving.
Follow-Up Assessment
  • At each office visit, the pediatrician should assess therapy compliance (if started), general health and well-being. The pediatrician can assess patient progress with self-report screens or appropriate screening tools designed for the suspected diagnosis
Intensive Outpatient Program (IOP)
  • An outpatient mental health therapeutic intervention more structured and intensive than traditional outpatient therapy. IOP’s usually meet 2-3 times per week and often involve individual, family, and group therapy.
  • See resource list
Link to Counseling
  • Obtaining services in the community for patients may or may not be difficult. During discussions about counseling, Pediatrician may assess whether therapy has started, if the therapeutic relationship is an appropriate match for patient, if frequency is appropriate, and if therapy type is a good fit for symptoms.
Maintenance Treatment
  • Used when a youth has reached recovery. Indicated when a youth has a history of chronic or severe psychiatric symptoms. Occurs every 1-3 months for a duration of one year or longer, based on clinical judgement. Goal is to foster healthy growth and development and to provide enough practice of strategy use to decrease the rate of recurrence.
Partial Hospitalization Program (PHP)
  • Outpatient mental health programs that patients attend for six or more hours a day, every day or most days of the week. These programs, which are more intensive that IOP but less intensive than inpatient hospitalization, will commonly offer group therapy, educational sessions and individual counseling. A PHP may be part of a hospital's services or a freestanding facility.
  • See resource list
Remission
  • A period of 12 or more weeks with no or few anxiety symptoms as determined by DSM 5 criteria or one of the following:
    • GAD-7 < 5
    • CYBOCS < 8
    • SCARED subscale scores below diagnosis cutoff
  • Absence of impaired functioning defined by one of the following:
    • CGI score of 1 or 2
    • CIS score < 15
Relapse
  • When the child or adolescent was in remission and symptoms reemerge. A relapse is considered a continuation of the index episode, not a new episode.
Recovery
  • Being in remission for a significant period (longer than 4 months).
Recurrence
  • When the youth has been in recovery but then experiences a new episode of psychiatric illness
Supportive Psychotherapy
  • Talk therapy involving active listening and reflection as well as education, support, and case management regarding family and school stressors. Supportive psychotherapy also often includes the teaching of specific skills such as problem-solving, coping, and sleep hygiene.
Telephone Support
  • Navigating mental health services can be confusing and frustrating. Patients who are depressed may experience personal barriers to scheduling and attending in-person visits, and may have difficulties articulating questions and concerns. Pediatrician offices, as medical homes for patient care, can increase availability for directing patients to the right resources and referrals by utilizing telephone support from a Social Worker or Nurse advocate. Telemedicine visits are available to providers and offer a convenient way to review therapy, response to medication and overall functioning. Office visits offer a better evaluation which includes in office self-report screens.