Anxiety and OCD — Medication Management Phases — Clinical Pathway: Outpatient Behavioral Health and Primary Care

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

Medication Management: Phases of Treatment

Medications are often added to psychotherapy for the treatment of Moderate / Severe Anxiety and OCD Treatment decisions are based on patient clinical presentation, SI, risk factors, and clinical judgment.
Other Non-pharmacologic Interventions are helpful
For detailed information regarding medication management, refer to ABC Anxiety Evaluation and
Treatment Protocol View ABC Protocol.

Monitoring Response

A follow-up rating scale and brief clinical interview is used to assess clinical response to treatment. Try to use the same rating scale (SCARED, GAD-7, CYBOCS) used for the initial evaluation; repeat monthly during acute treatment, and every 3 months during continuation and maintenance treatment.

Assess Functioning/Impairment using the Clinical Global Assessment of Functioning Scale (CGAS) or The Columbia Impairment Scale (CIS), Youth and Parent or the CGI   monthly during acute treatment and every 3 months during continuation and maintenance treatment.

PCP

Consult Psychiatry for Medication Management as clinically indicated

Acute Phase of Treatment
Goal: Remission of Symptoms by 12 weeks of SSRI/SNRI Treatment
Dose
  • Start low and go slow
  • Start SSRI at lower dose than adult dose to limit side effects and improve adherence
  • It takes 4 - 6 weeks to see full therapeutic benefit at any given dose of SSRI/SNRI
  • SSRI/SNRI Medication Dosing Recommendations
Titration
  • Titrate based on effectiveness and tolerance
  • Younger children often respond well to lower doses, therefore “start low and go slow”
  • Target doses in adolescents are similar to those used for adult patients
  • It takes 4 - 6 weeks to see full therapeutic benefit of any given dose of SSRI/SNRI
  • Consider PCP visit at 2 weeks to review possible side effects, monitor for compliance, timing of dose, clinical response, telemedicine is possible at this stage
  • Titrate the dose up if there is inadequate clinical response to treatment after 4 weeks of treatment with adequate, tolerable medication doses
  • SSRI/SNRI Medication Dosing Recommendations
Monitoring
  • Collaborate with family and other members of the treatment team (BH and PCP)
  • Evaluate effectiveness, tolerance, safety
Follow-up Timing
  • During initiation, evaluation by BH, PCP, and/or other team member
    • Weekly for 1st 4 weeks
    • Every 2 weeks for the next 4 weeks
    • Monthly as clinically indicated
  • Modify this schedule based in individual patient factors
  •  
  • When using alternative follow-up schedule
    • Consider documenting the clinical reasoning
    • Encourage family members to call immediately if there are any concerns and at scheduled intervals to provide updates between follow-up appointments
Measuring Clinical Response
  • Use a rating scale to assess clinical response
  • If able, use the same rating scale used in the initial evaluation (SCARED, GAD-7)
  • Use the scale to assess clinical response at the monthly during the acute phase
  •  
  • Assess Patient’s function every 3 months using:
Length of Treatment
  • For patients with minimal or no response after 12 weeks to treatment, consider the need for psychotherapy augmentation or medication change
Continuation Phase of Treatment
Goal: Avoid Relapse of Anxiety Symptoms
Follow-up Timing
  • Evaluate every 1 - 2 months or as clinically indicated
Focus on: Medication adherence
Dose optimization
Presence of side effect
Measuring Clinical Response
Length of Treatment
  • After patients have remission of symptoms, continue Treatment for another 6-12 months to avoid relapse
Maintenance Phase of Treatment
Goal: Avoid Relapse of Anxiety Symptoms
Follow-up Timing
  • Once the child has achieved recovery, determine whether maintenance treatment is needed to prevent recurrence of anxiety symptoms
Measuring Clinical Response
  • Reassess symptoms and function every 3 months
Length of Treatment
  • Continue medication for 12 months or longer as clinically indicated