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Psychiatric Consultation to Primary Care
Call or email PC2 at (858) 880-6405 , or contact us at eConsultSD.com
A behavioral health integration partnership program of Vista Hill, funded by San Diego County Department of Behavioral Health Services
May 22, 2012
Obsessive-compulsive disorder (OCD) can be a debilitating
disorder. The term “obsessive-compulsive” is loosely used in
everyday jargon, so it is important to be able to detect
clinically significant OCD.
OCD as defined in DSM-IV entails obsessions (intrusive,
A 13 year old male is being seen in his primary care provider’s
unwanted, excessive worrisome thoughts) and/or compulsions
office-- his mother reports: frequent hand washing, flushing
(rituals or forced habits) that impair everyday life that demand
the toilet repeatedly, opening and closing doors and repeating
time, interfere with daily living, and alienate people.
the same phrase over and over. As a young child, he was seen
Obsessions and compulsions can involve: preoccupation with
by a psychiatrist for conduct issues and, anger management
sexual, violent or religious thoughts; preoccupation with
problems in school. Mother may also have mental health
contamination, cleaning; checking for symmetry and order;
problems, stating there is a stalker watching the family—she
has made police reports but these have not been substantiated.
Maternal grandmother had a history of mental illness of
Patient are typically aware that their symptoms are irrational
and excessive but feel compelled to do them anyways. Rarely,
they have poor insight, making treatment more difficult. Some
patients present with psychotic delusions. The prevalence of
It is wise to speak with the youth without the mother present to
OCD is 2% in the adult population. Since 3 of 4 patients have
clarify the reported symptoms and assess for other concerns.
symptoms before adulthood, it is good to inquire about onset. .
A referral for counseling is usually indicated. Medication such
as fluoxetine or citalopram may be offered using a slow
OCD co-morbidities include anxiety, depressive, and eating
titration of 10mg. every two weeks to a target dose of 40mg.,
disorders in adults. Comorbidities in childhood include ADHD
with monitoring for physiological side effects and mental status
and tic disorders.
changes. A simple informational feedback loop with the
therapist is most desirable.
The YBOCS is a diagnostic tool that delineates symptoms and
rates the level of severity and insight of a patient.
Treatment options include psychotherapies such as Exposure
When you contact PC2 about a patient with behavioral health
Response Prevention (ERP), a cognitive behavior therapy, and
concerns, your question goes first to Bella Montgomery, RNP,
medications. ERP involves repeat exposure to triggers with
support and redirection from the patient’s ri
our triage clinician, who then contacts one of the PC2
psychiatrists: Mark Chenven, M.D., Charmi Patel Rao, M.D.,
or Will Connor, M.D.
Medication options include the SSRIs (Prozac, Paxil, Lexapro,
Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic
Callers to PC2 receive a time-sensitive response, followed by a
antidepressant). Slow titration is used to avoid worsening the
written note faxed to you for inclusion in the medical record.
anxiety, and patients often need higher doses for longer periods
Emailed questions and eConsultSD.com consults are answered
of time for a full effect.
within 24 hours.
Patience and persistence are needed. Periodic re-
PC2 consults are a no cost service,. PC2 is a component of
administration of the YBOCS tool may assist in monitoring
Vista Hill’s SmartCare Integrated Behavioral Healthcare
progress and can be useful in demonstrating clinical response.
Community Clinic Partnership Program, with funding from
As with most behavioral health problems, most patients do
Mental Health Services Act provided by San Diego Behavioral
better with a combination of medication and therapy.
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