Treatment resistance? Try psychotherapy
A treatment-resistant patient’s medication history alone may not explain why trial after trial has failed. To help such patients, also evaluate their psychotherapy histories.
CASE: TWO DECADES OF DEPRESSION
Mrs. H, age 48, had battled depression for more than 20 years and had tried numerous antidepressants, including several tricyclics and one monoamine oxidase inhibitor. She was not working and resisted social interaction because of a persistent belief that she was inferior.
When Mrs. H consulted with me, she was seeing a psychiatrist once a month for medication management. She was taking fluoxetine, 80 mg/d, and methylphenidate, 10 mg tid, but remained hopeless and demoralized.
While taking her history, I learned that Mrs. H had been a successful art historian. She seemed surprised when I asked about this; she said her previous psychiatrist had never asked about her work.
I also learned that Mrs. H was relatively euthymic for nearly 7 years in her early 30s. During that time she married, found a challenging job, and received therapy from a psychologist who “really listened and took me seriously.”
I recommended weekly psychotherapy and medication management, both of which I would perform. The first sessions were rocky as several medication augmentation strategies led to side effects and little else. Finally, I left her medications alone and listened to her story.
After 2 years of psychotherapy, Mrs. H is optimistic despite multiple stressors. She is an involved wife and mother, works at a respected academic institution, and has a growing network of friends.
Four history lessons
My experience with Mrs. H and other patients taught me four key lessons about evaluating psychiatric treatment histories:
- Ask about all past and current therapy contacts. Get details on each type of therapy performed, frequency and duration, and patient response to the therapist and therapy.
- Look for clues that suggest the patient is open to psychotherapy. Does the patient seem interested in his/her inner life? Does he/she show insight into his/her role in certain situations, especially those involving interpersonal interactions? Can he/she process analogy or metaphor? 1
- Don’t be afraid to try psychotherapy with a medication-resistant patient. A round of intensive psychotherapy may calm residual depression or anxiety symptoms.
- When possible, perform the psychotherapy yourself to become more familiar with your patients—especially if you are prescribing medication.
If you cannot perform the psychotherapy, refer the patient to a qualified therapist. Develop a network of therapists to whom you can refer patients. Talk regularly with therapists to bridge the gap in “split” treatment situations.
1. Kaplan HI, Sadock BJ, Grebb J. Kaplan and Sadock’s synopsis of psychiatry (7th ed). Baltimore: Williams and Wilkins, 1994;834.-
Dr. Stern is an instructor in psychiatry, Columbia University College of Physicians and Surgeons, and assistant attending psychiatrist, adult outpatient psychiatry clinic, New York-Presbyterian Hospital, New York, NY.