Getting to the bottom of ‘refractory’ disorders
When evaluating a patient diagnosed as having a “refractory” mental disorder, ask yourself:
- Is the working diagnosis correct?
- Could another undiagnosed condition be hindering response to treatment?
- Is the patient adhering to his or her prescribed treatment?
- Have prior medication trials used adequate dosages and durations?
For example, in a patient diagnosed with “refractory depression,” undiagnosed bipolar depression may explain the lack of response to antidepressant monotherapy. An undiagnosed general medical condition, such as hypothyroidism, would also explain the lack of response.
Also consider the effects of a comorbid psychiatric disorder. Anxiety, substance use, and personality disorders are common in patients with “refractory” depression.
Always suspect nonadherence—a frequent problem among patients with mental disorders—when assessing a “refractory” condition.1,2 Collateral sources of information such as family, friends, and previous inpatient and outpatient psychiatrists can help clarify this issue when the patient’s account seems unreliable.
If the patient is not adhering to prescribed medication, re-evaluate your therapeutic alliance by considering these questions:
- Has the patient seemed comfortable and open during recent sessions?
- Has he or she been able to discuss emotionally laden material that might lead to shame or guilt?
- Did the patient maintain eye contact and respond appropriately to questions and observations?
If not, your alliance may lack the trust necessary for optimal treatment. To build trust with your patient, discuss your concerns about nonaherence in a warm and supportive manner. As you identify and emphatically address your patient’s concerns, he or she will likely become more engaged and more adherent with all aspects of treatment.
If the patient has been following the treatment plan but complains of persistent symptoms, verify that an adequate dosage (often the maximum recommended) and duration (at least 4 to 6 weeks for major depression) of medication have been prescribed. Also assess the adequacy of any psychotherapy.3
1. Sadock BJ, Sadock VA (eds). Kaplan & Sadock’s comprehensive textbook of psychiatry (8th ed). Philadelphia: Lippincott Williams & Wilkins, 2004.
2. Hales RE, Yudofsky SC (eds). Textbook of clinical psychiatry (4th ed). Washington, DC: American Psychiatric Publishing, 2003.
3. Campbell WH. ‘Prescribing’ psychotherapy as if it were medication. Current Psychiatry 2004;3(7):66,-71.
Dr. Campbell is assistant professor, department of psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, and is residency program director and director of clinical services, department of psychiatry, University Hospitals of Cleveland.