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.
Addressing nonadherence
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 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