When patients undergoing treatment for psychiatric disorders do not improve, clinicians should consider such patients as experiencing a distinct treatment failure, rather than having a treatment-resistant disorder, said H. Paul Putnam III, M.D., in an editorial in The Journal of Psychiatric Research and Clinical Practice.
“Our responsibility to our therapeutic alliances demands that we avoid applying the term treatment resistance in practice and never quit searching for the true and possibly multiple causes of treatment failure,” Putnam wrote. “When we label an individual's diagnosis as treatment resistance, we are essentially objectifying our patient, distancing ourselves from our failure, and effectively abandoning the patient, along with the sense of hope we should be sharing.”
Epidemiological studies have indicated that between 20-60% of psychiatric patient cases eventually get classified as treatment-resistant, depending on the disorder. Yet Putnam asserted that there is no consensus definition or criteria for treatment resistance and that very often when a case is labelled “treatment resistant,” there are effective treatments that need to be identified and tried. Clinicians should consider the diverse reasons that may account for every case in which clinical improvement is not seen—including genetic, biological, psychological, and lifestyle causes.
He outlined some steps that psychiatrists can take with patients who experience a treatment failure, including:
- Ensure patient evaluations and monitoring efforts are thorough.
- Consider all possible comorbidities, including those outside psychiatry
- Confirm the therapeutic guidance has been provided with clarity.
- Re-examine the clinical reasoning of a diagnosis; self-assess and self-correct if needed.
- Assess the quality of the therapeutic alliance with the patient.
“There is still abundant reason for hope when early treatment attempts are disappointing,” he wrote. “Our attitude must embody this optimism, and we must share it generously with our patients as we continue to work with them and our colleagues until answers are found. Not only is this sharing the truth; it is an essential factor in their recovery.”
For more information, see Putnam’s Psychiatric News Special Report, “Rethinking Treatment Resistance as Impasse Rather Than Endpoint.”
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