Treatment Resistent Depression

[Fabio001]

Hi all. I have a general inquiry for the practicing physicians on this board regarding your go-to medications when a patient with features of atypical depression has been tried on a number of SSRI's and seems to be getting only minimal relief. How far do you go with adjuncts (bupropion, lithium, atypical antipsychotics) and in what order? At what point would you consider instituting a trial on an MAOI? Would you consider ECT before an MAOI? Also, any experience with the relatively new selegiline patch? Thanks guys!

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[Guyton]

Check the algorithm for depression on page 8.

http://www.jpshealthnet.org/sites/default/files/tmap_depression_2010.pdf

 

[splik]

Here's my summary of management of "treatment-resistant depression":
1. don't use the term "treatment-resistant depression". It's a meaningless term than often disguises something else altogether
2. revise your formulation - look at predisposing, precipitating, perpetuating and protective factors including aspects of drug therapy
3. review prior trials of drugs including dose, duration of treatment, side-effects, adherence
4. don't write the patient off until they have had an adequate course of some psychotherapeutic intervention - CBT, BA, IPT, ISTDP etc
5. review life events, relationships, work, ongoing sources of demoralization and powerlessness etc - drugs do not respond to **** life syndrome
6. review diagnosis
a. (Check CBC, CMP, GGT, ESR, CRP, TSH and urine toxicology, in young people consider celiac serology)
b. are they really depressed or just have a crappy life? (sorry you can't help much with the latter. many patients have both but again not gonna be able to do much if life circumstances don't change)
c. look for bipolarity without stretching the definition
d. look for PTSD
e. look for OCD or body dysmorphic disorder
e. comorbid anxiety disorders often lead to poorer treatment response (consider using transdiagnostic unified protocol)
f. if patient has borderline or narcissistic personality disorder this should be focus of treatment
g. subtype depression - look for psychosis (can be subtle), catatonia, melancholia, atypicality
h. use cognitive screen to look for dementia especially in older patients
7. Patient should not be regarded as having malignant depression until failed adequate trials of 3 antidepressants from at least 2 different classes.
8. 1 SSRI is enough, switching to another occasionally works, but don't try more than 2
9. don't increase the dose of an SSRI that is having no effect. If it doesn't work at 20mg it's not gonna work at higher doses
10. If patient gets partial response (using measurement like PHQ-9, HAM-D, MADRS, QIDS-SR) then augment with lithium or another antidepressant (such as mirtazapine or bupropion) but really don't faff about and just use lithium
11. I wouldn't bother using buspirone the evidence for it is fairly weak
12. no real supporting data to adding T3 to SSRIs
13. be suspicious about augmentation with neuroleptics and remember these are risky drugs. However occassionally that abilify augmentation really does work
14. If pt has CRP >1, OR melancholic, psychotic, or catatonic features start a TCA- start low, go slow. augmentation with lithium may be needed, or T3
15. I try to avoid ECT unless someone is hospitalizable. atypical depression doesn't respond as well to ECT as psychotic, melancholic or catatonic depression. ECT's effects are short-lived most of the time and evidence for maintenance therapy is very weak.
16. just because a psychotherapy has not helped before doesn't mean that it won't later on or a different modality wont. So much depends on therapeutic alliance and skill of therapist

In terms of MAOIs I would not use them until a patient had failed SSRI, SNRI, and bupropion either alone or in combination. Also if patient can tolerate use venlafaxine-mirtazapine combo. If pt has had partial response to antidepressant I would add lithium. Make sure patient isn't suicide risk and is reliable enough to follow diet. I would use selegiline (either oral or patch depending on their insurance first), or alternatively use Marplan as these are the best tolerated. Phenelzine (nardil) is the most poorly tolerated. Parnate (tranylcypromine) is part-metabolized to amphetamine and made a resurgance with STAR*D. I would avoid it really however. These drugs if effective are probably for life. Patients become precipitiously depressed upon discontinuing and nothing helps ever again including reinstituting the drug. The patient needs to know if you're prescribing it and it works it will be for life and possibly for death. Even if they have a massive intracranial bleed they will need to continue on it lest they become atrociously depressed.

Also once someone gets to the stage of needing an MAOI, its unlikely that an MAOI alone is going to be enough - only 15% will remit with MAOI monotherapy by that point. I like adding a low dose of lithium. You cannot add a TCA to an MAOI (but you can add an MAOI to a TCA, and can start them concomitantly). low doses of stimulants (methylphenidate) could also be cautiously tried.

It is fun to say "this drug is so powerful if you eat smelly cheese YOU WILL DIE!!!". great maximization of placebo effect too! However they should not be used lightly. At the same time don't faff around forever on the SSRI carousel. Also it is cruel to do trials of meds for 6-8 weeks if they don't work at all. If there is NO change in 1-2 weeks, there will probably never be a change - move on to the next treatment!

 

[splik]

also when were talking about atypical depression and MAOIs were not talking about this DSM atypical specifier. It's really quite irrelevant to treatment prediction if your patient is eating all the time and sleeping too much. You are interested in preserved mood reactivity, interpersonal rejection sensitivity (as a personality feature) and phobic/obsessional/panic symptoms. if they don't have any of those then it's not atypical depression.

 

[Armadillos]

15. I try to avoid ECT unless someone is hospitalizable. atypical depression doesn't respond as well to ECT as psychotic, melancholic or catatonic depression. ECT's effects are short-lived most of the time and evidence for maintenance therapy is very weak.

Why such a downer on ECT? Particularly now with ultra-brief pulse RUL ECT having a substantially improved side effect profile* while maintaining efficacy. Obviously there are tons of people out there doing ECT like they haven't learned anything in the last 30 years, but that doesn't mean you have to throw it entirely out of consideration for your outpatients.

IIRC for patients who reach remission with ECT, maintenance with TCA+Lithium will maintain remission in ~60% of patients at half a year. So if like 50-70% of people getting ECT can be treated into remission and then 60% of those remain in remission at half a year with maintenance therapy, thats nothing to scoff at considering a lot of depressed folks spend decades getting therapized and have tried every med-cocktail known to man, but many providers are still too afraid to try the single most effective treatment for depression.

*Edit, maybe the starred isnt so clear: After some quick googling, looks like I might have somewhat oversold the ultra-brief vs brief pulse ECT in my first paragraph, my thinking was based on some article I saw a year or two ago. I need to look into it more now, I might still have been right, but perhaps not as clear as I thought at first. Regardless I dont think it substantially changes my argument that ECT is underutilized and advancements in mitigating side effects have been and continue to be made.

 

[PistolPete]

Agree with splik except I think ECT is vastly underutilized in the US.

 

[hamstergang]

At the same time don't faff around forever on the SSRI carousel. Also it is cruel to do trials of meds for 6-8 weeks if they don't work at all. If there is NO change in 1-2 weeks, there will probably never be a change - move on to the next treatment!

Is this part anecdotal or based on stronger evidence? Because it seems useful to know if true.

 

[birchswing]

What about polysomnography?

Again, I'm not a doctor (my standard disclaimer), but sleep is the first thing I think of when I hear depression. Not getting enough oxygen to the brain would make anyone depressed.

 

[splik]

Why such a downer on ECT?

ECT is one of the sacred cows of psychiatry, widely touted as the most effective psychiatric intervention and the adverse effects downplayed for many years. Psychiatrists tend to get quite protective of ECT. I think part of this is because of the negative publicity for ECT being seen as "barbaric" or used as a tool of repression, coercion, mind-control, torture or crucifixion in popular culture and the hidden curriculum that ECT unquestionably works which is why we persist in using it 76 years after its gruesome origins in the slaughter house. As such there is a lot of rhetoric from ECT champions (e.g. Fink, Abrams, Sackheim etc) that vastly oversells the rather poor data base for ECT.

What troubles me is that many of the ECT trials are old and not reflective of practice today. Most of the trials re extremely poor quality and failed to report the adverse effects. Where the adverse effects were noted, patients were denounced as unreliable narrators or derided as "cranks" in journal articles! It is true that RCTs are not needed if indeed the effects are really as dramatic as claimed. Clearly some patients do respond marvelously to ECT. It certainly has a more rapid onset of action than other treatments and that is desirable. However the evidence for continued effects is quite poor - most patients do just as good/bad as people receiving other treatment at follow up in the good studies, the effects are usually short lived. Small sample sizes and other major difficulties in studies prevent any of the bolder claims you make.

I would be more prepared to make concessions to the beleagured evidence base if I had seen some positive responses to ECT. In my patient population however I have yet to see the magical response to ECT in depression including psychotic depression that we all hear about, but I have seen enough people transformed into gibbering wrecks from excessive ECT. I certainly won't take off the table as an option for depressed outpatients but I would not oversell it either.

 

[splik]

Is this part anecdotal or based on stronger evidence? Because it seems useful to know if true.

http://archpsyc.jamanetwork.com/article.aspx?articleid=668229

There is a response seen within the first week of treatment in meta-analyses. I would use to MADRS to monitor treatment-response as it is more sensitive to change. It seems reasonable to have a 4 week trial of the first antidepressant, but with subsequent trials if I'm not seeing ANY change (i.e. not even a couple of points) in a few weeks time to move on given that each subsequent trial is associated with less likelihood of response. It seems unnecessarily cruel to go through 6-8 week trials of a bunch of drugs and in practice I don't know anyone who actually does this.

 

[Armadillos]

ECT is one of the sacred cows of psychiatry, widely touted as the most effective psychiatric intervention and the adverse effects downplayed for many years. Psychiatrists tend to get quite protective of ECT. I think part of this is because of the negative publicity for ECT being seen as "barbaric" or used as a tool of repression, coercion, mind-control, torture or crucifixion in popular culture and the hidden curriculum that ECT unquestionably works which is why we persist in using it 76 years after its gruesome origins in the slaughter house. As such there is a lot of rhetoric from ECT champions (e.g. Fink, Abrams, Sackheim etc) that vastly oversells the rather poor data base for ECT.

What troubles me is that many of the ECT trials are old and not reflective of practice today. Most of the trials re extremely poor quality and failed to report the adverse effects. Where the adverse effects were noted, patients were denounced as unreliable narrators or derided as "cranks" in journal articles! It is true that RCTs are not needed if indeed the effects are really as dramatic as claimed. Clearly some patients do respond marvelously to ECT. It certainly has a more rapid onset of action than other treatments and that is desirable. However the evidence for continued effects is quite poor - most patients do just as good/bad as people receiving other treatment at follow up in the good studies, the effects are usually short lived. Small sample sizes and other major difficulties in studies prevent any of the bolder claims you make.

I would be more prepared to make concessions to the beleagured evidence base if I had seen some positive responses to ECT. In my patient population however I have yet to see the magical response to ECT in depression including psychotic depression that we all hear about, but I have seen enough people transformed into gibbering wrecks from excessive ECT. I certainly won't take off the table as an option for depressed outpatients but I would not oversell it either.

These are good points.

I haven't studied this in detail, but the consensus Ive heard is that most agree with you about the less than amazing quality of ECT studies. But I think their under-reporting of adverse events is somewhat inconsequential to modern ECT seeing as their bilateral sine wave ECT is a far cry from modern ECT. I would expect if PCI for MI were invented when ECT was we would be having the same argument.

Also, correct me if Im wrong, but there has never been a head to head study showing any treatment to be superior to ECT for treatment of depression. That tells me the effect is pretty substantial, because when a treatment has been around so long statistically you would expect the odd study showing X to be better than ECT just on random chance if they were even close in effectiveness.

 

[Merovinge]

Here's my summary of management of "treatment-resistant depression":
14. If pt has CRP >1, OR melancholic, psychotic, or catatonic features start a TCA- start low, go slow. augmentation with lithium may be needed, or T3

Could you point me in the direction of the evidence suggestive of this practice. I've never seen treatment nieve depression with any of those 4 modifers start with TCA over SSRI. Also interested in anyone who selects a TCA based off of CRP, is there something anti-inflammatory associated with TCA mechanism of action? Great write-up by the way!

 

[smalltownpsych]

I really appreciate your solid well-thought out approach and especially the "crappy life syndrome" part. Too many people overlook that. I would also throw substance abuse into that mix as it tends to both cause and ameliorate crappy life syndrome.

 

[Extralong]

Throw in some TMS

 

[OldPsychDoc]

I really appreciate your solid well-thought out approach and especially the "crappy life syndrome" part. Too many people overlook that. I would also throw substance abuse into that mix as it tends to both cause and ameliorate crappy life syndrome.

 

[wolfvgang22]

Good thread.
What is the most therapeutic and practical response to the patient with "crappy life syndrome"?

 

[splik]

Could you point me in the direction of the evidence suggestive of this practice. I've never seen treatment nieve depression with any of those 4 modifers start with TCA over SSRI. Also interested in anyone who selects a TCA based off of CRP, is there something anti-inflammatory associated with TCA mechanism of action? Great write-up by the way!

we're talking about "treatment-resistant depression" here so not SSRI naive. Yes I wouldn't start someone on a TCA to begin with (or ever if they were at risk of suicidal behavior) but TCAs should theoretically be the go to for psychotic depression in particular. In fact the older studies show little benefit of adding a conventional antipsychotic to a TCA in psychotic depression as the TCA alone is often enough.

as for CRP see: http://ajp.psychiatryonline.org/article.aspx?articleid=1888992 some may balk at there only being 3-point difference on MADRS, but that is essentially the difference between antidepressant and placebo, and a 3 point difference is the threshold for what NICE calls "clinically significant difference". It's the closest thing we have to a biomarker of treatment responsiveness so I sure as hell am using it.

 

[splik]

These are good points.

I haven't studied this in detail, but the consensus Ive heard is that most agree with you about the less than amazing quality of ECT studies. But I think their under-reporting of adverse events is somewhat inconsequential to modern ECT seeing as their bilateral sine wave ECT is a far cry from modern ECT. I would expect if PCI for MI were invented when ECT was we would be having the same argument.

Also, correct me if Im wrong, but there has never been a head to head study showing any treatment to be superior to ECT for treatment of depression. That tells me the effect is pretty substantial, because when a treatment has been around so long statistically you would expect the odd study showing X to be better than ECT just on random chance if they were even close in effectiveness.

I think the problem is you seem to have only a superficial knowledge of this whereas I am intimately familiar with the ECT literature. You appear to have an overoptimistic view of so called "modern ECT". brief pulse ECT has been around for over 50 years. There is actually no evidence of fewer cognitive problems with brief pulse vs ECT after the acute period. and what I'm most concerned about is long term memory problems no problem in the hour following ECT. There is no difference between the two that I know of, and most of the data looking at cognitive impairment is on those who had brief pulse ECT. newer would be ultrabrief pulse which certainly does seem to be associated with fewer neuropsychological side-effects. However it is probably not as efficacious, does not work as rapidly, and the evidence supporting it is fairly weak (mainly because it hasn't been studied). Really ECT is most impressive for its rapidity of onset. No other mainstream intervention shows such rapid onset of action. The evidence of sustained effects following acute treatment is fairly non-existent except in the poorer trials. The poor evidence for maintenance treatment and the significant cognitive effects that happen with repeated ECT mean that it is not something I would recommend. I certainly cannot think of a situation.

 

[splik]

Good thread.
What is the most therapeutic and practical response to the patient with "crappy life syndrome"?

I think we have to realize the limits of what we can do clinically. This is more about social care/policy/public health interventions.

In terms of how we can help these poor souls (though often they are not so much victims but active participants in generation their life chaos - see Hammen's "stress generation hypothesis")

I like Kleinman's term "empathic witnessing". i do think there is something powerful about bearing witness to the narratives of suffering, chaos, despair and disorder that our patient bring to us. so often we are unable to change the horrific situations that our patients are caught up in and they know it. sometimes feeling heard, less alone, and cared about is that that is wanted. often the antidepressant prescription is a kind of validation.

In the anthropological literature **** life syndrome is called "social suffering" referring to the chronic demoralization that people experience in situations they feel entirely powerless to change. as I have written elsewhere:

"Today the word depression provides a currency of validation. When we see a doctor feeling deflated, tired, sleepless, joyless, or sad, a diagnosis of depression is like a badge of honor for the wounded warrior, it confers recognition that we have suffered so. There is something reassuring to hear an ‘expert’ tell us they know what is wrong and they know how to help. When you feel like you are drowning, a prescription for a pill, is like a lifeline that keeps you afloat. And even though you know the reasons you feel so terrible, which you are constantly reminded of, it becomes convenient to believe that something as simple as a chemical imbalance is at the root of it all. Even if you realize that the remedy may be in deeper psychological work, having more money, a better relationship, a better economy, better behaved children, a sense of self-worth, or even taking better care of yourself, those things are unavailable or not forthcoming. We make do with what’s on offer. And what’s on offer is antidepressants. "

 

[Armadillos]

I think the problem is you seem to have only a superficial knowledge of this whereas I am intimately familiar with the ECT literature. You appear to have an overoptimistic view of so called "modern ECT". brief pulse ECT has been around for over 50 years. There is actually no evidence of fewer cognitive problems with brief pulse vs ECT after the acute period. and what I'm most concerned about is long term memory problems no problem in the hour following ECT. There is no difference between the two that I know of, and most of the data looking at cognitive impairment is on those who had brief pulse ECT. newer would be ultrabrief pulse which certainly does seem to be associated with fewer neuropsychological side-effects. However it is probably not as efficacious, does not work as rapidly, and the evidence supporting it is fairly weak (mainly because it hasn't been studied). Really ECT is most impressive for its rapidity of onset. No other mainstream intervention shows such rapid onset of action. The evidence of sustained effects following acute treatment is fairly non-existent except in the poorer trials. The poor evidence for maintenance treatment and the significant cognitive effects that happen with repeated ECT mean that it is not something I would recommend. I certainly cannot think of a situation.

You have frequently mentioned "except in the poorer trials", which ones specifically are you referring to? As you mentioned I have only a superficial knowledge of this, my understanding was that any of the individual older ECT studies would not be enough to stand alone in the modern day due to methodological problems, but that the effects are so large and consistent among all kinds of different studies with different methodological problems that you can't ignore the effect. So much so that at this point you can't really ethically take someone off all their meds and do sham ECT on them (I could easily be way off on this, as I said I don't have an intimate knowledge of the ECT literature, but people much smarter than me do and seem to interpret it differently than you).

I'm not doubting your comparative knowledge and expertise in the area, just trying to understand your reasoning in coming to a different view of the same data compared to many other psychiatrists and physicians in general. Somewhere you seemed to allude to some experience of seeing a patient have a particularly bad ECT outcome and curious if this was the beginning of your skepticism or if you were a skeptic first.

 

[smalltownpsych]

I think we have to realize the limits of what we can do clinically. This is more about social care/policy/public health interventions.

In terms of how we can help these poor souls (though often they are not so much victims but active participants in generation their life chaos - see Hammen's "stress generation hypothesis")

I like Kleinman's term "empathic witnessing". i do think there is something powerful about bearing witness to the narratives of suffering, chaos, despair and disorder that our patient bring to us. so often we are unable to change the horrific situations that our patients are caught up in and they know it. sometimes feeling heard, less alone, and cared about is that that is wanted. often the antidepressant prescription is a kind of validation.

In the anthropological literature **** life syndrome is called "social suffering" referring to the chronic demoralization that people experience in situations they feel entirely powerless to change. as I have written elsewhere:

"Today the word depression provides a currency of validation. When we see a doctor feeling deflated, tired, sleepless, joyless, or sad, a diagnosis of depression is like a badge of honor for the wounded warrior, it confers recognition that we have suffered so. There is something reassuring to hear an ‘expert’ tell us they know what is wrong and they know how to help. When you feel like you are drowning, a prescription for a pill, is like a lifeline that keeps you afloat. And even though you know the reasons you feel so terrible, which you are constantly reminded of, it becomes convenient to believe that something as simple as a chemical imbalance is at the root of it all. Even if you realize that the remedy may be in deeper psychological work, having more money, a better relationship, a better economy, better behaved children, a sense of self-worth, or even taking better care of yourself, those things are unavailable or not forthcoming. We make do with what’s on offer. And what’s on offer is antidepressants. "

Also, when working with people in this situation, I find the most success is with adolescents where, from a developmental standpoint, they are starting to develop relationships and potential for identification outside the core family system that is part and parcel of the suffering/victimization.
For the adults, I only see significant change when they involve themselves in a religious organization or recovery organization. When it comes to the younger children in these situations, I find it pretty disheartening.

 

[Salpingo]

as for CRP see: http://ajp.psychiatryonline.org/article.aspx?articleid=1888992 some may balk at there only being 3-point difference on MADRS, but that is essentially the difference between antidepressant and placebo, and a 3 point difference is the threshold for what NICE calls "clinically significant difference". It's the closest thing we have to a biomarker of treatment responsiveness so I sure as hell am using it.

That's interesting, but not sure I would jump to any clinical conclusions or treatment decisions based on this study. First, the choice of drugs in that study was unusual: picking a relatively "clean" and specific SSRI with a very "dirty" and nonselective TCA, and coming to a conclusion that norepinephrine is playing some sort of anti-inflammatory role (although didn't actually check to see if CRP changed with treatment?). If that's the case, why not just treat with a high dose SNRI? Why not bupropion with an NSAID? How do we know its not the anticholinergic/antihistaminic properties of nortriptyline and prescribe quetiapine or diphenhydramine instead?

Also, CRP is a weird biomarker in general. It can be from so many things, from smoking, diabetes, and CVD (a population that you may or may not want to give TCAs depending on how risk averse you are). It can also fluctuate on an almost daily basis. I don't think any other specialty relies on it as a specific marker by itself (I remember it was a big disappointment for cardiology).

Finally, I think one of the most telling results was the significant difference in drop out (~80% for escitalopram and ~60% for NTP).

I hope this inflammation research will open the doors to a better understanding of depression and hopefully further subtyping, but I haven't seen any of make its way to the office in any meaningful way.

 

[Salpingo]

You have frequently mentioned "except in the poorer trials", which ones specifically are you referring to? As you mentioned I have only a superficial knowledge of this, my understanding was that any of the individual older ECT studies would not be enough to stand alone in the modern day due to methodological problems, but that the effects are so large and consistent among all kinds of different studies with different methodological problems that you can't ignore the effect. So much so that at this point you can't really ethically take someone off all their meds and do sham ECT on them (I could easily be way off on this, as I said I don't have an intimate knowledge of the ECT literature, but people much smarter than me do and seem to interpret it differently than you).

I'm not doubting your comparative knowledge and expertise in the area, just trying to understand your reasoning in coming to a different view of the same data compared to many other psychiatrists and physicians in general. Somewhere you seemed to allude to some experience of seeing a patient have a particularly bad ECT outcome and curious if this was the beginning of your skepticism or if you were a skeptic first.

I think Splik's point is that there's a significant relapse rate after ECT (~30-40% even with significant psychopharm), and the answer so far has not been maintenance ECT. Thats been a major focus in the ECT research community. However, its up to you to infer that its not worth doing ECT in the first place since there's a significant chance they'll wind up back in the same place within the year (at least that's the way I'm reading the argument).

As for the longterm cognitive side effects, the literature suggests the opposite (not sure if it meets Splik's standards), and particularly elderly patients have shown improvement when their primary mood symptoms clear, which makes sense given what we know about geriatric depression. That's been my limited experience; I have had at least one patient who was "cured" of his dementia NOS diagnosis after ECT.

 

[Shikima]

Good thread.
What is the most therapeutic and practical response to the patient with "crappy life syndrome"?

This is more of a job for Philosophers than Psychiatrists. Although, this should be on the boards.....

 

[erg923]

This is more of a job for Philosophers than Psychiatrists.

Why? You can't divorce the patient from life circumstances/environment no matter how much you may want to.

 

[DJspreadsheet]

Why? You can't divorce the patient from life circumstances/environment no matter how much you may want to.

I wouldn't say it's a job for philosophers so much as it's a job for therapists. Of course you can't divorce the patient from their **** life, but the psychiatrist's role is about diagnosing and treating mental illness, not taking over as their case manager / life coach.

 

[Shikima]

I wouldn't say it's a job for philosophers so much as it's a job for therapists. Of course you can't divorce the patient from their **** life, but the psychiatrist's role is about diagnosing and treating mental illness, not taking over as their case manager / life coach.

Agreed. People that I'm seeing in clinic are looking for life coaches, the magic pill that will suddenly remove all the crap from their lives. Little effort is being had and personally speaking, I'm seeing people that I've seen the last year+ are finally coming to terms that they need to spend the effort, energy and time into their own well being.

 

[erg923]

I wouldn't say it's a job for philosophers so much as it's a job for therapists. Of course you can't divorce the patient from their **** life, but the psychiatrist's role is about diagnosing and treating mental illness, not taking over as their case manager / life coach.

I see:
1. I am am curious why a psychiatrist is not viewed as a therapist, even if "psychotherapy" is not the primary job description/duty? Should not all MH contacts be therapeutic, and by proxy, serve as "therapy"? Where are we drawing the line, exactly? How much should the psychiatrist discuss or not discuss this patients actual life with him/her?

2. If these people aren't "mentally ill," then why are so many being prescribed psychopharm solutions by psychiatrists for their ****ty lives?

3. What do we think about the therapeutic value of "bearing witness" to suffering? Do we think this is the role of a psychiatrist? If not, why? And who takes this role if they are not seeing a therapist (obviously cant force someone into therapy)? If the psychiatric doesn't, how does he avoid it?

PS: I will assume that you guys don't actually think psychotherapy="life coaching" even thought that was insinuated in the writing. I will give benefit of the doubt and chalk up too poor phasing.

 

[DJspreadsheet]

I see:
1. I am am curious why a psychiatrist is not viewed as a therapist, even if "psychotherapy" is not the primary job description duty? Should not all MH contacts be therapeutic, and by proxy, serve as "therapy"? Where are we drawing the line, exactly? How much should the psychiatrist discuss or not discuss this patients actual life with him/her?

2. If these people aren't "mentally ill," then why are so many being prescribed psychopharm solution by psychiatrists for their ****ty lives?

3. What do we think about the therapeutic value if "bearing witness" to suffering? Do we think this is the role of a psychiatrist? If not, who takes this role? If the psychiatric doesn't, how does he avoid it?

1 & 3. Some psychiatrists do engage in therapy. There are of course the brief therapeutic interventions, as well as the indirect therapeutic aspects that take place which you allude to (ie: bearing witness in a non-judgmental manner). There's also the therapeutic utility that's a byproduct of the doctor-patient relationship and its inherent structure and consistency. But all that is a bit woo-woo. If you want some serious digging and restructuring of your life, you should go to a person that specializes in that. A therapist. Of course there are psychiatrists that take special interest in that sort of thing and become analysts or whatnot. But prepare to pay cash because the structure of our insurance reimbursement does not look kindly on such endeavors.

2. Ask a plumber to remodel your home, he'll probably start with the faucets. There's also of course the obvious problem called 'human nature' - when a Borderline comes storming into your office, writing a script for Topamax is easier than having a come-to Jesus moment with them. Besides, if you don't write it, someone else will. Often times the recommendation will be Topamax, and oh, you need therapy (with some qualifier that the Topamax may help blunt your extremese, but therapy is the meat of the matter). The real travesty is the irresponsible prescribing that takes place. You know, the Borderline who doesn't only walk out with Topamax, but a fistful of Valium to help their anxiety. I think most of that sort of prescribing is done by primary care doctors or nurse practitioners (the same one's also diagnosing them as Bipolar), and it's the psychiatrist who's left with the residue. Again, it's often easier to let them swallow some Klonopin than it is to argue with them about how these medications will only make their life worse.

As far as my plans for practicing once I finish with residency. I intend to do a modicum of listening, but I also don't intend to have a panel full of people that would only benefit from therapy. Non-psychiatrists seem to forget that the psychiatric world isn't comprised entirely of soccer moms whose husband is banging the barista. There are plenty of seriously mentally ill people that need medicine and for whom therapy isn't appropriate. The psychiatrist is the only professional with any modicum of competence in these instances, and as such, that is the real job they are employed to do.

So in short, the life is a **** show people are more than welcome to come to a psychiatrist and get their Effexor filled, so long as they pay their bill. But don't expect the psychiatrist to start drafting customized "What Color Is Your Parachute" game plans for you. And don't expect the Effexor to do it either.

 

[erg923]

Adequate response, even if we don't fully agree on all points. Which, is exactly why I think psychiatry has become what it has become.

My only real objection comes in the statement that therapy "isn't appropriate" for seriously mentally ill individuals. This seems to view mental illness as symptoms, rather than an actual experience. I hope we haven't been lead into thinking intrapsychic conflicts don't influence the manifestation of serious psychopathology? If so, who taught you that?

I suppose I would also add that if you don't want to play the medication carousel game with the angry Borderline pt., then don't play it. "Somebody else will rx it" is a morally weak argument. Yes, its hard. But your job is suppose to be hard.

 

[DJspreadsheet]

Adequate response, even if we don't fully agree on all points. Which, is exactly why I think psychiatry has become what it has become.

My only real objection comes in the statement that therapy "isn't appropriate" for seriously mentally ill individuals. This seems to view mental illness as symptoms, rather than an a actual experience. I hope we haven't been lead into thinking intrapsychic conflicts don't influence the manifestation of serious psychopathology? If so, who taught you that?

Have you spent any time with a paranoid schizophrenic?

 

[erg923]

Have you spent any time with a paranoid schizophrenic?

About 150 SCIDs. SCIDs take a long time...

 

[DJspreadsheet]

About 150 SCIDs. SCIDs take a long time...

Then you'll know that some people have absolutely no insight. I didn't say therapy has no place in serious mental illness. I said that there are many seriously mentally ill patients where therapy would be of no utility. Same applies to the catatonic patient. Or the patient so depressed they don't talk or eat. Or the delirious patient. Or the demented. Or the manic. Or the cripplingly anxious. Then there's the whole world of people that may benefit from therapy once medications are utilized to bring them back to the land of the living. That's really what a psychiatrist is specially trained to do. Similarly, Tony Robbins would be a fine motivator for **** life syndrome, but he'd probably be a fvcck-up on the C/L service.

 

[Armadillos]

I imagine some of the PhD vs MD disconnect related to therapy and things like schizophrenia is context/timing of patient interactions. The MD is more likely to see the schizophrenic in the ER who stopped their meds a couple weeks ago and did <blank> that landed them in the hospital. The PhD is more likely to see the same person at a different time when they are functional enough to make it to their outpatient appointment. Obviously this isnt a hard a fast rule, PhDs work with inpatients as well, but on average (atleast during training) MDs seem to spend a lot more time with acutely decompensated folks compared to PhDs.

 

[DJspreadsheet]

I imagine some of the PhD vs MD disconnect related to therapy and things like schizophrenia is context/timing of patient interactions. The MD is more likely to see the schizophrenic in the ER who stopped their meds a couple weeks ago and did <blank> that landed them in the hospital. The PhD is more likely to see the same person at a different time when they are functional enough to make it to their outpatient appointment. Obviously this isnt a hard a fast rule, PhDs work with inpatients as well, but on average (atleast during training) MDs seem to spend a lot more time with acutely decompensated folks compared to PhDs.

Agreed. If you don't have inpatient/ED experience, it's very difficult to understand the depths of illness that are possible. It's also why popular culture just sees psychiatrists as pill-pushers. They insert their dysthymic emo nephew into every mental exercise of what a "patient" is, failing to understand there's a much more colorful world of illness out there.

 

[splik]

I have a special interest in psychotherapy for psychosis. I have worked with patients with "schizophrenia", prodromal psychosis, bipolar disorder, psychotic depression and catatonia. This includes intensive psychotherapy. I have treated one patient with psychotic depression with 5x week psychodynamic psychotherapy. There is a tendency for psychiatrists to invoke the severe-end"rhetorical device and claim that psychiatric drugs work benefit those with the most severe illness. Actually this is a leap from the data which really show that the more severely ill someone is, the less anything works and the less of a placebo response there is and the less regression to the mean. It is not really that our drugs work better in the more severely ill patients. In my experience even hospitalized patients can benefit from psychotherapy that is supportive in nature. I do not find using explicit CBT interventions to be all that helpful and interpretations are not well tolerated by most patients though Elyn Saks in discussing her own illness calls them "detoxifying". Really psychotherapy helps with anxiety in psychosis, feelings of isolation, disconnection, and despair. I think these are worthy goals.

In contrast, in acute and transient psychotic disorder psychotherapy alone can be effective for the psychotic symptosm and I would avoid using medications if at all possible. I have successfully treated to 2 patients with brief psychotherapeutic intervention and no neuroleptics at all very early in the course of their psychotic attack. In prodromal psychosis/at-risk mental state there is data supporting the use of both supportive psychotherapy and CBT reducing the number of people becoming schizophrenic by 50%.

Most people don't have the stomach for working therapeutically with psychotic patients but there is certainly data that shows it can be helpful. The Chestnut Lodge studies show that for most schizophrenic patients expressive psychoanalytic treatment is not helpful but supportive psychoanalytic therapy is helpful. Carl Rogers did work with hospitalized psychotic patients in the 1950s and 60s and showed there was some benefit. R.D. Laing, Leon Redler, Morty Schatzman etc showed that you could indeed use psychotherapy and alternatives to hospitalization in frankly psychotic patients. Loren Mosher's Soteria House studies showed that psychotic patients who would end up hospitalized otherwise could be effectively treated by non-medically trained individuals without drugs or low-dose neuroleptics. Burn out is high however.

Working effectively therapeutically with psychotic patients is indeed possible but is it is labor-intensive, draining, with high potential for burn out, and highly dependent on the skill of the therapist and desire to work with such individuals. Most psychotherapists are not interesting in doing such work or find it too frightening. Winnicott's famous paper "hate in the counter-transference" largely refers to the hateful countertransference elicited by psychotic patients.

I have found my most satisfying and meaningful work to be in working therapeutically and deeply with psychotic individuals. my friends would argue I am a bit on the psychotic side myself, but I do not believe patients with psychosis cannot benefit from psychotherapy. If they have no insight, even better. If they are hospitalized, better still. I would also hasten to add some commentators have overstated the case for psychotherapy. I do not believe it is going to lead to cure of psychosis in the majority of cases but it can certainly help in other ways and help people live better with psychotic symptoms. At the same time, the medical model has failed people experiencing psychosis. We expose too many people to toxic neuroleptic drugs, too many drugs, at too high doses for too long. The prognosis for schizophrenia is no better than it was a 100 years ago. The US is one of the worst places in the world to become psychotic in terms of recovery. Our patients deserve better than what is the standard of care.

have a look at: http://www.isps-us.org/index.html

 

[DJspreadsheet]

...

have a look at: http://www.isps-us.org/index.html

From reading your various contributions on this forum, I must say I find you a rather impressive person. Particularly with your knowledge base of some rather esoteric things. You're a resident as well, correct? All this is leading up to the following question: what in the hell is your reading schedule like?? Do you have a systematic way of digesting information? A daily reading goal? Anything of the sort? Or are you just Autistic. (I mean that in a complimentary way)

 

[erg923]

I imagine some of the PhD vs MD disconnect related to therapy and things like schizophrenia is context/timing of patient interactions. The MD is more likely to see the schizophrenic in the ER who stopped their meds a couple weeks ago and did <blank> that landed them in the hospital. The PhD is more likely to see the same person at a different time when they are functional enough to make it to their outpatient appointment. Obviously this isnt a hard a fast rule, PhDs work with inpatients as well, but on average (atleast during training) MDs seem to spend a lot more time with acutely decompensated folks compared to PhDs.

While factually accurate, I dont think that's where the divide comes from at all.

Splik's posts are great, and while I dont claim to have such a broad knowledge base, his understanding of the descriptive elements of psychopathology, as well an integrated understanding of psychopathology (as opposed to a pure medical understanding/explanation) usually does not seem as foreign to psychologists as it does to psychiatrists...at least to many of the ones on here. If one views schizophrenia in a slightly more philosophical way, not discounting sx as mere random byproducts of flawed neurotransmission (delusional systems serve a function or a need, right?), whilst taking into account the social basis of the illness (as well as its effects on personal agency and general social and occupational functioning), then arguing that psychotherapy "isnt appopriate" for serious mental illness (e.g., schizophrenia) is complete nonsense.

 

[Ceke2002]

I have a special interest in psychotherapy for psychosis. I have worked with patients with "schizophrenia", prodromal psychosis, bipolar disorder, psychotic depression and catatonia. This includes intensive psychotherapy. I have treated one patient with psychotic depression with 5x week psychodynamic psychotherapy. There is a tendency for psychiatrists to invoke the severe-end"rhetorical device and claim that psychiatric drugs work benefit those with the most severe illness. Actually this is a leap from the data which really show that the more severely ill someone is, the less anything works and the less of a placebo response there is and the less regression to the mean. It is not really that our drugs work better in the more severely ill patients. In my experience even hospitalized patients can benefit from psychotherapy that is supportive in nature. I do not find using explicit CBT interventions to be all that helpful and interpretations are not well tolerated by most patients though Elyn Saks in discussing her own illness calls them "detoxifying". Really psychotherapy helps with anxiety in psychosis, feelings of isolation, disconnection, and despair. I think these are worthy goals.

In contrast, in acute and transient psychotic disorder psychotherapy alone can be effective for the psychotic symptosm and I would avoid using medications if at all possible. I have successfully treated to 2 patients with brief psychotherapeutic intervention and no neuroleptics at all very early in the course of their psychotic attack. In prodromal psychosis/at-risk mental state there is data supporting the use of both supportive psychotherapy and CBT reducing the number of people becoming schizophrenic by 50%.

Most people don't have the stomach for working therapeutically with psychotic patients but there is certainly data that shows it can be helpful. The Chestnut Lodge studies show that for most schizophrenic patients expressive psychoanalytic treatment is not helpful but supportive psychoanalytic therapy is helpful. Carl Rogers did work with hospitalized psychotic patients in the 1950s and 60s and showed there was some benefit. R.D. Laing, Leon Redler, Morty Schatzman etc showed that you could indeed use psychotherapy and alternatives to hospitalization in frankly psychotic patients. Loren Mosher's Soteria House studies showed that psychotic patients who would end up hospitalized otherwise could be effectively treated by non-medically trained individuals without drugs or low-dose neuroleptics. Burn out is high however.

Working effectively therapeutically with psychotic patients is indeed possible but is it is labor-intensive, draining, with high potential for burn out, and highly dependent on the skill of the therapist and desire to work with such individuals. Most psychotherapists are not interesting in doing such work or find it too frightening. Winnicott's famous paper "hate in the counter-transference" largely refers to the hateful countertransference elicited by psychotic patients.

I have found my most satisfying and meaningful work to be in working therapeutically and deeply with psychotic individuals. my friends would argue I am a bit on the psychotic side myself, but I do not believe patients with psychosis cannot benefit from psychotherapy. If they have no insight, even better. If they are hospitalized, better still. I would also hasten to add some commentators have overstated the case for psychotherapy. I do not believe it is going to lead to cure of psychosis in the majority of cases but it can certainly help in other ways and help people live better with psychotic symptoms. At the same time, the medical model has failed people experiencing psychosis. We expose too many people to toxic neuroleptic drugs, too many drugs, at too high doses for too long. The prognosis for schizophrenia is no better than it was a 100 years ago. The US is one of the worst places in the world to become psychotic in terms of recovery. Our patients deserve better than what is the standard of care.

have a look at: http://www.isps-us.org/index.html

Psychotherapy is something that I think is vastly under utilised in cases of Psychosis. Of course depending on severity of psychopathology, where along the spectrum of disorders a person fits, effects on functioning within society, and so on, medication may very well be necessary and I certainly would never advocate replacing effective pharmacological treatment with talk therapy - but, psychosis, especially first episode psychosis can be a very frightening and confusing experience and if there's one thing I've heard from patients who are on the spectrum of psychotic disorders its that they want to be seen and heard and above all to have someone guide them through the experience both during and in the aftermath. Yes the medications generally work, but in my experience medication + psychotherapy works even better, and (again depending on severity of pathology etc) psychotherapy for psychosis has the potential to replace the need for medication in the first place, at least in certain presentations.

In terms of patient insight (whether into the illness itself and/or recognising and coping with their (dis)connection from 'reality'), I can say in my personal experience, that therapy by itself, and then going on to utilise what I learnt in therapy, went a long way towards quite quickly allowing me to develop insight and to therefore better manage my episodes if and when they did arise. I honestly don't know if I would have gotten that with pharmacological treatment alone.

 

[PistolPete]

Very nice thread. Thanks for the great post, splik.