The order of treament

[Mattalbie]

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Hi

Student question.

In a case where PTSD, schizophrenia and depression are present, which would be treated first? (ADM's and Anti Psychotics are prescribed). Any thoughts?

Thanks

 

[deleted176373]

Hi

Student question.

In a case where PTSD, schizophrenia and depression are present, which would be treated first? (ADM's and Anti Psychotics are prescribed). Any thoughts?

Thanks

Well that all depends... you can have varying degrees of symptoms. Mild, Moderate, or Major Depression. Schizophrenia, Residual Type with Prominent Negative Symptoms or Schizophrenia, Paranoid Type, two very different things.

The question while valid, lacks the clinical picture to make a determination, and thus makes for a great comprehensive exam question... how would you conceptualize and treat such a patient. You have the number 1 over-riding consideration to deal with first.

1. Is the patient safe and unlikely to harm themselves or others.

That is the first question, obviously, if the depression, schizophrenia, or the PTSD is serious enough to cause concern about the safety and welfare of the patient or others, that is what you treat first.

There is no "correct" answer beyond that you treat what you believe will give the greatest relief of overall symptom burden and likelihood of treatment success. So assuming if that no harm to themselves or others is a concern, you could start treating any of the three if you believed (based on your clinical judgment and case conceptualization) that the best course to achieve relief for the patient was to treat X.

Some patients will need to see success early in therapy, even small successes. Others are more willing to work to larger successes at the expense of short term gains, but with greater symptom relief. Once again, great question, but you could spend years learning just a small part of the answer.

Mark

 

[Cosmo75]

If the schizophrenia is controlled by meds and the person is not actively thought disordered/psychotic, then I'd go after depression next. In order to treat PTSD effectively the person needs to have sufficient coping skills in place to handle the treatment. I'm assuming you're going to use cognitive processing therapy or some other exposure based treatment, of course.

When I was at the VA, I had a client with pretty bad depression (some suicidal ideation) and PTSD. We treated the depression first, did some coping skills training, then started on the PTSD. By then, I think sufficient rapport had also been established to lessen the chance of drop out. PTSD treatment is pretty intense. Of course, always monitoring for any changes in those schizophrenia symptoms.

Hope that helps.

 

[Mattalbie]

Both very helpful replies thankyou.

In the case mentioned the person is not a danger to himself or to others.

So I am thinking treat anxiety first by exposure, depression by cbt, PTSD and then schizophrenia.

Another case involves anger management and bipolar depression. I'm thinking monitor the anger to see when it occurs (maybe manic phase) treat anger and then bipolar.

The cases in question are just exercises not actual patients

I am new at this so forgive my inexperienced replies.

 

[Ollie123]

Again, based off the information, there is absolutely no way for an answer to be "right", for reasons others have already stated.

If the schizophrenia is severe and uncontrolled, you can do all the anxiety therapy you want, its probably not going to be effective. Is the depression due to the PTSD? Did they come from a similar trigger (i.e. seeing a closer relative pass away, so you have bereavement that persists into major depression, and PTSD)? What symptoms bother the client the most? In some cases you may need to convince them to pursue a different course than they originally came in asking for, but it still needs to be taken under consideration what symptoms they consider primary. For the bipolar case, the anger may be a result of mania, and would subside on its own when the bipolar is brought under control. Then again, maybe the bipolar diagnosis is sketchy, and someone had a bipolar label tacked on because they are "irritable" when there is no evidence that a manic episode has ever happened.

There's simply no way to look at a list of diagnoses and decide what to do, that's not how the process works.

 

[Therapist4Chnge]

I start with the Reason for Referall.....why are they here to see me, or at least what is the given reason they are here to see me? Many times the given reason isn't the actual reason, but you'll find out when you start to gather more information. Obviously any suicidal/homocidal issues take precedence, but other than that I'd speak to the person about their needs, concerns, etc.

My personal bias is against responding to a Dx, as they are pretty much only useful for insurance claims and paperwork. I like to talk to the person and go from there. Rarely will you address 'one' Dx, as they are layered and don't function independantly of one another.

 

[Mattalbie]

Thanks.

Your replies have raised some great points.