Causes of Treatment Failure

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Dwight Kelly
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1 Causes of Treatment Failure 1. Misdiagnosis 2. Comorbidity 3. Non diagnosed Substance Abuse 4. Non adherence to prescribed medication Presenter has no conflict of interest to disclose Is Misdiagnosis the cause of Treatment Failure Patients do not often present with symptoms patterns that exactly match the DSM criteria. In some cases, misdiagnosis is a function of symptom overlap, while other patients may have more than one disorder. Review the DSM 5 criteria for MDD, Bipolar I and II, and Personality Disorders. (see handouts) Difficulty in diagnosing Bipolar II. Handrup 1

2 Comorbidity Comorbidity is defined as any pair of syndromes in the same patient where the diagnosis of one does not categorically exclude the diagnosis of the other. Clinical comorbidity is defined as one disorder influencing the course, outcome, or treatment response to the second coexisting disorder. McElroy, SL, et al, American Journal of Psychiatry, 2001, 158, Psychiatric Comorbidity in Bipolar Comorbid Condition Mean Rate of Comorbidity (&) Any Axis I disorder 65 Substance use disorder 56 Alcohol abuse 49 Other drug use 44 Anxiety disorder 71 Social phobia 47 PTSD 39 Kirshnan found 23 studies from Comorbidity in Bipolar Panic disorder 11 OCD 10 Binge eating disorder 13 Personality disorder 36 Migraine 28 Overweight 58 Obesity 21 Type 2 diabetes 10 Hypothyroidism 9 Krishnan,MB, Psychsomatic Medicine, 2005;67, 1 8 Handrup 2

3 Consequences of Comorbidity in Bipolar The majority of patients diagnosed bipolar disorder I and II, of all ages and both genders, have at least one comorbid psychiatric or medical disorder (and many more than one). This should lead to greater diagnostic vigilance and more through diagnostic assessment. Psycho pharmacotherapy should maximize therapeutic gain while minimizing the risk of exacerbating a comorbid condition. Berk & Dodd, Crucial Elements to an Accurate Diagnosis Presenting symptoms Past symptoms Social history Family history Developmental history Prior psychiatric treatment Prior medical treatment Bio psychosocial Formulation Key Principles 1. Do not try to be inclusive. You cannot explain all of the patient s difficulties. Focus on one or two themes that are at the core of the patient s problems. 2. Illustrate how certain developmental experiences may have contributed to the patient s current complaints. 3. ID stressors that may have triggered symptoms or unpleasant affective states that lead the pt. to seek help. Handrup 3

Bio psychosocial Formulation Key Principles 4. Predict how the patient s relationship patterns may influence the course of treatment whether psychotherapy, medication or a combination. 5.

Keep in mind that a formulation is only a hypothesis or a set of hypotheses. The formulation must be revised continuously as new data appear. Kassaw & Gabbard, Am J Psychatry 2002, 159:5.

4 Bio psychosocial Formulation Key Principles 4. Predict how the patient s relationship patterns may influence the course of treatment whether psychotherapy, medication or a combination. 5. Draw on present transference and countertransference data from your interaction with the pt. that may link the patient s past to current life problems. 6. Keep in mind that a formulation is only a hypothesis or a set of hypotheses. The formulation must be revised continuously as new data appear. Kassaw & Gabbard, Am J Psychatry 2002, 159:5. Common Diagnostic Tools Bipolar Depression Montgomergy Asberg DR MDD BDI R, PHQ9, HAM D, MDI, QIDS Mania & Hypomania Mood Disorders Q, Young Mania Rating Scale Anxiety GAD 7, HAM A Axis II PDBQ General Functioning QOL. BD Note: These tools are most helpful for screening and measuring effectiveness of treatment rather than diagnosing. Example Diagnostic Tool PDBQ Handrup 4

5 Whole Patient Approach The Four Perspectives of Psychiatric Diagnosis 1. Disease Perspective > Etiology > Pathophysiologic Process > Syndrome. What the patient has. 2. Dimensional Perspective > Potential. Provocation > Response. What the patient is. 3. Behavioral Perspective > Drive > Choice > Learning > What the patient does. 4. Narrative Perspective > Setting > Outcome > Sequence. What the patient encounters. Options for Managing Treatment Resistance Psychotherapy Psychodynamic Psychopharmacology Adjunct medication Genetic testing Therapist Consultation Therapist Supervision Case examples Patient 1 25 year old male Patient 2 24 year old female Patient 3 40 year old male Patient 4 55 year old women Patient 5 62 year old women Handrup 5

Mood Disorders for Care Coordinators

Mood Disorders for Care Coordinators David A Harrison, MD, PhD Assistant Professor, Dept of Psychiatry & Behavioral Sciences University of Washington School of Medicine Introduction 1 of 3 Mood disorders