Evaluating and managing patients who are not responding to treatment

Jill Williams, Caroline Eick

Research output: Chapter in Book/Report/Conference proceedingChapter

Abstract

In this chapter, we discuss some of the factors involved in the response to treatment and present a conceptual framework for dealing with a lack of treatment response (often termed treatment nonresponse). It can be important to define treatment response, since clinical outcomes can be very different from those used in research settings. The term treatment nonresponse is somewhat of a misnomer and should be interpreted broadly to include any failure of a therapeutic response. As many as 15 percent of depressed patients will fail to respond to treatment, although this percentage is much larger when one considers that as many as 70 percent achieve only a symptom response to treatment and not a true remission. There are several diagnostic and treatment issues to consider, ranging from general considerations like the therapeutic setting and diagnosis to specific treatment modalities, including psychotherapy and medications. Clients who fail to respond to typical treatments can provide the clinician with opportunities to re-evaluate and reconsider the case. Countertransference issues may be relevant, indicating that the goals of the patient and those of the clinician are not concordant. Successfully working with a treatment-resistant client may require taking time to reconsider the case, using a fresh perspective, and even consider the input of a consultant. One of the first issues to consider is the possibility of an inaccurate diagnosis. Related is the issue of comorbidity, which can be complex, as there can be one or more coexisting psychiatric disorders and coexisting substance use disorders, as well as medical problems and conditions that may be related to the substance use or present with overlapping symptoms. In addition, failure to respond to treatment can be a result of treatment issues. Treatments may simply be of too little intensity or duration to be effective. In the treatment of depression, for example, patients who are initially termed nonresponders often do well on higher medication doses or longer durations of treatment. In the treatment of addictions, much has been written about treatment matching based on the particular needs or problem areas of the individual patient. Too often patients receive a generic or programmatic treatment not tailored to their needs, and this may contribute to a lack of treatment response. Matching treatments based on the patient's motivational level can prevent the offering of overly intensive therapies to patients not ready to use them. Additionally, the treatment setting may not be best suited to the patient. Levels of care developed by the American Society on Addiction Medicine (ASAM) can help guide the clinician in using criteria to best justify the need for inpatient versus outpatient and other levels of care. Common reasons that contribute to treatment nonresponse include , inaccurate diagnosis , insufficient treatment , comorbidity: Axis I, axis II, axis III , clinician-client mismatch or failure to understand current motivational level. Process "addictions" are an important and often unrecognized aspect of treatment that may also contribute to a client's difficulty in treatment. These nonchemical compulsive behaviors are frequently seen in clinical practice as complicating the course of treatment, yet relatively little is known about their occurrence. These compulsive behaviors and their relationship to substance use disorders can have an effect on treatment outcomes.

Original languageEnglish (US)
Title of host publicationIntegrated Treatment for Mood and Substance use Disorders
PublisherJohns Hopkins University Press
Pages140-160
Number of pages21
Volume9780801881282
ISBN (Electronic)9780801881282
ISBN (Print)9780801871993
StatePublished - Jan 1 2003

All Science Journal Classification (ASJC) codes

  • Social Sciences(all)

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