Treatment-refractory mood disorders pose a significant problem for clinicians. Although biological approaches are usually emphasized in the treatment of patients with these disorders, preliminary findings from an ongoing, naturalistic, longitudinal study of treatment outcome support the notion that a subset of patients with treatment-refractory mood disorders may respond to careful integration of a psychodynamic therapeutic approach into the customary biological approaches. Ten psychodynamic principles that appear to be useful in work with patients with treatment-refractory mood disorders were identified based on a review of the records of 28 patients who were treated using this approach. These principles are presented, discussed, and illustrated by material from a representative case study.
Significant advances have been made in the treatment of mood disorders over the past decade. With these advances has come the recognition that 15%–50% of patients with mood disorders have treatment-refractory illness 1,2 and that only a minority of depressed patients recover fully on medications. 3 Crown et al. reported that patients with refractory unipolar and bipolar depression were at least twice as likely to require medical or psychiatric hospitalization as a depressed comparison group who did not have treatment-refractory illness. 4 They also reported that the hospitalized treatment-refractory group had six times the mean total medical costs and nineteen times the total depression-related costs of the comparison group. Treatment algorithms and augmentation strategies have been developed to help maximize therapeutic response and minimize treatment failure. Nevertheless, a subset of patients remains with mood disorders that are quite treatment refractory. These conditions often keep those treating them off balance, so that treatment may become chronic crisis management, with a focus on recovery from the last crisis or fending off the next one.
Thase et al. have argued for including a psychosocial component in the treatment of these patients. 2 However, Thase’s approach does not include attention to the role of unconscious mental processes or to the roles of transference and countertransference and their relationship to treatment refractoriness.
In this article, I discuss 10 psychodynamic principles that appear to be useful in work with patients with treatment-refractory mood disorders. The principles were derived from a study of 28 cases of treatment-refractory mood disorder treated at the Austen Riggs Center, a national referral center for patients with treatment-refractory disorders. In addition to general psychiatric treatment, the Riggs continuum of care includes a sophisticated milieu program within a completely open setting as well as four-times-weekly individual dynamic psychotherapy. Riggs is currently conducting an ongoing naturalistic, longitudinal follow-along study of patients during and after treatment at Riggs under the direction of J. Christopher Perry. This study assesses changes in symptoms as well as in defenses and conflicts using a number of measures. DSM-IV diagnoses were established using Perry’s Guided Clinical Interview. 5 The Longitudinal Interval Follow-up Evaluation (LIFE) 6 was used to assess the week-by-week course of Axis I episodes. Symptoms were assessed using the Symptom Checklist-90 (SCL-90), 7 the Hamilton Anxiety and Depression scales, 8,9 the Social Adjustment Scale–longitudinal version, 10 Global Assessment of Functioning (GAF), 11 and other measures. Measures of defenses were obtained using Bond’s Defense Style Questionnaire 12 and Perry’s Defense Mechanism Rating Scale, 13 while intrapsychic conflicts were assessed using Perry’s Psychodynamic Conflict Rating Scale. 14 Defenses and conflicts were rated based on video or audiotaped interviews of subjects shortly after admission to Riggs and at subsequent intervals of 6–12 months during and after treatment at Riggs for a total period of follow-up to date of 3–5 years. For all but self-report measures, raters established satisfactory interrater reliability in the use of these rating scales. Data from the first 57 patients who have been followed for 3–5 years were presented by Perry in 2001. 15 The completed study will report findings on more than 150 patients.
Results from the first 57 patients indicated a high percentage of treatment-refractory mood disorders in the sample (45 patients or 79%). For the purposes of this study, “treatment refractory” was defined as failure to respond to multiple trials of antidepressants, multiple outpatient treatments leading to impasse or chronic crisis management, and/or the need for multiple inpatient treatments. The mean number of major depressive episodes per patient was 3.2, with a range of 1 to 10. Thirty-nine of the 45 patients with treatment-refractory mood disorders (87%) met criteria for a major depressive episode at the time of the index admission, with 5 of the remaining 6 meeting criteria for dysthymia at admission. Of the 39 patients with a major depressive episode at the index admission, 32 (82%) met criteria for recurrent major depressive disorder, 5 (13%) met criteria for bipolar II disorder, 1 (2%) met criteria for bipolar I disorder, and 1 (2%) for bipolar disorder NOS (mania only with antidepressant-induction). 15 The 45 patients with treatment-refractory mood disorders represent a group of seriously disturbed patients, 18 (40%) of whom had had 6 or more self-destructive episodes, 23 (50%) of whom had made at least one serious suicide attempt, and 27 (60%) of whom had had 3 or more previous hospitalizations prior to the index admission. More than half (26) had histories of childhood abuse, which was associated with a greater number of Axis I disorders. The vast majority of patients in the treatment-refractory group (39 or 87%) had co-existing personality disorders, with borderline personality disorder most common.
Preliminary findings show evidence of significant improvement over 3–5 years of follow-up, with most of the change occurring after the first 2 years, whether or not they were still in treatment at Riggs or elsewhere. All but 5 of the 45 patients with previously treatment-refractory mood disorders showed improvement at last follow-up. Conservatively estimated effect sizes for the entire treatment-refractory group ranged from 0.4 (for self-report measures) to 0.5–1.0 (for employment, defenses, and Hamilton Anxiety and Depression scales) to 1.5 (for the GAF).
These preliminary findings suggest that the interdisciplinary psychodynamic approach developed at Riggs may be helpful to patients with treatment-refractory mood disorders who have prominent comorbid Axis II pathology and a history of trauma. In order to identify treatment variables that were associated with good outcome and extract underlying treatment principles, I reviewed a series of 28 representative cases, 16 of which were in the sample described above. The principles were initially extracted based on a review of the therapies of 2 patients from the sample whom I had personally treated. The principles were then revised and edited based on a review of 6 cases I had supervised as well as on a review of the medical records, including detailed monthly summaries of psychotherapy, and my participation in the extended case conferences of another 20 cases. The resulting set of principles was presented for comment to a group of five colleagues with experience with this kind of treatment, and the principles then underwent final revision.
While a study design without a control group cannot demonstrate that the treatment at Riggs caused the change in these patients, I suggest that a reasonable clinician who saw this degree of change in a previously treatment-refractory group of patients would be curious about what elements in the treatment approach might have been associated with the observed changes. Although my own unwitting clinical biases are a limitation of this methodology, the use of multiple cases to extract the principles and consultation with a group of colleagues to review them based on their experience helped mitigate this limitation. The resulting principles are offered as hypotheses that should be the subject of further testing in the future.
When Axis II pathology and other comorbid conditions complicate response to treatment, inclusion of a psychodynamic therapeutic approach may be useful. In this sample, therapists whose patients with treatment-refractory mood disorders had good outcomes tended to incorporate the psychodynamic principles shown in Table 1 in their therapeutic approach. Each principle is discussed in detail and illustrated in the sections that follow. Because the concepts embedded in the principles may be unfamiliar to some clinicians, material from a single representative case is presented to illustrate the principles being described, not to serve as a “one case proof” of the efficacy of the treatment approach.