Identifying the Causes of Treatment Failures in Psychiatric Illness

“You can’t assess a patient in 15 minutes,” Cynthia Taylor Handrup, DNP, APN, PMHCNS-BC, assistant clinical professor at the University of Illinois at Chicago College of Nursing, told her audience at the American Psychiatric Nurses Association 28th Annual Conference, held October 22-25, 2014 in Indianapolis, IN.

She said clinicians should “negotiate for the time to make an accurate diagnosis because sometimes, clinicians get it wrong.” What should clinicians do when they make a mistake? According to Handrup, the first thing is to admit the mistake, then incorporate it into their knowledge base and treatment plan. In fact, Handrup said it is mistakes that really increase knowledge.

Depression, bipolar II disorder, and personality disorders are very hard to distinguish, so this tends to be a group with a lot of misdiagnosis, especially patients with bipolar II disorder. “Clinicians tend to fall into two camps about this. There are people who diagnose a lot of people as having bipolar II disorder I and there are people who never use that diagnosis,” said Handrup.

In addition, patients do not often present with symptom 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.

Another cause of treatment failure is comorbidity. Patients may have another condition or disease state, whether it’s psychiatric or not, that interferes with the treatment being proved to the patient. But if you don’t know about another disease state and it is not being treated, it interferes with the treatment you are giving your patients, said Handrup. Many times a patient will be treated for a nonpsychiatric comorbidity with a medication that interferes with their prescribed psychiatric medications.

Non-diagnosed substance abuse can also be a cause of treatment failures. And in many cases, “you don’t know about patient substance abuse because they don’t tell you. They may just say, ‘I had one glass of wine or beer’,” said Handrup.

“Bipolar II disorder looks so much like someone who is drunk all the time. If you’re with an inebriated person, they’re grandiose. They’re doing all kinds of inappropriate things. It’s very similar,” said Handrup. “When you see a 20-year-old, you might consider substance abuse. But when your patient is a 90-year-old, substance abuse generally is not the first thing you consider. Instead, you might think about dementia, confusion, or balance issues.

Treatment failure can also occur due to non-adherence to prescribed medication. Patients often don’t tell their doctors that they stopped taking their medications.

So what do you do when you give patients medications and/or psychotherapy and they don’t get better? Go back to basics. “Put down your pencil. Make eye contact and talk with your patient,” said Handrup.

Try the “whole patient approach,” a new approach to diagnosis with four discussion areas:

• Disease Perspective: What the patient has
• Dimensional Perspective: What the patient is
• Behavioral Perspective: What the patient does
• Narrative Perspective: What the patient encounters

Handrup advised the audience members to “Look at what diseases and symptoms your patient has. What kind of a person are they? What are their lives like? Goals? Consider what they do for work, what kind of behaviors they have, what motivates them and what kind of experiences they have. Ask what their life is like and what kind of environment they live in. Listening to patient stories is the hallmark of psychiatry.”