McMaster team weighs in
on treatment-resistant depression

Part 2: Strategic Treatment Rehabilitation Team (START)

by Irene Patelis-Siotis, MD, FRCPC; Mika Tomac, BA, RN, MS Psychology; and Ian Smith, PhD, C. Psych,
Mood Disorders Program, St. Joseph’s Healthcare, Hamilton

To address the major clinical problem of chronicity that is so frequently encountered in the treatment of mood disorders, a special team within the Mood Disorders Program (MDP) at St. Joseph’s Healthcare, Department of Psychiatry and Behavioural Neurosciences at McMaster University was developed in early 2000. The team operates within an outpatient tertiary care system with a catchment area of 1.5 million.

The Strategic Treatment Rehabilitation Team (START) was conceived with the following prelim-inary goals: 1) to understand treatment resistance in this population, 2) to develop interventions to improve quality of life and functioning of these patients, and 3) to transfer patient care to the primary care physician with the goal of de-medicalizing care and improving accessibility by other patients in need of MDP services.

Patients are assessed by a multidisciplinary team using the following criteria: 1) patients have received optimal biopsychosocial treatments, and 2) they have difficulty regaining pre-morbid functioning and have been in the MDP at least 18 months.

The reality of our clinical practice confirms that patients optimally treated, both pharmacologically and psychotherapeutically, will often not sustain improvement in symptoms and/or functioning. Furthermore, after many years of illness, diagnostic distinction between major depressive disorder (MDD) and bipolar disorder (BD) becomes less relevant as affected individuals share common psychosocial issues necessitating comparable interventions. Optimal treatment is generally acknowledged as these patients are treated by psychiatrists with expertise in mood disorders following best practice guidelines and have access to in-house evidence based
psychotherapy approaches.

No diagnostic criteria were set for admission to START, although it was assumed that a primary mood disorder diagnosis such as MDD or BD would be present.

Between 2000 and 2004, almost 200 patients received a three-stage assessment package. The first stage includes the completion of a battery of psychosocial measures, chart review, and administration of the Structured Clinical Interview of Diagnosis (SCID I) as per the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). The second stage consists of an in-depth psycho-social history of the patient, a review of personality issues, and a motivation for change questionnaire. The final stage involves a team meeting where assessment results are presented and discussed, and then, collectively, the team formulates treatment recommendations for ongoing patient care.

Following the successful completion of these stages, the patient meets with START psychiatrist Dr. Irene Patelis-Siotis as well as the clinician who completed the START evaluation. Feedback is provided regarding the assessment as well as subsequent results and recommendations. Finally, the patient is followed in treatment by the psychiatrist who will manage the implementation of care vis-à-vis the defined recommendations.

At the beginning, we thought it would be possible for the patient to continue treatment with the referring psychiatrist thinking it was important to maintain and respect this relationship. However, this proved to not be effective—mostly because of the disruption in the continuity of care provided to the patient should more than one psychiatrist be involved. Also, the patient could find himself/herself caught between conflicting formulations resulting in counterproductive behaviours.

When START was first implemented, we identified several barriers that needed to be addressed, including: 1) barriers to the assessment process, 2) barriers to the implementation of interventions, and 3) systemic barriers.

Assessment barriers
We quickly recognized how difficult and painful it was for our patients to “tell their story again." The two-hour psychosocial interview would frequently activate distressing memories and issues patients were reluctant to share at the time. We sometimes had to give more time to allow them to share these difficult subjects.

We also observed reluctance and/or fear to proceed with either change, or possibly a discharge to the care of the family physician—a problem we had anticipated. Many patients experienced anxiety related to losing their treating psychiatrist—a person they had trusted for many years.

Finally, there were instances where the SCID and our clinical diagnosis were different from the diagnosis of the referring team. In some of these situations we identified an Axis II diagnosis that helped explain this clinical picture. For example, a previous diagnosis of Bipolar Type II could not be confirmed but rather the diagnosis was MDD with borderline personality disorder (BDP), or MDD with significant perfectionism which can be easily mistaken for hypomania. Alternatively, we faced clinical situations confirming the Axis I
diagnosis of the referring team, but our assessment revealed that other Axis I or II comorbidities were perpetuating the functional impairment. In other words, these patients had a diagnosis of Bipolar II that had stabilized, but they continued to experience symptoms secondary to the comorbid diagnosis.

The decision to change a diagnosis is delicate particularly when the emphasis is on personality pathology. We believe there is no clear answer to this question. Our approach to the problem was always driven by what we felt would best serve the patient. In some cases, patients are very invested in their diagnosis—which can become a problem if it prevents them from moving on with their lives. Therefore, the decision to change a diagnosis was only made to facilitate and enhance further recovery and acceptance of the limitations imposed on them by the illness.

Barriers to the implementation of interventions
Most patients transferred to our team struggled with the biological/psychological paradigm and they frequently presented at appointments requesting medication changes. In fairness to our patients, this is usually a reflection of our own difficulties as psychiatrists to remain flexible, open-minded and challenge ourselves to truly integrate these two approaches rather than seeing them in competition with each other.

These patients had already received “gold standard" treatment for their illness, including a multiple medication regime that had been tried over the years. For this reason, we believed proceeding with more medication changes would not enhance recovery, but rather education about the role of psychosocial interventions and a personal commitment to change during the recovery process were the most important interventions.

The choice our patients had to make about relying less on medications was presented as a risk or an experiment they needed to take to determine whether they would proceed with this approach. This method was in keeping with the cognitive behavioural therapy (CBT) patients had received earlier in their treatment. Similarly, it became clear we needed to help patients shift their expectations of the meaning of recovery, however we were also acutely aware of our need to remain open to the possibility of changing medications in the course of our treatment should the pharmacological treatment become suboptimal due to a relapse or recurrence of mood disorder
symptoms.

Many patients believe that symptom relief only occurs with medication. We therefore realized the need to support our patients shifting this belief to include psychosocial interventions with the help of various other tools available to them to improve their recovery. This shift in beliefs implies more responsibility on the part of the patient to work towards improving their quality of life.

We also encountered the problem of patients repetitively missing appointments, which we identified as enduring patterns of avoidance and difficulty taking responsibility for change. Once we established that the avoidance was not a direct result of the Axis I disorder, we gave the patient many opportunities to attend appointments where we used standard cognitive behavioural interventions to address these actions. If this approach was unsuccessful we would proceed with a discharge to the primary care physician with a carefully written, non-punitive letter to the patient explaining the rationale for their discharge emphasizing they may not be ready to proceed with this component of the treatment. Moreover, focusing on this lack of readiness allowed us to keep the door open for a re-referral if needed.

Systemic barriers
We also identified several systemic barriers that helped to maintain chronicity. The lack of community resources and poor communication between the systems involved prolonged the medicalization of care for our patients who would otherwise have benefited greatly from being treated in the community rather than a specialized tertiary care system. However, due to the lack of resources and the stigma of psychiatric illness, at times we had no choice but to continue treating these patients.

Changes were made to address this problem. We began our discharge procedure months ahead of the actual discharge date and we involved family members and all systems engaged in the care of the patient. A pre-discharge letter is also given to the primary care physician advising him/her of the plan to discharge the patient and a follow-up telephone call is made by the START psychiatrist to discuss any concerns.

Finally, we encourage our patients to attend appointments with their general practitioner and begin to address mental health issues during these appointments. This is designed to facilitate the transfer of responsibility during a brief “shared care" period should any problems arise.

Patients received the necessary treatments to address the diagnosis or factors contributing to chronicity following the completion of START. Most of these treatments included CBT targeting anxiety disorders, relationship management, or a referral for dialectical behaviour therapy for BPD, as well as specific interventions targeting problems of substance abuse/dependence and unspecified cognitive deficits. Furthermore, about 12 per cent of our patients were identified as having achieved optimal recovery thus being ready for discharge. Likewise, patients diagnosed with comorbid personality disorders were prepared for discharge to their general practitioner or a community agency.

Acknowledgements
Team members (current): S. Berry, RN; S. Chudzik, MSc, CPsych; K. McKabe, MSW; Ian Smith PhD; TA Tabak, BA, RSSW;
M. Tomac, BA, RN.

Team members (past): P. Bieling, PhD; C. Chater, OT; D. Fry, OT; M. Mach, MSW; H. Wheeler, PhD; R. Whyte, MSW.

© Copyright 2007. Canadian Psychiatry Aujourd'hui. All rights reserved.

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McMaster team weighs in on treatment-resistant depression

Part 2: Strategic Treatment Rehabilitation Team (START)

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McMaster team weighs in
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