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A view from Riggs: treatment resistance and patient authority--introduction to paper VIII: "Standards of care and patient autonomy".

In this eighth article in the Riggs series Marilyn Charles addresses a problem familiar to those of us who work with treatment resistant patients: What shall we do when a patient has already failed to benefit adequately from treatment consistent with the standard of care? Each of the Practice Guidelines published by the American Psychiatric Association includes a clear statement that it is not to be construed as defining the standard of care for a disorder, yet most clinicians would want to consider these recommendations in assessing the standard of care. The Practice Guidelines are extraordinarily helpful resources for all clinicians, yet several interesting things are notable that are relevant to the problem of working with treatment resistant patients. For example, although the Practice Guidelines, organized and written by disorder, often note the adverse impact of comorbidity on treatment outcome, there is no systematic definition of what constitutes treatment resistance across disorders or for any one disorder, and no section in each guideline systematically addressing the vexing treatment problem of how to deal with the significant proportion of patients who fail to respond to treatment for a given disorder. If one looks elsewhere in the field one can occasionally find definitions of treatment resistance, for example for major depressive disorder, but these are striking for their nearly exclusive focus on the failure of a sequence of biological treatments—as if psychosocial issues were neither part of the problem nor of the solution when it comes to treatment resistance. As we have been noting in this series of articles, treatment resistance may be much more than the failure of symptoms to remit when various receptors are tweaked and may represent in part a characterologically based failed adaptation to life and to functioning competently. Further, if one surveys the Practice Guidelines, the recommended treatment for most disorders for most patients is at a level of intensity offering fewer outpatient sessions (and fewer inpatient days) than