When Does Treatment End?

When is it okay to discontinue psychiatric treatment?  Is a patient ever “cured” of a psychiatric illness?  It sounds like a straightforward question, but it’s also one that is rarely asked, at least by psychiatrists.

To be honest, I hadn’t really given it much thought myself, until recently.  A large proportion of my patients actually improve with treatment (thank goodness!), and sometimes I ask myself, “Does he need to see me anymore?”  And isn’t that the goal of medicine?  To cure someone?  To rehabilitate him?  To “fix” him?  To be able to say to someone, “Congratulations, you’re cured!”  Sure, I can decrease the frequency of his office visits because he seems “stable,” but why can’t I let go completely?

We don’t do that often enough in psychiatry, and I can’t figure out why.  The “bio-psycho-social” model of psychiatry, the three-tiered foundation on which modern psychiatric care is built (although not immune to criticism), incorporates psychological and social components, two factors which are often amenable to change, especially with a motivated patient.  Do we not believe that we can cause biological change, too?  And perhaps reach the point where we’ve corrected whatever biological defect we identified, and let our patient go forth and be happy, in the absence of psychiatric medication?  Or do we honestly believe that the biological defect is so tenacious, so permanent, that we must continue to medicate indefinitely?

To be sure, there are cases of chronic mental illness in which ongoing, life-long medication management is necessary to guarantee the safety and well-being of a patient.  There are also cases in which short-term treatment is the rule.  In my practice, for instance, I do not initiate treatment with a medication like a benzodiazepine or Suboxone without some discussion of how and when the medication will be discontinued—sort of an “exit strategy,” so to speak.

But there are countless other patients who reach a sort of therapeutic “plateau”:  they feel overwhelmingly better than they did when they first presented for care, they’ve “responded to treatment,” and while they may not have eliminated 100% of their symptoms or solved all of their presenting problems, they feel well enough that they can be trusted to move onward.  Is another six months on antidepressants really going to make a difference in this patient?  Is a psychostimulant really necessary now that this patient has developed new organization and study skills?  Has this patient adopted new ways to cope with his aggression or obsessiveness such that medications are no longer necessary?  These are the questions that we really ought to be asking more frequently than we do.

Most psychopharmacologists would argue that therapeutic success is not only the result of medication management, but, significantly, the justification for continuing with medication management. In other words, a patient achieves remission from depression because of the medication, not because of the steps he has taken to improve his lifestyle, his self-esteem, his relationships, etc.  (Or, to be more accurate, the medication permits him to make—and maintain—the lifestyle changes that helped to emerge from his illness.)  Stopping medication and discharging a patient is a breach of the therapeutic contract.  Aren’t we taught that relapse is a part of this disease?  Yes, it is, for some patients.  But how do we determine which ones?

Psychologists and psychotherapists receive extensive training in ending the therapeutic relationship with a client —a process they refer to as “termination.” A key component is determining whether a client is appropriate for termination, and whether the original treatment goals have been met.  The process of termination celebrates the success of the therapy and, symbolically and practically, awards the client with a new identity, granting him or her with the newfound ability—and responsibility—to face obstacles that initially seemed insurmountable.  Why we don’t challenge ourselves to do the same thing in psychiatry is a mystery to me.

The American Psychiatric Association recently published its revised treatment guidelines for major depression.  In the entire 100-page document, the section on “Discontinuation” is only one paragraph, on page 20.  It says nothing about when to discontinue, how to discontinue, or which patients are the best candidates for discontinuation.  Instead, it simply advises the doctor to inform the patient “of the potential for a depressive relapse and [establishing] a plan for seeking treatment in the event of recurrent symptoms.”  Good advice, but it says nothing about what constitutes success.

Perhaps we continue care indefinitely because we believe lifelong pharmacotherapy is essential to correct the abnormality that exists in the brain.  Unfortunately, with few exceptions, science really hasn’t been able to make that connection.  Perhaps we continue care because we don’t believe in our patients’ ability to maintain the gains they have achieved without our help.  This, too, is unfortunate, as it inherently denies the patient’s own capacity for improvement and change.

Whatever the reason, it’s time for our field to think seriously about how we “end” care.  Not to admit failure—on the contrary, to refocus our efforts on achieving a successful outcome for the patient while preserving the patient’s autonomy and independence whenever possible.  It’s respectful, responsible, and the right thing to do.

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7 Responses to When Does Treatment End?

  1. Texss says:

    Great read. I'm no Dr. but it seems almost irresponsible to start treating a patient without some sort of "exit strategy" after the initial assessment. This of course doesn't mean a deadline must be placed on treatment but at the least a goal of some sort. I mean without the proverbial "finish line" how do we know to stop running? I would like to think that any given patient could be made aware of said finish line and through treatment and practice have the ability to acknowledge when they've crossed it.

  2. geezer840 says:

    Excellent blog. You make clear that the Dr. patient relationship, like all relationships, is seen differently by each of the participants. I wonder what the patient would say if asked about this same subject. Does the patient want to be 'free' from the dependence on either a medication or of the treating physician? Does the patient see the Dr. as 'needing' him as a patient? Is 'success' achieved when the patient is free of his affliction or when the Dr. is free of the patient? Could be there are two answers.

  3. Iatrogenia says:

    This is a very important point, well said, Dr. Balt.

    Initially, antidepressants were not recommended for long-term use. They have been widely prescribed for 20 years, now more than 27 million people over the age of 6 are taking them (two-thirds of them female).

    It’s merely folklore that patients need life-long medication to “balance” neurotransmitters.

    Why do you suppose psychiatry hasn’t addressed this question?

  4. Iatrogenia says:

    There’s actually a bit more than a paragraph about discontinuation in the American Psychiatric Association Practice Guidelines Treatment of Patients With Major Depressive Disorder, Third Edition, originally published in October 2010, see http://tinyurl.com/3lmlg8j

    More than a paragraph but still not much guidance.

  5. DL says:

    Perhaps it’s because many of them, and the pharmaceutical companies certainly, know there may be no safe exit from taking antidepressants. My husband is currently suffering through Effexor withdrawal, after being appropriately titrated down. It is unconscionable what is kept from the public about these drugs.

  6. Iatrogenia says:

    According to http://www.guideline.gov/content.aspx?id=24158, summarizing the 2010 APA Practice Guideline for Major Depression:

    “To reduce the risk of relapse, patients who have been treated successfully with antidepressant medications in the acute phase should continue treatment with these agents for 4–9 months[I]. In general, the dose used in the acute phase should be used in the continuation phase [II]. To prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended [I], with the best evidence available for cognitive-behavioral therapy.”

    This recommendation is graded as having the top level of empirical evidence backing it up — that’s what the [I] and [II] mean.

    Now, this recommendation is for Major Depressive Disorder (MDD). Many people with situational depression or mild-to-moderate depression are misdiagnosed with MDD. (I have no idea what might be called “the acute phase” in those situations. Maybe when the patient went to the doctor and asked for a drug?)

    Still, even if you did have MDD, even in the most conservative evaluation, if you have responded to the medication, discontinuing is justified in 4-9 months — not years and years later.

    (If the medication never did anything for you, I might ask: “Why am I taking this anyway?” For most people, taking psychiatric medication is elective — if you don’t want to take it, you don’t have to agree to it. But — you must take responsibility for your own emotional welfare, and stop looking to drugs as the answer.)

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