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The Difficult-to-Treat Psychiatric Patient

Edited by Mantosh J. Dewan, M.D., and Ronald W. Pies, M.D.

  • ISBN 978-0-88048-949-2
  • Item #8949

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Why do some psychiatric patients fail to get better, even when in the care of competent clinicians?

Treatment-refractory conditions are all too common in everyday clinical practice. Treatment resistance occurs across the full spectrum of psychiatric disorders, incurring enormous emotional, economic, and social costs. In the United States, treatment of depression alone costs more than $40 billion annually, and as many as 40% of patients with depression have a treatment-refractory form of the illness.

This groundbreaking clinical guide starts where standard textbooks end, focusing on clinical strategies to be used after all basic treatment options, such as medication and psychotherapy, have failed. In this book expert contributors address the sequential clinical steps in treating difficult-to-treat psychiatric patients by offering a blend of evidence-based clinical recommendations, detailed case vignettes, treatment algorithms, and—when necessary to go beyond the reach of evidence—the clinical wisdom of leaders in the field.

The chapters in this user-friendly, practical guide are organized by major disorder. Each chapter offers concrete recommendations on what to do when the usual first steps in therapy are ineffective, including evidence for biopsychosocial treatments alone versus in combination, generic versus specific therapies, and literature reviews and the latest expert wisdom. A sampling includes

  • The management of the complex and often refractory bipolar disorder, which involves replacing or combining lithium treatment with anticonvulsants or atypical antipsychotic agents with adjuncts such as benzodiazepines, thyroid hormone, and electroconvulsive therapy, but also—above all—with careful attention to the therapeutic alliance.
  • The importance of combined therapeutic modalities for patients with schizophrenia—especially given managed care's cost-cutting strategies, which deprive many schizophrenic patients of effective treatment modalities such as family therapy or early use of an atypical antipsychotic.
  • Combination treatments for anxiety, with medications adjusted over time as symptoms wax and wane, and early and appropriate interventions to mitigate internal and external environmental stressors.
  • The emphasis on common sense, optimism, a sense of humor, and an iron constitution as the most important tools for clinicians wishing to work with the most severely ill patients with borderline personality disorder.
  • The importance of individual differences in biological vulnerability, emotionality and expressiveness, cognitive schemas and beliefs, prior traumatic experience, resilience, and coping strategies for successful treatment of posttraumatic stress disorder.

Packed with up-to-date information of immediate relevance, this volume will prove invaluable in both classroom and clinical practice, for everyone from beginning interns and residents to experienced psychiatric and medical practitioners and social workers.


  • Contributors
  • Chapter 1. Introduction
  • Chapter 2. The difficult-to-treat patient with bipolar disorder
  • Chapter 3. The difficult-to-treat patient with schizophrenia
  • Chapter 4. The difficult-to-treat patient with depression
  • Chapter 5. The difficult-to-treat patient with anxiety disorder
  • Chapter 6. The difficult-to-treat patient with posttraumatic stress disorder
  • Chapter 7. The difficult-to-treat patient with borderline personality disorder
  • Chapter 8. The difficult-to-treat patient with dissociative disorder
  • Chapter 9. The difficult-to-treat patient with eating disorder
  • Chapter 10. The difficult-to-treat patient with substance abuse
  • Chapter 11. The difficult-to-treat patient with dementia or traumatic brain injury
  • Chapter 12. The difficult-to-treat psychiatric patient with comorbid medical illness
  • Chapter 13. Special somatic treatments
  • Chapter 14. Summary: clinical wisdom in psychiatry
  • Index

This is an invaluable book. Treatment resistance is a common problem in psychiatry, and this invaluable book offers useful information on how to identify and treat this problem. Every psychiatrist should have a copy on their reference shelf, and I would suggest that it be required reading for psychiatric residents. I look forward to subsequent editions of this excellent book.—William Miles, M.D., Doody's Health Science Book Review Journal, 1/1/2002

The Difficult-to-Treat Psychiatric Patient should prove a useful text for clinicians in psychiatry and psychology and other behavioral specialists. The writing is concise, the information is accurate and recent, and it seems to have been edited in a very thoughtful, utilitarian manner. It is a book that I began using myself and recommended to colleagues before I finished reading it.—JAMA, 1/1/2002

It is invaluable to have a resource like The Difficult-to-Treat Psychiatric Patient which is thorough, impartial, and user-friendly. I heartily recommend it to any mental health professional who has struggled with these issues, and who has wished they had sage advice at their fingertips.—Neil B. Sandson, M.D., Journal of Nervous and Mental Disease, 1/1/2002

The chapters of this invaluable volume comprise a set of treatment manuals for many of the most resistant patients in psychiatry. The expert authors recruited by Drs. Dewan and Pies lucidly describe therapeutic approaches that have been shaped by comprehensive knowledge, balanced judgment, and common sense. As both a concise review of major psychiatric syndromes and a guide to overcoming treatment impasses, The Difficult-to-Treat Psychiatric Patient should be in the lending library of every psychiatric residency director, as well as on the bookshelf of any clinician who struggles to help these challenging patients.—Edward K. Silberman, M.D., Director of Residency Education, Department of Psychiatry and Human Behavior, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania

Every clinician, whether at the beginning or nearing the end of his or her career, has encountered patients who present a challenge for one reason or another. Drs. Dewan and Pies have produced a book that will be helpful to clinicians at every stage of their career in stepping back and thinking through how to address problematic clinical situations. The last chapter, which sums up the state of our knowledge, clarifies directions for future research and provides collegial support for those struggling through those difficult times, is a gem.—Allan Tasman, M.D., Department of Psychiatry and Behavioral Sciences, University of Louisville School of Medicine, Louisville, Kentucky

Whether novice or master clinician, there is not a psychiatrist who has not, at times, found difficult patients frustrating as well as challenging. This pearl-studded book, The Difficult-to-Treat Psychiatric Patient offers enlightenment, aid, and solace to the most harried of clinicians, with its balanced trove of new treatments, research, and practical psychotherapeutic and psychopharmacologic guidance. In this superbly edited book, help is readily at hand!—Don R. Lipsitt, M.D., Clinical Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts

[I]t is a thorough and eminently readable account of the many ways a clinician can treat the patient who is not getting better.—Psychiatric Services, 1/1/2002

An incisive, well-written and nearly comprehensive guide to patients for whom treatment failure appears a likely outcome. Perhaps the most valuable element of The Difficult-to-Treat Psychiatric Patient is the overall tone of the volume. The editors manage to convey both sympathy and reassurance for psychiatrists who are faced with especially challenging patients. . . . In short, [this book] is an extremely valuable reference work to which psychiatrists should refer early and often during periods of therapeutic frustration.—Michael Brodsky, M.D., Metapsychology Online Book Reviews, 1/1/2002

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