Do you get all of your patients into remission? Do you always have this as your treatment goal?
A decrease in symptoms with happier mood, less anxiety and worry, adequate sleep and energy, and fair self-esteem is a treatment response. Too often patients are satisfied with a treatment response. The definition of treatment response is a dirty, dark secret in mental health. Medication studies in Psychiatry define treatment response as at least a 50% decrease in symptoms. All too often patients are satisfied with a treatment response. To put this into perspective, if a patient presents to a physician or other medical professional with a blood pressure of 180/110 and that physician or other medical professional gets the patient’s blood pressure down to 150/90, it would be called a treatment “response”. But we would call it a lousy doctor.
The full resolution of all symptoms with a return to complete and full function in all areas of life is called remission. We want our patients to be happy, calm, sleep well, have good energy, and have excellent concentration and memory. We want their self-esteem to be appropriately excellent. We want them to function to their maximum ability in all areas of their life; at home, with family, during leisure activities, at school or work, with friends. We want them to be calm. We want them to worry appropriately when it is indicated.
Remission is important for a number of reasons. Patients who have a treatment response, but not a full remission, continue to have psychosocial limitations. They continue to have some difficulties at home, at work, and at play. An important study evaluated patients three months after they started treatment for Major Depression. They divided these patients into two groups, one who had attained full remission and the other who had responded, but had not remitted. They followed these patients for two years. They found that patients who had responded, but had not fully remitted, had three times the number of recurrences or relapses of Major Depression as those patients who were in remission. We know that psychiatric disorders reap havoc upon comorbid medical conditions. We know, in fact, that Major Depression is the single best predictor of death six months after an MRI. Failure to achieve remission worsens the prognosis of medical disorders. It also increases utilization of medical services not only for the psychiatric disorder but also for the medical disorder. Patients who are not in remission are more likely to abuse alcohol and drugs, partly self-medicating. Finally, failure to achieve remission increases the worst possible outcome in mental health treatment, i.e. suicide. Our goal has to be to get patients into remission!
Try hard to get all of your patient into remission. Be relentless. Learn about psychotropic medications. Learn the multiple factors involved in correctly choosing the proper antidepressant medication. There are over 15 of these factors! Learn the art and science of their proper use. Educate yourself about the similarities and differences between antidepressants, about how to successfully augment and combine psychotropic medications, about when benzodiazepines should be used and when benzodiazepines should not be used, about the proper role of antipsychotic medications, about the various ways that mood stabilizers work, about the role of antidepressants in various depressive disorders including Bipolar Disorder. Learn about the proper strategies for combining psychotherapy and medication tailored toward the specific psychiatric disorder involved.
Do you get all of your patients into remission? Do you always have this as your treatment goal? Try hard to get all of your patients into remission. Be relentless!