Are Our Patients Getting Better?

I am in my office with a patient whom I will call Sara. I have been seeing her in therapy for over two years. Her treatment has included a combination of psychotherapy and pharmacotherapy.

Although Sara is an adult in her early 20s, her mother is the one who sounds the alarm when Sara decompensates. For the last six months there have been fewer calls from her mother with concerns about imminent suicidality. Her mother no longer sleeps in the hallway outside Sara’s door at night out of fear Sara will attempt to harm herself. With a combination of weekly therapy sessions and four psychotropic medications, Sara is stabilizing. Sara has symptoms of bipolar disorder, borderline personality disorder, and body dysmorphic disorder but doesn’t fit neatly into any category.

This scenario, taken from an actual case in my practice, is not unique and will remind most clinicians of similar cases in their own practices. Three of the challenging questions in such cases are the accuracy of the diagnosis, the treatment to be followed, and the outcome of the interventions.

Due to the challenges in Sara’s case with a debate over the diagnoses and a need for multiple medications for stabilization, the outcome measurements are critical in determining the effectiveness of treatment. There will be few specifics in the psychiatric literature to guide treatment on such complex cases. I will focus on the third challenge of outcome in this article.

The first challenge is the diagnosis. Sara does not have a clear DSM-IV diagnosis. Several of my colleagues, both in the psychotherapy and psychopharmacology communities, disagree on the diagnosis.

The second challenge is the treatment. Sara has reached only a moderate degree of stabilization on a combination of weekly psychotherapy and four psychotropic medications. Repeated attempts to simplify her treatment regimen have led to destabilization.

The third challenge is the outcome. Is the patient getting better? In the case of Sara, by all external observations she was getting better. There were fewer periods of suicidality and fewer calls from her mother, and her mother wasn’t sleeping in the hallway anymore. Sara had overcome a particularly paralyzing issue in therapy, and her social circle was extending. In spite of this, Sara could not see any change. So there was a dilemma. Was I deluding myself as to her progress? If not, how could I convey Sara’s progress to her?

About this time, I attended an APA symposium at which Dr. David Sheehan of the University of South Florida spoke. Together with Dr. Y. Leerubier of L’Hôpital de la Salpêtrière in Paris, France, he developed a validated diagnostic and tracking instrument, called the Mini International Neuropsychiatric Interview Tracking. I was familiar with these types of tools from my days in more formal research after leaving residency, but hadn’t considered using this tool in my private practice. I thought completing rating forms would be an unacceptable exercise for private patients.

Dr. Sheehan mentioned that his private patients appreciated this addition to their treatment protocol. I thought of Sara and decided to try it. Integrating Dr. Sheehan’s M.I.N.I. Tracking (with permission) and other rating scales into my practice has helped me follow my patients’ progress in treatment.

Using the rating scales has provided many benefits. They have provided data to help track patient progress. My patients have embraced the system, much as Dr. Sheehan reported in his practice. The time and effort the patients invest in completing these scales increase their active participation in their care. With this system, clinicians can determine whether a treatment will produce the same results in their naturalistic setting as it does in a clinical trial. Data from this tracking system have been helpful in obtaining benefits for my patients from their insurance providers that might otherwise have been denied.

The many advantages of the tracking system have been worth the extra time and effort it takes to collect and process the data, which are considerable.

And, Sara now sees some of the improvement she is making! ▪

Dr. Price is a psychiatrist in private practice in Reno, Nev., and a clinical assistant professor of psychiatry at the University of Nevada-Reno. He is also president of the Nevada Psychiatric Association and a member of the APA Committee of Early Career Psychiatrists.