Treating Chronic Depression: Psychotherapy and Medication

Depressive illness often becomes chronic or recurrent, and patients may recover only partially. Despite all the new and effective drugs, at least 25 to 35 percent of patients with clear-cut mood disorders do not respond in a satisfactory way even though there can be some relief of symptoms. These chronically ill patients can be identified by careful examination and are characterized by what Badal calls a “predicament.” The predicament is caused by a combination of two factors: an intolerably painful and troublesome relationship with a significant other, and a personality deficit that prevents the patient from solving that relationship problem in an acceptable way. When patients do not respond to treatment and their cases become chronic, the doctor-patient relationship must become a long-term therapeutic alliance. The personality problems may require intensive psychodynamic treatment. Combined treatment-i.e., medication, psychosocial intervention, psychotherapy, and rehabilitation-is commonly required for these patients. The appropriate use of medication often makes it possible to conduct a successful psychotherapy. In identifying the problems causing the basic predicament of these chronic patients and successfully bringing them back into the mainstream, psychotherapists should have access to enough details and general principles of pharmacotherapy to evaluate the progress and the effects of the medication, and allow them to communicate intelligently with the person prescribing. Badal addresses five areas of treatment with these cases: The doctor-patient relationship, pharmacological treatment, psychosocial interventions, psychotherapeutic programs, and rehabilitation. He formulates an approach to recognition and treatment of all the various types of these hard-to-treat chronic and refractory mood disorders. A Jason Aronson Book

Table of Contents:
Part 1 PART I: The Predicament and Its Effect on Chronicity Chapter 2 The Predicament-Evolution of the Concept Chapter 3 Definitions and Clinical Descriptions of Chronic Chapter 4 Chronicity in Practice Chapter 5 Review of the Current Literature on Chronicity in Mood Disorders Chapter 6 Identifying the Predicament Using the Multiaxial System of DSM-IV Part 7 PART II: Treatment of Chronic and Refractory Mood Disorders Chapter 8 Treatment Principles and Methods for Chronic Mood Disorders Chapter 9 Case Examples of the Treatment of Chronic Mood Disorders Part 10 Summary and Conclusions Part 11 Appendix I. Medications Currently Used for Treatment of Mood Disorders Part 12 Appendix II. Example of Documentation for Gaining Approval for a Program of Rehabilitation of a Patient with a Chronic Mood Disorder Part 13 Appendix III. Annotated Bibliography

About the Author :
Daniel W. Badal, M.D., began his research in clinical and laboratory work on depression and other mood disorders at the Massachusetts General Hospital and the Harvard Medical School, and later at the Medical School and at the School of Social Work of the Case Western Reserve University. He continues teaching residents and medical students at Case Western Reserve Medical School. In 1999, Dr. Badal was awarded the American Psychiatric Association Tenth Annual Nancy C. A. Roeske, M.D. Certificate of Recognition for Excellence in Medical Student Teaching. He also teaches on the psychology and psychodynamics of mood disorders and on the use of medication in combination with psychotherapy and psychoanalysis to analytic candidates at the Cleveland Psychoanalytic Institute.

Review :
Depression was once considered an intermittent condition in which the vast majority of patients responded relatively quickly and completely, and which, untreated, was associated with a high rate of spontaneous and complete recovery. Over the past 20 years, systematic research observations of people suffering from depression in naturalistic settings and the results of controlled clinical trials have led to the realization that depression is most often a chronic unremitting condition that all too frequently only partially responds to treatment, even in the face of the impressive array of new and effective medications available today. Treating Chronic Depression is a practical, comprehensive, and clinically focused review of the conceptualization and treatment of chronic depression. Badal incorporates firsthand clinical observations and case vignettes into a thorough review of the published literature on chronic depression. His keen insights on the important factors contributing to chronicity reflect several decades of clinical experience and an impressive understanding of both the psychological and neurobiological factors underlying depression. This book is a must-read for clinicians interested in the treatment of depression. In a very thoughtful and refreshing way, Dr. Daniel Badal shares with us his decades of specialized and evidence-based experience with treating patients with depression. The book is especially valuable at this time, when the treatment of depression is often at risk of being dehumanizingly technical, impersonal, and inadequate. He presents a novel way of quantitatively assessing a patient's vulnerability to chronic depression. However, his focus on 'treating the predicament' reminds us that there is a person at the center of our work. Treatment of Chronic Depression, by Dr. Daniel Badal, is an eminently readable text that provides an unusual view into work with depressed patients over a protracted period of time. It is rare that a practitioner, let alone one with Dr. Badal's sensitivity and insight, has access to long-term, continuous work with such patients. From his experiences we learn of the variability of this disorder and the thoughtful attention and skill that is required to most effectively assist depressed patients throughout the course of what is often a lifelong illness.