Factors facilitating or preventing compulsory admission in psychiatry

355 tive symptoms or severe residual anhedonia, or in a patient with an anxiety disorder despite increased avoidance behavior, or in a patient with schizophrenia despite high levels of negative or cognitive symptoms. Functioning or distress are often not taken into account when defining an (in)adequate response, while, in some patients with schizophrenia, learning to cope with a treatment resistant hallucination can significantly decrease dis­ tress and hence improve quality of life. The reason why most definitions of treatment resistance re­ quire two previous unsuccessful treatment episodes is also unclear. The Sequenced Treatment Alternatives to Relieve De­ pression (STAR*D) trial documented that, with each treatment step, an incremental gain in the response rate is observed, but there is also an incremental dropout rate and a higher and faster rate of relapse. Furthermore, in defining treatment resistant schizophrenia, only pharmacotherapy is considered, while, in defining treat­ ment resistant anxiety disorders, both pharmacotherapy and psychotherapy are taken into account. It is remarkable that, in treatment resistant depression, psychotherapy or neuromodu­ lation (except electroconvulsive therapy) are most often not con­ sidered. The fact that outcome in trials with treatment resistant pa­ tients provide different results depending on whether the two treatment episodes with inadequate response were both retro­ spective or whether one was retrospective and the other one prospective further documents the difficulty in obtaining a ho­ mogeneous patient population. The recommendation that each of the two treatment epi­ sodes should have lasted “at least six weeks” is understandable from both a trial design and a clinical point of view, since few non­responders within the first six weeks will respond later, but again is far away from daily practice: health insurance da­ tabases show that a third treatment step is on average started after 43 weeks, which is important to take into account, since duration of an illness episode predicts outcome. It is understandable that classification attempts are now moving away from two categories (non­resistant or resistant) versus staging and “levels of resistance” approaches. These are based on number of treatments (with different treatments getting diff erential weights), episode duration and symptom severity. More fundamentally, it has been suggested that the expres­ sion “treatment resistance” is “devoid of empathy”. Indeed, the expression seems to blame the disorder or even the patient: for example, a lay press article mentioned that a new antidepres­ sant “can cause rapid antidepressant effects in many people with ‘stubborn’ depression”. Finally, the concept of “treatment resistance” stems from an acute illness model with remission or cure as the goal. Unfortu­ nately, not all patients with psychiatric disorders can reach that symptom­free goal. That’s why the use of the more collabora­ tive expression “difficult to treat” psychiatric disorders could be preferred. This expression may fit better with the recurrent or chronic nature of some psychiatric disorders. Achieving a meaningful life in spite of limitations can be(come) the ultimate treatment goal. This also resonates with the “recovery” movement, which identifies regaining personal control and establishing a person­ ally meaningful life, with or without residual symptoms, as the objective to pursue.