Treatment resistance in people with chronic mental disorders – core clinical issues, social inclusion and getting the balance right
Article first published online: 17 AUG 2013
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Acta Psychiatrica Scandinavica
Volume 128, Issue 4, pages 320–321, October 2013
How to Cite
Becker, T. and Lang, F. U. (2013), Treatment resistance in people with chronic mental disorders – core clinical issues, social inclusion and getting the balance right. Acta Psychiatrica Scandinavica, 128: 320–321. doi: 10.1111/acps.12154
- Issue published online: 15 SEP 2013
- Article first published online: 17 AUG 2013
The authors of this discussion paper are right in stating that ‘full integration and participation in society remain an elusive goal’ for people with chronic mental disorders , and they discuss initiatives to include farms (‘care farms’ in the authors' terms) in care provision for this target group. The authors state that care farms, in the Netherlands, have increased in number from 75 (1998) to more than 1000 (2009), and they consider care farms to be examples of socially embedded practice enhancing social inclusion and participation of people with chronic mental disorders. The authors use depression as an example pointing to the fact that full remission is not reached by all patients with depression and that, even if symptoms improve, social and occupational functioning may not improve sufficiently. If remission is achieved, stigma and discrimination can constitute barriers to a satisfying social life. The authors describe two small-scale studies which found that participants with treatment-resistant depression working with farm animals or involved in farm-based horticulture activities were found to improve in depression severity. A randomised controlled trial resulted in a significant decrease in depression severity among people involved in farm-based horticulture. The approach is promising, and the authors refer both to the tradition of psychiatric institutions including agricultural work and, in their references , to the current broader concept of the ‘capabilities approach’ in introducing to their paper.
Chronic depression and treatment-resistant depression are overlapping mental health problems with a relatively high prevalence, and they constitute a heavy burden for the individuals involved, their families and carers, mental healthcare systems and society at large . Non-utilisation of specific mental health care among people with depression is an issue with the treatment rates ranging from about 33–40% of people suffering from major depressive episodes . Identification and treatment of depressive states in primary care have been considered an important issue in improving depression care . Clearly, with increasing severity of depression, there is an increase in treatment uptake, and a higher proportion of patients are treated in specialist mental health care settings . In secondary and tertiary mental health services, there is an issue of ensuring evidence-based treatment in line with treatment guidelines for people with chronic depression. Specifically, this refers to ensuring access to augmentation treatment strategies (e.g. lithium, antipsychotics), to making sure electroconvulsive treatment is available at a high professional standard, to ensuring psychotherapeutic expertise making use of current evidence-based and manualised treatment packages such as the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Interpersonal Therapy (IPT). All along, psychosocial issues must be addressed. Workplace problems such as prolonged leave of absence and workplace presenteeism (to name just two) need to be taken into consideration. Nowadays, there is deep-brain stimulation to be considered, too.
The concept of care farms for people with chronic mental illness builds on a tradition within mental health care by which daily living activities, household chores, communal life, workshop approaches, therapeutic communities and workplace support systems are part of the therapeutic armamentarium. The therapeutic community approach has been a core element of mental health care since institutions such as the York retreat, in the UK, reformed therapeutic practice in the early 19th century. However, treatment strategies have evolved, and providing targeted medical interventions is a core challenge of mental health services. In addressing the dual problems of chronicity and treatment resistance in depression, a whole series of interventions need to be available wherever and whenever patients with long-term depressive state are treated. Referring chronically depressed patients to care farms could take them away from the medical trajectory of fighting treatment resistance. Iancu et al.  address this issue in pointing out that psychiatric treatment and care farms could be ‘sequenced or provided simultaneously’. However, walking along the line outlined by the authors could lead us astray by not focusing on the core clinical issue of chronic depression.
The authors are to be congratulated on highlighting the therapeutic potential of horticultural or farm work (which, as stated in the paper, is relevant for people with a broad range of long-term mental health problems). Surely, there is scope for this treatment approach. However, the authors are likely to agree that social inclusion should be realised in routine, day-to-day activities of people with mental health problems in families, at the workplace, fighting for adequate wages, reducing early retirement, using supported employment to get people back into work without major focus on creating disorder-specific agricultural therapy settings. Iancu et al.  highlight a valuable approach but let us not forget that we have to face the core clinical challenge of fighting chronic depression and resolving treatment resistance – let every patient have all treatment options that he or she will give informed consent to.