Dr. David Mintz begins by noting:

During the past 2 decades, psychiatry has benefited from an increasingly evidence-based perspective and a proliferation of safer, more tolerable, and perhaps more effective treatments. Despite these advances, however, treatment outcomes are not substantially better than they were a quarter of a century ago. 1 Treatment resistance remains a serious problem across psychiatric diagnoses. 2 One likely reason that outcomes have not improved substantially is that as the pendulum has swung from a psychodynamic framework to a biological one, the impact of meaning (ie, the role of psychosocial factors in treatment-refractory illness) has been relatively neglected, and psychiatrists have lost some potent tools for working with the most troubled patients. http://www.austenriggs.org/images/up...-24%283%29.pdf

Dr. Mintz like many others seems to find the biological model deficient. Studies show:

A series of meta-analyses of FDA databases (examining an unbiased sample, including negative, unpublished studies) shows that although antidepressant medications are effective, the placebo effect accounts for between 76% and 81% of treatment effectiveness. 5-7 Placebo does not mean imaginary or untrue. Placebos produce real, clinically significant, and objectively measurable improvements in a wide range of conditions, including psychiatric disorders. 8,9 And, placebo responses produce measurable changes in brain activity that largely overlap medication-induced improvements. 10 The patient’s desire to change and a positive transference to the doctor and his or her medications can mobilize profound self-healing capacities—capacities that appear to be even more potent than the medication’s active ingredient.

Although most of our patients ask us for help, many are conflicted about getting well if their illness has created some conscious or unconscious benefit. If a patient is not “ready to change,” it is unlikely that a medication, however potent, will produce a therapeutic effect. Beitman and colleagues 11 found, in a placebo-controlled trial, that patients who received a benzodiazepine for anxiety and who were highly motivated to change had the most robust response. However, placebo recipients who were highly motivated to change had a greater reduction in anxiety than patients who took the active drug but were less ready to change. Readiness to change was found to be the single most powerful determinant of treatment effectiveness—even more potent than type of therapy (ie, active vs placebo).

In 1912, Freud 12 noted that the unobjectionable positive transference (consisting of such things as the patient’s belief in the doctor’s salutary intentions, the wish to use the doctor to get better, and the desire to win the doctor’s love or esteem by genuinely trying to get better) was a key factor in the patient’s ability to overcome symptoms. This unobjectionable positive transference, ie, the therapeutic alliance, is one of the most potent ingredients of treatment. 12,13 In a large, placebo-controlled, multi-center trial of treatments of depression, Krupnick and colleagues 14 showed that patients were most likely to respond when they received the active drug and had a strong therapeutic alliance. Those least likely to respond when given placebo had a poor therapeutic alliance. Patients who received placebo and who had a strong treatment alliance had a significantly more robust therapeutic response than patients who received an antidepressant but had a poor therapeutic alliance. Taken together, these studies examining the relative effectiveness of biologically and symbolically active aspects of the medication suggest that meaning effects in psychopharmacology are more potent than biological effects.

Mintz gets into the meat of the article when talking about pharmacological treatment resistance and the elements of psychodynamic psychopharmacology. He concludes:

There are many sources of pharmacological treatment resistance. When treatment resistance arises from the level of meaning, interventions are not likely to be successful unless they address problems at the level of meaning. Psychiatric care providers who operate from either a dogmatic psychotherapeutic paradigm or a psychopharmacological paradigm are hobbled by having access to only half the patient. Psychodynamic psychopharmacology combines rational prescribing with tools to identify and address irrational interferences with healthy and effective use of medications. We should not neglect psychodynamic contributions that enhance the integration of meaning and biology. It is the capacity to integrate and understand complex situations that more than anything else lends its particular power to our discipline and gives us skills for working with particularly troubled patients.

An interesting article that is significant because it stresses the need to look at all aspects of the treatments available when dealing with an illness exhibiting resistance to limited treatment options.