To the Editor.
—The discussion and recommendations for the treatment of chronic depression presented by Dr Goodwin1 were comprehensive and timely, but incomplete. The patient described may have benefited from a course of electroconvulsive treatment (ECT), if his health insurance would have paid for it. Electroconvulsive treatment remains one of the safest and most effective treatments for moderate or severe major depression not responsive to antidepressant medication.2The patient's internist and psychiatrist described counter-transference reactions of helplessness, frustration, and depression. Beck et al3 recommended that such "difficult patients" should be treated by psychotherapists who "remain optimistic" and who can identify and deal with their own dysfunctional cognitions.3In a well-staffed community mental health center, an experienced case manager could have attempted to solve conflicts with the patient's insurance carrier. The psychiatrist should have provided the complete medical psychotherapy, pharmacotherapy, and perhaps even ECT. There should have
Chutkow LR. Treatment of Chronic Depression. JAMA. 1996;275(24):1883. doi:10.1001/jama.1996.03530480025031