Who Defines Success? Realistic Goals and Hidden Nonadherence

"Who Defines Success? Realistic Goals and Hidden Nonadherence" takes up the question of who actually gets to decide when treatment has succeeded.

Dr. Harding argues that success has to be patient-driven, since suffering itself resists objective measurement. She cites a JAMA study finding that fifty-six percent of patients being treated for depression don't believe full remission is even achievable, suggesting that "good enough" may be the realistic goal for many. In her intervention psychiatry practice, she sees patients who have failed up to seven medications and function poorly at work, yet still resist changing course because, as one patient put it, the wheels are still on the bus, and a possible ten percent gain doesn't feel worth risking destabilization.

She asks every new patient, at the first visit, what getting better would actually look like for them, then checks back on that personal benchmark periodically rather than at every visit. Remission can feel like a distant leap, she says, so those smaller milestones matter. She adds that full remission can create its own problem: patients from her early ketamine research, before esketamine existed, sometimes didn't know what to do with their lives once no longer depressed, having built their identity around being unwell. She questions whether the field is truly prepared to help patients live in remission, not just reach it.

Dr. Citrome agrees patients define "better" differently and stresses asking about the subjective meaning of each symptom, since some, like sex drive, are rarely volunteered even though patients expect a clinician to raise them. The conversation turns to adherence: patients often soften the truth out of politeness, so "I don't like this medicine" usually means the medicine has already been stopped. Dr. Citrome discloses his own missed blood pressure doses to normalize this, which helps patients admit their gaps. He describes uncovering, through careful questioning, that a patient had already lowered her citalopram dose months before an FDA-mandated change required it.

The next episode, "Improving but Not Feeling It: Anticipatory Anhedonia and Cognition," features Erin Crown, MHS, PA-C, CAQ-Psychiatry on why some patients cannot recognize their own improvement even when the data shows it.