Psychodynamic Prescribing: Meaning Matters With Medicine

Medicine is potent, but “meaning”—what pills mean to patients, patients’ goals in treatment, and the relationship between the psychiatrist and patient—can make the difference in whether medicine works, said David Mintz, M.D., director of psychiatric education at The Austen Riggs Center in Stockbridge, Mass., in an address titled “Improving Outcomes in Treatment Resistance Through Ordinary Medical Psychotherapy.”

Christina Rahr Lane

Mintz, who is also chair of the APA Caucus on Psychotherapy and has written widely on the subject of the psychodynamics of prescribing medication, spoke at a conference celebrating the 100th anniversary of The Austen Riggs Center last month in Stockbridge, Mass. (Psychiatric News).

“Psychiatric medications have direct but also symbolic effects,” he said. “The placebo effect is real and powerful, and the effects of meaning rival the potency of medications.”

He presented evidence from several studies by Irving Kirsch, M.D., of Harvard Medical School and colleagues who used FDA data (which include unpublished pharmaceutical-sponsored studies) suggesting that placebo effects account for much of the response to antidepressants. Moreover, he cited a 2006 study in the Journal of Affective Disorders re-analyzing data from the NIMH Treatment of Depression Collaborative Research Program. The data indicated that the effects of the prescribing psychiatrist—that is, the patient’s perception of the relationship with the treating psychiatrist—accounted for greater variability in outcomes than did the medication alone.

Mintz also presented data from a 2009 study by James Kocsis, M.D., a professor of psychiatry at Weill Cornell Medical College, and colleagues in the Journal of Clinical Psychiatry demonstrating that a patient’s preference for treatment—that is, whether the patient received the treatment that he or she preferred—is a potent moderator of treatment response for patients with chronic forms of major depressive disorder. For instance, Kocsis and colleagues found that 45% to 50% of patients responded when treatment (whether medication or psychotherapy) matched what they preferred. Just 22.2% of patients responded when they received nonpreferred psychotherapy, while only 7.7% of patients responded when they received nonpreferred medication.

Mintz said these studies are part of a large and growing database pointing to at least three important points for physicians: psychosocial factors, especially the relationship between the prescribing psychiatrist and patient, are crucial in the response to medication; listening to what the patient wants in treatment makes a difference; practicing “at the top of one’s license” requires attention to psychodynamic aspects of prescribing medicine.

“How you prescribe can be more important than what you prescribe,” Mintz said. “If we are not listening to what patients want, we are contributing to treatment resistance.”

In comments to Psychiatric News after the conference, he said clinicians are pushed by multiple forces—economic factors, time pressures, the emphasis on symptom checklists—to think of patients in primarily biomedical terms.

“But often psychosocial factors will make the difference between treatments that work and ones that don’t,” he said. “For treatment-resistant patients, it is important to consider whether there are psychological factors that end up in opposition to the intent of pharmacologic treatment. Unless the treater is able to think biomedically and psychosocially and to intervene on both levels, we are effectively working with one hand tied behind our backs.”

Mintz offered these tips for effective psychodynamic psychopharmacology:

• Know your patients to the best of your ability: “A better understanding of patients allows us to align with their goals, identify potential psychosocial sources of treatment resistance, and identify basic relational patterns that have the potential to interfere with effective pharmacotherapy,” Mintz said. “It also supports patients’ sense that we’re invested in them, which promotes better outcomes.

• Attend to ambivalence about medicine: Nearly all patients are ambivalent about taking medications. “Several studies have suggested that patients are more likely to expect harm from medications than they are to expect help,” Mintz said. “When this is the case for an individual patient, it can be helpful to understand the origins of their fears so they can be addressed, rather than unconsciously undermining treatments.”

• Address transference and countertransference when prescribing: “The most troubled patients fill us with the same distressing feelings that they are trying to rid themselves of, potentially pushing us toward irrational prescribing,” Mintz said. “The capacity to recognize that our prescribing may be driven by irrational factors creates a space to recognize when that is occurring so that rationality can be restored or consultation sought.

Mintz said a psychodynamic approach to prescribing can help ground clinicians when they are working with complex patients, provide a consistent framework for interpretation of the patient’s problems, and promote empathy when the therapeutic relationship is difficult.

“Evidence suggests that having a psychodynamic formulation, particularly of difficult-to-treat patients, helps preserve the prescriber’s capacity for empathy, which is one factor known to support good pharmacotherapy outcomes,” Mintz said. ■