Medication: a dialogue between a psychoanalyst and a general psychiatrist
A panel discussion between Dr. Arthur Propst, psychoanalyst, and myself, on the role of medication. This took place on 1996-2-14, as part of the Canadian Psychoanalytic Society Extension Program, in Montreal.
Three stories
patient on MAOI with hypertensive crisis
I would like to start by telling you a story. It concerns a patient that I was seeing weekly for symptoms of depression, anxiety, difficulty in her relationships with her husband and at work. She had tried a number of different antidepressants and antianxiety medications, but seemed to have the best response to an MAO inhibitor. As you know, this class of medication requires that careful attention be paid to diet, to avoid foods such as ripe cheese or chianti wine which can interact with the medication to produce dangerously high blood pressures.
The patient had just returned from a vacation to the South Pacific. While on one of the islands, she told me, she had sampled some of the local beer, and shortly afterwards had developed an excruciating headache radiating upwards from the back of her neck. accompanied by difficulties with her vision. Very worried that she might be having a hypertensive crisis brought on by the unfiltered beer she had drunk, she consulted a local physician who gave her medication to reduce her blood pressure. Back at home after the vacation, the headaches continued, as did her vision problems, and she asked me to order a CAT scan, fearing that she might have had a small stroke.
Fortunately, the scan was negative. However, it came out over the next several sessions that she had been experimenting with “forbidden” foods for a long time while on the MAO inhibitor, partly out of curiosity, but also in response to self-destructive urges, which she had successfully concealed up to this point. Now that it was out in the open, unfortunately, the self-destructive behaviour increased in variety and intensity, culminating in my hospitalizing her.
Patient who did not fill his prescriptions
I have another story about a patient, told to me by a surgeon who treated this man for cancer. The patient became depressed and was referred to a psychiatrist, who began psychotherapy. At some point during the treatment, the psychiatrist felt that antidepressant medication was indicated, and began prescribing it. As the patient seemed to respond well, the psychiatrist continued to give him prescriptions. This went on for a couple of years, until the cancer recurred. The man eventually died. His wife, going through his papers, found all the prescriptions, neatly filed away in chronological order.
Woman who responded to Prozac
The last case is another woman who was referred to me by her GP. Physically abused as a child, she suffered from a chronic low-grade depression, but had recently become severely depressed and unable to function as a mother or homemaker. She had been to several mental health professionals but felt that they hadn’t made much difference. I began her on Prozac, and although it took a couple of months before she showed a response, she eventually improved so much that she told me, “I’ve never felt this good in my entire life!”
Buoyed by this success, I contracted with her for a course of insight-oriented therapy, with a very positive outcome.
Three effects of medication: therapeutic, side, placebo
You all know that medication can have a direct therapeutic effect, it can have side effects, and there is also a placebo effect. These three cases indicate to me that medication can have these three kinds of effects on the therapist, and therefore on the therapy, never mind the patient!
My therapeutic success with the woman I put on Prozac made me optimistic that I could help her even more, and I’m sure that it predisposed her to respond positively to my interventions.
The psychiatrist treating the depressed cancer patient obviously felt that the medication was helping, even though the patient was not getting a pharmacologically active substance. We can speculate about the meaning to the patient and the therapist of the written prescription which the patient took such care to file away.
Finally, the use of an MAO inhibitor for purposes of self-harm by the first woman shook my confidence in my ability to be helpful, and eventually the therapy foundered.
Treatments have effects on the treater: ability to “sell” the treatment
We normally talk about the effects of treatments on the recipient. These examples illustrate that treatments also have powerful effects on the treater. Why do I bring this up? Because what I have learned over the past number of years is that my ability as a salesman is vital to my effectiveness as a physician. And it’s hard to sell something you don’t believe in. Thus if I am led to believe that a medication is helpful, whether directly or through a placebo effect on me, the prescriber, I will be more successful at convincing other patients that this medication will also help them. Conversely, if I perceive a medication as problematic, I may even steer patients away from it.
Applies equally to other treatments, including psychotherapy
I should also add that other treatments, including psychotherapy, will also have direct effects, placebo effects, and side effects on the people who provide them. And again, a therapist’s belief in his or her product will strongly influence how well they can sell that product to patients, and thus how well the product works.
Thus, if you think medication will not help your patient, chances are excellent that it will not help, even when prescribed by someone else.
I am biologically oriented
Let me make it clear that I am a biologically oriented psychiatrist. My undergraduate degree is in electrical engineering, and I worked for a number of years as a computer systems engineer before going into medicine. Thus I tend to look upon the brain as an organ, and that all its functions, including cognition, memory, behaviour, emotions, etc. have a biologic underpinning. Thus, they are susceptible to modification by biologic means, such as medication. This in no way reduces the importance of interactions with people, including psychotherapy, in the functioning of this organ.
The brain is like a computer, with hardware and software
You can compare the brain to a computer which needs software to do anything useful. The computer hardware is genetically determined and can be modified by an enriched environment; injury and disease cause loss of function or deterioration. The software in the case of the brain is the information which is learned and stored through the person’s interactions with parents and other people, especially therapists. Clearly, the software is much more important than the hardware; after all, it’s what made Bill Gates the richest man in the world!
Prescribing medications has become complex
targeting of symptoms
In psychiatry, prescribing of medications has become a lot more complicated in recent years. It used to be that the best you could do was to target a patient’s symptoms: for anxiety, you prescribed anti-anxiety drugs; for depressive symptoms, antidepressants; for psychosis, antipsychotic agents; for mania, antimanic medications; for insomnia, hypnotic drugs.
treating specific illnesses
As a result of people experimenting with drugs in conditions beyond the narrow indications for which the drugs were initially approved, it was learned that certain very specific illnesses could be effectively treated. Panic disorder, for example, in which antidepressants can eliminate the panic attacks but not the anticipatory anxiety. Obsessive-compulsive disorder was found to respond, at least partially, to serotonin uptake blockers such as anafranil, and the newer SSRI’s. Stimulants such as ritalin are widely used to treat hyperactivity in children. Low dose antipsychotic medication is effective in reducing the tics of Tourette’s syndrome. Tricyclic antidepressants are used for certain cases of bedwetting.
This requires accurate diagnosis
The point I want to make is that in order to provide effective treatment in today’s environment requires that an accurate diagnosis be established first.
treating specific behavioural traits
But the future holds the promise that we may be able to treat not only symptoms or diagnoses, but specific behavioural traits that cut across diagnostic groups. For example, low serotonergic function has been associated with impulsive behaviour, including suicide. Thrill-seeking behaviour exists on another continuum which correlates with levels of the enzyme mono-amine oxidase. Although the alteration of personality traits through the “Miracle of Modern Chemistry” smacks of Big Brother and of “Clockwork Orange”, would it not be useful if there were a way to tone down someone’s impulsive behaviour to the point where psychotherapy became possible?
Questions to ask the audience
- How many have patients in psychotherapy?
- How many of this group have patients who are also on medication?
Did you know that at the Columbia University Center for Psychoanalytic Training and Research, a recent study of psychoanalytic candidates’ training cases showed that the 27 candidates had a total of 56 training cases. Of these, 24 cases, or 43%, were diagnosed with an axis I mood or anxiety disorder, 19 with either depression or dysthymia, and 5 with an anxiety disorder. Sixteen out of the 24 (ie two-thirds) with axis I disorders were on medication. This represents 29% of all the training cases.
Forty-five training analysts at the same Columbia University Center for Psychoanalytic Training and Research were sent questionnaires that asked how many patients in analysis they had seen in the past 5 years and for details about any of those patients who had taken psychotropic medication. The analysts reported that in the past 5 years, 51 (18%) of 277 patients in analysis were also taking psychotropic medication. Most of these patients had been diagnosed with a unipolar mood disorder and were treated with some type of antidepressant.
- How many prescribe the medication themselves?
- How many refer to a psychopharmacologist?
- Do you refer:
- at the beginning of therapy?
- during therapy?
- at the end?
- What problems have you encountered?
- Were there any positive aspects to the experience?
Working with a psychopharmacologist
I’ve had a number of patients who were also seeing someone else in psychotherapy, and a couple of patients who I was seeing in psychotherapy who were being prescribed medication by another physician. It seems from your responses to my question that dividing the treatment among two treaters is relatively common.
commonly, the therapist refers to a psychopharmacologist
The most common type of referral seems to be from the psychotherapist to a psychopharmacologist. Typically, the patient is referred for a medical consultation because there appears to be a pattern of symptoms that the therapist recognizes as being medication-responsive, or because the symptoms have not responded to the psychotherapy.
patient’s reaction to the referral
The patient may experience the referral, for example, as a sign that the therapist has given up on him or her, or that the therapist is incompetent or helpless.
The psychopharmacologist may become the all-good object in the patient’s eyes.
Other reactions are also possible. In any case, there are many things that may occur that interfere with either or, more likely, both treatments.
what can be done?
Are there things that can be done to minimize the problems? I think so. I would suggest that for the therapist, a referral to a psychiatrist should be a routine even before starting therapy. This will help identify disorders that are known to respond to medication, and minimize the transference splitting that can occur when the referral occurs during the therapy. It also minimizes the possibility of countertransference “rescue” fantasies on the part of the psychopharmacologist.
One issue in interpreting the results of studies comparing medication to psychotherapy for the treatment of depression has to do with the severity of the depression. Severely depressed patients who have stopped eating or drinking, never mind talking, are usually hospitalized, and thus will not be considered for psychotherapy studies.
As an engineer, I am biologically oriented. But that does not mean that I believe that medication is always the answer. For example, I am very reluctant to prescribe benzodiazepines, and certainly not in the long term except for rare situations. I tell patients that if their brains actually functioned better with such medication, evolution would have built it in.
When a medication is prescribed and the patient experiences side effects, this will arouse transference and countertransference feelings. But it opens up possibilities for discussing these. For example, how does the patient react when experiencing a harmful side effect? Does he blame the doctor? Does he blame the medication and shield the doctor? Does he blame himself?
Some patients expect a magic cure, eg medication, that will not require any effort on their part. For others, medication may be accepted as a crutch, but will the patient be willing to undergo withdrawal from dependence on the crutch?
When the patient pins all his hopes on medication, in a sense it is idealizing the doctor. Devaluation eventually ensues.
Some patients feel comforted by having medication at hand and available, even if they use it rarely or not at all. It thus represents a transitional object.
I have been in situations where I am seeing a patient for medications who is concurrently in psychotherapy with someone else. Questions:
- what if the therapist does not agree that the patient needs medications?
- what if the therapist believes the patient should be on medications, but the psychiatrist believes not?
- how should the two communicate, eg if the therapist feels the patient may be experiencing a side effect which the medication prescriber seems to be unaware of?
- does direct communication between the two foster the patient’s dependence? if the patient is expected to act as a go-between, is this like the situation of a child of divorced parents?