TCPR: Dr. Mintz, what is psychodynamic psycho-pharmacology?
Dr. Mintz: Psychodynamic psychopharmacology is a way of thinking about treatment—treatment resistance in particular. When patients don’t respond to medications, it asks what else might be the problem besides just the wrong diagnosis or the wrong medications. It addresses the central role of meaning and interpersonal factors in psychopharmacologic outcomes. It doesn’t tell you what to prescribe, but it gives guidance about how to prescribe to get the best results. Whereas evidence-based practice looks at how the patient is like other patients, psychodynamic psychopharmacology encourages consideration of what is unique about the patient (Mintz D & Belnap BA, J Amer Acad Psychoanalysis Dynamic Psychiatry 2006;34(4):581–601; Mintz D & Flynn D, Psychiatr Clin North Am 2012;35(1):143–163).
TCPR: What are some examples of those unique aspects of patients that influence outcomes?
Dr. Mintz: There are dozens of psychosocial factors that affect medication outcomes. Patient preference is a potent one. It makes a huge difference if patients get the treatment that they want. For example, in one study, when patients with depression were randomized to a treatment they wanted—either psychotherapy or psychopharmacology, about 50 percent got better. However, when people who wanted medication were randomized to the psychotherapy group, only a quarter of them got better. And when people who wanted psychotherapy were randomized to the psychopharmacology group, only about seven percent of them responded (Kocsis JH et al, J Clin Psychiatry 2009;70(3):354–361). Another important factor is whether the patient is ready to get better. We know, for example that when patients who are not ready to change (based on a “readiness to change” battery) are given a medication, they do worse than patients who are ready to change, even when these patients receive a placebo (Beitman BD et al, Anxiety 1994;1(2):64–69).
TCPR: So we should be paying more attention to what our patients prefer.
Dr. Mintz: Absolutely. Sometimes, when people come to a psychiatrist, we have already made up their minds for them in a way. This can stand in the way of our patients getting better.
TCPR: What can you tell us about the doctor-patient alliance and its role in treatment?
Dr. Mintz: It is really about giving the patient greater authority, bringing them in as a partner rather than establishing yourself as the one who knows best, even before you know what the patient wants. We psychiatrists have to pay attention to the fact that our environment applies considerable pressures upon us to objectify patients or to think about them in a biomedically reductionistic way.
TCPR: Is there evidence that a good doctor-patient alliance improves outcomes?
Dr. Mintz: Studies have found that patients with a good alliance receiving placebo had greater reductions in depression than patients in a poor alliance receiving an active drug (Krupnick JL et al, J Consult Clin Psychol 1996;64(3):532–539). Psychiatrists are sometimes not familiar with the evidence for the profound effect of psychosocial factors on outcomes, so familiarizing oneself with that evidence base goes a long way toward helping resist pressures to treat patients as if they are neurotransmitter soup. Furthermore, I think we need to know the patient; what he or she really wants. This is where the psychodynamic aspect comes in. A person may want to be rid of their depression on the surface, but beneath that there are likely to be more potent motivations, like the desire to be loved, or to escape some crushing burdens. And you, the psychiatrist, need to try to understand what your patient is most trying to get, and not make the assumption that the important thing is to stop this or that symptom.
TCPR: But if we don’t address symptoms and the underlying illness, but instead just give the patient what they want, then are we doing ultimately a disservice to the patient?
Dr. Mintz: That is an interesting question. There is no alliance if either participant is simply submitting to the will of the other. Rather than reflexively giving them what they want, I would say that we should support them in getting what they want. We have to be guided by therapeutic principles. I’m concerned, however, that we are not mental health professionals anymore; we have become mental illness professionals. Health isn’t just about an absence of symptoms; health is about resilience and being in charge of yourself. It is useful to hold a developmental perspective, always asking what is it that will help the patient get where they want to go. And that may mean not treating symptoms at times because treatments can also get in the patient’s way. For example, a patient who requires four milligrams of Klonopin a day to eliminate anxiety might be just too compromised to achieve their goals. To what extent do you want to really participate in that? We are not simply trying to get rid of symptoms; we are trying to help people get back into life.
TCPR: Can you tell us about the role of the placebo effect in psychopharmacology?
Dr. Mintz: Studies suggest that placebo effects may account for more than three quarters of the effects of medications, or at least antidepressants. The thing is, placebo effects are real. You can lower blood pressure, you can cure ulcers. Depression is often so difficult to treat that we should be using every tool in our armamentarium, including optimizing the relationship and mobilizing the placebo effect.
TCPR: You have written about patients being ambivalent about symptoms. Can you describe what that means, how to identify it, and then how to use that in our treatment?
Dr. Mintz: Patients are in conflict; they want many things at different levels. Patients are often ambivalent about taking their pills because they expect to be harmed, more even than they think they will be helped. Similarly, the most ill patients often have experienced profound powerlessness in their lives, and find that they can be more powerful in their illness than they ever were in health. So I always keep in mind that patients may become attached, consciously or unconsciously, to covert benefits of their illnesses.
TCPR: What are “counter-therapeutic” uses of medications, which you have also spoken about?
Dr. Mintz: One example is when the patient learns to rely on medication instead of relying on people. They have come to the conclusion that you can’t count on people, but your pills will be there for you. And so they get upset and they turn to their medications; their world becomes increasingly depopulated because they turn less and less to people, and they are caught in a depressing vicious circle. This person is never going to stop being depressed because of the way he uses medications to avoid healthy developmental steps.
TCPR: Many outside influences keep us from approaching our patients in the ways you’re talking about. Can you talk about some of these factors?
Dr. Mintz: The concept of the 15-minute med check is probably the most destructive thing in psychiatry, because it already presupposes that all you are there to do is check the meds, and the person is left out of it. Our whole idea of the 15-minute med check is a massive experiment. There is no evidence base whatsoever for working this way. Most drug trials are done in environments where there is a tremendous amount of human contact. Patients are seen weekly, often with additional supports like nurses. To the extent that psychosocial factors matter, it is totally unfounded for us to be generalizing from that environment to the environment of the 15-minute med check.
TCPR: How, then, can we build this alliance?
Dr. Mintz: I don’t think it is so much about the time, but about the stance you take: that you and your patient are partners. Research in primary care settings has found that eliciting patient preferences takes no extra time. So a lot of this is a false assumption that you need hours and hours to build this kind of alliance.
TCPR: Many of us are being asked to perform measurement-based care, where we might be measuring outcomes that are just not relevant to the patient. Is this reality of practice still compatible with establishing a decent alliance with the patient?
Dr. Mintz: That is definitely a problem. Psychopharmacologic treatment resistance has doubled every five years since the early ‘80s. There has been a 3,200 percent increase in references to treatment-resistant psychiatric conditions during that time period. And I think it is in part due to a shift in the delivery of care, which promotes an objectifying approach to the patient. Now this includes things like engaging with a computer screen instead of a patient. However, since about 2009 there has been an increasing amount of attention to psychosocial factors in the prescribing process.
TCPR: What was special about 2009?
Dr. Mintz: The philosopher of science Thomas Kuhn said that scientific revolutions occur because the science gets better and better until it starts encountering its limits. The paradox of our focus on evidence-based practice is that it became clear that far too few of our patients are recovering on medications. So, in 2009 and the beginning of 2010 you started to see a slew of articles coming out into popular media—Time, Newsweek, The Wall Street Journal, and The New York Times—about the limitations of antidepressants and stating that there is a lot more for us to do to address the problems that our patients have.
TCPR: You are proposing that there is a lot of treatment resistance and it might be due to the failed alliance between the prescriber and patient, and that when done properly, the medications plus the alliance together will be successful.
Dr. Mintz: At least more successful. Obviously, I am not claiming it is a panacea. Our medications remain limited in terms of their biological effectiveness and our psychosocial approach may support effectiveness or detract from it. Treatment resistance is a real problem, and so we should be using every evidence-based tool we have to help our patients get better.
TCPR: This all sounds great from a theoretical standpoint. But does this require anything extra to practice this way?
Dr. Mintz: There are a lot of simple things that anybody can do, beginning with resisting pressures to think reductionistically about patients. Ask patients what they want, ask what they might stand to lose if treatment works, and understand something about their lives and their relationships. If you know, for instance, that this person is scared of dependency in relationships, you could anticipate that if a medication works, it might frighten them. Then you can begin to address that fear with them, before it leads to treatment discontinuation. That, I think, any psychologically-minded person can do. I have begun to regret the term psychodynamic psychopharmacology because my other acronym for it would be JPOGCC (just plain old good clinical care), and I think that is something that is ideally a part of doctoring, whatever you are doing. I am optimistic that with the pendulum swinging we will see more research on psychosocial aspects of medications, and as the ball gets rolling, the field of psychiatry will be in a better position to resist care delivery models that really promote an objectification of the patient.
TCPR: Thank you, Dr. Mintz.
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