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 ge, 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 his or her 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.