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Medication

"Factors such as meaning effects, therapeutic alliance, ambivalence, and patient autonomy have a powerful and measurable impact on the outcome of pharmacotherapy and must be considered if we are to treat the whole person."​

-David Mintz, MD, DFAPA

Beyond Biology

There is significant evidence that psychological and interpersonal elements greatly influence medication treatment outcomes. A psychodynamic approach combines evidence-based pharmacology with psychodynamic insights and methods. It recognizes the value of the patient-physician therapeutic alliance and the complex nature of the patient’s treatment wishes. Factors affecting treatment can be explored and changed, such as:

  • Ambivalence towards medication

  • Experiences of disempowerment

  • Development of secondary gains of the illness​

Reviews of FDA clinical trials of antidepressants indicated that 75% to 81% of a drug response can be attributed to nonpharmacological effects.

A comprehensive list of the factors that promote optimal response to medication can be found at the end of this page.

Take me there now.

Patient Empowerment

This approach focuses on addressing symptoms in relation to how they affect the your daily functioning and reaching your life goals. Acknowledging the role of the attitudes, fears, and desires on treatment outcomes can transform the process from passive care that you receive to active recovery that you do. This happens through:

  • Encouraging patient autonomy through education on how psychosocial factors influence treatment

  • Collaborating with the patient to uncover fears and deeper desires, helping to understand the impact on treatment

  • Using insights gained from this process to inform prescribing practices, moving away from an authoritarian approach

A Psychodynamic Approach to Medications

Recognizing how psychological and interpersonal elements influence medication use can pave the way for treatment that fosters active recovery. The same psychodynamic principles and techniques employed in therapy are utilized in the process of selecting and taking medication. A patient’s unconscious mental landscape significantly affects their psychological response to medication (e.g. placebo or nocebo effect) and influences their medication-related behaviors.

The physician must be more than just a ‘prescriber’ who relies on mental algorithms and checklists to select a medication and then dictates that the patient take it without question. Instead, the physician works alongside the patient in a collaborative exploration of the patient's mental world to identify any anti-therapeutic influences at play. By bringing unconscious elements into awareness, patients can be empowered to make more conscious decisions regarding their medication. This approach also allows physicians to change the ways they participate in the dynamic to enhance the effectiveness of medication treatment.

Unconscious

Much of mental life happens outside our conscious awareness, including drives that may counter treatment goals or contribute to nocebo effects. The physician's role is to facilitate bringing the unconscious into the patient’s awareness, allowing them to begin gaining understanding and control over these influences.

Psychodynamic Concepts Relevant to Medication

What factors promote optimal response to medication?

Physician

Patient

  • Strong sense of empowerment

  • Belongs to systemically privileged communities

  • Lack of early childhood trauma

  • Higher expectations for medications

  • Engaging in treatment voluntarily

  • View of illness as primarily psychological

  • Displays warmth and empathy

  • Psychological orientation to illness & treatment

  • Exhibits therapeutic optimism

  • Builds a strong therapeutic alliance

  • Shows investment in the patient & their improvement

  • Skilled, effective communication

  • Nonauthoritarian communication style

  • Positive affect & voice tone

  • Emotionally present during appointments

  • Focused on the patient during appointments

  • Collaborates on treatment targets & diagnosis

  • Supportive of patient autonomy

  • Engages patient in shared decision making

  • Respects the patient's treatment preferences

  • Engaging in treatment voluntarily

Note: all links above will take you to a different site in a new window. I have no personal or professional affiliations with the authors and organizations.

Source: Mintz, David. Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient. American Psychiatric Association Publishing, 2022.

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