THE PSYCHOLOGY OF MEDICATION TREATMENT
By David M. Goldstein, M.D.
Director, Mood Disorders Program
Georgetown University Medical Center
For many years, various psychotherapies (talk therapies) were the mainstay of treatment for depression and manic depression, but in recent years, psycho-pharmacology (the science of psychiatric drugs) has made great strides. Psychotherapy appears to improve the patient's social and vocational functioning, whereas drug treatment is most effective against physical symptoms-disturbances in sleep, appetite, and energy-and on the prevention of relapse. It was once believed that these two treatment approaches would conflict with one another, but we now know that the opposite is true: combining them can enhance therapeutic outcome.
Of particular interest to me is the psychological aspect of psychopharmacology, that is, the psychology of taking psychiatric medication, prescribing it, or referring someone for treatment with it. This article focuses on that aspect of the overall treatment process.
Taking medication is rich in meaning for the patient. One's feelings about the process of taking medication can significantly influence compliance with the doctor's instructions for taking it. Compliance is very important for the person with depression because for antidepressants and mood stabilizers to be effective, they must be taken in sufficient dosages and for sufficient lengths of time. Side effects can subvert the treatment by causing the patient to miss doses or stop taking the drug altogether. The relationship between the doctor and patient is crucial in fostering a free and open two-way communication about how to take the drugs and what to do about side effects if they occur. The need for this dialogue seems straightforward and obvious; what, however, can interfere with this dialogue?
On the patient's part, at least four attitudes can subvert the alliance between doctor and patient. The first of these is the belief "I should be able to overcome this illness by myself." In this instance, the patient feels defeated by taking the medications, as if doing so were an acknowledgment of weakness. Patients with this attitude believe that they should always be able to control what is happening to their bodies and that any recognition that they cannot is an admission of failure. Many patients struggle with this issue before coming to see the doctor and continue to worry about it silently during the treatment. It is an issue that should be raised and discussed openly.
A second troublesome attitude for patients to have is the fear that taking the medication will put them under the control and domination of the doctor. In this instance, the doctor is usually viewed as authoritarian and controlling. This attitude may undermine the collaborative atmosphere that is helpful for a positive treatment outcome and may lead patients to overreport or underreport therapeutic responses to the drug as well as side effects. Alternatively, patients with the attitude may prematurely discontinue the medication or make changes in dosage without consulting the doctor. Sudden, unexplained withdrawal from treatment often is based on this fear of being controlled by the doctor.
A third attitude that patients may have in connection with taking medication is a feeling of passivity. Here the doctor is viewed as a beneficent, protective, motherly figure who will take care of everything. This attitude may bring the ill person into the doctor's office, but it does not support a collaborative relationship. Again, patients may underreport side effects or exaggerate benefits from the medication as part of this passive and dependent attitude in relation to the doctor. Patients may unconsciously resent the doctor in this kind of a relationship and be motivated to undermine the treatment as a way of defeating him or her.
A fourth type of harmful attitude is for patients to believe that the doctor is disappointed in them or is giving up on working with them in psychotherapy. This attitude may reflect a feeling of guilt about taking the medication.
In all of these examples, the person's developmental history is very important because people universally tend to repeat in the present their childhood attitudes and patterns of behavior. Patients may feel the same kind of dissatisfaction with the doctor that they felt with their parents upon seeking help during childhood.
The act of prescribing a medication also has psychological aspects. People enter medicine with a wish to be able to help others who are suffering from illnesses. When that wish is frustrated, some physicians react poorly. One common response is overprescribing. For example, a physician may start to feel helpless because a prescribed treatment is not going well. He or she may react by prescribing too many medications or too much of a given one. A much better response to feelings of helplessness is to admit to the problem and ask for assistance. Consultation with other physicians is commonplace in medicine and another's viewpoint may break a therapeutic impasse. A physician may also respond to frustration by becoming non-empathic, or "cold," often because he or she is angry about something in the treatment. Although raising the issue of a lack of empathy may take courage on the part of the patient, it may rescue the treatment process.
A final area of medication treatment to be explored involves the third person who may participate in the process: the referral source. The psychology of referral is of increasing concern today because of the trend toward split treatment situations in which the patient sees a psychiatrist for medication and a psychiatric nurse, social worker, psychologist, or other mental-health counselor for psychotherapy. Most often a patient's first contact for the treatment of depression is with a psychotherapist other than a psychiatrist. What if that therapist feels competitive with the doctor or is fearful of "losing control" over the treatment? A referral can be made with enthusiasm, optimism, and encouragement; or it can be made half-heartedly, with guilt attached. Sometimes patients struggle with the feeling that they are abandoning their psychotherapist when they go for a medication consultation. Once again, the solution to these various destructive undercurrents is open communication-among the patient, the doctor, and the psychotherapist. The doctor and the psychotherapist should consult with each other on a regular basis and have clearly established roles in relationship to the patient. All psychotherapy issues should go to the psychotherapist and all significant medical questions to the psychiatrist. There are times when split treatment doesn't work and the patient is better off seeing one person for both psychotherapy and medication.
- Gabbard, G.O. Dynamic pharmacotherapy of depression. The Psychiatric Times November, 1991.
- Bradley, S.S. Non-physician psychotherapist-physician pharmacotherapist: A new model for concurrent treatment. Psychiatric Clinics of North America. 13:2, June, 1990.
- Rounsaville, B. J., Klerman, G.L., Weissman, M.M. Do psychotherapy and pharmacotherapy for depression conflict?: Empirical evidence from a clinical trial. Arch. General Psychiatry 38:24-29, 1981.
I am NOT a doctor and make no pretense to that effect. I AM bipolar and I AM an educator who has spent many hours carefully researching bipolar illness. Information provided on this site is not meant to supplant or replace the advice and directives of your physician or therapist. Your psychiatrist, psychopharmacologist, and therapist have the final word in all cases.
Though great care has been taken to insure the accuracy of all information provided here, the information itself is presented "as is." You, the reader, bear the entire risk in its use and dissemination.