The art of prescribing psychotropic medications

Clinical experience and research suggest that patients respond best to pharmacotherapy when they feel understood by their prescriber, like their prescriber, and feel that the prescriber likes them. This “therapeutic alliance” is a partnership characterized by a warm, open and caring prescriber sharing responsibility for the medication treatment with a patient who agrees to take the medication as prescribed and accurately report about its efficacy and side effects. For the patient, there is assurance that the prescriber will be available for consultation as the treatment progresses. For the prescriber, there is assurance of a cooperative patient who can be trusted to make contact if any issue related to the treatment arises. Research has shown that medication adherence and treatment outcome are improved in the setting of a valid therapeutic alliance1. Why is a therapeutic alliance necessary? The sensible prescriber understands that patients may have many pre-conceived negative thoughts about psychotropic medications. For example, some patients believe that taking a medication means “I must be crazy”2 or be out of behavioral control. They may think or ask themselves: Do I really need medication? Do I like (trust) this prescriber? Does medication mean that I am weak, emotionally inadequate, a failure in life? Will medications change my personality or my ability to function? Will I lose my creativity, my physical prowess, my emotional sensitivity? For some individuals, taking psychotropic medications may be a sign of characterological weakness, or a failure of religious faith, or disobedience with family (and group) rules, practices and beliefs. The sensible prescriber understands that, for some people, being prescribed a psychotropic medication is evidence that they are too sick to benefit from psychotherapy or another mental health approach. For some paranoid patients, medication may represent a specific threat to their autonomy. A hopeless depressed person may refuse medication as useless: how will a drug change a hopeless condition? Patients with schizophrenia are sometimes unaware that they are ill and cannot understand the reason for medication. The sensible prescriber recognizes, therefore, that offering medication may be more complicated than simply picking the right drug and dosage. Sensitivity to the patient’s background and beliefs can help develop the alliance that will facilitate effective prescribing. The therapeutic alliance and sensible prescribing can be recognized as examples of transference and countertransference. In many societies, prescribers (“medicine men”) are perceived as powerful and authoritarian. Whether a patient can trust and respect a prescriber of psychotropic medications may be influenced by past experiences with prior figures of authority. The sensible prescriber understands that hopelessness, depressed mood and suicidal ideation are not only part of a mood disorder, but may also communicate a long-standing low self-esteem that can be therapeutically explored in a gentle discussion. Some patients are embarrassed by their symptoms and lack of personal control over their behavior, and feel that prescription of a psychotropic medication signals personal failure. Adult patients, when sick, especially with disturbing or crippling symptoms, may become regressed and needy3, 4, and even act in a child-like manner. In order to not feel helpless, others may behave in an arrogant, insulting, disrespectful way in the consultation. Still others who value rigid control may ridicule the importance of the prescriber and his/her medication. Some individuals believe that only psychotherapy can truly help emotional suffering. In these cases, the patient may demean the prescriber of psychotropic medications as only a “mechanic” who has little appreciation for the complexity of his/her experience. Sometimes these patients may make the prescriber feel uncomfortable or irritated. Some patients may remind the prescriber of someone (such as a parent) who may have been arrogant or insulting, thereby triggering countertransference feelings that might interfere with forming a therapeutic alliance. There are also individuals whose emotional suffering paradoxically solves some problem in their lives that has resisted solution. This can also be seen in families who praise and support the prescriber, but then manage to interfere with the patient taking the medication. It is not unusual that an individual’s psychiatric symptoms may serve to stabilize an otherwise unfixable individual or family problem. The sensible prescriber will understand these dynamics and not insist on treatment with medication until a more stable therapeutic alliance has been created. One guideline to sensible prescribing and building a therapeutic alliance is for the prescriber of psychotropic medications to recall his/her own emotional responses to illness that required medication treatment. How did you feel when sick, frightened or even disabled in encountering a prescriber for the first time? Was it reassuring, or was it more frightening? Did the prescriber seem to care, show concern, ask useful questions? Did the prescriber look at you or just type into a computer? Did the prescriber become distracted during the interview, seem to rush, look at his/her watch frequently? Did you like the prescriber and did you feel that the prescriber liked you? Would you return for a second consultation? “Empathic transactions do not occur in a vacuum: a reciprocal relationship exists between the patient and his or her treater”5. Prescribing clinicians should fully use their diagnostic and interviewing skills when evaluating an individual for medications. Medication prescription that is associated with sensitive inquiry into the circumstances of the patient’s current (and past) psychological difficulties results in an improved therapeutic alliance and better treatment outcome6. Prescribing is an art as well as a science. Within the therapeutic alliance, therefore, the prescriber listens to the background and context of the overt symptoms rather than just listening to a recitation of the symptoms7. Appreciation of how the patient feels about him/herself can provide a starting point for a valid alliance that may enhance the therapeutic benefits of the prescribed psychotropic medications. For some patients and prescribers, the formation of a therapeutic alliance early in treatment leads to years of therapeutic interaction for chronic and recurrent disorders. Sometimes this alliance focused on medication also becomes the basis for ongoing psychotherapy8. The rapidly growing knowledge of the neurobiological underpinnings of some psychiatric disorders is providing an increasingly scientific basis for their drug treatment. However, it is unfortunate that, as prescribers learn more about neurobiology, they appear to be paying less attention to the empathic component of prescribing. It would be helpful to many patients seeking psychotropic drug treatment, as well as to their prescribers, if psychopharmacology training programs included discussions of sensible prescribing and therapeutic alliance in their curricula, in conjunction with the science of psychotropic drug treatments9.