Mindful Psychopharmacology

I was pleased to read the overwhelmingly positive response to Daniel Carlat's New York Times Magazine piece Mind Over Meds in the letters to the editor, including my own.

Perhaps we are at the end of an era where, under the influence of the pharmaceutical industry and health insurance industry, clinicians prescribe psychoactive medication in 20 minute visits, with minimal attention to the experience of the person they are treating.

I am not "against" psychoactive medication, which can, in certain circumstances, offer significant benefit. Framing of the discussion as being pro or anti-medication leads to antagonism and polarization, which is not useful. Rather I would advocate for "mindful" use of medication.

David Mintz and Barri Belnap, psychiatrists at the Austen Riggs Center, in a 2006 article in the Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry propose the term "psychodynamic psychopharamcology." Such an approach looks at the patients experience as a whole rather than focusing exclusively on symptoms and dose of medication. They reference a 1996 NIMH study showing that patients who had a good relationship with their doctor and took a placebo had a greater reduction in symptoms than patients who had a poor relationship with their doctor and received an active drug.

Mintz and Belnap quote Sir William Osler, the father of modern medicine, who said, "It is much more important to know what sort of patient has a disease than what sort of disease a patient has." In the conclusion, they write,

A straightforward "scientific" approach to prescription establishes a "rational" basis for treatment choice, but runs the risk of neglecting the unique impact of the patient's subjectivity, failing to attend to the patient's authority and missing the importance of relationships and of meaning to cure.

Both Carlat and Mintz's articles focus on use of medication in adults. For children the issue is equally important and significantly more complex. Family and developmental issues must be taken into account.

For example, a 10 year old boy I treated did very well initially on stimulant medication. As he entered adolescence, he began to display developmentally appropriate argumentative and occasionally oppositional behavior. His parents attributed his behavior to a "symptom" of his ADHD. All family conflict was channeled into discussion of his dose of medication. In turn he became increasingly angry, perhaps because his experience was not recognized and his legitimate feelings attributed to a "disease." The long term consequences on this boy's development of such behavior cannot be good. Dr. Mintz, in his work with seriously troubled young adults, has seen up close the ill effects of disregard for a child's developmental context, and in his words,"funnelling" of all family problems into a child's medication.

Kyle Pruett,a child psychiatrist at the Yale Child Study Center, has an eloquent discussion of this subject in Pediatric Psychopharmacology: Principles and Practice.Two Harvard psychiatrists, Peter Chubinsky and Nancy Rappaport, have an article in the 2006 Journal of Infant, Child and Adolescent Psychotherapy entitled, "Medication and the Fragile Alliance: The Complex Meaning of Psychotropic Medication to Children, Adolescents and Families"


I hope that clinicians who prescribe psychoactive medications for children, including both pediatricians and child psychiatrists, will incorporate "psychodynamic psychopharmacology" into their practice, and think about the complex meaning of medication for children and their families. Equally important is that our culture change our expectation, and accept the limitations, of the role of medication in promotion of children's mental health.