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Austelle CW, Seery E. Psychodynamically Informed Brain Stimulation: Building a Bridge from Brain to Mind. Am J Psychoanal 2024; 84:285-310. [PMID: 38871924 DOI: 10.1057/s11231-024-09444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Since its inception, psychiatry has undergone several periods of radical identity transformation. Initially limited to psychotherapy alone, the advent of medications stimulated an era of biological psychiatry. For years, medications served as the mainstay of biological treatments, paralleled by a rise in treatment resistance. Brain stimulation therapies are psychiatry's newest arm of intervention and represent an area ripe for exploration. These techniques offer new hope to treatment-resistant patients, but in a manner often dissociated from psychoanalytic conceptualization and the practice of psychotherapy. There is growing interest in bridging this divide. In this article, we continue the efforts at interweaving what may seem to be disparate approaches through the topic of treatment resistance. This article aims to engage interventional psychiatrists in considering psychosocial dimensions of their treatments and to provide education for psychoanalytic clinicians on the history, mechanism of action, and applications of brain stimulation technologies.
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Affiliation(s)
- Christopher W Austelle
- MD, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Erin Seery
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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2
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van Schalkwyk GI, Parker TN, Horne JG, Agapoff JA. Resilient Prescribing: An Approach to Psychotropic Use in Deployed Environments. Mil Med 2023; 188:236-240. [PMID: 37026707 DOI: 10.1093/milmed/usad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/25/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
Resilient prescribing is an approach to the use of psychotropics that considers the significance of the treatment beyond the direct effects of the medication. Within this strengths-based approach, those who are prescribed medications must retain a sense of self-efficacy, understand the importance of their own actions in their recovery, have reasonable expectations of what a medication can and cannot do, and avoid the adoption of a disempowering illness identity. These constitute the principles of resilient prescribing. In this manuscript, we explore these principles with consideration for how they may be applied in deployed settings where the ability of service members to recover from behavioral health concerns is mission critical. These principles offer a roadmap to prescribing that builds upon the service members' own strengths and has the potential to amplify the positive impacts of mental health treatment.
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Affiliation(s)
| | - Trisha N Parker
- Shaping Your Future Psychiatry, Virginia Beach, VA 23464, USA
| | - Jenna G Horne
- 384th Wellness Clinic NCOIC, Camp Arifjan, 09330, Kuwait
| | - Jame A Agapoff
- Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i at Manoa, Honolulu, HI 96813, USA
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3
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Rogalski D, Barnett N, Bueno de Mesquita A, Jubraj B. The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health. PHARMACY 2023; 11:pharmacy11020062. [PMID: 36961040 PMCID: PMC10037595 DOI: 10.3390/pharmacy11020062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023] Open
Abstract
Pharmacists have traditionally supported the prescribing process, arguably in reactive or corrective roles. The advent of pharmacist prescribing in 2004 represented a major shift in practice, leading to greater responsibility for making clinical decisions with and for patients. Prescribing rights require pharmacists to take a more prescriptive role that will allow them to contribute to long-standing prescribing challenges such as poor medication adherence, overprescribing, and the need for shared decision-making and person-centered care. Central to these endeavors are the development and possession of effective consultation skills. University schools of pharmacists in the UK now routinely include consultation skills training, which is also provided by national education bodies. These challenges remain difficult to overcome, even though it is understood, for example, that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. More recently, a concerted effort has been made to tackle overprescribing and the harm that may occur through the inappropriate use of medication. In routine pharmacy work, these priorities may linger at the bottom of the list due to the busy and complex nature of the work. Solutions to these problems of adherence, optimizing benefits of medication, and overprescribing have typically been pragmatic and structured. However, an arguably reductionist approach to implementation fails to address the complex patient interactions around prescribing and taking medication, and the heterogeneity of the patient's experience, leaving the answers elusive. We suggest that it is essential to explore how person-centered care is perceived and to emphasize the relational aspects of clinical consultations. The development of routine pharmacist prescribing demands building on the core values of person-centered care and shared decision making by introducing the concepts of "relational prescribing" and "open dialogue" to cultivate an essential pharmacotherapeutic alliance to deliver concrete positive patient outcomes. We provide a vignette of how a clinical case can be approached using principles of relational prescribing and open dialogue. We believe these are solutions that are not additional tasks but must be embedded into pharmacy practice. This will improve professional satisfaction and resilience, and encourage curiosity and creativity, particularly with the advent of all pharmacists in Great Britain becoming prescribers at graduation from 2026.
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Affiliation(s)
- David Rogalski
- Camden and Islington NHS Foundation Trust, London RG24 9NA, UK
| | - Nina Barnett
- London North West University Healthcare NHS Trust, London HA1 3UJ, UK
- Medicines Use and Safety Division, NHS Specialist Pharmacy Service, London HA1 3UJ, UK
| | | | - Barry Jubraj
- Medicines Use and Safety Division, NHS Specialist Pharmacy Service, London HA1 3UJ, UK
- School of Pharmacy, University College London, London WC1E 6BT, UK
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4
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King I, Shapiro Y. Learning the "Science of the Art of Prescribing": From Evidence-based Algorithms to Individualized Medicine in Psychiatric Care. J Psychiatr Pract 2022; 28:409-420. [PMID: 36074111 DOI: 10.1097/pra.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this review is to highlight the limitations of the traditional diagnosis/evidence-based symptom reduction paradigm and advocate for an individualized medicine approach that incorporates psychological and relational aspects of prescribing in addition to the objective patient presentation. Potential barriers, challenges, and proposed future directions for improving education in psychological and relational aspects of prescribing are discussed. Psychological aspects of prescribing, as recently spelled out in the field of psychodynamic psychopharmacology, are generally acknowledged as important, but they do not have a well-defined position in contemporary residency training throughout North America. While residents receive in-depth exposure to diverse aspects of what to prescribe in their psychopharmacological training, and they work with patients' subjective and relational meaning and the quality of the therapeutic alliance in their psychotherapy rotations, an integrated approach to how to prescribe is generally lacking. Despite many legitimate challenges, the authors suggest that teaching an integrated approach that incorporates objective, subjective, and relational factors in the provision of psychopharmacology and utilizing evidence-based principles of individualized care should be prioritized in both residency training and the provision of psychiatric treatment as a whole.
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Affiliation(s)
- Ian King
- KING and SHAPIRO: Department of Psychiatry, University of Alberta, Edmonton, AB, Canada
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5
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Konstantinidou H, Chartonas D, Rogalski D, Lee T. Will this tablet make me happy again? The contribution of relational prescribing in providing a pragmatic and psychodynamic framework for prescribers. BJPSYCH ADVANCES 2022. [DOI: 10.1192/bja.2022.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SUMMARY
We describe the importance of relational factors in prescribing practices and discuss how they may influence treatment outcomes. Although relational factors play a part in every clinician–patient interaction, they are particularly relevant when managing patients with complex emotional needs. We discuss how relational prescribing can add value when incorporated into standard practice. We introduce psychodynamic theory principles, and we suggest a framework to facilitate reflection and support decision-making when clinicians are faced with complex prescribing decisions.
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Mintz D. Recovery from Childhood Psychiatric Treatment: Addressing the Meaning of Medications. Psychodyn Psychiatry 2022; 50:131-148. [PMID: 35235407 DOI: 10.1521/pdps.2022.50.1.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Medications exert effects not only through biological mechanisms but also through the meanings that they carry. While positive effects (e.g., the placebo effect) are broadly recognized, psychiatry is often less attuned to the negative effects that are mediated through the meaning of medications. These negative effects may be especially pronounced when noxious meanings and countertherapeutic aspects of medications are incorporated into the unfolding development of a child and not countered by psychotherapeutic experiences that allow iatrogenic meanings to be placed in context. In this paper, psychosocial mechanisms, by which medications may cause harm, are explored. These include adverse effects on identity, impaired agency, impaired affective competence, and negative effects on the patient's relationship with care. When such harm has occurred at the level of meaning, it is best addressed at the level of meaning. Examples of psychotherapeutic work with young adults is offered to demonstrate the process of reworking developmental harm related to the meaning of medications.
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Affiliation(s)
- David Mintz
- Director of Psychiatric Education/Associate Director of Training/Team Leader, Austen Riggs Center
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Shapiro-Thompson R, Fineberg SK. The State of Overmedication in Borderline Personality Disorder: Interpersonal and Structural Factors. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:1-13. [PMID: 36185615 PMCID: PMC9524237 DOI: 10.1007/s40501-021-00255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review a)This review paper describes the state of prescribing practice in Borderline Personality Disorder (BPD), wherein medications are prescribed far more than either evidence or practice guideline would recommend. First, we describe the frequencies of medication use and polypharmacy in people with BPD. Recent findings b)In subsequent sections, we elaborate two main categories of factors that lead to overmedication of people with BPD: the interpersonally mediated and the structural. We consider interpersonally mediated factors to arise from communications of patients in distress and the well-meaning efforts of their prescribers to provide relief for certain overwhelming affective states. We are particularly focused on patterns of countertransference in prescribing that are directly linked to specific aspects of BPD pathology. We consider structural factors to arise from the complexities of medical and medicolegal systems and the contemporary patterns of financing medical care; we postulate that these complexities often compel prescribers to start medications, with associated disincentives for decreasing or discontinuing those medications over time. Summary c)More research is needed to understand how to best use medications in BPD, for example in targeted combination with psychotherapeutic and psychosocial interventions. However, current practice often departs markedly from the evidence. We recommend the dissemination of accessible, generalist BPD-treatment models in outpatient and inpatient practice; increased early detection of BPD; and increased diagnostic disclosure. We also recommend for individual providers and systems to implement prospective treatment plans that draw from BPD-specific psychosocial models. This approach can employ tiers of interventions to minimize reactive prescribing by anticipating high affect and offering BPD patients steadily empathic evidence-supported care.
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8
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Psychanalyse et pharmacopsychologie. ANNALES MEDICO-PSYCHOLOGIQUES 2021. [DOI: 10.1016/j.amp.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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9
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Nasir M, Li F, Courley S, Olten B, Bloch MH. Meta-Analysis: Pediatric Placebo Response in Depression Trials Does Not Replicate in Anxiety and Obsessive-Compulsive Disorder Trials. J Child Adolesc Psychopharmacol 2021; 31:670-684. [PMID: 34558984 DOI: 10.1089/cap.2021.0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Placebo response has been identified as an important factor influencing the success of adult antidepressant trials, yet little research of placebo response has been conducted in pediatric populations. Understanding disorder-specific and transdiagnostic predictors of pediatric placebo response is important in designing successful child psychopharmacological trials. Methods: A PubMed search was conducted for all pediatric antidepressant randomized controlled trials treating depression, anxiety, or obsessive-compulsive disorder (OCD). A random-effects model was utilized to examine the magnitude of placebo symptom improvement using standardized mean difference (SMD) and placebo response rates. Stratified subgroup analysis was performed by diagnostic indication. Meta-regression was utilized to search possible correlates of placebo symptom improvement and placebo response rate. Results: Thirty antidepressant trials involving 2911 participants receiving placebo were included in this meta-analysis. Magnitude of placebo improvement and placebo response rates varied significantly across disorders; being greater in depression (SMD = 1.44, 95% confidence interval [CI]: 1.18 to 1.71) than anxiety disorders (SMD = 1.09, 95% CI: 0.77 to 1.41) and the lowest in OCD (SMD = 0.71, 95% CI: 0.32 to 1.12). Different predictors were associated with placebo response in different indications. Conclusions: Both the magnitude and predictors of placebo response in pediatric depression trials do not replicate across anxiety and OCD. Based on our results, across disorders, minimizing the number of sites might significantly reduce placebo improvement. In addition to these, we could potentially decrease the placebo response in depression trials by increasing the number of subjects enrolled per study site, minimizing the number of study visits and conducting the studies in the United States. Further research is needed into the predictors of placebo response in pediatric anxiety and OCD.
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Affiliation(s)
- Madeeha Nasir
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Fenghua Li
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samantha Courley
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Baris Olten
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael H Bloch
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut, USA.,Yale Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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10
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Agarwal AK. Psychiatric practice: Some personal observations. Indian J Psychiatry 2020; 62:644-649. [PMID: 33896968 PMCID: PMC8052892 DOI: 10.4103/psychiatry.indianjpsychiatry_249_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/30/2020] [Accepted: 04/17/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Anil Kumar Agarwal
- Retired Professor, Department of Psychiatry, K. G's. Medical College, Lucknow, Uttar Pradesh, India
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11
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Abstract
After participating in this activity, learners should be better able to:• Assess medication management in patients with borderline personality disorder (BPD)• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy ABSTRACT: Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients' relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient's medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient's preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient's relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.
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12
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Böhmer MW, Krüger C. Therapeutic relationships and the problem of containment: Experiences of patients at a psychiatric training hospital. S Afr J Psychiatr 2019; 25:1246. [PMID: 31745442 PMCID: PMC6852003 DOI: 10.4102/sajpsychiatry.v25i0.1246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 06/21/2019] [Indexed: 11/25/2022] Open
Abstract
Background The biopsychosocial model emphasises the role of human relationships in psychiatric care. Therapeutic relationships that improve treatment outcome and provide containment are desperately needed by patients in distress. Despite the importance of human relationships, they are neglected in an era dominated by biological psychiatry. Aim This qualitative research project explores the experiences, perceptions and subsequent needs of patients. The role of therapeutic relationships, and the factors that patients felt influenced their relationship with their therapists, were examined. Setting A psychiatric training hospital in South Africa. Method Thirty in-depth semi-structured interviews were conducted with 15 inpatients. A qualitative, explorative-descriptive, collective case study design was used. Purposive sampling ensured maximum variation and richness of information. Grounded theory methods were used to analyse transcribed recordings. Results Patients valued therapeutic relationships that provide containment and potentially obviate the need for ‘measures of control’. A model of containment was developed to demonstrate the various factors that interact in the attempt to provide containment to patients in a psychiatric training hospital system. Conclusion Training hospitals should emphasise the role of therapeutic relationships in achieving containment and positive treatment outcomes. In developing countries, severe shortcomings in mental healthcare resources hinder the building of personal therapeutic relationships.
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Affiliation(s)
- Manfred W Böhmer
- Department of Psychiatry, University of Pretoria, Pretoria, South Africa
| | - Christa Krüger
- Department of Psychiatry, University of Pretoria, Pretoria, South Africa
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13
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Review of "Common Factors," Personal Reflections, and Introduction of the Shaving Brush Model of Integrated Psychotherapies. J Psychiatr Pract 2019; 25:374-378. [PMID: 31505522 DOI: 10.1097/pra.0000000000000418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This column reviews and updates "common factors" in psychotherapy, as originally described by Saul Rosenzweig in 1936. The author, a psychiatrist who has used multiple modalities of psychotherapeutic treatment over 4 decades, shares personal reflections concerning these "common factors" and introduces a model of integrated psychotherapies named for his grandfather's shaving brush.
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Mintz D. Recovery from Childhood Psychiatric Treatment: Addressing the Meaning of Medications. Psychodyn Psychiatry 2019; 47:235-256. [PMID: 31448987 DOI: 10.1521/pdps.2019.47.3.235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Medications exert effects not only through biological mechanisms but also through the meanings that they carry. While positive effects (e.g., the placebo effect) are broadly recognized, psychiatry is often less attuned to the negative effects that are mediated through the meaning of medications. These negative effects may be especially pronounced when noxious meanings and countertherapeutic aspects of medications are incorporated into the unfolding development of a child and not countered by psychotherapeutic experiences that allow iatrogenic meanings to be placed in context. In this paper, psychosocial mechanisms, by which medications may cause harm, are explored. These include adverse effects on identity, impaired agency, impaired affective competence, and negative effects on the patient's relationship with care. When such harm has occurred at the level of meaning, it is best addressed at the level of meaning. Examples of psychotherapeutic work with young adults is offered to demonstrate the process of reworking developmental harm related to the meaning of medications.
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Affiliation(s)
- David Mintz
- Director of Psychiatric Education/Associate Director of Training/Team Leader, Austen Riggs Center
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15
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Abstract
This column reviews the history of the Austen Riggs Center on the occasion of its centennial. Riggs has come to stand for high quality, state of the art, biopsychosocial, psychodynamic treatment in contemporary psychiatry and psychoanalysis. This column reviews elements of the positioning of Riggs in the field, and contributions that have emerged from Riggs that continue to have an impact on psychiatry, psychoanalysis, and their intersection-psychodynamic psychiatry.
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Abstract
The rationale, content, and teaching techniques used for a psychiatry residency psychodynamic therapy course based on Psychodynamic Therapy: A Guide to Evidence-Based Practice (Summers & Barber, 2009) are presented in the context of their evolution over the last two decades and the challenges of teaching this topic in the current environment. The central elements of an exciting and engaging psychotherapy teaching program-feelings, framework, and freedom-are explained. Specific topics such as psychodynamic formulation, using videos, self-disclosure, and resistance are discussed.
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Affiliation(s)
- Richard F Summers
- Clinical Professor of Psychiatry, Senior Residency Advisor, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
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17
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Weinberg E, Mintz D. The Overall Diagnosis: Psychodynamic Psychiatry, Six-Minute Psychotherapy, and Patient-Centered Care. Psychiatr Clin North Am 2018; 41:263-275. [PMID: 29739525 DOI: 10.1016/j.psc.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Optimal patient care in psychiatry necessitates attention to the treatment relationship and to the patient's experience as an individual. The growth of patient-centered medicine has led to an increased appreciation of the importance of the biopsychosocial formulation, the personhood of both the patient and the physician, the autonomy and authority of the patient, and the therapeutic alliance. Patient-centered medicine, developed by the seminal psychoanalytic theorist Michael Balint, has its roots in psychodynamic concepts. A psychodynamic approach to psychopharmacology improves psychiatric prescribing, and guides the psychiatrist in providing brief, limited psychotherapy, similar to that which the Balints recommended in primary care practice.
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Affiliation(s)
- Elizabeth Weinberg
- Austen Riggs Center, 25 Main Street, Box 962, Stockbridge, MA 01262, USA.
| | - David Mintz
- Austen Riggs Center, 25 Main Street, Box 962, Stockbridge, MA 01262, USA
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Shapiro Y. Psychodynamic Psychiatry in the 21st Century: Constructing a Comprehensive Science of Experience. Psychodyn Psychiatry 2018; 46:49-79. [PMID: 29480783 DOI: 10.1521/pdps.2018.46.1.49] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Psychodynamic psychiatry is not limited to psychotherapy practice. It is defined by systematic attention to the "common factors" underlying both psychotherapy and psychopharmacology outcomes, which include the patient's subjective systems of meaning and the complex flow of the patient-provider relationship in addition to the patient's "objective" psychopathology. It allows for a non-reductionist milieu where the meaning of the illness and the full complexity of the treatment process can be explored in order to achieve a qualitative and lasting change in the patient's psychopathology. The author proposes an integrated psychobiological model of psychiatric care where attention to the patient's subjective experience and the unique flow of the patient-provider relationship stand on an equal footing with the patient's objective behavioral and symptomatic presentation. This model provides a common foundation for diverse psychopharmacological and psychotherapeutic interventions to enable a paradigm shift from symptom- or syndrome-focused approach to individualized, process-oriented philosophy of care. Psychodynamically informed treatment provision helps to unify psychiatric practice by integrating objective, subjective, and intersubjective science in order to construct a systematic science of experience.
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Affiliation(s)
- Yakov Shapiro
- Clinical Professor, Department of Psychiatry, University of Alberta, Edmonton, Canada
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19
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Abstract
PURPOSE/BACKGROUND This commentary deals with the neglected issue of the art of psychopharmacology by recounting the authors' journeys. METHODS/PROCEDURES First, a model of medical science situated within the history of medicine is described including (1) a limitation of the mathematical model of science, (2) the distinction between mechanistic science and mathematical science, (3) how this distinction is applied to medicine, and (4) how this distinction is applied to explain pharmacology to psychiatrists. Second, the neglected art of psychopharmacology is addressed by explaining (1) where the art of psychopharmacotherapy was hiding in the first author's psychopharmacology research, (2) how the Health Belief Model was applied to the art of medicine, (3) how the second author became interested in the Health Belief Model, and (4) his studies introducing the Health Belief Model in psychopharmacology. The authors' collaboration led to: (1) study of the effect of pharmacophobia on poor adherence and (2) reflection on the limits of the art of psychopharmacology. FINDINGS/RESULTS Low adherence was found in 45% (116/258) of psychiatric patients with pharmacophobia versus 22% (149/682) in those with no pharmacophobia, providing an odds ratio of 2.9 (95% confidence interval, 2.2-4.0) and an adjusted odds ratio of 2.5 (95% confidence interval, 1.8-3.5) after adjusting for other variables contributing to poor adherence. IMPLICATIONS/CONCLUSIONS Different cognitive patterns in different patients may contribute to poor adherence. Specific interventions targeting these varying cognitive styles may be needed in different patients to improve drug adherence.
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John AP, Singh NM, Nagarajaiah, Andrade C. Impact of an educational module in antidepressant-naive patients prescribed antidepressants for depression: Pilot, proof-of-concept, randomized controlled trial. Indian J Psychiatry 2016; 58:425-431. [PMID: 28197000 PMCID: PMC5270268 DOI: 10.4103/0019-5545.196710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patients are educated about their illness and its treatment at the time of diagnosis. However, little is known about how much of this education is retained and how it influences knowledge about, attitudes toward, and experiences with medication in antidepressant-naive patients with depression. METHODS Antidepressant-naive outpatients with International Classification of Diseases-10 dysthymia or mild to moderate depression, who were advised antidepressant monotherapy, were randomized to control (n = 22) or intervention (n = 17) groups. Control patients received treatment as usual, and intervention patients received, in addition, a face-to-face, individualized, 10-min education session about the nature of depression, antidepressant treatment, efficacy and adverse effects of the prescribed drug, and plan of management. Knowledge about the illness and its treatment were assessed at baseline (before the educational intervention) and 6 weeks later. At follow-up, experiences with treatment were also evaluated. The study was double-blind. RESULTS At baseline, patients had poor knowledge about their illness and its treatment (most patients could not even name their diagnosis); however, few held unfavorable attitudes toward their prescribed medicines. At follow-up, there were modest improvements in both sets of outcomes. There were no differences between intervention and control groups in knowledge and attitude outcomes at baseline and end-point. Drug compliance did not differ between groups. However, importantly, intervention patients experienced a significantly larger number of adverse events than controls (mean, 3.5 vs. 1.7, respectively). CONCLUSIONS For ethical reasons, patients need to be educated about their illness and its treatment. However, such education may be a two-edged sword, with an increased nocebo effect as the most salient consequence. Failure to identify benefits in our study may have been the result of a Type 2 error. This study provides a wealth of information on a large number of issues related to knowledge, attitudes, and experiences of depressed, mostly low-income outpatients in relation to education about depression and its treatment, and future research can build on the findings of this study. We also provide an extensive discussion on directions for further research.
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Affiliation(s)
- Annie P John
- College of Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nagendra Madan Singh
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nagarajaiah
- Department of Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Chittaranjan Andrade
- Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Vijapura S, Laferton JAC, Mintz D, Kaptchuk TJ, Wolfe D. Psychiatrists' Attitudes Toward Non-Pharmacologic Factors Within the Context of Antidepressant Pharmacotherapy. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2016; 40:783-789. [PMID: 26646406 PMCID: PMC4899297 DOI: 10.1007/s40596-015-0470-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/24/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Recent meta-analyses of antidepressant clinical trials have suggested that up to 82 % of response can be attributed to non-medication-related factors. The present study examines psychiatrists' attitudes regarding non-pharmacologic factors within the context of antidepressant pharmacotherapy. METHODS A web-based, 20-question cross-sectional survey was distributed to 101 staff psychiatrists and 48 post-graduate trainees in psychiatry at an academic hospital in Boston, MA. Demographics, practice characteristics, beliefs about non-pharmacologic factors affecting prescribing practices, perceived response and remission rates, and opinions about the need for further investigations in the psychopharmacology process were assessed. RESULTS Overall completion rate was 53 %. The final sample included 79 responses. The medians for clinician-perceived response rates (54 %) and remission rates (33 %) were in agreement with published rates. The reported median of the what portion of clinical outcomes is believed to be due to placebo effects (26 %) was numerically lower than suggested by literature. The contribution of the active ingredients of medications was perceived to be significantly higher than the contribution of patient characteristics and clinician characteristics. A longer time since graduation from medical school was significantly associated with higher belief in the effect of the active ingredients of antidepressant medications and with less perceived importance of placebo effects. CONCLUSION These findings suggest a discrepancy between empirical evidence and psychiatrists' beliefs on the impact of placebo effects on clinical outcomes. Educating antidepressant prescribers about the evidence based on psychosocial mediators of placebo effects' contribution to outcome may represent a promising strategy for improving clinical outcomes.
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Affiliation(s)
| | | | | | | | - David Wolfe
- Brigham and Women's Hospital, Boston, MA, USA
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22
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Psychotherapy and Its Role in Psychiatric Practice: A Position Paper. II. Objective, Subjective, and Intersubjective Science. J Psychiatr Pract 2016; 22:321-32. [PMID: 27427844 DOI: 10.1097/pra.0000000000000161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the first article in this 2-part series, we outlined a psychobiological model of psychiatric treatment and reviewed the evidence showing psychotherapy to be a form of biological intervention that induces lasting alterations in brain structure and function. In this second article, we focus on the adaptive model of psychopathology, the effectiveness of psychotherapeutic interventions, the synergistic effects of combined psychotherapy and psychopharmacology treatments, and attention to the patient's subjective experience and the doctor-patient alliance to complement an "objective" case formulation. The evidence strongly suggests the need for an integrated treatment approach based on the objective, subjective, and intersubjective science that forms the foundation of psychiatry as a clinical discipline, in which psychotherapy and psychopharmacology are seen as complementary treatments within a systemic approach to psychiatric care and training. What emerges is the integrated psychobiological model of care with a complex treatment matrix unique to each patient-provider pair and comprised of biological, experiential, and relational domains of treatment which form the foundation of psychiatry as a science of attachment and meaning.
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Psychotherapy and its Role in Psychiatric Practice: A Position Paper. I. Psychiatry as a Psychobiological Discipline. J Psychiatr Pract 2016; 22:221-31. [PMID: 27123801 DOI: 10.1097/pra.0000000000000159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Economic, political, and ideological landscapes have impacted the practice of psychiatry throughout its evolution as a medical discipline. Despite enormous scientific advances over the course of the past century, many psychiatrists continue to operate with a split Cartesian picture of mind versus brain and entrenched ideological positions ranging from biological "chemical imbalance" to rigidly followed manualized psychotherapy approaches, both of which frequently result in fractured clinical care. With the impact of systemic economic and political pressures in Canada and the United States, the attention to the doctor-patient relationship has taken a back seat to high-volume practices, computerized assessment tools, and the focus on evidence-based treatments for behaviorally defined syndromes in the Diagnostic and Statistical Manual of Mental Disorders that often come at the expense of the patient's experience of his or her illness. We spend much time teaching the next generation of psychiatrists what to prescribe versus how to prescribe; what manualized treatments to administer versus questioning why our patients engage in dysfunctional patterns of thinking, feeling, and relating to others, and what impact these patterns may have on their interaction with us in the here-and-now of the treatment setting. In this paper, we propose an integrative psychobiological model, in which biological interventions carry personal meanings, and relational transactions in the treatment setting are a form of learning that results in lasting physiological changes in the brain. Psychiatry needs to reconnect with its roots as a science of attachment and meaning, in which attention to the objective, subjective, and relational domains of the patient-provider experience is equally foundational for any successful treatment outcome.
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Konstantinidou H, Evans C. Pharmacotherapy and psychotherapy: the challenges of integrating two paradigms. PSYCHOANALYTIC PSYCHOTHERAPY 2015. [DOI: 10.1080/02668734.2015.1051096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Fava GA. Rational use of antidepressant drugs. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 83:197-204. [PMID: 24969962 DOI: 10.1159/000362803] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 04/10/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Giovanni A Fava
- Affective Disorders Program, Department of Psychology, University of Bologna, Bologna, Italy
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26
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Kok G, Burger H, Riper H, Cuijpers P, Dekker J, van Marwijk H, Smit F, Beck A, Bockting CLH. The Three-Month Effect of Mobile Internet-Based Cognitive Therapy on the Course of Depressive Symptoms in Remitted Recurrently Depressed Patients: Results of a Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2015; 84:90-99. [PMID: 25721915 DOI: 10.1159/000369469] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 10/15/2014] [Indexed: 11/19/2022]
Abstract
Background: Internet-based cognitive therapy with monitoring via text messages (mobile CT), in addition to treatment as usual (TAU), might offer a cost-effective way to treat recurrent depression. Method: Remitted patients with at least 2 previous episodes of depression were randomized to mobile CT in addition to TAU (n = 126) or TAU only (n = 113). A linear mixed model was used to examine the effect of the treatment condition on a 3-month course of depressive symptoms after remission. Both an intention-to-treat analysis (n = 239) and a completer analysis (n = 193) were used. Depressive symptoms were assessed using the Inventory of Depressive Symptomatology (IDS-SR30) at baseline and 1.5 and 3 months after randomization. Results: Residual depressive symptoms showed a small but statistically significant decrease in the intention-to-treat group over 3 months in the mobile CT group relative to the TAU group (difference: -1.60 points on the IDS-SR30 per month, 95% CI = -2.64 to -0.56, p = 0.003). The effect of the treatment condition on the depressive symptomatology at the 3-month follow-up was small to moderate (Cohen's d = 0.44). All analyses among completers (≥5 modules) showed more pronounced treatment effects. Adjustment for unequally distributed variables did not markedly affect the results. Conclusions: Residual depressive symptoms after remission showed a more favorable course over 3 months in the mobile CT group compared to the TAU group. These results are a first indication that mobile CT in addition to TAU is effective in treating recurrently depressed patients in remission. However, demonstration of its long-term effectiveness and replication remains necessary. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Gemma Kok
- Department of Clinical Psychology, University of Groningen, University Medical Center Groningen, Groningen, Germany
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27
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Chessick RD. What hath freud wrought? Current confusion and controversies about the clinical practice of psychoanalysis and psychodynamic psychotherapy. Psychodyn Psychiatry 2014; 42:553-583. [PMID: 25494580 DOI: 10.1521/pdps.2014.42.4.553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article discusses the current state of psychoanalysis and the challenges to the fundamental premises of Freud's psychoanalysis by those who have shifted to relationship or so-called two-person psychologies in our field. The author begins by briefly describing a parallel to the recent history of psychoanalysis in the sudden rise and fall of scholastic philosophy in the 14th century. He then focuses on contemporary attacks on Freud's psychoanalysis as a science, based on the contention by two-person psychologists that free association by the patient and evenly hovering attention by the analyst are actually impossible. He reviews Freud's idea of psychoanalysis, discusses psychodynamic psychotherapy, both conceived as scientific treatment procedures, and describes the current assault on their metapsychological and epistemological foundations. Returning to the parallel between what happened to medieval scholasticism and what has happened to psychoanalysis, he examines why this happened, and the resulting fragmentation of psychoanalytic practice. The article concludes with suggestions for the integration of various schools of psychoanalysis, reminding us of Benjamin Franklin's warning: "We must, indeed, all hang together or, most assuredly, we shall all hang separately."
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Affiliation(s)
- Richard D Chessick
- Emeritus Professor of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine; Emeritus Training and Supervising Psychoanalyst, The Center for Psychoanalytic Study in Chicago
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28
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Tekkalaki B, Tripathi A, Trivedi JK. Welcome biological breakthroughs, supply psychosocial insights. Mens Sana Monogr 2014; 12:79-91. [PMID: 24891799 PMCID: PMC4037903 DOI: 10.4103/0973-1229.130315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/07/2014] [Accepted: 02/19/2014] [Indexed: 12/28/2022] Open
Abstract
Human behaviour, emotions, and cognition are complex to understand and explain. It is even more difficult to understand the basis for abnormal behaviour, disturbed emotions, and impaired cognitions, something mental health professionals are trying for long. In these pursuits, psychiatry has traversed through eras of humours, witchcraft, spirits, psychoanalysis, and gradually deviated from other medical specialities. Now, with recent biological breakthroughs like advances in psychopharmacology, neuroimaging and genetics, increasingly more emphasis is being given to the biological model of psychiatric disorders. These new biological models have given a more scientific appearance to the speciality. It has also revolutionised the management strategies and outcome of many psychiatric disorders. However, this rapid development in biological understanding of psychiatry also leads to a new wave of reductionism. In an attempt to deduce everything in terms of neurons, neurochemicals, and genes, can we neglect psychosocial aspects of mental health? Patients' personality, expectations, motives, family background, sociocultural backgrounds continue to affect mental health no matter how much 'biological' psychiatry gets. Biological and psychosocial approaches are not mutually exclusive but complementary. Integrating them harmoniously is the skill psychiatry demands for comprehensive understanding of mental and behavioural disorders.
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Affiliation(s)
- Bheemsain Tekkalaki
- Assistant Professor of Psychiatry, Navodaya Medical College, Raichur, Karnataka - 584 121, India
| | - Adarsh Tripathi
- Assistant Professor, Department of Psychiatry, King George Medical University, Lucknow - 226 003, Uttar Pradesh, India
| | - J K Trivedi
- Late Hon. Member WPA, Professor & Ex. Head, Department of Psychiatry, King George Medical University, Lucknow - 226 003, Uttar Pradesh, India
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Mallo CJ, Mintz DL, Lewis KC. Integrating psychosocial concepts into psychopharmacology training: a survey study of program directors and chief residents. Psychodyn Psychiatry 2014; 42:243-254. [PMID: 24828593 DOI: 10.1521/pdps.2014.42.2.243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A growing body of evidence suggests that psychiatric medication outcomes are shaped significantly by psychological and social factors surrounding the prescribing process. Little, however, is known about the extent to which psychiatry programs integrate this evidence base into residency training or the methods by which this is accomplished. Psychiatry residency program directors and chief residents participated in an exploratory online survey to establish how psychosocial factors known to impact medication outcomes are integrated into psychopharmacology education. While participants highly valued the importance of psychosocial factors in the prescribing process, there was limited emphasis of these factors in psychopharmacology training. Additionally, some teaching methods that could advance understanding of complex interactions in the psychopharmacology relationship were found to be underutilized. Given that medication outcomes are significantly influenced by psychosocial factors, psychiatric educators have a responsibility to teach residents about the evidence base available. Residents exposed to this evidence base will be better equipped to manage the complexities of the psychopharmacology role. The results of this study offer clues as to how psychosocial factors may be more fully integrated into residency psychopharmacology training.
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Abstract
In recent decades the psychoanalytic perspective has been increasingly marginalized in medical school education. This has been driven by political tides, competition with neuroscience education, shifting practice models, and the dominance of an evidence-based perspective. The costs both to medical trainees and to the field of psychoanalysis are considerable. Reasons are presented for why academic psychiatry departments might be motivated to integrate more psychodynamic training into basic medical education and for why organized psychoanalysis might have an interest in developing a greater presence in medical schools. Various formats are discussed in which psychoanalytic theory and technique might effectively be introduced. Finally, broader strategies are proposed for addressing students and their developmental needs such that resistances to learning psychodynamics are reduced.
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Affiliation(s)
- David Mintz
- Austen Riggs Center, Stockbridge, MA 01262, USA.
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31
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Chubinsky P, Hojman H. Psychodynamic perspectives on psychotropic medications for children and adolescents. Child Adolesc Psychiatr Clin N Am 2013; 22:351-66. [PMID: 23538017 DOI: 10.1016/j.chc.2012.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recent trends in pediatric psychopharmacology have resulted in advances in treatment but also an overly optimistic and, at times, simplistic extension of pediatric psychopharmacology practice. Concerns about these changes in the field are discussed. The authors outline how understanding the meaning of medications to all those involved in the prescribing process can help integrate our thinking about this complex interaction with patients and their families.
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Affiliation(s)
- Peter Chubinsky
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA.
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32
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Mallo CJ, Mintz DL. Teaching all the evidence bases: reintegrating psychodynamic aspects of prescribing into psychopharmacology training. Psychodyn Psychiatry 2013; 41:13-37. [PMID: 23480158 DOI: 10.1521/pdps.2013.41.1.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The discipline of psychiatry appears poised at the edge of a paradigm shift. Enthusiasm about psychopharmacological treatments and neuroscientific understandings is giving way to a sobering recognition of the limitations of current biologically oriented approaches. Psychiatry training programs have both an opportunity and a responsibility to address the challenges presented by the evidence. Although the average psychiatrist would profess a biopsychosocial ideal, an examination of our practice, journals, and training curricula suggests that we still have a long way to go before we employ a truly integrated model. There is a compelling, though oft-neglected evidence base demonstrating that pharmacologic treatment outcomes are as dependent on psychological and interpersonal factors as on medical ones. In order to maximize our usefulness to patients, psychiatry must embrace more complex and integrated understandings, transcending reductionistic models that promote mind-body splits. This article explores some of the costs of a model that places disproportionate emphasis on a biological framework. Relevant evidence bases are reviewed that demonstrate the utility of emphasizing the psychology of psychopharmacology. Implications for psychiatric training are considered, and suggestions are made for better integrating meaning factors into psychopharmacology education.
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