Dr. David Mintz begins by noting:

During the past 2 decades, psychiatry has benefited from an increasingly evidence-based perspective and a proliferation of safer, more tolerable, and perhaps more effective treatments. Despite these advances, however, treatment outcomes are not substantially better than they were a quarter of a century ago. 1 Treatment resistance remains a serious problem across psychiatric diagnoses. 2 One likely reason that outcomes have not improved substantially is that as the pendulum has swung from a psychodynamic framework to a biological one, the impact of meaning (ie, the role of psychosocial factors in treatment-refractory illness) has been relatively neglected, and psychiatrists have lost some potent tools for working with the most troubled patients. http://www.austenriggs.org/images/up...-24%283%29.pdf

Dr. Mintz like many others seems to find the biological model deficient. Studies show:

A series of meta-analyses of FDA databases (examining an unbiased sample, including negative, unpublished studies) shows that although antidepressant medications are effective, the placebo effect accounts for between 76% and 81% of treatment effectiveness. 5-7 Placebo does not mean imaginary or untrue. Placebos produce real, clinically significant, and objectively measurable improvements in a wide range of conditions, including psychiatric disorders. 8,9 And, placebo responses produce measurable changes in brain activity that largely overlap medication-induced improvements. 10 The patient’s desire to change and a positive transference to the doctor and his or her medications can mobilize profound self-healing capacities—capacities that appear to be even more potent than the medication’s active ingredient.

Although most of our patients ask us for help, many are conflicted about getting well if their illness has created some conscious or unconscious benefit. If a patient is not “ready to change,” it is unlikely that a medication, however potent, will produce a therapeutic effect. Beitman and colleagues 11 found, in a placebo-controlled trial, that patients who received a benzodiazepine for anxiety and who were highly motivated to change had the most robust response. However, placebo recipients who were highly motivated to change had a greater reduction in anxiety than patients who took the active drug but were less ready to change. Readiness to change was found to be the single most powerful determinant of treatment effectiveness—even more potent than type of therapy (ie, active vs placebo).

In 1912, Freud 12 noted that the unobjectionable positive transference (consisting of such things as the patient’s belief in the doctor’s salutary intentions, the wish to use the doctor to get better, and the desire to win the doctor’s love or esteem by genuinely trying to get better) was a key factor in the patient’s ability to overcome symptoms. This unobjectionable positive transference, ie, the therapeutic alliance, is one of the most potent ingredients of treatment. 12,13 In a large, placebo-controlled, multi-center trial of treatments of depression, Krupnick and colleagues 14 showed that patients were most likely to respond when they received the active drug and had a strong therapeutic alliance. Those least likely to respond when given placebo had a poor therapeutic alliance. Patients who received placebo and who had a strong treatment alliance had a significantly more robust therapeutic response than patients who received an antidepressant but had a poor therapeutic alliance. Taken together, these studies examining the relative effectiveness of biologically and symbolically active aspects of the medication suggest that meaning effects in psychopharmacology are more potent than biological effects.

Mintz gets into the meat of the article when talking about pharmacological treatment resistance and the elements of psychodynamic psychopharmacology. He concludes:

There are many sources of pharmacological treatment resistance. When treatment resistance arises from the level of meaning, interventions are not likely to be successful unless they address problems at the level of meaning. Psychiatric care providers who operate from either a dogmatic psychotherapeutic paradigm or a psychopharmacological paradigm are hobbled by having access to only half the patient. Psychodynamic psychopharmacology combines rational prescribing with tools to identify and address irrational interferences with healthy and effective use of medications. We should not neglect psychodynamic contributions that enhance the integration of meaning and biology. It is the capacity to integrate and understand complex situations that more than anything else lends its particular power to our discipline and gives us skills for working with particularly troubled patients.

An interesting article that is significant because it stresses the need to look at all aspects of the treatments available when dealing with an illness exhibiting resistance to limited treatment options.

[Wysteria]

Dear Byzantine,

I'm not any kind of expert, but in trying very hard to understand this article, some questions come to my mind.

One is that with the limited amount of time allotted to the psychiatrist to truly discover what is going on with the patient, how are they supposed to get to know what goes on in our minds well enough to truly even get the diagnosis right. It seems that everyone I know has had multiple diagnosis. I went from Bi-Polar to MDD-severe to now Depression with Dissociative mood disorders and BPD. If I don't write out journals, poems, research articles, letters and descriptives of what is really happening in my mind, my pdoc doesn't have a clue unless I am hospitalized and he gets a chance to actually talk to me for a little while. Also I am very lucky that he knows my T, and they do actually talk sometimes and get a feel for what is going on. Unfortunately, recently, my T asked him to back off any type of therapy with me as to not "cross any boundaries". I hated this and do not feel it is in my best interest.

Secondly, I have been on every medication known to the pharmaceutical industry over the last 10 years. Thus I know I have put my body through a lot of stress and experimentation in terms of the possible long term effects of all these drugs on my liver and other organs in the body, let alone the stress of the anxiety, etc that the illnesses themselves have put on my body. How can we justify all this contamination if indeed we are not sure of the diagnosis because of inadequate contact and relationship with pdoc, and also in terms of the lack of efficacy due to the questions brought up in the article you posted? Is placebo effect enough to truly justify the potential risks?

Third, pdocs are no longer really trained in the interpersonal therapeutic relationship dynamics. My pdoc is gifted and personable but admitted readily that he was in no way a T when he tried to step in while my T was gone. My T confirmed that pdocs are no longer even trained in doing therapy and establishing and maintaining relationships the way that T's are. They are doctors. Most of what they learn interpersonally they learn on the job. How do you/they propose to bring pdoc's back into the equation of really getting into a therapeutic relationship with patients when they are not even trained any more to do so?

I know I'm not very savvy with all of this, but I don't see how to make it work. I feel I have been blessed with a very gifted healer, but I know the difference and what most experience and have been there myself. Most people don't really have much of a "relationship" with pdocs at least in the states as far as I am aware. They are primarily script writers. I don't know what else to do to get better. All my care-givers say that I try very hard in therapy and am med compliant. But I continue to struggle. Whether I "get" something from being ill, I can't be sure. All I know is I still hurt too much. Your article is discouraging to me, and just makes me even more determined to continue efforts to communicate better with my wonderful pdoc.

Most Respectfully,
Wysteria Blue

[Rose76]

I get frustrated that when I say I feel poorly, somebody starts chirping in with "Well, it sounds like your meds need adjusting."

I am told that I have TRD. That leads straight to "Well, maybe it's time you tried ECT."

I heard of a study once that found that patients felt better just by being informed that their doctors were thinking about them, compared to a control group.

Dr. Mintz's point resonates with me. I think the psychopharmacological paradigm is a bit overly ascendant these days in structuring what care is delivered. I don't know that there is a lot we can do about that in the short run. The reasons for that, IMHO, are noted well in the post by Wysteria.

Your article is discouraging to me,

I did not write the article. All who disapprove of my choice of articles are invited to put me on ignore.

[Gus1234U]

wow me again, Byz~!

[Wysteria]

Dear Byzantine,

I thought you put the articles up here to discuss. I was just trying to ask some questions and get your point of view or other's. I did not mean for you to take offense, I'm sorry. I don't know why you have such a sharp tongue for me and ask me to ignore you when obviously I would have liked to have heard your thoughts. I thought you were to be respected for your knowledge and love of truth. I actually liked the article so much I printed it out to take to my pdoc.

I'm sorry that I have offended you. But I won't put you on "ignore" for I have liked some of what you have said in the past.

Hugs and a smile...I think maybe you need a lot of them...

(And maybe next time I reply to one of your posts I should add a Starbucks coupon too, no?)

Respectfully and trembling,
Wysteria Blue

[sorrel]

Ok, so says Freud.
But, what if you bring Kleinian theory into the equation?! :P