Chapter 1. Think Again About Prescribing: The Psychology of Psychopharmacology
Publication: Thinking About Prescribing: The Psychology of Psychopharmacology with Diverse Youth and Families
We work in the dark—we do what we can—we give what we have. Our doubt is our passion and our passion is our task. The rest is the madness of art.Henry James, The Middle Years
The children who come to us, and the families who accompany them, bring ideas, positive and negative feelings, mental images, past experiences, and hopes about who we are, whether we can help, and even the medications we may prescribe. As clinicians, we are no less engaged, often sharing in their doubts and hopes of finding the perfect solution (and potion) for their particular troubles. Yet for all our understanding of pharmacokinetics, drug-environment interaction, and pharmacogenomics, we remain intrigued when an agent happens to work, or not, for this patient, at this time.
Psychopharmacotherapy is the use of a psychoactive medication with psychotherapy. It places emphasis on a therapeutic relationship, on behavior and affects, and on developmental and social determinants. Referred to as “single provider integrated treatment,” or “combined treatment,” it is increasingly rare in psychiatric practice (Gabbard and Kay 2001; Janicak et al. 2010; Moran 2009) despite its proven efficacy (Gabbard and Kay 2001).
This chapter examines the dynamic implications of medication use within the wider domain of pharmacotherapy. Pharmacotherapy includes thorough diagnostic evaluation for children and adolescents referred for consideration of medication treatments. Much more than a “med check,” this modality is complex, because prescribing clinicians strive to integrate quality patient care with the ever-changing time, economic, and administrative constraints of practice. As classical psychoanalysis tried to parse the influence of the “gang beneath the couch,” we struggle to grasp the significance and influence of the “gang inside the prescription pad.” In the sections that follow I discuss the 1) role of the therapeutic alliance, 2) psychological meaning of medication itself, 3) influence of developmental considerations, 4) meaning of the process of medicating, 5) psychological meaning of the context in which prescribing occurs, 6) extramural influences that affect prescribzing, and 7) effects of the shared-case context on prescribing.
Whether one is practicing psychopharmacotherapy or pharmacotherapy, the appropriate framework begins with the therapeutic relationship itself. In my decades of practice, prescribing evolved from a paternalistic and alliance-undermining act to a valued asset in treatment. Those same decades began with a handful of marginally effective (if side effect–ridden) agents for seriously affected children, used primarily in academic settings. Now we have scores of effective therapeutic choices, many marketed directly to parents, prescribed primarily in outpatient settings.
Still, Blackwell’s (1973) admonition prevails: “Too often a prescription signals the end of an interview rather than the start of an alliance.” This is especially true in the child-parent-therapist triangle, in which the parents’ often urgent need for relief adds pressure to “do something” before sufficient understanding and therapeutic trust exist. With our increasingly acute clinical populations, a deeper attention to alliance, psychodynamics, diagnoses, and symptoms is crucial.
The Therapeutic Alliance
Joshi and colleagues (Joshi 2006; Joshi et al. 2004) summarized the interpersonal process literature relevant to pediatric pharmacotherapy, highlighting the need to understand both the alliance in the doctor-patient relationship and the dynamics shaping the doctor and parent-caregiver relationships. In preadolescent children, the doctor-caregiver alliance is especially salient (Alexander and Dore 1999). During adolescence, as patients assume more responsibility for their own care, clinicians often need to help parents avoid intrusive or controlling styles and attitudes about taking medication while maintaining a proper monitoring and supervisory relationship. The psychiatrist needs to be seen more as an ally of the teen rather than simply as an agent of caring adults.
The most helpful guidance in forming a good alliance I can recommend is to consider the following: How you are with your patient is as important as what you do with your patient. Poor alliances lead to premature termination of care (Magnavita 1993), just as good ones, in which patients feel heard and understood, lead to better follow-up and outcome (Zisook et al. 1979). A growing empirical database directly links a strong alliance in pharmacotherapies with positive clinical outcomes (Joshi 2006).
Greenberg and Horvath (1994) suggest that a “good enough alliance” (with both patient and parent or caregiver) is paramount for the therapy to proceed. Whereas the alliance in adult psychotherapy is established relatively early (by the third to fifth session) (Alexander and Dore 1999), a meta-analysis of outcomes in child and adolescent psychotherapy linked later-session relationship measures more strongly with outcomes than earlier-session measures (Shirk and Karver 2003). An early alliance is important for successful collaboration between parents and caregivers (Joshi 2006):
Alliance development is a series of windows of opportunity, decreasing in size with each session. . . . [T]he foundation for collaborative work entails adjustments in both the client’s and therapist’s procedural expectations and goals. The longer the participants find themselves apart on these issues, the more difficult it becomes to develop a collaborative framework. (p. 240)
Havens (1978, 1988, 2000) reminds us that to many patients, the doctor’s trustworthiness and decency are not givens, and that “behavior problems” in general and mental illness in particular are tricky subjects to discuss. He suggests that the investigative language and tone we use deliver vitality to the relationship: “[The language we use to inquire] is as important as the matter being investigated or treated. . . . [I]n fact, the two bear a symbiotic relationship to each other” (Havens 1978, p. 336). He reminds us that patients enter wondering whether the “mind doctor” will be concerned, engaging, suspicious, judgmental, or, worse, indifferent. He advises listening carefully to receive the patient’s ideas without being intrusive and avoiding the “look of mock concern” so abhorrent to teenagers (Havens 1978).
Havens offers three “psychological analgesics” that can facilitate the approach to, and the management of, painful topics. These “analgesics” might be “prescribed” for difficult matters, including the need to take psychotropic medication:
1.
Protect self-esteem. Self-esteem is vulnerable because patients are affected by having to come to a psychiatrist. Patients may also be affected if their parents feel guilty for being the “cause” of the problem through bad parenting, contributing genetic vulnerability, or both.
2.
Emote a measure of understanding and acceptance. When successful, the patient’s problem is grasped intellectually, and the patient’s and family’s predicament is understood from their point of view.
3.
Provide a sense of future. Many families have experienced frustration and failure in finding solutions, resulting in diminished hope. Discussion about expectations for treatment that still acknowledges fears or even hopelessness may preserve opportunities for change: “It may seem hopeless to you for now” (Havens 1978, p. 340).
The Psychological Meaning of Medication Itself
A 14-year-old girl who had initially responded well to a brief course of pharmacotherapy began to complain that she felt like a “poser” because of taking a selective serotonin reuptake inhibitor (SSRI):
I know I’m less depressed and irritable. My boyfriend says I’m easier to be around, but I’m not sure this is really me. I feel like this poser [posing as another]. Like, every time I take my pills it reminds me that I’m this screw-up who can’t manage her feelings on her own. I hated feeling suicidal, but hey—maybe that’s more me.
Besides pointing the way to the psychological work that she needed to do on her depression, she articulated a concern many of our patients and their parents have about medicine as change agents: “Will it change me, my or others’ ideas of me, and not just my symptoms or behavior?”
A 10-year-old had a behavior-changing response to stimulant medication that allowed him to transfer to a better school, sustain new friendships, and return to his beloved violin lessons. His father, who’d suffered similarly but gone untreated, was concerned that all we’d done was a “naughty-ectomy, not real therapy.” His son, somehow aware of his father’s concerns, would occasionally taunt him: “Just call me Speedo [aware he was on a stimulant]—I am what I take!”
Medications and their representations shape-shift in our patients’ imaginations as they search for the meaning of “taking pills.” They have been depicted in my patients’—and their parents’—dreams and daydreams variously as poisons, magic potions, “mind restraints,” aphrodisiacs, handcuffs, binoculars, microscopes, brain “implants,” and contraceptives, to mention a few. There is no shortage of grist for the metaphor mill; each one is important to pursue (Mintz and Belnap 2006; Pescosolido 2007; Rappaport and Chubinsky 2000).
For psychiatry residents and fellows, Joshi (2006) reminds us that effective medication regimens may often collapse during the transitions in care common on 6-month “psychopharm rotations.” In a study examining patient outcomes during transfer to a new pharmacotherapist (Mischoulon et al. 2000), nearly one-third of psychiatric residents’ patients were negatively affected by treatment transfer or termination, regressing clinically or requiring medication changes. The relationship with the prescribing physician was obviously important to patients, such that forced termination had negative effects similar to those of transfers to a new psychotherapist. The authors recommend that sufficient notice be given to help patients deal with the forthcoming loss or change and describe specific suggestions to aid in processing this transition (Mischoulon et al. 2000). In my teaching experience, we encourage trainees to inform families and patients midway into a clinical rotation to allow sufficient processing by all parties. We also strongly discourage use of the term “psychopharm rotation,” just as we eschew the term “med check” with youth. These terms fall far short of what actually happens in the room, whether working in pharmacotherapy or psychopharmacotherapy.
The timing of the prescription in ongoing psychotherapeutic work is rich with meaning—why now and not before or later? Should we attempt to relieve symptoms pharmacologically before they are understood by both patient and clinician? When symptoms are severe and acute, the need to medicate often precedes full understanding. In less acute circumstances, premature prescribing may undermine patients’ sense that they can cope with these symptoms:
“Don’t you think I can do this by myself?” asked a 13-year-old girl, after we began to discuss an anxiolytic to help her manage her recurring panic attacks away from home. We examined her idea that I was giving up on her ability to understand herself and her behavior by even suggesting medication. In case I’d missed the point, she acted out sufficiently to scare her parents. Subsequently, she re-engaged in psychotherapy and observed that the more aware she was of her “triggers,” the less medication she required.
Beyond connections between timing and meaning, however, another question hectors the act of prescribing: Will medication mean treat or treatment to this particular patient? Gratification and frustration are balanced and rebalanced in successful psychopharmacotherapy, but awareness of this paradox helps therapist and patient avoid therapeutic diversions (Boris 1994).
Developmental Considerations
Remaining alert to changes in the meaning of the medication to patients as they move into new developmental terrain is especially relevant for clinicians working with children and adolescents. The significant changes in bodily preoccupation, impulsive discharge, and mood lability that occur in pubescence cast any past agent that may have affected weight (gain or loss), endocrine function (galactorrhea), skin appearance (acne), genital arousal or dysfunction, or mood itself in a new light. What may have been acceptable side effects before become intolerable as they emerge during, or simply complicate, already exquisitely sensitive developmental tasks. This is made more complex by the fact that nearly all “side” effects, from extrapyramidal symptoms to nausea, are less well tolerated in younger populations.
Salient for the child and adolescent population—and their caregivers—are the physical properties and dosing requirements of the medications themselves (Table 1–1). For many patients, especially younger ones, function follows form. The prevalence of normative magical thinking makes the color, shape, design, and form (liquid vs. solid) part of the child’s attitude toward the medication.
| Physical properties of the medicine itself | |
Form | Liquid, tablet, capsule, or injectable forms may each carry different meanings (e.g., liquid is for “babies,” injections are “punishments”) |
Size | The bigger the pill (or its milligram value), the bigger the problem, or conversely |
Labeling and printing | Personalized associations to imprinted numbers or letters |
Color | Associations to candy or poison |
| Timing of the dosage | |
Frequency | More frequent, more trouble, or conversely, more help |
AM or PM | AM for school, PM for sleeping or dreaming troubles |
During school | Concern about stigma |
Self or parent administered | Self is good and mature, whereas parent is now doctor’s agent |
Source. Adapted from Pruett et al. 2010.
K. swallowed her clonazepam, but no other solid tablets, because her initial was “cut into it for me.”The pink color of a schoolboy’s guanfacine “always makes [him] think of peppermint candy.” This cocktail of wish and suspicion, sweetened with the candy association, was sufficiently positive to help him adhere to taking it regularly. The “candy connection,” however, deeply worried his mother, a recovering casualty of the drug culture.
Methylphenidate has generated the most imagery because of its widespread use:
Charlie, 8, devised a morning ritual involving an empty prescription bottle that he kept in his shoe. It reminded him when dressing to remind his mother, who “forgets half the time.” Why a shoe? He heard his father tell his grandmother how Charlie’s meds helped him “keep his feet on the ground.” Charlie thought, “Just like shoes.” How does he feel about taking meds? “They’re little mines with codes stamped on them for each little monster inside me that they’re going to blow up that day. Then I’m not such a problem!”
Asking about remembering rituals—or lack thereof—gives some understanding of deeper attitudes and ambivalence about specific drugs and their roles. What Charlie did not like about taking medication, however, was the way he got his midday dose at school:
The nurse puts all our pills on her metal cart in these little cups with our names on them. She wheels it down the hall to our classroom door. Six boys and two girls go to the door and wait in line, and she watches us swallow the pills—right there. The whole class watches. It’s stupid—I feel so weird.
Medication needn’t mean shaming. Longer-acting stimulant preparations are rendering midday doses at school far less common, lessening the social toll associated with daily visits to, or from, the school nurse.
Potential meanings of dosing frequency also are not wasted on children. If children find their medicines helpful, and the medicines are given in the context of a supportive alliance, more frequent dosing can actually be reassuring. In less positive circumstances, when the effects are more ambiguous, more frequent dosing can be intrusive, resented, or read as a sign of “being sicker.”
Closely tied to frequency is dosage size. Older children and younger adolescents can become preoccupied with the mathematical value of the dose, assuming that the smaller the number, the less “sick” they are. The converse is also true.
A young adolescent girl was on her third attempt to find the right medicine for her elusive mixture of panic and depression. She was working hard in her psychotherapy but was getting discouraged. When she read the label, she realized that she was getting “hundreds of milligrams!” of a new drug, and since it was “only helping a little bit!,” she concluded that she must be much sicker than she or the therapist thought.
The cost of medication as experienced by the family has meaning for the child or adolescent patient because of their dependent status. When children overhear or directly encounter their family’s discussion about prescription costs, especially in the face of spotty coverage by disparate insurance plans, the child can feel like a further burden on their family. To avoid this further complication of adherence, it is best discussed privately and preemptively with the parents.
The Psychological Meaning of the Process of Medicating
If primum non nocere is our maxim primum, second is giving care with confidence and hope: “State of mind in which expectation is colored by hope and faith is an effective [therapeutic] force with which we have to reckon” (Freud 1905, p. 289). The power of this shared state of mind between therapist and patient influences medication choice for the patient’s symptom relief. It is this confident, hopeful mindset that we have attempted to factor in, or out, using placebo controls in regulated drug trials.
The problem—and intrigue—with placebos is that they work through their meaning. Although they are pharmacodynamic blanks, they have been shown to be 55%–60% as effective as codeine and aspirin for analgesia (Kirsch 1997). Cognitive neuroscience suggests a mode of action more complex than the previously favored endorphin release theory. Expectancy theory suggests that what the mind believes about the immediate future is based on conditioning from past experience, mediated through immune-endocrine system interaction (Kinsbourne 1999).
So why the placebo’s seedy reputation? Placebos muddy the waters of efficacy studies because their high “rate of relief” casts doubt over more chemically active agents that performed acceptably (Puig-Antich et al. 1987). They also carry with them the folklore of the persuasive, patent medicine–hawking “doc” who sold “proven effective” placebos and alcohol- and morphine-laced compounds (all for about the same price) to loyal, witness-bearing clientele.
The classic prospective study by Park and Covi (1965) highlighted placebo effects of medicating anxious patients. Though a “small n” study with no child participants, its findings remain theoretically compelling:
Fifteen newly admitted [outpatient] neurotics . . . , mean age 35, were seen in an hour-long interview for evaluation of anxiety. In a follow-up 15–30 minute interview, they were placed on a waiting list for intervention, and introduced in a standardized way to a nonblind placebo trial. They were told the placebo was ‘a sugar pill with no medicine in it’ that had helped people with similar conditions. Pink capsules in a t.i.d. dosage were prescribed for a week, with a subsequent interview and symptom checklist. (p. 335)
All but one patient completed the treatment course, and all but one of the completers experienced “some to a lot” of improvement. One-third wished to continue the placebo, refusing to transfer to an active agent, two felt “cured,” and almost half of the completers believed it was a “real” drug. Half of the believers experienced side effects.
The authors concluded that “1) patients can be willing to take placebo and improve despite disclosure, and that belief in the pill as drug was not a requirement for improvement; and 2) improvement was not related to belief in the nature of the pills, but did appear related to certainty of belief” (p. 344). Placebos apparently need not be “lies that heal” (Harrington 1997) because the treating doctors were “optimistic about the study, yet anxious about telling the patients that they would receive placebo. The [resulting] combination of enthusiasm and alertness must have had a strong positive impact on the patients” (p. 343). N.B: Placebo is Latin for “I shall please.” Ethical considerations would probably preclude a similar trial in children, though the forces at work in the therapeutic alliance could be similarly influential in pharmacotherapy with children and adolescents.
Confident hope is a powerful and useful element in the process of medicating: “placebos can elicit (both) solace and side-effects” (Schowalter 1997, p. 682). Parents respond powerfully to confident hope regarding medication. When parents are supportive and respectful of the child-clinician alliance, adherence and outcome improve. But when their response is fueled more by their own wishes, denial, or projections, outcomes can be undermined. Toffler et al.’s (1999) “achievement by proxy” formulation describes the negative influence on children when their growth and development become a means to a parental end, focusing on the circumstance of high-achieving children and adolescents. Clinicians need to be aware that analogous “treatment by proxy” dynamics can also shape clinical relationships with parents.
The Psychological Meaning of the Context in Which Medication Is Prescribed
There is, to paraphrase D. W. Winnicott, no such thing as just a prescription. Prescriptions are never written in a vacuum, devoid of relational or diagnostic context or marketing influence. The dominant context in which we prescribe is the parental one. The parent must consent, facilitate payment and access, usually dispense, monitor, renew, ensure adherence, deal with resistance, and often explain to a balky child yet again why they “have to” take pills.
Thoughtful appreciation of all parental attitudes is a prerequisite for successful medication usage and clinician efficacy. Mothers and fathers have overlapping but distinct concerns about their children’s health and well-being (Pruett and Pruett 2010). Each parent’s concerns are best understood in the context of the parents’ relationship with each other, not simply with the child. Typically, one parent is more forgiving, the other more judgmental—one more optimistic, the other less hopeful—and the clinician will likely hear at least one “I told you it wasn’t just in our son’s head!”
Clinicians can safely assume that parents are well down their own road of frustrated and spent solutions when they meet for the first appointment. Parents may feel relief when medication is suggested because of the affirmation of the seriousness and accuracy of their concern for their child’s difficulties. They may also feel less judgmental and self-deprecatory about failures to date, seeing medication—and its prescriber—as potential new allies. Such alliances are subject to the usual projections and fantasies that parents have about the people to whom they turn for help with their children—positive idealization when the medicines “work,” doubt and conflict when they do not. The latter may only show itself in “forgotten renewals” or missed “med checks.”
A newer player in the parental-clinician domain is the influence of direct-to-patient marketing of genetically guided prescribing recommendations. Some parents are arriving with personal pharmacogenomic profiles of their child’s drug-metabolizing enzymes, which they have been assured “will help the prescriber choose the best medication with the fewest side effects.” We know that genetic variations can determine impaired response to drugs, and this approach holds promise, as seen in “poor metabolizer” variations in atomoxetine breakdown. The American Society of Pediatric Hematology/Oncology, however, cautions against routine clinical application of these data because of the lack of high-quality pediatric research (Schuft 2019).
Given the rate at which primary care physicians and advanced practice registered nurses are currently prescribing psychoactive medication to adults, it is likely that parents have had their own experiences with mood- and behavior-altering medicines. A child’s positive experience with medication can motivate the parent to investigate their own needs, especially if there are symptom similarities (e.g., fathers of sons with successfully treated ADD and ADHD are especially common).
Less supportive medication attitudes can foul, prevent, or prematurely terminate an alliance. Unexamined loss and grief over having a child “so sick” as to warrant a diagnosis or medication are common. Parents may see this as the start of a lifelong journey with chronic illness.
We know from antibiotic and insulin adherence studies that the more serious a parent feels their child’s illness to be and the better understanding they have of the illness itself, the stronger the treatment adherence. Research illuminates several useful techniques to enhance adherence. Hack and Chow (2001) suggest the following:
1.
It is important to attend first to the alliance through actively engaging patients and families in ways to communicate adherence success. Daily medication journals or charts are useful tools.
2.
The alliance can be strengthened and adherence improved by scheduling sufficient time for office visits, planning for the next appointment as soon as feasible.
3.
Written instructions and clinician availability by phone, e-mail, or health information portals decrease miscommunication about dosing and side effects.
4.
Because duration of treatment and frequency of dosing contribute to adherence, less frequent dosing can improve adherence substantially (Liptak 1996).
5.
Timing and simplicity of the dosing regimen can be tailored to enhance adherence; pairing doses with everyday activities such as meals, homework, or regular screen time can create reminders (Weinstein 1995).
6.
Palatability (apparently more important to adults than to children; El-Chaar et al. 1996) may matter more to a particular child; liquid availability and flavoring options exist (provided by most pharmacies) if pill size, consistency, or taste is an issue.
7.
Although cost is generally not correlated with adherence (Matsui 1997), it remains a burden for many families. If there is a good alliance, the resultant atmosphere of trust and safety allows families to more comfortably discuss financial stressors (Hack and Chow 2001).
What parents do understand about their child’s diagnosis and needs warrants discussion in its own right, not simply in terms of the therapist’s wish for adherence. As information floods families, we hear questions about “chemical imbalance.” Although informed patients typically promote positive outcomes (Healy 1997), this particular concept should be used cautiously. It may mask meanings anywhere from a legitimate request for thoughtful diagnostic clarification to avoiding personal or emotional issues or signal a more superficial “boutique approach” to well-being and personal enhancement (Parens 1998). Valenstein’s (2002) sobering discussion in Blaming the Brain of the scientific understanding of the role of “biochemical imbalance” in mental illness keeps us wary of prematurely attributing any shared meaning to this phrase.
Schools are important contexts for medicating therapists to consider. Because children’s and adolescents’ distress are often externalized, attentional and disruptive behavior disorders are frequently more obvious at school than at home. School officials may share in the “delusion of precision” (Gutheil 1982), perceiving drugs as uniformly effective agents, if the pharmacotherapist would just prescribe them. Schools feel mounting pressures to control the child’s behavior or disruptiveness for reasons beyond concern for the well-being of a particular child: overcrowding, understaffing, the meritocracies of mandatory testing, and pressure from other parents, to name a few. Parents may or may not cooperate or agree with the school’s concerns, facilitating or frustrating appropriate use of medications in an individual case. Parents may also feel that a different classroom or teacher, approach, or curriculum would be more effective than medication as a sole intervention.
Appreciation of these larger system interactions when considering medication will likely improve the efficacy of intervention. The reverse is also true: to not prescribe under such systemic pressures can be seen, or experienced, as withholding, not caring about, or being insensitive to the degree of child or parental distress.
Social media and internet information platforms increasingly influence older school-age and adolescent populations. Patients now arrive for consultation with narratives from their peers and browser-generated “information” about “meds that work and meds that suck.” Clinicians who inquire “What have you heard about the medicines we’re thinking of trying?” are usually rewarded with helpful context and “attitude” about potential medications.
Extramural Influences That Affect Prescribing
The combined corporate influences of the pharmaceutical and managed care industries can shape and even preclude the therapeutic alliance. They are strange bedfellows to the clinician and the prescribing process because their missions are typically disparate. Making a living while doing good would seem the common goal, yet the corporate structures and ethics that vaunt profitability over access flirt with incompatibility in the practitioner’s realm of primum non nocere.
In 2019, the pharmaceutical industry spent $30 billion a year on promotion and advertising in the United States; 68% of that total was spent on advertising campaigns in our journals, at our meetings, and through direct contact between physicians and their tenacious, highly incentivized sales forces (Mole 2019). The sales force is well trained, chosen for its tenacity, and supported by strong incentives. In 2020, there were about 81,000 “reps,” 1 for every 8 practicing physicians in the United States (Sufrin and Ross 2008). Some academics have had sufficient concern about the easy traffic between residents, “drug reps,” teaching hospital administrations and their research-funding base, and the pharmaceutical industry that they suggested regular and ongoing vigilance of the “pharmaceutical-academic complex” (Angell 2000).
In 2008 and 2009, a few high-profile exposés of egregious profiteering on the part of some nationally recognized academic experts encouraged the FDA to tighten up things, and the Pharmaceutical Research and Manufacturers of America endorsed 1) science-based, rather than ad-libbed, promotion of products; 2) articulation of “negative effects” when present; 3) only “‘modest” (by local standards) comped dinners; and 4) reps speaking with clinicians only if spoken to by clinicians first.
When the Affordable Care Act was signed into law in 2010, it created the Open Payments database in the hope that documenting conflicts of interest in research funding and kickbacks to prescribers would loosen Big Pharma’s grip on prescription promotion, but little changed. Each year from 2014 to 2018, drug and medical device companies spent between $2.1 billion and $2.2 billion paying doctors for speaking and consulting, as well as on meals, travel, and gifts for them. These figures do not include research spending, but they do include royalties (Ornstein et al. 2019).
The reason for this caution grows: Marketing works. A pharmacotherapist is more likely to prescribe a drug over the next few days after its pharmaceutical representative takes them to lunch or supplies them with literature (Orlowski and Wateska 1992). Even though prescribers see themselves as intellectually independent of corporate influence, the language they use to describe a drug’s properties to themselves and their patients is derived more from advertising than from the more objective scientific literature (Lexchin 1997). Regardless of how physicians see themselves, their patients and families may see them as being unduly influenced. Furthermore, patients express concern about their physicians’ susceptibility to such pressure (Mainous et al. 1995).
Direct-to-patient (DTP) marketing—primarily to parents—has been so effective that it gives new meaning to the word “compliance.” The National Institute for Health Care Management cited $2 billion as the direct-to-consumer marketing tab back in 2000 and saw it as closely tied to increases in prescription drug sales, including psychoactive ones (Findlay 2000). That number is now closer to $30 billion (Schwartz and Woloshin 2019). Some of the information in DTP marketing frequently raises a parent’s level of concern about a child’s behavior, prompting him or her to seek consultation sooner rather than later. But it has also led to inappropriate direct-to-physician voice mail and e-mail requests that a specific agent be prescribed over the phone or by return email for a child never seen by the clinician.
Managed care is another prominent member of the “gang inside the prescription pad.” The limits on approval, duration, or nature of therapeutic contact or arbitrarily covered medications and services themselves have turned prescription writing into one of the only reliably reimbursable acts therapists can perform on behalf of their patients and their livelihood. The current 15-minute “med-check” session standard diminishes the therapeutic alliance to an encounter between a “med checker” and a “customer” with a target symptom. Policy statements from the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association oppose “the use of brief medication visits” because of the failure to include the “role of psychosocial intervention, including psychotherapy . . . in the treatment plan” (American Academy of Child and Adolescent Psychiatry 2001; see also Torrey et al. 2017). Some have pointed to the concept of the “med check” as inherently inaccurate (Moran 2009). Others have challenged the concept altogether when working with youth (see Rosen and Glowinski in Chapter 6, “#KeepItReal,” of this book).
Gabbard and Kay (2001) observed that it is “not really possible to know” what is transpiring between a therapist and patient during a session coded as a “medication visit,” suggesting important psychotherapy may also be going on during these encounters.
It’s not as if the patient says “I’m only in for a med check, so I’ll only talk to you about benefits and side effects of my meds.” . . . [This highlights the importance that] basic psychodynamic principles—transference, countertransference, resistance, and therapeutic alliance—play in all of our interactions with patients. Regardless of modality, as psychiatrists, we need to be integrators par excellence.
Pressure from the managed care domain to do something “effective and do it fast” may be at work in the ongoing increase of prescriptions of psychoactive medication to preschoolers (Zito et al. 2000) and possibly the increasing trend toward polypharmacy.
The American Psychiatric Association work group behind “Beyond ‘Med Management’ ” (Torrey et al. 2017) has suggested that 1) the “med-check” label be replaced with the term “psychiatric care visit,” 2) the moniker “prescriber” give way to “psychiatric care provider,” and 3) symptom rating scales, previous use of medications, aims for the visit, and family history data be collected by a trained psychiatric medical assistant or even user-friendly software (Torrey et al. 2017). These suggestions would increase the amount of focused, comprehensive thinking clinicians could do about prescribing.
The Shared Case: From Split Treatment to Shared Treatment
As reimbursement systems change and evolve, it has become common practice for the child and adolescent psychiatrist to take on the role of medication prescriber, while psychotherapy is offered by a separate (usually nonmedical) clinician. Larger team practices can ameliorate some boundary troubles, but liability, clinical, boundary, transference and countertransference, and systems issues still swirl about the axis connecting these symbiotic components of treatment. The only way to prevent split treaters from splitting the treatment is through effective and frequent communication.
A 13-year-old girl was referred for a pharmacotherapy consultation because of her therapist’s concerns about increasing inability to concentrate at school, inattention to her homework, and increasing social isolation. A diagnosis of ADHD seemed likely from teacher questionnaires. On interview, her thought rituals, obsessive anxiety-containing behavior patterns, and need to have “everything just right” (which she reported took hours) before she could even start her homework suggested a prominent anxiety component (in which SSRIs might be more appropriate than stimulants). When I e-mailed the therapist to share my initial impressions and suggest that we discuss this further, she replied with additional information about a strong family history for ADD and was reluctant to accept my recommendation but agreed to talk on the phone. Discussion led to resolution, avoiding a potentially ensnaring boundary complication for this young girl who was already sufficiently anxious and confused, a miniscule time expenditure compared with the costs of ineffective treatment.
The upfront commitment to clear treatment planning and diagnosis is a universally effective vaccine against interdisciplinary collaboration dysfunction. Sharing information about each other’s practices, training, practice patterns, and settings can create mutual respect that protects against future conflict or splitting by some patients or families. Discussion of medication changes before they are instituted results in less confusion and resistance. Fax or secure e-mail communications are sufficient for most shared data. Clarifying at the outset what is salient for collaboration about this particular child and family is key, including level of vigilance, adherence, or potential for misuse, among others. These issues argue for changing the name from split treatment to shared treatment. See Chapter 6 of this book for further discussion on this topic by Mari Kurahashi and colleagues.
Clinicians wisely prescribe in the context of medications already being prescribed, sharing recommendations with the primary care physician to avoid potential drug interactions and side effects that evolve over the course of treatment, preventing misattributions by the psychotherapist to changes in sleep, sexual behavior, irritability, and other symptoms. A thorough, culturally informed biopsychosocial psychiatric evaluation, not simply a symptom search, lays the foundation for a holistic understanding of what medications mean psychologically to a patient and to their family during the course of treatment.
Future Research
Unanswered questions remain regarding how digital technologies, including e-prescribing, paid advertising on such platforms, and social media are affecting patient adherence and clinician prescribing practices. Drug pricing—especially when it seems erratic or arbitrary—is another domain that influences and confuses clinicians and patients’ families and as such is in need of careful study. Advances in personalized medicine and the influence of pharmacogenomics need clarifying for child and adolescent populations.
Conclusion and Recommendations
•
When thinking about medicating, remember that it is the patient, not the drug, that deserves our major attention. Decisions about prescribing medication need to be made in the context of the therapeutic alliance, with less emphasis on the probability of reimbursement.
•
Keep in mind that the formulation always precedes the prescription, not vice versa (with the possible exception of emergencies). Thorough clinical conceptualization is not gilding the drug-treatment lily. It is necessary for making good treatment choices, evaluation, and ongoing reevaluation of drug choice and combined treatment effectiveness.
•
Resist intimidating time constraints, especially in appointments at the beginning of the consultation. If you have done your diagnostic work and built your alliances accordingly, the relationship will matter more than the time spent sustaining it (Tasman and Riba 2000; Tasman et al. 2000).
•
Create and sustain all the relationships necessary to address the child’s needs, including parents and other caregivers, teachers and other school staff, collaborative therapists, primary care providers, and others important to the patient.
•
Do not prescribe for a patient you cannot remember between appointments. You are forgetting them because neither of you is sufficiently invested in a relationship worth remembering—an infrastructure of insufficient substance to support pharmacotherapy or any therapy, for that matter.
•
Be perpetually aware of the seductions of marketing. They are getting to you and affecting your judgment about drug choice.
•
Use “chemical imbalance” discussions with caution, because it may be difficult to predict what they mean to any given patient or their parents.
•
Neither over- nor undersell any one drug as part of the treatment regimen. Medications carry sufficient “magic” on their own. Telling parents and patients there are other choices invites them to be collaborators in psychoeducation, not just pill consumers.
•
Treat your patients as though the therapeutic relationship matters more than the pills. It usually does.
•
Remember the words of Jeree Pawl, president emerita of Zero to Three: National Center for Infants, Toddlers and Their Families: “How you are matters as much as what you do.”
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Thinking About Prescribing: The Psychology of Psychopharmacology with Diverse Youth and Families
Pages: 1 - 23
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Published in print: 18 January 2022
Published online: 5 December 2024
© American Psychiatric Association Publishing
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