In Practice

A practicing doctor's views on psychiatry and contemporary culture.

The (Modest) Future of Psychopharmacology

How prescribing can benefit from psychology

Today, the New York Times “Freakonomics” blog is running a “quorum” on our knowledge of the mind. The site asked contributors: How much progress has psychiatry made in the last century? Is our psychology adequate to guide our prescribing of psychotherapeutic drugs?

I’m afraid I answered at length, so that my contribution is more a primer than a standard blog posting. Even so, I worry that I did not represent my views with precision.

To flesh out my response to the second question: Prescribing can benefit from any amount of psychological sophistication.

What doctors want to know about their patients is simply everything: how they have been affected by adversity, how impulsive they might be, how they think about medication, how stoical they are in the face of discomfort, how they function when they are doing well, what private thoughts or predilections will influence their choices—you name it. We need awareness of cultural forces, such as how a patient’s family or ethnic subculture regards emotion and emotional disorders. Done properly, prescribing draws on the “therapeutic alliance,” a relationship grounded in deserved trust. To qualify for our role, psychiatrists require awareness that extends to our blind spots and our presentation of self. As with every aspect of medicine, medicating mental illness is a demanding job.

I recall that early in Listening to Prozac, I described a young man who, after I had prescribed a medication, returned to the office complaining of anxiety. I assumed that a drug side effect was the cause—until I realized that the patient had not taken the medication and was concerned about my response to what he considered to be disobedience. To consult effectively, psychiatrists need to understand the two-person dynamic that colors the encounter.

By writing (in response to the Times’s inquiry) that yes, our psychology is adequate, I mean only that I don’t imagine we require some other sort or quality of knowledge—a new psychology, with the level of difference that Freud proposed when he introduced the notion of a dynamic unconscious that applies the force of early sexual experience to every openly expressed thought and behavior. To prescribe well, we need to be good doctors, but we don’t need to acquire new magic.

At least, new magic in that arena (a counterintuitive psychology) is not what I wish for first, when I worry about prescribing. We are sorely in need of indicators to predict who will respond to a given compound and who will suffer side effects. We would like to know what determines the shape, speed, and duration of recoveries. The relevant markers might be biological or psychological (this personality has that risk), but the knowledge would be conventionally medical. As I say in the Times blog, what subtlety we require is a function of the drugs we have to hand. If we could reliably achieve refined effects—tweaking self-image, adjusting anxiety, rounding out memory, optimizing self-doubt, heightening confidence, modulating impulsivity—then psychopharmacology might be reduced to its proper role, as a constituent of psychotherapy.

Peter D. Kramer is a psychiatrist and author. His books include Against Depression and Listening to Prozac.

more...

Subscribe to In Practice

Current Issue

Just Say It

When and how should we open up to loved ones?