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Psychoanalysis and Pharmacotherapy - Incompatible or Synergistic?

Psychoanalysis and Pharmacotherapy - Incompatible or Synergistic?

Is the rising use of psychotropic medication to treat anxiety and mood disorders incompatible with the psychoanalytic approach?

As a psychopharmacologist and psychoanalyst who frequently provides consultation to analysts regarding medication for their patients, Steven P. Roose, M.D., professor of clinical psychiatry at Columbia University's College of Physicians and Surgeons, has studied this question and presented his findings and opinions in various scientific papers, books and meetings.

His most recent talk--part of a panel called "Are Therapists from Venus, Pharmacologists from Mars?"--was given in May at the American Psychiatric Association's (APA) annual meeting in San Diego. There, he specifically discussed sequencing medication and psychotherapy treatments.

In a telephone interview with the Psychiatric Times before that meeting, Roose, who is also codirector of the Late Life Depression Research Clinic at New York State Psychiatric Institute, shared his overall views on medication's role in psychoanalysis.

Q. What is the history of medication use in psychoanalysis?

Roose: In the late 1950s, when psychotropic medications first became available, the modality was mostly greeted with outright rejection by the psychoanalytic community. Medication was characterized as treatment that relieved symptoms but didn't affect underlying psychic conflicts then considered to be the etiology of psychological illness. It was reluctantly conceded that reduction of florid symptoms, albeit superficial, could be useful to the degree that it controlled behavior disruptive to development of transference, thereby facilitating analytic treatment. But still, it was strongly believed that psychoanalysis is a deep and curative treatment that should be left undisturbed whenever possible, and medication was considered an undesirable intrusion that should be supplemented only as a last resort. So even when effective, medications were to be considered, at best, a necessary evil.

Over the next decades, many studies showed medications worked well alone and even better in combination with psychotherapy, yet in those studies, the drugs were combined with either interpersonal, cognitive or supportive psychotherapy rather than dynamically-oriented treatment. But recently, a number of psychoanalytic authors, among them David Kahn, M.D., of the department of psychiatry at Columbia University and Shepard Kantor, M.D., at the New York Psychoanalytic Institute, have themselves concluded that combining medication and analysis may have a synergistic, beneficial effect.

Anecdotally, even Anna Freud, when visiting the New York Psychoanalytic Institute in the early 1980s, expressed surprise at the almost complete rejection she saw there of drugs being used during psychoanalytic treatment. She said she'd used psychoactive drugs with three patients in severe states of depression and in no case did the use of medication interfere with the progress of analysis. In fact, she said, the medications helped the analysis maintain itself during phases when patients might otherwise have needed hospitalization.

Recent evidence, however, indicates that medications are increasingly being used. In a 1995 study we did at Columbia University Center for Psychoanalytic Training and Research, where I'm a faculty member, we found that in the prior five years, about 18% of training analysts' cases were on medication, primarily for dysthymia or major depression. Even more importantly, 62% of those analysts had at least one patient on medication. Since no data on this topic have been reported prior to our study, it can't be known whether ours represents an increase in medication prescription with analysis, but I think it's reasonable to conclude that it does.

Furthermore, for 84% of patients treated with medication, analysts in our study concluded there was not only the expected therapeutic response to medication, but also a positive effect on analytic process as well3/4 results that contradict the belief that medication undermines the psychoanalytic situation. Since these training analysts represent a select group chosen by each local psychoanalytic institute and approved by the American Psychoanalytic Association, their use of medication represents clinical practice of leaders of the psychoanalytic community. And the overall analytic community's interest in the topic is reflected by the numerous sessions devoted to it at the American Psychoanalytic Association's scientific meetings.

So much has changed in the psychoanalyst's attitude, especially when it comes to schizophrenia, bipolar illness and depressions. But despite that open recognition, there's still competition between different models of the mind that strongly influences treatment choices and makes our eclecticism perhaps more apparent than real.

Q. How is that competition manifested?

Roose: One way is that clinicians artificially divide psychopathology by saying Axis I disorders are biologically hardwired, i.e., not derived from psychic conflict, and therefore not amenable to psychotherapeutic interventions. In contrast, Axis II disorders are seen as resulting from psychic conflict, and therefore amenable to interpretation, implying that psychological treatment and not medication should be the primary treatment modality. It should be recognized that such a division has no empirical basis and serves only to promote misguided competitions in our field. And, of course, such competitions also can harm the patient, who may not get needed medication because of theoretical issues.

Q. So when is it appropriate to medicate during psychoanalysis?

Roose: Considerations are similar in all disorders, but let's take depression as a specific example. Over the years, there's been an increasing divergence between psychoanalysts' concept of depression and diagnostic categories of affective disorder used in clinical psychiatry. Underlying the differences in diagnostic approaches are significant differences in theories of etiology.

But in clinical settings, we don't need resolution of theoretical conflicts regarding etiology to develop a system to guide medication use in combination with psychoanalysis. Rather, we must focus on phenomenology. Data establishing efficacy of medication in affective syndromes were collected in studies that included patients based on phenomenology of their symptoms, including chronicity, content and intensity, not the presumed etiology or meaning of the depression. Of course the depression had meaning to these patients, and like all patients, they presumably had elaborate conscious and unconscious fantasies to explain what was happening. Even if, in its origination, depression is brain state without content, as meaning-seeking and meaning-creating creatures, we're compelled to attach meaning and cause to every feeling. Although the psychic content coupled to a physiological tone may in fact produce inaccurate and misleading understandings, whatever the veracity of our self-interpretations, it's critical to acknowledge that identifying and understanding meaning isn't equivalent to establishing etiology.

Yet for the clinician struggling to decide on treatment for a depressed patient, meaning isn't the critical dimension. Rather, what should guide clinicians as to whether medication will be helpful to a specific patient is phenomenology of the psychopathology. If a patient meets diagnostic criteria for an affective syndrome, or any other syndrome, medication should be considered. It's not that every patient should be on medication, but in all such patients, it must be given serious consideration and if not recommended, there should be good rationale as to why not. It must be recognized that the effectiveness of a so-called biological treatment no more proves that there is a biological etiology to an illness than an effective psychological treatment proves there is a psychological etiology. Effective medication treatment, like effective psychotherapy, is not evidence that favors any theoretician; it only helps the patient.

Actually, many psychoanalysts have already come to this position regarding melancholic depression. They may still maintain they can determine both cause and dynamic meaning of the symptoms while concurring that rapidly effective somatic therapy is the treatment of choice.

Although the psychoanalytic perspective may no longer have significant relevance to melancholic depression or bipolar illness, psychoanalytic theory is still important, if not critical, when trying to understand the mechanism of transitory depressive affect states and the relationship of those states to experiences of hurt and maintenance of self-esteem and anger.

In addition, with or without medication, psychodynamically based therapy may have an important role in treatment of patients with chronic depressive states. Over the years, these patients have been labeled as having characterological depression, depressive neurosis and now dysthymic disorder, but regardless of label, the depressive affect permeates every part of the patient's life with widespread and profound effects on object relations, career, parenting and identity. Whatever the etiology of affect, the patient and analyst understand the mood as a consequence of fantasies, conflicts, drives and transferences. For these patients, the depressed affect is a fundamental part of their life narrative.

But again, it's important to emphasize that etiology of the depressive affect is not the crucial issue in terms of its impact on psychological development. By analogy, a significant physical malformation such as a missing limb is clearly not psychological in origin, but just as clearly such a defect will be a critical influence, albeit not the only influence, on the child's psychological development. Thus, as opposed to treatment for melancholia which is an episodic illness that has no demonstrated relationship to character structure or defensive operations and responds well to somatic treatments alone, treatment for a chronic dysthymic disorder may require understanding the dynamic meaning of the depressive affect and its impact on character structure, sense of self and interpersonal relations.

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