Psychotherapy Perspectives in Medication Management

It is now customary psychiatric practice to think of a patient's illness as primarily biological in origin-so much so that, for many illnesses, published practice guidelines almost exclusively describe medication strategies. Psychotherapy, when it is mentioned, is usually in the form of patient education about the nature of the particular illness and supportive work aimed at helping the patient cope with its symptoms.

Clearly, there has been a paradigm shift in American psychiatry during the last 25 years that is no less remarkable for its unanimity of focus than the previous chorus of apparent agreement about the wonders of talk therapy. While cognitive behavioral therapy is granted a certain legitimacy, it is similar to pharmacotherapy in that it focuses on the outer manifestations of the illness or the symptoms per se and avoids at all costs any hint of the dynamic psychiatry that once filled the halls of academia.

The nature versus nurture controversy is not new and the controversy is far from over, but supporters of the nature viewpoint have found a particularly appealing way to present mental illness. Axis I disorders are boldly portrayed as " chemical imbalances" in patient brochures, news articles and other educational materials.

The problem with this portrayal is that, while some day we may accumulate the knowledge to demonstrate the particulars of this perspective, no such chemical imbalances have been unequivocally demonstrated for any disorder. We are offered interesting conjectures, educated guesses that are forever shifting as the latest data are accumulated. The continual construction of new hypotheses is how science should proceed. But good science is normally modest. It clearly distinguishes between soft knowledge and what is known. It does not trumpet a few brilliantly placed pieces of a jigsaw puzzle as the solution to the entire puzzle.

It isn't that researchers are unaware of the difficulties of integrating current knowledge with theory. Frustration with the chemical imbalance neurotransmitter model has, for instance, led authors to propose an intracellular hypothesis to explain the effectiveness of various medications (Duman et al., 1997). I would like to suggest a different approach.

While it is acknowledged that the DSM-IV is not a nosology based on etiology, the implicit premise of the chemical imbalance perspective is that certain DSM-IV -defined " disorders" are lacking a given neurotransmitter in a particular part of the brain that is somehow related to the disorder. In the gray area are expansions of the basic illness with so-called spectrum disorders. Presumably, there is a genetic or biological link that explains the usefulness of certain medications across the entire spectrum of the related disorders. The weakness of this formulation is that medications such as the selective serotonin reuptake inhibitors (SSRIs) are proving efficacious in so many Axis I and Axis II disorders that to consider all of these forms of misery as part of the same biological spectrum is stretching credulity. Occam's razor demands a more parsimonious approach.

I would argue that there are certain psychological effects of medications that make them useful in a variety of DSM-IV -defined disorders not because they are necessarily correcting a chemical imbalance, but because the psychological effect is useful. Rat pups that are isolated from their mother and littermates produce ultrasonic sounds that are indicative of stress. SSRIs reduce these sounds (Oliver, 1994). Is a chemical imbalance being corrected? I doubt it.

A case can be made that SSRIs are efficacious in conditions as disparate as borderline character, depression, obsessive-compulsive disorder, anorexia nervosa, panic disorder, social phobias and so forth because increasing serotonin has a psychological impact that is nonspecific to the disorders in question. Alcohol will produce inebriation in a person with schizophrenia, obsessive-compulsive disorder or depression, as well as in someone with no psychiatric diagnosis. Analogously, SSRIs typically impact individuals in ways that are not specific to diagnosis.

I will go one step further. Understanding the psychological effects of medications such as the SSRIs can lead to productive uses of the medication even when a specific DSM-IV symptom or disorder is not the issue.

What is that effect? The most frequent description that I have heard from my patients of the effects of SSRIs is an attitude of " it doesn't matter" or " don't sweat the small stuff" or " what's the big deal?" This don't-sweat-the-small-stuff perspective, I believe, is the SSRIs' unique blessing and curse. It means relief from worry, relief from the feeling that something is missing, needs to be done or needs to be fixed. Thoughts such as " my makeup isn't right," " the sky is falling," " I won't be able to pay my bills," " I'm not smart enough" -the chatter that occupies the unsettled mind-are endless and particular. The emotion is more basic.

SSRIs supply, if not always happiness, a nice contented feeling that all is well and will be well. They can allow parents to play with their children more, fret less over the details, appreciate what is, and actually want to do the proverbial modern mantra-stop and smell the roses. SSRIs are the answer to existential angst. Perhaps if Sisyphus had been born in the 1990s, he could have left that rock alone and had a nice snooze.

On the other side of the equation, I have a psychiatrist colleague who took Prozac (fluoxetine) to relax and enjoy his vacation. It worked very well. He told me that he continued it at home when he returned. He quickly stopped it when he found himself thinking, " Who cares?" when his patients described their problems.

There are other examples.

Mrs. L. had originally required 40 mg of Paxil (paroxetine) per day to recover from a postpartum depression. After 12 months on the medication, an incident happened that disturbed her. During her lunchtime, she was visiting her 1-year-old son at his day care center when one of the workers began screaming at another infant instead of picking her up. The next day Mrs. L. went shopping during her lunch break. Later that week a co-worker became tearful during the course of a conversation with Mrs. L. regarding her own child's day care center. Only then did Mrs. L. wonder about her decision to go shopping the day after she had witnessed the day care worker's inappropriate reaction. She wondered if her Paxil had made her indifferent when ordinarily she would have reacted and worried about such a thing.

We decided to taper the dose of medicine to 20 mg. Sure enough, on less medicine there was a dramatic change in her perspective about many things. For the first time I learned about the pressures she had been under at the time of her original hospitalization. Mrs. L. had tried to find time to be the same powerhouse worker at her job that had brought her so many promotions in the past, an ideal mother for her newborn infant and responsive to her husband's very exacting standards about her housekeeping. Suddenly, without the higher doses of Paxil, her fury poured out. She described, in detail, episode after episode in which her husband stood to the side and endlessly critiqued her adequacy as a mother. The higher doses of medication had muted her responsiveness and allowed his criticism to go in one ear and out the other, but now there would have to be change " or else." Mrs. L. also acknowledged that she had not been doing her job as carefully as in the past and eventually the company would discover her drug-induced " what the hell" attitude. At home, she had bounced several checks, which she never did before being on the medication.

Therapy now turned to how her life would have to change. She seriously considered quitting her job. She loved being a mother and didn't want to miss out on her son's crucial early years. She demanded changes in her husband (with the threat of divorce). Her new assertiveness rapidly put him on good behavior even before marriage counseling started. Occasionally she became tearful about her dilemmas. Although we discussed the possibility of returning to higher doses of medication, she was not eager to do this. She felt her tears were about real things and did not consider herself depressed. She felt neither hopeless nor helpless. Her sleep was not as restful; she sometimes tossed and turned. But she was OK. We joked that we might go up on the Paxil temporarily if and when she needed a vacation from her stresses. In fact, throughout, I was concerned that her greater emotionality might be a prelude to the return of her original symptoms. But our perspective was quite different than an automatic increase of medicine at the first sign of tears. As it happens, she did not need to return to higher doses. She did quite well, eventually deciding to work part time. Three months after making that decision, she was the happiest she had been in years.

It is noteworthy that when she was reduced to 10 mg (at her urging), there was another change. She again noticed dust on her furniture and the haphazard placement of pictures on her table. She arranged them more aesthetically. She did not feel driven to fix these things. She took pride in her newly regained attention to detail.

She also regained a degree of empathy for her husband. There was the danger that she was returning to a dynamic of taking care of everyone and everything, of offending no one, a role that she had assigned herself from early on in childhood. This pattern may have played a part in her original postpartum depression as she tried to juggle her responsibilities and became overwhelmed, consequently generating forbidden anger at her newborn.

Mrs. L.'s case illustrates the potential downside of too much of a good thing, too much of the " well, whatever" feeling. From a DSM-IV perspective, her 40 mg emotional blunting would not be identified as a problem. Only by viewing the patient's needs and her clinical presentation in terms of a psychological narrative could the treatment properly focus on what once would have been, and obviously still is, deservedly a high priority-to help the patient in her struggle to come to terms with her psychological makeup, and to do the best she can in reconciling her dynamics and values and the reality of her situation.

Medication may, or may not, play an important role in reaching a desirable acute and/or chronic equilibrium in these matters, but the issue cannot even be approached if DSM-IV " symptoms" are used as the sole guideline. Nor, it must be added, would these issues have been addressed in what has become standard psychiatric practice-the once-a-month 15-minute med check.

Viewing SSRIs as " well, whatever" medications, I believe, best accounts for their usefulness in so many disorders. It is precisely this feeling that is so helpful in obsessive-compulsive disorder. Similarly, the ability of patients with anorexia nervosa to not freak out after they have put on a pound or two is helped by a dose of that attitude. The same can be said for body dysmorphic disorder. In panic disorder, the loss of patients' exquisite sensitivity to their body sensations is extremely helpful, as is the dulling of their sense of danger. Ditto for phobias of all varieties, including social phobias. Many a patient with a short fuse has been helped by SSRIs. While the fury of intermittent explosive disorder patients, once provocation has occurred, may not be helped by SSRIs, the medication often makes it harder to push their buttons. When effective, perceived insults go in one ear and out the other.

As I implied above, the perspective I am presenting, if correct, leads to clinical distinctions that may not be related to diagnosis. For example, I saw a 15-year-old boy who had broken his father's heart by quitting the basketball team and by not producing his usual good grades. The question was whether he was depressed. There was a hint of rebelliousness in this teen-ager but no obvious dysphoria. He could still have a great time with his friends, including playing basketball for fun. He wanted to take it easy, to coast for awhile.

As I got to know him, what emerged from our talks was that an enormous amount of stress built up in situations where his father expected him to do well. Here was a guy who had developed a " well, whatever" attitude as a defense, a not uncommon phobic posture among teen-agers (and adults) who avoid situations when the going gets tough. With luck, therapy could help him understand and work through his difficulties with his father and help him approach competitive situations with greater equanimity. If I used medication, an important component of the decision would not be whether this patient was diagnosable as having a subclinical depression. My focus would be on his " well, whatever" attitude. Would it be worsened by an SSRI, or would the medication lessen his anxiety and fear sufficiently to take on challenges and not resort to avoidance?

Therapeutic decisions regarding forbidden impulses revolve around similar treatment dilemmas. If I sense that a person is gambling, drinking or eating excessively out of incessant frustration, SSRIs can be markedly effective. On the other hand, the " well, whatever" attitude extends to discipline and standards, including moral standards. Some patients, able to battle their temptation to drink, gamble, overeat and the like, find that they loosen the reins too much on SSRIs.

Increasing courage and lessening the fear of irrational consequences are very helpful in phobias, but that same decreased fear of consequences can apply to rational fears. Sometimes SSRI-induced decisiveness can lead to ill-advised risk taking. One significantly depressed patient whom I saw refused to be medicated because she reported that an earlier impetuous decision to go ahead with a marriage could only be explained by her medication. Off of SSRIs, she was normally extremely cautious, carefully considering all possibilities. On the SSRI, this changed to " What the heck...you only live once." I could not reject her observation out of hand.

SSRIs are extremely useful in anger management when a low frustration tolerance is leading to frequent eruptions. On the other hand, many patients have proudly related to me how they told someone off that they had been itching to tell off. Like alcoholics the morning after, some of the time their boldness was later regretted. Analogously, the misbehavior of many delinquents and those with conduct disorder is frequently driven by unending anger and unappeased needs. SSRIs can be helpful here. But it is also possible that an SSRI can contribute to the courage needed to do outrageous things, including crimes. These issues should be weighed by the clinician. I realize that the last issue has been sensationalized by the media and the " Prozac defense" rejected by the courts, but I do not think it is impossible.

Let us return to depression.

Mr. T. was a 30-year-old man who was very unhappy in his marriage. He had always pictured a family life with two or three children. His wife, a beautiful woman whom he had originally been smitten by, had never wanted kids. Mr. T. had assumed she would change her mind. But now, six years into the marriage, he had realized that there would be no change of heart. She was to be the project of the marriage, her vulnerabilities, her needs, the vicissitudes of her emotions. It had gotten old for Mr. T. Over the years, he had noticed his impatience with her grow into indifference and then sarcasm. He came for help when he had become depressed.

I'll put the issue in a nutshell. What if Prozac worked like a charm and completely rid him of his depression? What if Prozac returned bounce to his life and now he found he could, after all, live happily with the status quo? What if 25 years from now, Mr. T. were to wake up and suddenly realize he had wasted his life? He really had wanted children and a family all along. What if he wouldn't allow a doubling of his Prozac dose at that point, seeing it as a drug that had deceived him and cheated him of what had been meant to be?

There are times when removing the symptoms of depression might not be a valid choice, times when depression is serving a function. It can be an alarm signal that something is heartbreakingly wrong. Often people can learn to make do, learn to live with what is. When there is no choice, or life is not very good but is good enough, the individual's ability to justify or rationalize his existence is a stabilizing force. Sometimes, however, more powerful emotions occur. The individual feels stuck, at a dead end, defeated. A depressed person's self-questioning (and self-depreciation) can represent a search for a way out of the trap, a need for change or for setting off in a new direction. Depression may mean that internal change is taking place: they may be learning to reevaluate priorities, set goals less high, or finally take chances for things that really matter. For instance, depression may provide the impetus for a person to begin to appreciate the importance of loved ones rather than career or, conversely, to realize that taking care of family needs and stifling individual ambition no longer work.

Not infrequently, depression occurs at times of passage. Adjustments that worked 10 years earlier have worn out. Every truth eventually becomes a lie. A solution to a problem may eventually become the new problem. Marriage may have brought an end to feeling lost, lonely and directionless, but marital responsibilities may later become a prison. Being a bit of a rascal, being able to dance around and away from problems may have broken many a bad mood, but eventually comes the time to pay the piper. There are thousands of scenarios that culminate in depression.

Change is not always possible. A person dying or in wretched poverty doesn't need recognition that change is needed. That is obvious. However, even in the cases of those in such dire circumstances, we cannot escape the observation that there are those who die with relative ease and peace of mind, and others who go screaming into the abyss. Inescapable poverty is tolerated better by some and worse by others. What makes the difference? In some cases it is religion, spiritual values, a deep love, and sense of loyalty from and between those who matter.

Those who favor a biological perspective might further argue: What about individuals who are neither sick nor poor, but who get depressed? What about those who appear to have everything, the love of family members, good friends and career success, yet still get depressed? There are certainly individuals who have put on a big act, who have fooled even themselves, never dared to challenge their assumptions, pathways and dreams. When they get what they wanted, they realize it wasn't what they needed after all.

Undoubtedly true, but are there individuals who are biologically predisposed to depression? Are the examples of the scenarios I have described merely precipitants, stress factors that would not have caused serious difficulties unless biological factors were at work? Certainly we have long known that depression can result from hypothyroidism, pancreatic cancer and as a side effect of certain medications. There are depressions that run in families. We cannot dismiss genetic priming. But I would argue that even if many current biological assumptions will eventually be proven accurate, if we grant that certain people are biologically predisposed to depression, and the unhappy tale they tell is merely a precipitant of foreordained illness or, using a different model, the result of their negative thinking, it still behooves the clinician to consider that the precipitant is not meaningless. The timing of their misery holds crucial clues to the etiology and cure.

It is true that for certain severely depressed individuals, symptoms are so overwhelming and in need of mitigation, and their despair so palpable, that it would be cruel to not offer quick and effective relief. Moreover, a patient may be so much in the savage grip of his or her symptoms that addressing anything else would be irrelevant, not to mention useless.

However, this rule is not absolute. I once saw a patient, not with depression, but with anxiety bordering on panic, who wanted a tranquilizer. He worked in security at a jai alai facility and had discovered Mafia influence in the gambling activities. He was to testify the following week. A rock had been thrown through his window and written threats placed in his mailbox. He had sent his wife and children to her mother's house and sat alone in his house listening for every suspicious sound. He was terrified. He wasn't sure if he would go ahead and give testimony. I refused to give him medication. If he was going to be a hero and take a chance with his survival, the decision would have to come undrugged.

Analogously, it is in the best interest of patients on SSRIs to be warned that the medication could distort their judgement when it comes to decision-making, especially big decisions. We cannot automatically assume that their symptoms only represent pathology and that feeling good (or more ominously, as psychiatrist Peter Kramer put it, " better than well" ) represents normalcy. Therefore, decisions made when they feel confident and good are truly good decisions. The chemical imbalance perspective seems innocent enough when propagandists use it to convince patients that their symptoms are not signs of weakness, that they should get treatment because they have a medical disease. But clearly, we are not doing our patients a favor if they are not warned of the downside of this viewpoint.

Finally, we should address the traditional psychoanalytic view on medication, " No pain, no gain." There are valuable lessons to be learned in passing through the trials that life sometimes offers us (with or without symptoms). True, in therapy, we mean optimal anxiety, optimal dysphoria, optimal stress fosters growth. The spirit can be broken and distorted by too much of a bad thing. And certainly, many patients are so overwhelmed by their symptoms that they cannot learn anything during the meltdown of their ability to cope. Only after medication restores a firm underpinning can they begin to address their problems. As always, the skill and wisdom of the psychiatrist is called upon to weigh these factors and to help guide the patient to a reasonable course.

References:

References1.Duman RS, Heninger GR, Nestler EJ (1997), A molecular and cellular theory of depression. Arch Gen Psychiatry 54(7):597-606.
2.Oliver B, Molewijk E, van Oorschot R, et al. (1994), New animal models of anxiety. Eur Neuropsycho-pharmacol 4(2):93-102.