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Prescribe first, ask questions later?

Vol. 4, No. 5 / May 2005

Dr. Susan Stern’s comments on the role of psychotherapy in her psychiatric practice may have inadvertently foreshadowed psychiatry’s demise as a profession (“Pearls: Treatment resistance? Try psychotherapy,” Current Psychiatry, February 2005).

Dr. Stern shared the story of Mrs. H, who has had depression nearly half her life. The patient’s condition persisted despite numerous antidepressants across several classes. Dr. Stern then tried “several medication augmentation strategies” to alleviate the depression, but nothing worked.

“Finally,” Dr. Stern explained, as if she had exhausted all obvious and reasonable options, “I left her medications alone and listened to her story.”

Excuse me, but had Dr. Stern not realized that Mrs. H’s story might be relevant—even central—to her 20-year battle with depression and to her recovery? If this is a revelation, then psychiatry is on life support.

Too many psychiatrists have stopped listening to their patients and have become obsessed with finding the right drug augmentation strategy. Yet as Dr. Stern’s piece amply demonstrates, a prescribe-first-and-ask-questions-later approach spells almost certain failure—if not disaster—for both the patient and profession.

Although psychotropics have their place, psychiatry’s greatest legacy—the healing power of the doctor-patient relationship—has been allowed to slip silently beneath the waves. Your patients are hurting and they need you, not just your drugs. Put down your pens, close your mouths, and open your ears and hearts. Listen with your “third ear,” as Theodor Reik implored. The results will amaze you.

Barry D. Berger, PhD
Clinical psychologist and president
Mission Psychological Center, Mission, TX

Dr. Stern responds

Dr. Berger’s response to my Pearls article indicates a growing view that psychiatrists in general use medications first to treat depression, with psychotherapy as a mere afterthought. Most psychiatrists I know, however, are interested in doing what they feel is right for the patient, whatever the treatment modality.

A desire to institute or change medications early in the therapeutic process may stem from various sources, including the acuity of the patient’s clinical situation (in which not addressing a patient’s medications would be considered negligent).

Patients often expect psychopharmacologic intervention when they see a psychiatrist. Whether this attitude stems from a fantasy of “instant cure” or is simply a resistance to self-exploration, we should use every means available to address their suffering. The purpose of my article was to illustrate that patients who are considered “refractory” or “resistant” to medications can still be responsive to psychotherapy.

Susan Stern, MD
Instructor in psychiatry
Columbia University College of Physicians and Surgeons
New York, NY

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