Medication Management During Psychoanalysis

The use of psychotropic medication represents the most prevalent and dramatic change in psychoanalytic technique in the last thirty years. When the psychoanalyst prescribes medication, he or she assumes

a second role and the two functions, psychoanalyst and psychopharmacologist, employ different theoretical frameworks, clinical data, and technical procedures. For example, the appropriate use of psychotropic medication relies on a phenomenologically based diagnostic system and a more traditional doctor-patient relationship.This is obviously different from psychoanalytic metapsychology and technique. Most of the literature has focused on the impact of prescribing medication on the function of the analyst; little has been written about the impact of the analytic situation on the practice of psychopharmacology.

This study reviews the medication management during 77 candidate analytic cases begun at the Columbia University Center for Psycho-analytic Training and Research between 1994 and 1999. At the beginning of analysis, 52% of analytic cases (40/77) had a current Axis I mood or anxiety disorder; 39% (30/77) were on medication at some point during analysis.

Narrative summaries were created for all of the 77 cases from documentation in patients' charts of affective symptoms, Axis I diagnosis, and medication treatment. The narrative summaries illustrate the basis for the candidates' decisions about medication treatment. These narrative summaries suggest that pharmacological decisions during analysis were often based on inadequate or inappropriate data, or on countertransference, or were unduly influenced by theoretical struggles or conflicts between supervisor and candidate.

Overall, this study suggests that medication management during psychoanalysis is often not optimal.