Robert Scharf, M.D.

Questions about medication during psychoanalysis reach deeply into our understanding of how analysis functions and probe basic issues of therapeutic design. Judiciously prescribed medication may facilitate a psychoanalytic process in a patient with disturbed neurophysiology who is otherwise untreatable with psychoanalysis. Freud looked forward to the potential of psychotropic agents in his 1938 “Outline,” and the discovery of most of the major classes of psychologically remediating drugs followed just a decade and a half later, in the mid-1950s. Ostow recommended their application to analytic patients in two papers and a monograph, appearing between 1960 and 1966. His most recent observations are contained in a chapter of a book edited by Jacobs and Rothstein (Ostow, 1990). As psychopharmacology has focused on patients with affective disorders, it has become apparent that there are many more individuals with milder forms of major mood disturbances associated with neurophysiological dysfunction, who can now effectively be treated with medication (Akiskal, 1981, 1983). Some of these patients are reasonably high functioning and have routinely been analyzed without the use of medication. Most of these cases are depressed or mildly bipolar individuals who tend to progress slowly in analysis, have long treatment courses, and may terminate because of a stalemate rather than by reaching a satisfactory analytic conclusion. Other cases can barely function, or cannot function at all in an analytic situation, but are nonetheless analyzable with adjunct medication. Besides Ostow, Cooper (1985), Wylie and Wylie (1987), Auchincloss (Panel, 1990a), and Wylie (Panel, 1990b) have reported examples of such psychoanalytic cases. In this discussion I am mainly referring to patients with depression who are medicated while being treated in analysis. The same clinical points probably hold for analytic patients who receive drugs for severe obsessive-compulsive or panic disorder symptoms, bu