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Feb 09

Psychopharmacologist

I am not a psychopharmacologistI am not a psychopharmacologist.

A patient who I have been seeing for almost a year and who has been depressed throughout that period came in to see me today and we talked about her mood over the last couple of months.

She has been markedly less depressed, and I was congratulating myself on the most recent medication change we had made. Then, almost by accident, just as she was leaving our appointment, she happened to mention that she was feeling a little bit sad today because of relationship with a young man that had just ended.  So I asked her when it had started, because I know that relationships matter a huge deal in terms of her mood, and she told me that it had started at almost exactly the time that her mood started to improve.

As it happened, she and I have had some challenges working together. She had previously seen a psychiatrist who practiced in the more or less traditional New York psychopharmacologist manner, meaning fifteen or twenty-minute appointments every two or three months. I don’t have “medication visit” appointments,  and she continually wondered why I felt the need for longer appointments. She also often told me that “you don’t need to know that” when I would ask a personal question about, for example, her relationship status.

Back to my session, I pointed out that there was a perfect correlation between her improved mood and starting this new relationship, and noted that we had discussed the reasons for the improvement and had concluded that it was due to a medication change, when, in fact, it correlated better with her starting the relationship. I wondered why she hadn’t told me about the relationship.  She said she didn’t think that it was relevant and then I said, “but we know relationships matter a huge amount and that when you ended your last relationship is when you started becoming more depressed.” She had to admit that this was the case and, after an extended discussion, she decided that the issue was really that she felt uncomfortable talking about relationships with me. It is not something that psychopharmacologists need to know. In other words, it was an issue about her sense of being uncomfortable with me, which is, ironically, a good part of the reason why I felt we needed to meet more often, to try to develop a relationship in which she would feel comfortable talking about personal matters that affect mood. It is really hard to develop much of a close relationship with a psychiatrist who you see for only ten or fifteen minutes every three or four months.

Another example of the challenge with the traditional “psychopharmacologist” role is that the quality of the relationship in the sense that I am working as a real partner to someone struggling with depression is very important. Without time to get to know the other person it’s easy to miss changes in how the person’s feeling about our working relationship. For example, another one of my patients came in today and reported that her depression had increased even though there had been no change in medication. It emerged, as we talked some more, that for the first time she’d actually been forgetting some of her doses of medication (which could of course explain her dip in mood, except that her dip in mood preceded those forgetful episodes).

I found myself wondering about the conversation that we had in our last session and it occurred to me that in that session we had, jointly I thought, decided that we would taper one of her medications before starting a new antidepressant. At first she said that she had felt that that was a joint decision and so it couldn’t explain the dip in mood and that change in her ability to remember her medications. But on further reflection she decided that she had come into the session hopeful about starting and antidepressant, and even though she had agreed with my logic about discontinuing the other medication before starting the antidepressant, she had come away from the meeting feeling more discouraged.

Again, that knowledge which also allowed us to reestablish our strong working relationship and agree on a new plan, would not have been possible had I just been seeing her for brief medication check visits, as her former psychiatrist had done.

All of this is part of why I do not consider myself a psychopharmacologist.  In my practice I find that it’s only possible to figure out whether mood changes are due to medication changes if I know about other aspects of a person’s life, and that’s only possible with a certain degree of comfort and connection.

And it’s also true that a strong collaborative relationship and a realistic sense of hope about the future is almost always part of recovery from a chronic depression, or other mood condition.

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