Is Your Prescribing Really Evidence Based?
David Mintz, MD
"Posted with permission of Psychiatric News, American Psychiatric Association, © 2016. This article originally appeared in the May 20 issue of Psychiatric News PsychoPharm bimonthly enewsletter (Volume 2, Issue 9).”
Studies point to the role of the psychiatrist and importance of the therapeutic alliance in predicting patient outcomes.
Despite advances in neurobiology and drug development, and increasing pressure to deliver “evidence-based” psychiatric care, studies show many patients living with psychiatric illness remain resistant to psychiatric treatments.
One factor contributing to this trend may be that we are overlooking some of the relevant evidence bases when deciding on treatments for our patients. While the term “evidence based” is primarily used to refer to evidence from medication trials, it often fails to take into account other aspects of pharmacotherapy. Is it possible we are so focused on what to prescribe that we are overlooking what the evidence suggests about how to prescribe?
During the seminar “Psychodynamic Psychopharmacology: Applying Practical Psychodynamics to Improve Pharmacologic Outcomes with Treatment-Resistant Patients” at APA’s 2016 Annual Meeting, I described recent evidence to suggest psychiatrists may be overlooking the psychosocial aspects of the prescribing process (1).
Meta-analyses of antidepressant trials in the FDA database suggest that 76 to 81 percent of antidepressant outcome is attributable to placebo (2, 3, 4). A study by McKay and colleagues found that while both psychiatrists and treatments contribute to outcomes in the treatment of depression, more effective physicians achieved greater reductions in depression with placebo than less effective physicians achieved prescribing an active drug (5). Other research suggests that a good therapeutic alliance may contribute more to antidepressant response than treatment with active drug (6).
An empowering, patient-centered, nonauthoritarian stance is one of the most potent tools in the psychiatric armamentarium. Autonomy support (7), involving patients in decision-making (8), and respect for patient preferences all significantly enhance antidepressant outcome. A study by Kocsis and colleagues found that when patients expressing a preference for either medications or psychotherapy were randomized to a condition where they received their preferred treatment, approximately half showed a significant antidepressant response. When patients who preferred medications received psychotherapy, however, only about a quarter responded. When patients preferring psychotherapy were given medications, the response rate fell to 7.7 percent (9).
Bedside manner matters, too. A recent study exploring the impact of tone of voice on appointment adherence found that for every standard-deviation interval above the mean of warmth in voice tone, there was a corresponding 162 percent increase in appointment adherence (10).
Other studies demonstrate how the presence of technology may affect the course of treatment. One recent naturalistic study of treatment continuation found that 77 percent of patients returned for a second appointment following an intake in which the doctor did not interact with the computer. If, however, the doctor interacted with a computer even once, only 27 percent of patients returned for a follow-up visit (11).
Despite escalating pressure to maximize efficiency, we must continue to recognize that meaning effects medication. It is time for psychiatry to embrace all the evidence bases and capitalize on the potency of a truly integrated biopsychosocial practice.
- Mintz, D, and Flynn, D. How (not what) to prescribe: Nonpharmacologic aspects of psychopharmacology. Psychiatric Clinics of North America. 2012;35(1):143-163.
- Chong W, Aslani P, Chen T, et al. Effectiveness of interventions to improve antidepressant medication adherence: A systematic review. Int J Clin Pract. 2011; 65:954–975.
- Khan A, Warner H, Brown W. Symptom reduction and suicide risk in patients treated with placebo in antidepressant clinical trials: an analysis of the Food and Drug Administration database. Arch Gen Psychiatry. 2000;57:311-317.
- Kirsch I, Moore T, Scoboria A, et al. The emperor’s new drugs: an analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment. 2002;5, Article 23.
- McKay K, Imel Z, and Wampold B. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect Disord. 2006;92:287-290.
- Krupnick J, Sotsky S, Simmens S, et al. The role of therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol. 1996; 64:532-439.
- Zuroff D, Koestner R, Moskowitz D, et al. Autonomous motivation for therapy: A new common factor in brief treatments for depression. Psychother Res. 2007;17(2):137-147.
- Woolley S, Fredman L, Goethe J, et al. Hospital patients' perceptions during treatment and early discontinuation of serotonin selective reuptake inhibitor antidepressants. J Clin Psychopharm 2010;30:716-719.
- Kocsis J, Leon A, Markowitz J, et al. Patient preference as a moderator of outcome for chronic forms of major depressive disorder treated with nefazodone, cognitive behavioral analysis system of psychotherapy, or their combination. J Clin Psychiatry. 2009;70:354-61.
- Cruz M., Roter D, Cruz R, Wieland, M, Larson S, Cooper L, and Pincus H. Appointment length, psychiatrists’ communication behaviors, and medication management appointment adherence. Psychiatric Services. 2013; 64(9):886-92.
- Rosen, D, Nakash O and Alegría M. The Impact of Computer Use on Therapeutic Alliance and Continuance in Care During the Mental Health Intake. Psychotherapy. 2015; 53(1):117-23