A commentary on existential psychopharmacologic clinical practice: Advocating a humanistic approach to the “med check”

Abstract

A patient must feel heard before she will listen. If a clinician does not first listen carefully to a patient's story, pharmacotherapy is reduced to a random target shoot, ineffective and even dangerous. Psychotherapy training teaches clinicians how to listen, among other things, and, unfolding over an hour, has valuable effects. Psychopharmacotherapy, by contrast, often is shoehorned into a 15-minute session, called a “med check,” inhibiting the therapeutic alliance and frustrating both patients and clinicians. That brief clinical contact is intended to include a symptom review, discussion of medication effects, update of relevant medication conditions and treatments, review of significant current life events and stressors, and completion of administrative forms and prescriptions. Rarely is there time for adequate documentation without typing during the session, a distracting practice encouraged by burgeoning caseloads and widespread adoption of electronic medical records. In this article, our main claim is that the success of clinical psychopharmacotherapy requires adoption of a psychotherapeutic stance. We have previously described in detail the process and components of both initial evaluation and follow-up visits in psychopharmacotherapy practice.1 We describe “existential psychopharmacology,” based on the existential tradition in psychiatry,2 emphasizing that a human-to-human connection must be established for successful medication treatment. Empathy precedes and potentiates prescription. In this article, we have described an approach incorporating some principles of what we call existential psychopharmacology and have detailed the core components of a quality follow-up visit. A listening-oriented approach to the first part of the visit, followed by specific questioning to clarify reported symptoms and elicit needed additional detail, enhances follow-up and adherence to medication treatment. Empathic listening also supports the development of a treatment plan based on shared decision-making, informed by psychoeducation to promote evidence-based decisions. The “med check,” currently seen by some as a superficial clinical contact, can be of great value when empathic listening and evidence-based decision-making are joined with thoughtful prescribing and adequate time to do it, as in the rest of medicine.