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Smith, D.C. (1999). The Limits of Biological Psychiatry. J. Amer. Acad. Psychoanal., 27(4):671-680.

(1999). Journal of American Academy of Psychoanalysis, 27(4):671-680

The Limits of Biological Psychiatry

Douglas C. Smith, M.D.

Psychoanalysts have struggled for decades with the issue of psychiatric medications. Despite Freud's predictions of future biologic treatments (Freud 1940), psychoanalysts were reluctant, generally speaking, to accept the use of medications because it was assumed that medicines treated symptoms only, and did nothing to cure the underlying problems. Medications were believed to actually be counterproductive to analysis because by relieving symptoms, they would take away the patient's motivation for working in analysis (Marmor, 1981).

More recently, psychoanalysts have by and large taken a more pragmatic approach. If prescribing a pill works, prescribe it. If it helps, use it. To some degree, analysts have had to adopt this approach because the biologic revolution has had such sweeping momentum that analysts were in danger of losing business or becoming irrelevant. Medications seem to bring about relief far more quickly and inexpensively than analysis. Third-party payers often only pay for treatment if medication is prescribed. Psychiatric medications are believed by many to be the standard of care, which causes many therapists and analysts to fear that they are placing themselves in legal jeopardy by not prescribing or referring for medications.

A recent issue of Psychoanal. Inq. (18 [No 5], 1998) was entirely devoted to the subject of psychiatric medications and it typified the current level of discussion among psychoanalysts as they debate how to integrate (or not) biologic and psychoanalytic models. The issue has also been a renewed topic of interest at psychoanalytic meetings. Underlying all sides of the discussion is the assumption that psychiatric medications are effective. This assumption, however, needs to be challenged. I will limit the scope of this challenge to antidepressant medicines, because 90% of the medicines prescribed for patients undergoing psychoanalysis are antide-pressants (Roose and Johannet, 1998).

From a historical perspective, it should be noted that nearly every civilization has had effective medicinal treatments for depression. The list of reputed antidepressants would be several pages long.

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