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I prescribe, therefore I am?

Published online by Cambridge University Press:  02 January 2018

Melissa Gill
Affiliation:
Cavan Mental Health Service, Cavan, Ireland, email: melissa.gill@hse.ie
MacDara McCauley
Affiliation:
St Brigid's Hospital, Ardee, Co Louth, Ireland
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Abstract

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Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © Royal College of Psychiatrists, 2014

In their qualitative study, we imagine that Martean & Evans Reference Martean and Evans1 captured the views of the majority of psychiatrists on their experiences of prescribing for personality disorder. Although we could identify with all of the themes determined as reasons for prescribing, we feel that the article highlighted a number of worrying trends within the profession that need to be addressed.

There appears to have been a shift away from a psychotherapeutic approach in psychiatry toward a distinct reliance on prescribing. The authors describe a theme of utilising prescribing as a method of communicating empathy. We would argue that it is disappointing if psychiatrists can only demonstrate empathy through the use of a prescription pad. It would seem that potential harm, in the form of possible serious side-effects, addiction, polypharmacy and indeed overdose facilitated by such a prescription may be more likely than benefit. Primum non nocere would suggest that, in the absence of convincing evidence for prescribing for personality disorders, the responsibility lies with the doctor to examine alternatives.

The authors themselves identify one potential solution in their recognition that ‘problems as much or perhaps more than diagnosis may be crucial to explore for patients with personality disorder’. Problem-solving therapy has been shown to improve depression, hopelessness and personal problems in patients who self-harm Reference Townsend, Houston, Altman, Arensman, Gunnell and Hazell2 and has demonstrated specific benefit as a preliminary measure for patients with a personality disorder. Reference Huband, McMurran, Evans and Duggan3 Perhaps this may be a useful initial intervention to avoid feeling helpless in such consultations. Longer-term options such as dialectical behaviour therapy and specialised counselling for trauma experienced in childhood allow deflection away from the prescription.

While we acknowledge that treating patients with personality disorders is often challenging, we believe the profession needs to move away from the notion of ‘I prescribe, therefore I am’. Ultimately, the increased focus on psychotherapy in the updated curricula of both the Royal College of Psychiatrists and the College of Psychiatrists of Ireland represents a positive paradigm shift in training toward a return to the psychotherapeutic, rather than solely prescribing, role of the psychiatrist.

References

1 Martean, L, Evans, C. Prescribing for personality disorder: qualitative study of interviews with general and forensic consultant psychiatrists. Psychiatr Bull 2014; 38: 116–21.Google Scholar
2 Townsend, E, Houston, K, Altman, DG, Arensman, E, Gunnell, D, Hazell, P, et al The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 2001; 31: 979–88.CrossRefGoogle ScholarPubMed
3 Huband, N, McMurran, M, Evans, C, Duggan, C. Social problem-solving plus psychoeducation for adults with personality disorder: pragmatic randomised controlled trial. Br J Psychiatry 2007; 190: 307–13.CrossRefGoogle ScholarPubMed
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