The Doctor-Patient Relationship in Pharmacotherapy: Improving Treatment Effectiveness

The authors of this relatively brief book, all well-established academic psychiatrists, address the doctor-patient relationship for psychiatrists who practice mainly as diagnosticians and pharmacologists.

The book starts out slowly; an overview gives basic but sometimes forgotten advice such as "Listen to your patients, treat them as individuals, and give them choices." Chapters on the therapeutic alliance and the initial interview are unrevealing and only briefly review concepts that should have been covered during training. The chapter on compliance, called adherence here, serves as a reminder of what we should provide to patients and why at times patients are unable to use the help we try to give.

The rest of the book is stronger, although it is still only an overview. A chapter on transference and countertransference discusses the fact that, for better or worse, no one is neutral—not the doctor, the patient, the office, the insurance, the pills, or the family. Since any honest practitioner will admit failure in at least some instances, this chapter can be helpful to practitioners attempting to sort out the reasons and deal with them. The next chapter discusses "split treatment" or collaboration between the "pharmacologist" and another therapist or medical physician. The advice is generally practical and sound, and following it could improve treatment and prevent annoying or dangerous situations.

The final chapter reviews "difficult" patients—those who are reluctant, chronically suicidal, or terminally ill. The authors leave out some common types of "difficult" patients, such as those with chronic pain and those who abuse substances. The best advice they offer here is to get a second opinion; other than that, the chapter is too superficial to be of much help. Also, I'm not sure it is necessary, for example, to help patients make funeral arrangements, but each case is different, and one does what is indicated at the time.

Overall, this book covers an important subject but leaves out a lot—older patients, financial issues affecting treatment, persons with chronic mental illness, and so on—and it only skims the surface of what it does cover. It also presents to some extent a "straw man": the checklist-wielding psychopharmacologist who doesn't connect with patients. However, the book would serve as a useful introduction for a resident or someone whose training neglected these issues. It could also serve as a fairly painless, though not scintillating, check for those of us who fear that we have become overly efficient. I know that I was more aware of my interactions with patients after reading this book.

Dr. Szeeley is associate professor of psychiatry at the University of Medicine and Dentistry of New Jersey in Camden.