Episode 244: Psychodynamic Psychopharmacology: Insights from Dr. David Mintz

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David Puder and David Mintz have no conflicts of interest. 

In this episode, I engage in a shared-interest conversation with Dr. David Mintz, a psychiatrist with over 30 years of experience at the Austen Riggs Center, about his book Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient. Mintz explores the integration of psychodynamic principles into medication prescribing, emphasizing that psychiatric treatments are not purely biomedical but profoundly shaped by meaning, symbolism, attachment and interpersonal dynamics. Drawing from his work with treatment-resistant patients, often those with histories of early adversity, the discussion distills how psychodynamics influence medication efficacy, adherence, and overall recovery.

Central to Mintz's approach is the concept of "meaning effects," where patients' worldviews and expectations dramatically alter drug responses across conditions. For example, placebo effects yield effect sizes of 1.4 for antidepressants and 0.59 for antipsychotics, often rivaling or exceeding biological mechanisms, especially in depression where symbolic activity predominates. In depression, placebo responses often predominate due to the high susceptibility of symptoms to psychological expectations, whereas in psychosis, multifaceted biological factors, such as dysregulation in dopamine (e.g., mesolimbic hyperactivity), glutamate (e.g., NMDA hypofunction), serotonin (e.g., 5-HT2A hyperactivity), GABA (e.g., reduced inhibitory signaling), and neuroinflammatory pathways (e.g., elevated cytokines and microglial activation) all exert a stronger influence, leading to comparatively smaller placebo effects. Patients with adverse childhood experiences may transfer expectations of harm onto prescribers, manifesting as transference, which undermines adherence and amplifies nocebo responses (adverse effects from negative expectations). Mintz advocates preemptively discussing nocebo to reduce its occurrence and foster mentalizing (patients' ability to reflect on whether reactions stem from the drug or internal psychology). 

Attachment styles inform prescribing strategies in psychodynamic psychopharmacology. For fearful-avoidant [AAI: often Unresolved/Disorganized or Cannot Classify] patients, or more broadly patients who will anticipate harm and are prone to nocebo effects, a "start low, go slow" approach helps them acclimate without malevolently interpreting side effects; dismissive-avoidant [AAI: Dismissing] types, or more broadly those expecting no help and at risk of quick dropout, benefit from quicker dose escalation to demonstrate efficacy early. Patients with disorganized [AAI: Unresolved/Disorganized] attachments require empowerment through providing information and a sense of control to address underlying feelings of powerlessness. 

Mintz frames initial evaluations around aspirational (where are they trying to get), person-centered goals rather than symptoms, tracing themes of powerlessness back to origins (e.g., authoritarian parents or helplessness they felt in a divorce) to build alliance and psychoeducate on how these shape responses.

The dialogue delves into defenses like medicalized jargon (for example a patient using the word "anhedonic" signals they have been in the medical system) or clinging to diagnoses (e.g., "my bipolar" as a vertical split externalizing guilt in cluster B personalities, e.g. “the good stuff is me, the bad stuff is my bipolar”, relieving shame but hindering responsibility and worsening impulsivity). Secondary gains from illness, such as spousal attentiveness from having a “medical issue”, create ambivalence about recovery, which prescribers must illuminate, and the family must allow a shift from, for the patient to improve. Mintz stresses uncertainty in improvement: "I never know why" patients remit, as placebo, meaning, or spontaneous factors interplay, urging humility over reductionism. 

I love that in psychodynamic therapy, we embrace the principle of multiple causality, recognizing that a patient's symptoms or behaviors stem from a complex interplay of factors, such as unconscious conflicts, early relational patterns, biological vulnerabilities, and sociocultural influences, all converging multidimensionally to reflect higher reflective function through nuanced mentalization and curiosity about underlying mental states, rather than relying on oversimplified, clichéd explanations like "my anger is just my bipolar" or "change your mindset" common in pop psychology.

We also discuss how countertransference emerges as a tool for insight; prescribers resonate with patients' helplessness or rage, potentially leading to irrational polypharmacy (e.g., 15 meds from evoked desperation). Mintz uses formulations for distance, like Neo seeing the Matrix code, to mentalize reactions (e.g., reaction formation against aggression causing over-accommodation). Personal therapy is essential to uncover blind spots, normalizing ongoing self-exploration for ethical prescribing.

We discuss one of my favorite studies on “Psychiatrist Effect” McKay 2006, showing the best psychiatrist’s placebo outperforms the worst psychiatrist’s active drugs. I emphasize the importance of reflective function in understanding why the best therapists are the best therapists.

Deprescribing is sometimes key here, emphasizing lifestyle (I love cardio/sauna for anxiety, strength training/creatine for depression, and consider keto for psychosis/bipolar), psychotherapy and patient responsibility over passive "fix me" mindsets that can keep a patient stuck. When patients are reduced to biological framings of their condition, this risks a fixed pessimism and lower self-efficacy towards their role in the solution.

In closing, Mintz reiterates relational nuance, as open-label placebos retain efficacy, and humility fosters partnerships. This episode illuminates psychodynamic psychopharmacology as a paradigm shift, urging prescribers to increase awareness of psychodynamics underlying pharmacotherapy for deeper, more sustainable healing.