ORIGINAL ARTICLE

 

Dynamics of psychopharmaceutical use and relationship with psychoanalytic psychotherapy in the mental health interface: an integrative review

 

 

Marcio Rocha Damasceno^{I, II}; Italla Maria Pinheiro Bezerra^II; Lídia Maria Nazaré^III; Andréia Almeida Mendes^IV; Luiz Carlos de Abreu^{II, V}

^IPsicólogo, Mestre em Políticas Públicas e Desenvolvimento Local, Mestre em Psicanálise, Professor e Coordenador do Curso de Psicologia do Centro Universitário UNIFACIG - Manhuaçu (MG), Brasil
^IIPrograma de Mestrado em Políticas Públicas e Desenvolvimento Local. Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM). Vitória (ES), Brasil
^IIIProfessora, Doutora em Letras, Professora do Centro Universitário UNIFACIG - Manhuaçu (MG) e da UEMG - Carangola (MG), Brasil
^IVProfessora, Doutora em Linguística, Professora do Centro Universitário UNIFACIG - Manhuaçu (MG), Brasil
^VLaboratório de Delineamento de Estudos e Escrita Científica. Centro Universitário Saúde ABC, Santo André, SP, Brasil

Correspondence

 

 

---

ABSTRACT

INTRODUCTION: Drug use has been discussed by various authorities and health professionals, and a change in attitude. Among them, psychoanalysts and psychotherapists recognize the importance that the theme has been having in recent decades, considering the rational use of psychotropic drugs as supporting psychoanalytic treatment.
OBJECTIVE: To analyze the use of psychotropic drugs and their relationship with psychoanalytic psychotherapy in the interface of mental health.
METHODS: This is an integrative review of the MEDLINE Database based on a statement of preferred reports for systematic methods and meta-analyzes (PRISMA) through the descriptors: Psychotropic Drugs and Psychoanalysis Drug Therapy and Drug Misuse and Drug Use and Signs and Symptoms, filtering the results by title and summary specificity and only studies available in their full version and conducted in humans were detected.
RESULTS: 42 articles were selected for final analysis. The object of article analysis was submitted to the analyst who treats his patients and conducts clinical trials with drug interaction, as well as therapeutic transfer complement as a clinical resource for treatment of psychoanalytic sessions. In addition, the results of this drug interaction were evidenced as supporting factors in the clinical treatment of clients exposed to the clinical session.
FINAL CONSIDERATIONS: The use of psychoactive drugs and psychoanalytic psychotherapy Shows as an association capable of proving interaction and integration of the personality aspects and the psychological structure of the individual. It is a clinical condition that can be stimulated in the mental health treatment of individuals suffering from mental / emotional distress.

Keywords: psychotropic drugs, psychoanalysis therapy, drug misuse, mental health, signs and symptoms.

---

 

 

Authors summary

Why was this study done?

There is a high rate of people using psychoactive drugs to relieve existential suffering, without medical orientation.

This study aimed to analyze the use of psychoactive drugs and their relationship with psychoanalytic psychotherapy at the interface of mental health.

With the Mental Health Services (CAPS and Psychological Attendance Service), the combined treatments of psychotherapy and medication were implanted and It's interaction with other professionals could be observed.

It was observed that it is not only the drugs are responsible for the improvement of the patients' health, but other therapies are important as well.

What did the researchers do and find?

In this study, we tried to gather information through the bibliographic review in 42 articles that deal with the subject, either by the combination of psychological and pharmacological treatments and how this combination can bring a greater dynamics in the improvement of the symptoms and sufferings of the subject.

The studies also presented several examples of analysts / psychiatrists who treated their patients and the observations made from the drug intervention, mainly on the therapeutic transfer with and without the medication and the effects of it.

Some authors showed that the medication helped in the treatment, as others, showed that there were significant changes and a strengthening of the transfer, with the use of the medication.

What do these findings mean?

These findings confirm that not only medication is good for the relief of suffering, but that psychotherapy can greatly help as well as reduce the costs of the treatment, especially in the public sector where there is an indiscriminate use of medicines.

The dynamics between the use of psychoactive drugs and psychoanalytic psychotherapy presents itself as a beneficial association capable of absorbing and integrating aspects of the personality and the psychic structure of the subject.

In the context of the Public Policies in Mental Health, strategically designed to consolidate the change in the model of treatment of mental disorders, they have effectively progressed as well as functioning to the new practices that integrate the necessary advances for the continuity of the Psychiatric Reform, but also the different stages and procedures of therapeutic and scientific research.

The use of psychoactive drugs is presented as a treatment option for the symptoms of mental suffering.

 

INTRODUCTION

The high consumption of medicines has been discussed by several authorities and health professionals, resulting in a change in attitude regarding them. Psychoanalysts and psychotherapists recognise the importance that this topic has taken over the last decades, considering the rational use of psychotropic drugs as adjuvants of psychoanalytic treatment. It is also known that the high consumption of psychotropic drugs has become a serious public health problem, unprecedented in history, with political, social and economic implications and presenting a major challenge in several areas of interdisciplinary knowledge¹.

According to the World Health Organisation (WHO), more than 50% of all medicines are incorrectly prescribed, dispensed and sold, and more than 50% of patients use them incorrectly. In addition, over 50% of all countries do not implement basic policies to promote rational drug use. The situation is worse in developing countries².

Ordinance No. 3.916 of 30th October 1998 from the Brazilian Health Ministry approved the National Policy of Medicines as an essential part of the National Health Policy, which aims to ensure the necessary safety, efficacy and quality of medicines, as well as the promotion of the rational use and population access of medications, as this contributes to the social development of the country and the consolidation of the Unified Health System (SUS)³.

In the last two decades, the Mental Health Policy has undergone important changes since Law No. 10,216, 2001 of the Ministry of Health, consolidating a set of mental health care regulations of the SUS, redirecting the model of psychiatric care and regulation, especially for patients hospitalised for many years and foreseeing the possibility of punishment for unnecessary, arbitrary or involuntary hospitalisation⁴.

In 2011, within these public health policies, through Ordinance No. 3,088, 23rd December, the Psychosocial Care Network was established under the SUS for people suffering from a mental disorder and with needs arising from the use of crack, alcohol and other drugs. As per Article 5, the Psychosocial Care Network consists of several health sectors, such as basic health units, primary care teams for specific populations, living centres and psychosocial care centres in their different modalities, among others⁴.

Psychoanalytic psychotherapy is a modality of psychological intervention that has its roots based in psychoanalytic theory. Therapy, from this approach, is more effective than personality restructuring and seeks to see the person as a whole and not just the symptoms, observing the dynamics of function in multiple life situations and personal interactions. It is one of the therapies included in the mental health public policies by proposing specific treatments for this type of patient.

Freud⁵ pointed out that the subject, facing founding incompleteness and in search of lost happiness, would find in drugs, and in the abuse of psychoactive drugs, a way to avoid suffering. The relief afforded by them would raise the hope of eliminating this subjective division, i.e. the subject's incompleteness to face a lack.

The French philosopher Jacques Derrida⁶, in his book 'Plato's Pharmacy' (1997), drew attention to the antithetical senses present in the term pharmakon, which can be either a medicine or a poison; the dose necessary to provide the effect as a medicine is similar to the toxic dose. That is, the medicine can quickly turn into an evil, the benefit in detriment.

The mechanisms of action of psychotropic drugs are well-known. It is also recognised that many therapists do not successfully try to use medication, and there must be other factors, unrelated to psychotropic drugs, responsible for these differences. Just as the use of a placebo has a positive response in about 30% of depression cases, it may also be due to the situation, the personality of the patient and/or analyst, meaning the effect may occur by transference. In fact, transference phenomena and unconscious fantasies can develop in many ways, providing opportunities even for a better understanding of analytical psychotherapy⁷.

Psychopharmaceuticals modify the relationship of the subject with the demand that comes to the doctor: the subject asks for medicine to find relief. Research and diagnostics have advanced in evidence-based medicine, in which psychotropic drugs have found territory for the development of research, with the support of laboratories and the pharmaceutical industry. Demand for quality health care, combined with the need for the rational use of resources, both public and private, has contributed to increasing pressure on healthcare professionals to ensure the implementation of evidence-based practice⁸.

Inviting a subject to question their symptoms is an indicator of the most fundamental and singular truth of the desire and the core of being. It is the explicit investigation of the symptom into the obscure uncertainty of what constitutes it as its cause and requires the subject to assume the task of building his or her own destiny⁹.

With the National Mental Health Policy, it has been observed that special attention is needed regarding medication and psychotherapy, because the Rede de Atenção Psicossocial (RAPS), established to consolidate this open and community-based care mode, has, in its guidelines, an organisation of networked services, increasingly regionalised and with the establishment of intersectoral actions to ensure comprehensive care. Regarding the current importance of new forms of treatment that include various specialties, among them is the use of psychotropic drugs and psychotherapy. Thus, the aim of this study was to analyse the use of psychoactive drugs and the relationship with psychoanalytic psychotherapy in the mental health interface.

 

METHODS

This was an integrative review performed using PubMed (http://www.ncbi.nlm.nih.gov/pubmed), which is a free access search engine to the MEDLINE database of citations and abstracts of biomedicine research articles. We used a methodology that provided the synthesis of knowledge and the incorporation of the applicability of results of significant studies in practice. The literature review was performed in August 2018.

Search strategy

The search was done in three stages as follows: the first happened by combining the keywords: Psychotropic Drugs AND Psychoanalysis Therapy AND Drug Utilisation, finding 4 results. The second one was performed by combining the keywords: Psychotropic Drugs AND Psychoanalysis Therapy and Signs and Symptoms, finding 57 results. The third search was performed by combining the keywords: Psychotropic Drugs AND Psychoanalysis Therapy, providing 468 results between titles and summaries.

PubMed searches generated a total of 529 articles. After filtering by title and abstract, 70 articles were left for full reading, of which 42 met the inclusion criteria for this review (Figure 1).

Eligibility criteria

Included studies were in English language and presented the relationship between medication and psychoanalytic psychotherapy. Reviews, meta-analyses, editorials, letters to the editor, theses, dissertations, articles that were not in English and that used illicit drugs and/or medications that were not psychoactive drugs were excluded.

Study characteristics

The selected studies were those that presented information about the use of psychotropic drugs and the results in psychoanalysis.

Regarding the objectives, we evaluated the importance of medication in the development of the analysis, but some studies were included that had little interference in its development.

 

RESULTS

Searches generated a total of 529 articles. After reading the title and abstract, 70 were selected for full reading, of which 42 articles met the eligibility criteria (Figure 1). Reasons for exclusion were: duplicates (n = 62), non-English articles (n = 106), review/discussion articles (n = 26), articles on illicit drug use (n = 26), papers that did not use psychotropic drugs (n = 15), abstracts published in annals and other events (n = 6), articles not available for full reading (n = 22) and the use of other therapeutic approaches (n = 224).

 

DISCUSSION

It is expected that the psychoanalytic psychotherapist is aware of the effects of psychotropic drugs in their practice, and will not be seduced into using these drugs and developing a reasoning that medicated patients can facilitate the conduct of the analysis. This does not mean that the medicine is harmful, nor does it eliminate its effectiveness in relieving suffering. However, it is important to be aware because sometimes the analyst's own anguish in enduring the patient's anguish can lead to referring the patient, in order to feel supported in the company of the psychiatrist.

Ryang¹⁰ points out that nowadays the use of biomedication is considerable and one of the concerns regarding our physical and mental well-being. He also emphasises that medication reduces social problems in individuals, transforming them into builders of a new system that involves not only the perception of health and disease, but that brings a truth, either through the use and sale of medicines for mental health as well as psychological assessment. This approach demonstrates the scientific advances of medicine and its biologisation in recent years, by using imaging exams to aid in the diagnosis and assess the effectiveness of medicines.

Freud stated that psychotherapy would be more scientific in the future. Today, we witness this with the advent of psychotropic drugs. On one side, we see the powerful transference deeply worked by the father of psychoanalysis, i.e. that psychotherapy can no longer modify transference and, although less easily identifiable, transference can modulate the subjective experience of a drug action¹¹. It has been emphasised that transference is considered to be an intense affective bond, which is automatically and continuously established between the patient and the analyst, through the unconscious desires that are updated on certain objects. This shows that he subjective organisation of the patient is commanded by an object, and a certain kind of connection is established in the analytic relationship. However, Wylie and Wylie¹² show that the analytical process is more successful with drug administration, facilitating transference and, consequently, interpretation.

Combination treatments for personality disorder

Personality disorder is a specific and serious disturbance of the individual's character constitution and behavioural tendencies, usually involving various personality areas, and is almost always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to manifest into adulthood. It is, however, unlikely that a diagnosis of personality disorder will be appropriate before of 16 or 17 years old¹³.

Below there are some inferences about the combination of medication and psychotherapy in the treatment of personality disorder (borderline) that has as its characteristic emotional instability, as well as unclear or disturbed self-image. There are usually chronic feelings of emptiness. A propensity to engage in intense and unstable internal relationships can cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a range of suicide threats or acts of self-harm (although these may occur without obvious precipitants)¹³.

The practices of combining medication with psychotherapy in the treatment of patients with borderline personality have significant limitations, but there is evidence that much remains to be researched in this area¹⁴. Medication combined with the psychotherapeutic technique is an effective method for outpatient treatment, and 81% of studied patients showed excellent results¹⁵.

Bateman and Fonagy¹⁶ conducted a study comparing the effectiveness of partial hospitalisation and psychoanalytic care for patients with the same personality disorder, noting it to be far superior than psychiatric care alone. In another paper, these authors, in 2003, presented a comparison of treatment costs, reporting considerable savings after combined treatment, even stating that taking medication is not generally considered a particularly regressive experience¹⁶.

Brockman¹⁷ reinforces that, especially in patients with borderline personality disorder, medication can be either an overvalued hope or a terrifying assault. In other research, psychotherapeutic and pharmacological treatment produce satisfactory results that may contribute to a continuous effort not only in relation to the patient, but also in helping to determine the diagnosis¹⁸. Again, has been is found that the combination of drugs and psychotherapy is becoming more and more evident and that, in the coming years, it will tend to increase, especially in borderline personality cases¹⁴.

The evolution of treatments

When talking about the evolution of drug treatments, one can only address the evolution of psychopharmacology in a half century of practice. In recent times, psychopharmacological treatment was divided into antipsychotic, antidepressant, anxiolytic and mood stabilising drugs. Today, this division is less valid than in the past, as many drugs of a class are used for disorders previously attributed to another class.

In the 1950s, the focus of psychoanalysis on the individuality and particularity of patient responses offered an invaluable model for the variability of drug responses among patients. Psychodynamic and sociological research on early psychopharmaceuticals has helped in understanding new pharmaceuticals¹⁹.

In the 1970s and 1980s, psychodynamic and sociological psychotherapeutic approaches and psychoanalysis fell out of favour or lost influence in psychopharmacological research. Psychiatrists using more abstract analytical theorisations were losing out to the Diagnostic and Statistical Manuals of Mental Disorders, third edition (DSM-III). Today, pharmacology in psychiatry and medicine focus on 'rational targets' located in the body, i.e. symptoms, by which undeniable benefits have been obtained¹⁹.

Prior to the development of modern psychotropics and antidepressants, psychopharmacological therapy could do little more than sedate and soothe restless or anxious souls. Psychoanalysts, on the other hand, invested against the use of medication during this period, as drugs interfered with dysphoric effects and the development of their ability to withstand depression and anxiety, and thereby emotional growth.

Thirty-five years later, many writers continue to insist on avoiding psychotropic medication for similar reasons, even though we are in the sixth decade of modern psychopharmacological therapy that has transformed the treatments of all mental illness²⁰. This confirms major changes in treatment design with the variety and applicability of these drugs.

Society is often motivated to seek quick solutions to its problems, and with emotional disorders, it is no different. Such disorders are the result of trauma and stress inherent to the human condition. According to psychoanalysis and psychotherapy, symptom formation can be characterised as the failure to advocate for urgent operations or maladaptive life strategies. A century of psychoanalytic writing has repeatedly demonstrated the effectiveness of psychoanalysis, both theory and practice, in alleviating and healing human emotional conditions.

The feelings behind the medication

A discussion that also arises is about the feelings themselves, regarding the prescription and the emotional attachments in this process, arising countertransference issues²¹, which are the analyst's unconscious set of reactions to the subject, and more particularly to transference, which may interfere with the therapeutic process^22,23.

Gottlieb²⁴ states that psychoanalytic treatment is, in fact, compatible with the effects of mind-altering drugs and the medical management procedures that necessarily accompany their prescription. Even today's medicines are different from yesterday's and we must recognise that psychoanalysis has also changed.

As a growing number of general psychiatrists are becoming familiar with psychoanalytic concepts of object relations (which emphasises the relationship aspect of all behaviours, including the interaction between doctor, patient and medication), they will inevitably apply the psychotherapy/pharmacotherapy combination, systematically or not. In practice, the analyst should work based on a knowledge of physiology and pharmacology, which are the most distant points of the patient's emotional life²⁵.

Also, according to these authors, the analyst should start the session a little further away, in order to review the doses, symptoms, side effects, etc.; only then should the analyst get closer during the session. Finally, it is necessary to discuss the discontinuation of medication with the patient, allowing them to freely express their fears and anxieties. This means that it is not the end of therapy, because it is not advisable that the two treatment modalities end together²⁵.

The therapeutic alliance or not?

A study conducted in the United States, Canada and Australia addressed the importance of professionals knowing when to use psychopharmaceuticals and the evolution of treatments, combining psychoanalytics and medications²⁵. In other cases, the analytical process and medication are a rich source of information about the impact of medication, psychological function and its neurobiological substrate, as well as the underlying disorder²⁷.

Frosch's study reported²⁸ that it is important to help the drug user to achieve or regain healthy narcissism, such as a sense of dignity, based on relationships of achievement rather than spurious feelings of omnipotence induced by drug use. There is evidence that, in early-stage development, social and cultural experiences contribute to patterns of drug abuse behaviour, not just the libidinal stages of development as stated by Freud. These drug addicts share the need and immediacy of coping. Is in this point where psychoanalytic psychotherapy can contribute to the understanding of the multiple psychological manifestations, biological and social factors.

The therapeutic alliance, which begins with genuine respect for the uniqueness of the individual and his or her life and world experience, is very important for treatment. Psychiatrists should treat their patients as if the relationship were more important than pills in the treatment²⁹. It is important that this type of treatment has a differentiated conduct; thus, instead of interpreting unconscious conflicts, the therapist should be mindful of assisting the changes induced by psychotropic medication³⁰.

A research on patients with depressive disorder has shown how the use of correlated psychotherapy and antidepressants helps to reduce psychological symptoms, but a more complete understanding is still needed to improve this process³¹. In another study, it was confirmed that antidepressant and psychoanalytic psychotherapy treatments produce more satisfactory results than therapeutic methods alone^14,32.

In a survey conducted on a population in Germany in 1990 about preferences for various treatment methods, 50% of respondents endorsed psychotherapy as a beneficial treatment, compared with 40% against it, noting an increasingly critical tendency toward psychotherapy, especially psychoanalysis, in contrast to the enthusiasm in the field of psychiatric drugs for mental disorders³³.

The fantasies of madness are closely linked to the use of psychoactive drugs, and there must be a separation with this type of treatment, i.e. separating the drug from the analytical process, so that there is no countertransference that may interfere with the therapy³⁴. In contrast, the use of psychotropic drugs can facilitate better communication during the therapeutic process, as well as deepen interpersonal relationships, especially in patients who have been unsuccessfully treated for years by drugs or therapies. When there is a combination of these treatments and a deep relationship established between the therapist and the patient, subject reconstruction is effected³⁵.

Consistent with current mental health policies, combined treatment has been statistically shown to be more effective than pharmacotherapy or psychoanalysis alone. It should be emphasised that combined treatment improves psychic integration and other fundamental changes in psychic structure, which are the goals of psychoanalysis³⁶. Greene³⁷ reinforces that today's medicines are different from yesterday's. Psychoanalysis has also changed. The old requirements for psychoanalytic treatment no longer determine how we think and behave clinically. Psychotropics have become more effective and safer.

A survey was conducted on outpatients, in which one group received medication and psychotherapy, a second group received only medication and a third group received only psychotherapy. It was found that those who received the combined treatment had better outcomes in terms of symptom improvement³⁸. Wilson³⁹ uses Winnicott's theory of transitional objects, an expression introduced by D.W. Winnicott, to designate a material object that has elective value for the infant and young child, particularly at the moment of falling asleep (the edge of a blanket or sheet, or a napkin to suck on, for example). It was considered by the author to be a normal phenomenon that allows the child to make the transition between the first oral relationship with the mother and the 'true object relation'⁴⁰. Thus, the association between medication and this process may be vital to elucidating psychopathy in therapeutic aspects and to clinically improve the development of the patient in this process, confirming the benefits that can be obtained with combined treatment.

On the other hand, when the analyst is sceptical regarding medication, there is a defence that goes against the loss of prestige and autonomy. This can also be observed in a posture of neutrality, i.e. barriers to transference and countertransference. It has become evident that analyst is expected to have an open mind in terms of integrating medication and analysis⁴¹.

Antidepressants have improved significantly, making psychotherapy faster and more effective, acting on autonomous ego functions such as regulating and modulating affect⁴². One point that exposes the context is that the present discussions can be increasingly encouraged in which the biological meets the psychological and not against each other. It is noteworthy that the psychoanalyst should help patients to facilitate this meeting, because a professional has the most preparation, as well as a technique and singular ability to attentively listen to patient complaints⁴³.

Clinical skills are leaning toward better understanding. Nowadays, it is possible to observe a change in the mentioned characteristics. The time is now, and the immediate present predominates without pause or break, so it is necessary to constitute a before and after. With this non-time performance, haste is imperative. The increase in technical, impersonal therapeutic approaches is witnessed as a response to the 'clinical encounter', not only in psychiatry but in other medical specialties⁴⁴. What is evident is the response based solely on the set of signs and symptoms classified in an ordered nosological system and the impoverishment of the human relationship with the patient. Suffering is taken as a statistic, and the divorce of body and mind takes place. In an evidence-based clinic, the answer should be prompt effectiveness. There is no room for doubt, not knowing or postponing, in the clinic of certainty⁴⁵.

Mental health policies

In Brazil, psychiatric reform and public policies on mental health have brought joyful surprises, as approaches in which listening with the consent and participation of an individual with mental suffering have become possible and allowed within the offered therapies, not only the medication and the elimination of the symptom. It is worth mentioning some important milestones in the Brazilian psychiatric reform process, such as the progressive closure of psychiatric hospitals in the 1980s, reducing the number of beds by more than a half⁴⁵.

The implementation of the substitute network, the Centros de Atenção Psicossocial (CAPS) occurred in the 1990s, with more than 150 units throughout Brazil. Therapeutic residential services (sheltered centres) were critical to this process, as was the rehabilitation provided by the 'Volta ao Casa' program as well as the involvement of civil society, mainly through the organisation of technicians, family members and users in the anti-asylum movement; this mobilisation defined the guidelines for the national mental health policy⁴⁵. With this new proposal, there was also a clientele intended for mental health services, such as users of benzodiazepines and antidepressants. Most were women who may have had a complicated life history or have been through difficult times, and thereby have received a psychiatric diagnosis and prescription drugs. These patients may have used psychotropic drugs for nearly their entire lives, and become organically and psychically accustomed to the medicine.

On the other hand, there are several users in psychology, often referred to endless psychotherapy, whose objectives are often unclear to either the health professional or the service user⁴⁵. According to a technical document from a mental health group in the state of Minas Gerais, Brazil, it is key to implement an intersectoral space that is not made by the prior definition of health, focused on social assistance or cultural aspects. There are no clearly drawn boundaries that complement each other to form a pre-defined whole. Rather, the various involved sectors interpenetrate and articulate, move and remake, touch and change, transforming the whole in this movement. Intersectoriality only withdraws from the commonplace of the buzzwords when inventing plural places of citizenship⁴⁵.

The national mental health policy comprises the strategies and guidelines adopted by the country with the purpose of organising assistance to people with specific treatment and care needs in mental health. It provides attention to people with needs related to mental disorders such as depression, anxiety, schizophrenia, bipolar affective disorder, obsessive compulsive disorder, including those with harmful use and dependence on psychoactive substances (alcohol, cocaine, crack and other drugs). Within the guidelines of the SUS, it has been proposed to implement a plurality of user service networks with different degrees of complexity that promote comprehensive care for different demands, from the simplest to the most complex. Approaches and proposals should be based on scientific evidence. This policy seeks to promote greater social integration, and the strengthen the autonomy, protagonism and social participation of individuals with mental disorders⁴.

Patients with mental disorders within the SUS receive care in the psychosocial care network (RAPS), which is being expanded and strengthened, without prejudice against any of its components, maintaining the policy of community assistance in the territory. It is as non-invasive as possible while maintaining deinstitutionalisation actions (patient discharge from psychiatric hospitalisation)^46,47. It is no longer the idea that psychiatric hospitals should shelter residents, nor should they be closed. These institutions should be able to receive patients in acute clinical conditions for short, humanised hospitalisations and with a view to their return to territorial services in a location close to their relatives⁴.

Throughout this study, it was possible to observe how psychoanalysts consider the contemporary clinic as one of the great challenges in the cultural context, linked to psychoactive drugs. This issue requires further studies because there is a limited psychoanalytic literature on the use of psychoactive drugs in the psychoanalytic clinic and few reports of successful clinical experiences.

The use of psychotropic drugs is current and present as a treatment option for the symptoms of mental suffering, due to its practicality and speed in obtaining satisfaction or the mitigation of these symptoms. However, not enough is understood about this dynamic interaction between psychoanalysis and medication, as well as the uses of these approaches in line with the suffering of the subject, the relationship between psychoanalyst/doctor and the patient, mental health provision and its policies.

The implementation of comprehensive care for individuals with mental/emotional distress is an urgent and necessary process in the field of assistance provided by the SUS and private health plans, as it has the potential to reduce the daily suffering of patients affected by these mental/emotional disorders.

In the insertion of social processes and local development with broad conceptions and perspectives for the understanding and articulation of social relations with health policies, the national reality must be considered, as well as the fact that health is not characterised only as the absence of disease, but also as a situation of perfect physical, mental and social well-being.

Moreover, it is emphasised that the autonomy of the human being, in the full exercise of will, transcends the socio-cultural and genetic environment and the distance from physical balance. In this line of implementation of the drug and psychoanalytic association, it is possible to glimpse a further stimulus for the early beginning of the process of re-establishing mental health conditions, with full respect for cultural, social and religious differences.

Finally, the use of psychotropic drugs and psychoanalytic psychotherapy as a beneficial association capable of absorbing and integrating aspects of the personality and the psychic structure of the subject.

In the context of mental health public policies, strategically designed to consolidate changes in the approach to treating mental disorders, they have effectively progressed as a more responsive space and allow for interdisciplinarities that integrate the necessary advances for the continuity of the psychiatric reform, but also to the different stages and procedures of therapeutic and scientific research.

The use of psychotropic drugs is current and present as a treatment option for the symptoms of mental suffering, due to its practicality and speed in obtaining satisfaction and alleviating symptoms.

 

REFERENCES

1.Santiago J. A droga do toxicômano: uma parceria cínica da era da ciência. Belo Horizonte: Relicário, 2017.         [ Links ]

2.Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Uso racional de medicamentos: temas selecionados. Brasília: Ministério da Saúde, 2012.         [ Links ]

3.Brasil. Ministério da Saúde. Presidência da República. Casa Civil. Subchefia para assuntos jurídicos. Lei nº 10.216. [cited 2018 Oct 28] Available from: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm        [ Links ]

4.Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria nº 3.088 de 23 de dezembro de 2011. [cited 2018 Oct 28] Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt3088_23_12_2011_rep.html        [ Links ]

5.Freud S. Freud (1930-1936): o mal-estar na civilização e outros textos. São Paulo: Companhia das Letras, 2010; p. 13-122.         [ Links ]

6.Derrida J. A farmácia de Platão. São Paulo: Iluminuras, 2005.         [ Links ]

7.Frey BN, Mabilde LC, Eizirik CL. A integração da psicofarmacoterapia e psicoterapia de orientação analítica: uma revisão crítica. Rev Bras Psiquiatr. 2004;26(2):118-25. DOI: http://dx.doi.org/10.1590/S1516-44462004000200009        [ Links ]

8.Sampaio RF, Mancini MC. Estudos de Revisão Sistemática: um guia para síntese criteriosa da evidência científica. Rev Bras Fisioter. 2007;11(1):83-9. DOI: http://dx.doi.org/10.1590/S1413-35552007000100013        [ Links ]

9.Laurent E. Como engolir a pílula? In: Miller JA. Ornicar? De Jacques Lacan a Lewis Carroll. Rio de janeiro: Jorge Zahar, 2004.         [ Links ]

10.Ryang S. A critique of medicalisation: three instances. Anthropol Med. 2017; 24(3):248-60. DOI: http://dx.doi.org/10.1080/13648470.2017.1389169        [ Links ]

11.Brokman R. Aspects of psychodynamic neuropsychiatry II: psychical locality and biology: toward the neurobiology of psychotherapy. J Am Acad Psychoanal Dyn Psychiatry. 2011;39(2):285-311. DOI: http://dx.doi.org/10.1521/jaap.2011.39.2.285        [ Links ]

12.Wylie HW Jr, Wylie ML. An effect of pharmacotherapy on the psychoanalytic process: case report of a modified analysis. Am J Psychiatry. 1987;144(4):489-92. DOI: http://dx.doi.org/10.1176/ajp.144.4.489        [ Links ]

13.Classificação Internacional de Doenças CID - 10: Classificação de Transtornos Mentais e de Comportamento da CID-10: Descrições clínicas e diretrizes diagnósticas. Porto Alegre: Artmed, 1993.         [ Links ]

14.Waldinger RJ, Frank AF. Transference and the vicissitudes of medication use by borderline patients. Psychiatry. 1989 Nov; 52(4):416-27. DOI: http://dx.doi.org/10.1080/00332747.1989.11024466        [ Links ]

15.Lesse S. Combined drug and psychotherapy of severely depressed ambulatory patients. Am J Psychotherapy. 1966;11(Suppl):S123-30.         [ Links ]

16.Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156(10):1563-9. DOI: http://dx.doi.org/10.1176/ajp.156.10.1563        [ Links ]

17.Brokman R. Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient. Psychiatr Clin North Am. 1990;13(2):287-95.         [ Links ]

18.Snyder S. The interaction of psychopharmacology and psychoanalysis in the borderline patient. Psychiatr Q. 1980;52(4):240-50. DOI: http://dx.doi.org/10.1007/bf01080285        [ Links ]

19.Ramos MA. Drugs in context: a historical perspective on theories of psychopharmaceutical efficacy. J Nerv Ment Dis. 2013;201(11):926-33. DOI: http://dx.doi.org/20.1097/NMD.0000000000000062        [ Links ]

20.Rickles WH. Listening to Prozac, with the third ear: a psychoanalytic theory of psychopharmacology. J Am Acad Psychoanal Dyn Psychiatry. 2006;34(4):709-33. DOI: http://dx.doi.org/10.1521/jaap.2006.34.4.709        [ Links ]

21.Chemana R. Dicionário de Psicanálise. Porto Alegre: Artes Médicas, 1995.         [ Links ]

22.Rubin J. Countertransference factors in the psychology of psychopharmacology. J Am Acad Psychoanal. 2001;29(4):565-73. DOI: https://doi.org/10.1521/jaap.29.4.565.21538        [ Links ]

23.Gottlieb RM. Mind, madness, and medications: situating psychoanalysis. J Am Psychoanal Assoc. 2006;54(3):739-44. DOI: https://doi.org/10.1177/00030651060540030601        [ Links ]

24.Donovam SJ, Roose SP. Medication use during psychoanalysis: a survey. J Clin Psychiatry. 1995;56(5):177-8.         [ Links ]

25.Hamilton NG, Sacks LH, Hamilton CA. Object relations theory and pharmacopsychotherapy of anxiety disorders. Am J Psychother. 1994;48(3):380-91. DOI: https://doi.org/10.1176/appi.psychotherapy.1994.48.3.380        [ Links ]

26.Doidge N, Simon B, Brauer L, Brant DC, First M, Brunshaw J, et al. Psychoanalytic patients in the U.S., CANADA, and Australia: I. DSM-III-R disorders, indications, previous treatment, medications, and length of treatment. J Am Psychoanal Assoc. 2002;50(2):575-614. DOI: https://doi.org/10.1177/00030651020500021201        [ Links ]

27.Wright JL. Psychoanalysis in conjunction with medication: a clinical research opportunity. J Am Psychoanal Assoc. 2006;54(3):833-55. DOI: https://doi.org/10.1177/00030651060540031601        [ Links ]

28.Frosch WA. Psychoanalytic evaluation of addiction and habituation. J Am Psychoanal Assoc. 1970;18(1):209-18. DOI: https://doi.org/10.1177/000306517001800111        [ Links ]

29.Silvio JR, Condemarín R. Psychodynamic psychiatrists and psychopharmacology. J Am Acad Psychoanal Dyn Psychiatry. 2011;39(1):27-39. DOI: https://doi.org/10.1521/jaap.2011.39.1.27        [ Links ]

30. Rivera JLG. Psychotherapy and Pharmacotherapy. J Am Acad Psychoanal Dyn Psychiatry. 2007;35(2):173-77.         [ Links ]

31.Creed F, Guthrie E, Ratcliffe J, Fernandes L, Rigby C, Tomenson B, et al. Does psychological treatment help only those patients with severe irritable bowel syndrome who also have a concurrent psychiatric disorder? Aust N Z J Psychiatry. 2005;39(9):807-15. DOI: https://doi.org/10.1080/j.1440-1614.2005.01686.x        [ Links ]

32.Kane Jr FJ, Haper RG. Psychotherapy: past training and current practice. Gen Hosp Psychiatry. 1992;14(2):131-4. DOI: https://doi.org/10.1016/0163-8343(92)90038-C        [ Links ]

33.Angermeyer MC, Matschinger H. Public attitude towards psychiatric treatment. Acta Psychiatr Scand. 1996;94(5):326-36. DOI: https://doi.org/10.1111/j.1600-0447.1996.tb09868.x        [ Links ]

34.Tutter A. Romantic fantasies of madness and objections to psychotropic medication. J Am Psychoanal Assoc. 2009;57(3):631-55. DOI: https://doi.org/10.1177/0003065109333504        [ Links ]

35.Nishizono M. The anaclitic drug-psychotherapy--a synthesis of psychoanalysis and high dose drugtherapy. Folia Psychiatr Neurol Jpn. 1965;19(1):9-15. DOI: https://doi.org/10.1111/j.1440-1819.1965.tb00030.x        [ Links ]

36.Purcell SD. The analyst's attitude toward pharmacotherapy. J Am Psychoanal Assoc. 2008;56(3):913-34. DOI: https://doi.org/10.1177/0003065108323376        [ Links ]

37.Greene MA. The effects of the introduction of medication on the psychoanalytic process: a case study. J Am Psychoanal Assoc. 2001;49(2):607-27. DOI: https://doi.org/10.1177/00030651010490020901        [ Links ]

38.Leo D. Treatment of adjustment disorders: a comparative evaluation. Psychol Rep. 1989;64(1):51-4. DOI: https://doi.org/10.2466/pr0.1989.64.1.51        [ Links ]

39.Wilson SN. The meanings of medicating: pills and play. Am J Psychother. 2005; 59(1):19-29. DOI: https://doi.org/10.1176/appi.psychotherapy.2005.59.1.19        [ Links ]

40.Laplanche J, Pontalis JB. Vocabulário da Psicanálise. São Paulo: Martins Fontes, 1996.         [ Links ]

41.Press M. The uses of medications in psychoanalysis: what we know, what is uncertain. Panel reports. J Am Psychoanal Assoc. 2008;56(3):949-55. DOI: https://doi.org/10.1177/0003065108324063        [ Links ]

42.Marcus ER. Transference and countertransference to medication and its implications for ego function. J Am Acad Psychoanal Dyn Psychiatry. 2007;35(2):211-8. DOI: https://doi.org/10.1521/jaap.2007.35.2.211        [ Links ]

43.Kaplan M, Delgado SV. When worlds converge: combining depth psychotherapy and psychotropic medications. Bull Menninger Clin. 2006;70(4):253-72. DOI: https://doi.org/10.1521/bumc.2006.70.4.253        [ Links ]

44.Canongia AI. O pharmakon na interface do dispositivo analítico: o pathos na busca de sua verdade. Rev Latinoam Psicopat Fund. 2006;9(3):410-22. DOI: http://dx.doi.org/10.1590/1415-47142006003003        [ Links ]

45.Minas Gerais. Secretaria de Estado de Saúde. Atenção em Saúde Mental. Marta Elizabeth de Souza. Belo Horizonte: 2007.         [ Links ]

46.Atrash HK. Health Disparities: Challenges, Opportunities, and What You Can Do About It. J Hum Growth Dev. 2018;28(3):223-31. DOI: http://dx.doi.org/10.7322/jhgd.152156        [ Links ]

47. Roiste A. Nurturing resilience: the 'ordinary magic' of everyday life. J Hum Growth Dev. 2018;28(3):278-82. DOI: http://dx.doi.org/10.7322/jhgd.152175        [ Links ]

 

 

Correspondence:
Italla.Bezerra@emescam.br

Manuscript received: November 2018
Manuscript accepted: May 2019
Version of record online: October 2019