I prescribe, therefore I am?

In their qualitative study, we imagine that Martean & Evans ¹ 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 ² and has demonstrated specific benefit as a preliminary measure for patients with a personality disorder. ³ 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.