Why some patients quit their meds and others cling to them
STUDY: Monteiro de Castro J et al, Br J Psychiatry 2026
STUDY TYPE: Review/commentary
FUNDING: Independent
Background
A patient’s attachment style, the pattern of trust and distrust they bring to close relationships, shapes their experience of medications. This paper applies attachment theory to psychopharmacology.
Summary
The authors link four adult attachment styles (secure, preoccupied, dismissive, fearful) to patterns of medication engagement:
- Secure patients collaborate, tolerate side effects, and stay on treatment long enough to benefit.
- Preoccupied patients (high anxiety, low avoidance) seek reassurance, report side effects more readily, and often stop medication before it has a chance to work.
- Dismissive patients (low anxiety, high avoidance) distrust dependence altogether. They skip visits, quietly stop medication, and give up fast when results disappoint.
- Fearful patients (high anxiety and avoidance) swing between clinging to care during crises and fleeing it once the crisis passes, and they’re especially prone to nocebo-like reactions, where fear of harm itself produces side effects.
Mistaking these attachment-driven patterns for pharmacologic treatment failure fuels unnecessary dose changes, augmentation, and polypharmacy. Before you add a second medication for treatment resistance, ask whether the problem is a relational one: Does the patient trust you, and do they trust the pill?
Practice Implications
- For anxious, reassurance-seeking patients, offer more structure: closer follow-up and clear guidance, without over-explaining every side effect, which can reinforce worry.
- For dismissive patients who minimize symptoms and skip visits, push dosing a bit faster so they see results before they lose interest, and keep the door open, non-judgmentally, if they disappear and come back.
- For fearful patients, go slower on dose increases and lean into a steady, predictable relationship. That reduces the nocebo effect this group is prone to.
- Learn more in David Mintz’s book, Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient (he is an author on the paper).
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
