Medication and the Therapeutic Alliance

David Mintz is a psychiatrist at Austin Riggs

The relationship between clinician and patient may explain as much of the response as the medication itself

STUDY: Mintz DL et al, American Journal of Psychiatry 2026

STUDY TYPE: Clinical commentary (narrative review)

FUNDING: Independent

Background

Most evidence-based prescribing means matching a drug to a diagnosis, with little attention paid to the setting and relationship. This commentary from the Group for the Advancement of Psychiatry argues that the working relationship between clinician and patient, the pharmacotherapeutic alliance, deserves the same evidence-based status.

The Study

• A synthesis of meta-analyses, randomized trials, and the psychotherapy alliance literature applied to pharmacotherapy.
• Covers clinician factors (warmth, empathy, optimism), patient factors (illness severity, attachment style, insight), and structural factors (visit length, frequency, computer use, telepsychiatry).

Results

In the National Institute of Mental Health’s landmark depression trial, alliance contributed as much to outcome as whether patients received psychotherapy or medication. A meta-analysis of eight pharmacotherapy studies put the alliance effect size at 0.30 across disorders, on par with many medications.

Strengthening the Alliance

Warmth, empathy, and authenticity strengthen alliance, while optimism has a double edge. It helps treatment-naive patients but injures trust for those who have a history of non-response to meds. Patients with more severe illness or insecure attachment styles have more difficulty forming an alliance, but these harder-to-reach patients may be the ones who benefit most from alliance-focused care.

Follow-up frequency also matters. Antidepressant trials showed roughly a 1-point drop on the Depression scale (Hamilton Depression Rating Scale) for each added follow-up visit in the first six weeks, far more visits than most patients get in practice.

Typing During Visit

Computer use during the visit can impair the alliance. In one study, 77% of patients returned when the clinician didn’t type during their intake, versus 27% when they did. That 2016 study was not randomized, however, raising the possibility that warmer clinicians are less likely to do that.

AI scribes may reduce that risk, but they have risks of their own (a new study links them to more passive treatment plans). If you use a computer:

• Maintain eye contact while typing with a wireless keyboard
• Invest in a quiet keyboard (Logitech MX Keys S is favored by New York Magazine and has worked well for me)
• Share the screen as a collaborative tool (if your EMR creates visual graphs of rating scales, patients can view their progress over time)
• Summarize the information you’re entering to the patient

Collaboration

Collaborative, shared decision making improves response. In one trial, patients treated with their preferred option, medication or psychotherapy, reached remission about 50% of the time, versus roughly 25% when given medication after preferring psychotherapy, and under 8% when given psychotherapy after preferring medication.

Practice Implications

1. If you use a computer during visits, keep eye contact, turn the screen toward the patient, and narrate what you’re entering.
2. If patients can’t afford more frequent visits, consider other ways to enhance connection (have them update you through the portal after 2 weeks).
3. The lead author, David Mintz, has more in his book, Psychodynamic Psychopharmacology, and in our Carlat interview with him.

—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

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