Psychopharmacology is commonly framed as a biologically driven intervention targeting neurochemical mechanisms of mental illness. Yet the effectiveness of psychiatric medications in real-world clinical settings depends not only on pharmacologic efficacy but also on patients’ engagement with treatment, attitudes to medication and responses to clinicians within the therapeutic relationship. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1–Reference Mintz and Flynn4} Treatment satisfaction with medication has emerged as an important determinant of clinical outcomes, particularly in individuals with serious mental illness requiring long-term pharmacotherapy. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1} Patients who perceive medication as untrustworthy or misaligned with their needs are more likely to show poor adherence and require frequent treatment changes. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1} Although pharmacologic properties of medication clearly influence treatment satisfaction, relational and psychological factors have a central – albeit underestimated – role in shaping how medications are experienced. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1,Reference Mintz and Flynn4,Reference Taylor, Barnes and Young5,Reference Goldberg, McIntyre, Swartz, Freeman, Mago and Citrome6} Attachment theory offers a coherent model for understanding these influences and improving prescribing and deprescribing practices in psychiatric care.

Attachment theory describes how individuals seek, perceive and respond to support during periods of stress. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1,Reference Adams, Wrath and Meng2,Reference Mintz7} Early caregiving experiences shape internal working models of self and others that guide expectations about trust, dependency, autonomy and safety throughout adulthood. ^{Reference Adams, Wrath and Meng2,Reference Adams, McWilliams, Wrath, Adams and Souza3} Seeking psychiatric care can itself be conceptualised as an attachment behaviour: patients signal distress, seek proximity to clinicians and interpret treatment recommendations through relational expectations that may operate outside conscious awareness. ^{Reference Adams, McWilliams, Wrath, Adams and Souza3,Reference Taylor, Barnes and Young5} In this context, psychotropic medications are also experienced as relational objects embedded in meanings of care, control, safety and dependence. ^{Reference Mintz and Flynn4–Reference Mintz7}

Contemporary models conceptualise attachment both categorically (secure, preoccupied, dismissing, fearful) and dimensionally, along orthogonal axes of anxiety and avoidance. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1–Reference Mintz7} The attachment anxiety dimension is characterised by distrust in independent coping, fear of rejection, and hyperactivating strategies such as amplification of distress and reassurance-seeking. ^{Reference Adams, Wrath and Meng2,Reference Adams, McWilliams, Wrath, Adams and Souza3} By contrast, attachment avoidance is marked by struggles with emotions and intimacy, with deactivating strategies that include denial of attachment needs, avoidance of close relationships and compulsive self-reliance to cope with perceived relational unavailability. ^{Reference Adams, McWilliams, Wrath, Adams and Souza3} Mapping patients along these two primary attachment dimensions may provide a clinically meaningful framework for developing tailored intervention strategies and predicting patterns of engagement and treatment adherence. ^{Reference Adams, Wrath and Meng2,Reference Adams, McWilliams, Wrath, Adams and Souza3}

Individuals with secure attachment (i.e. low anxiety and avoidance) tolerate both autonomy and dependence and use support effectively under stress. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1–Reference Adams, McWilliams, Wrath, Adams and Souza3} These patients are more likely to communicate openly about treatment response, collaborate with clinicians and remain engaged long enough for medications to demonstrate benefit. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1,Reference Adams, McWilliams, Wrath, Adams and Souza3} Secure attachment is also associated with higher satisfaction with medication treatment and outcomes compared with the three insecure attachment styles. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1,Reference Mintz7}

Patients with preoccupied attachment (i.e. high anxiety and low avoidance) often display heightened vigilance to relational cues and bodily sensations. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1–Reference Adams, McWilliams, Wrath, Adams and Souza3} In clinical settings, this may manifest as excessive help- and reassurance-seeking or heightened sensitivity to perceived side-effects or treatment inefficacy. ^{Reference Adams, Wrath and Meng2,Reference Adams, McWilliams, Wrath, Adams and Souza3,Reference Taylor, Barnes and Young5,Reference Mintz7} Such patients may appear to be highly engaged with services yet remain ambivalent about treatment. This pattern may contribute to repeated medication adjustments, intolerance of early adverse effects or premature discontinuation before therapeutic benefit emerges. ^{Reference Mintz and Flynn4,Reference Mintz7} A more directive and containing stance, with structured guidance and closer follow-up (particularly early in treatment), may help to manage anxiety without reinforcing dependency.

Individuals with dismissive attachment (i.e. low anxiety and high avoidance) tend to prioritise autonomy, minimise distress and distrust dependence on others. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1–Reference Adams, McWilliams, Wrath, Adams and Souza3} In psychopharmacologic care, this may appear as reluctance to disclose symptoms, scepticism towards medication, irregular attendance or unilateral discontinuation of treatment. ^{Reference Adams, McWilliams, Wrath, Adams and Souza3,Reference Taylor, Barnes and Young5,Reference Mintz7} Dismissive patients, who carry a basic expectation that they will not be helped, may easily give up on medication when results are disappointing. ^{Reference Adams, Wrath and Meng2,Reference Adams, McWilliams, Wrath, Adams and Souza3,Reference Mintz7} Dismissive attachment may lead patients to avoid dependence on medication or healthcare services, although these risks can be mitigated through clear communication, collaborative decision-making and continuity of care. ^{Reference Mintz and Flynn4,Reference Taylor, Barnes and Young5,Reference Mintz7} Clinically, these patients may benefit from more aggressive dosing that demonstrates results more rapidly. ^{Reference Mintz7} An effective approach may also involve maintaining a consistently non-judgemental stance that maximises the likelihood of re-engagement following treatment interruption.

Fearful attachment (i.e. high anxiety and avoidance), which is characterised by simultaneous desire for closeness and fear of harm, may produce the most unstable interaction and treatment patterns. ^{Reference Wang, Wang, Wei, Qi, Wang and Sun1,Reference Adams, Wrath and Meng2,Reference Mintz7} Patients with fearful attachment may seek care during crises yet withdraw from treatment once distress subsides or relational tensions emerge. ^{Reference Adams, Wrath and Meng2} These patients often experience the therapeutic relationship as both necessary and threatening, creating cycles of engagement and disengagement that complicate medication management. ^{Reference Mintz7} Fearful attachment may also increase vulnerability to nocebo-like responses, in which expectations of harm amplify perceived side-effects or undermine medication tolerability. ^{Reference Mintz and Flynn4,Reference Mintz7} Providing safety and acceptance through emotionally attuned guidance may support greater stability and engagement. Advancing medication dosing more cautiously may also be helpful with these patients, as side-effects fuel their concerns about being harmed by caregivers and consequent avoidant strategies.

Emerging consensus recommendations emphasise the importance of psychosocial factors such as attachment in how patients respond to medication reduction. ^{Reference Goldberg, McIntyre, Swartz, Freeman, Mago and Citrome6} For insecurely attached patients, tapering medication may evoke fears of abandonment, loss of protection or invalidation of illness and may serve as evidence that clinicians are unreliable or withdrawing care. ^{Reference Goldberg, McIntyre, Swartz, Freeman, Mago and Citrome6} Failure to account for the relational dynamics underlying (de)prescribing risks misattribution of clinically significant challenges such as mistrust towards treatment initiation, non-adherence, intolerance and resistance to tapering as pharmacologic treatment failure, which in turn may perpetuate unnecessary medication changes, augmentation strategies and polypharmacy. ^{Reference Goldberg, McIntyre, Swartz, Freeman, Mago and Citrome6,Reference Mintz7}

Psychiatry frequently invokes the biopsychosocial model, yet the focus on evidence-based pharmacotherapy almost always references the evidence for specific medication effects rather than the evidence base offering guidance about the psychosocial aspects of effective prescribing. Attachment theory offers a practical rationale for integration of relational understanding into medication management. Given the relational nature of prescribing, clinicians’ own attachment style may also shape the therapeutic alliance and prescribing decisions; this warrants further study. ^{Reference Adshead8} By recognising how attachment influences patients’ expectations, fears and responses to medication, clinicians may better anticipate patterns of adherence, intolerance and disengagement. Furthermore, recognition of a patient’s attachment style, operationalised through the related framework of mentalising capacity, can establish a basis for psychotherapeutic interventions aimed at enhancing metacognition. ^{Reference Inchausti, MacBeth and Dimaggio9} This work could eventually facilitate treatment (de)prescribing practices by fostering better awareness and regulation of attachment-driven responses, while also establishing a personalised roadmap for therapeutic progress that incorporates acquired knowledge of the patient’s mental world.