Factitious Disorder: Is Any Medication Ever Appropriate?
A single patient whose third unexplained hypoglycemic hospitalization this year was traced to covert insulin use. No voice here thinks a drug treats deception itself — the disagreement is whether that leaves any legitimate role for pharmacotherapy at all.
J.R., a 38-year-old woman, has been married to her husband for twelve years, and it was he who found the insulin vials — two of them, unlabeled, tucked inside a zipped compartment of her bag — while packing for what became her third hospital admission this year for severe hypoglycemia. She has no history of diabetes. The first two episodes were worked up as spontaneous hypoglycemia of unclear cause; this time, blood drawn during the actual episode showed an insulin level that was markedly elevated with a suppressed C-peptide and a negative sulfonylurea screen — the specific biochemical signature of exogenous insulin administration, not an insulinoma or any endogenous cause. Confronted gently with the lab result, she denied any knowledge of the vials and became distressed, but did not leave against medical advice, and has remained in the hospital for observation while the team works out what happens next. Her husband, who brought the vials to the nurse's station himself rather than confronting her directly, has asked the team more than once whether "there's a pill for this" — a question this case doesn't have a simple answer to.
There is no medication trial evidence to answer him with, and the shape of that absence is worth stating precisely. Eastwood and Bisson's 2008 systematic review of factitious-disorder management searched the literature and found 32 case reports and 13 case series — and not one randomized trial, of any intervention. Their conclusion was not that psychotherapy works and drugs do not; it was that the evidence was insufficient to evaluate any management technique at all, with no discernible difference in outcome between confrontational and non-confrontational approaches, or between psychiatric medication and none. Krahn and colleagues' series of 93 patients diagnosed at a single center over 21 years is a fair illustration of what that literature is made of: careful observation, no controls, no randomization. Her PHQ-9, obtained today, comes back at 16 — moderate-to-severe range — raising a genuinely separate question from the one her husband asked: not whether a medication treats factitious disorder, which nothing does, but whether a real depressive syndrome accompanying it deserves its own treatment regardless.
Care planning meeting, day two of the admission
There's no medication that treats what actually happened here, and I want to give you the strongest version of that rather than the convenient one. Eastwood and Bisson's 2008 systematic review found 32 case reports and 13 case series in this entire literature and no randomized trials at all. Within that observational material they specifically compared psychiatric medication against none and found no discernible difference in outcome. Krahn's 93-patient series is the same picture from a single center. Starting something under the banner of treating this risks becoming another object inside the same pattern the diagnosis describes.
You're right that nothing treats factitious disorder itself, and I'm not proposing anything does. But her PHQ-9 came back at 16 today, moderate-to-severe, and comorbid depression is documented throughout the same observational literature you're citing as common in this population. That's a real, separate diagnosis, and declining to treat it because the primary condition is hard to treat would undertreat something that has its own criteria and its own reason to be addressed.
And I'd press on the review you just quoted, because you quoted it fairly and it cuts both ways. Eastwood and Bisson concluded there was insufficient evidence to evaluate any management technique — that finding is symmetrical. It doesn't license medication, but it doesn't license withholding it either, and it certainly doesn't establish the psychotherapy-only plan you're proposing as the evidenced alternative. When the evidence base is that thin about the primary condition, the comorbidity that does have a treatment literature is the part we can actually act on. I take the incorporation risk seriously — I'm not dismissing it. But the answer to that risk is careful framing and monitoring, not withholding treatment from a genuinely depressed patient.
I don't think either of you is wrong, and I'm not going to settle which of you is right about whether to prescribe. What I want on the record before anyone writes an order: she has demonstrated, three times this year, the willingness and the means to covertly self-administer a substance capable of killing her. Whatever gets prescribed, if anything does, needs a plan that accounts for that specific, documented behavior — not a plan built as if this were an ordinary depression evaluation.
Concretely, that means avoiding anything dangerous in overdose or diversion, favoring an agent with a wide safety margin, and real thought about how adherence gets verified in a patient whose reporting we already know isn't reliable. That's a safety question underneath your disagreement, not a vote on it.
Agreed: no medication started today for factitious disorder itself, and the appropriateness of treating her depression is not resolved today either — the psychologist and psychiatrist remain in real disagreement, carried forward rather than settled.
What was agreed, and treated as a genuine prerequisite rather than a formality: if sertraline is started, it happens only after a concrete monitoring plan is in place — pill counts, a structured follow-up interval, and explicit involvement of her husband in dispensing, agreed to by her directly rather than imposed.
The psychiatrist's case for treating a real, independently documented depression moves forward — on the hospitalist's terms, not as a bypass of them.
The psychologist's position holds by default — not because the depression argument was wrong, but because no safe way to act on it was found.