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The Future of Psychiatry

The Future of Psychiatry as Clinical


Neuroscience
Charles F. Reynolds, III, MD, David A. Lewis, MD, Thomas Detre, MD,
Alan F. Schatzberg, MD, and David J. Kupfer, MD

Abstract
Psychiatry includes the assessment, originate from studies of etiology and (SWOT) analysis of psychiatry and
treatment, and prevention of complex pathophysiology based in clinical and identify strategies for strengthening its
brain disorders, such as depression, translational neuroscience. To ensure its future and increasing its relevance to
bipolar disorder, anxiety disorders, broad public health relevance in the public health and the rest of medicine.
schizophrenia, developmental disorders future, psychiatry must also bridge These strategies encompass new
(e.g., autism), and neurodegenerative science and service, ensuring that those approaches to strengthening the
disorders (e.g., Alzheimer dementia). Its who need the benefits of its science are relationship between psychiatry and
core mission is to prevent and alleviate also its beneficiaries. To do so effectively, neurology, financing psychiatry’s mission,
the distress and impairment caused by psychiatry as clinical neuroscience must emphasizing early and sustained
these disorders, which account for a strengthen its partnerships with the multidisciplinary training (research and
substantial part of the global burden of disciplines of public health (including clinical), bolstering the academic
illness-related disability. Psychiatry is epidemiology), community and infrastructure, and reorganizing and
grounded in clinical neuroscience. Its behavioral health science, and health refinancing mental health services both
core mission, now and in the future, is economics. for preventive intervention and cost-
best served within this context because effective chronic disease management.
advances in assessment, treatment, and The authors present a Strengths,
prevention of brain disorders are likely to Weaknesses, Opportunities, and Threats Acad Med. 2009; 84:446–450.

Editor’s Note: A commentary on this article appears major neuropsychiatric illness is These, as we illustrate below, are
on pages 413 and 418. evolving, thus rendering artificial the differences of degree—not absolutes.
boundary between psychiatry and
According to the World Health
Psychiatry is the medical specialty neurology.1 The artificiality of this
boundary has profound implications Organization, neuropsychiatric
disorders account for at least 20% of
that seeks to help (i.e., assess and treat) for psychiatry’s future. Our thesis is
people and families living with complex that the two disciplines, which were the global burden of illness-related
brain disorders including depression, once united, should be, at least disability, and all represent complex
bipolar disorder, anxiety disorders, partially, reintegrated as clinical disorders of brain function.2 Psychiatry,
schizophrenia, substance abuse neuroscience (Figure 1). That said, like neurology, rests on a foundation of
disorders, developmental disorders we also acknowledge that whereas clinical neuroscience. It also encompasses
such as autism, and neurodegenerative and is informed by a broad range of basic
psychiatrists and neurologists share a
disorders such as Alzheimer dementia. biological and social sciences and has at its
common interest in the central nervous
Traditionally, disorders falling into disposal many tools (e.g., brain imaging,
system, their interests can and often do
the province of psychiatry have been genetics, neuropsychopharmacology,
diverge, resulting in group affiliations
those of unknown etiology, and, as neurophysiology, epidemiological models
that are key for professional identity.
researchers have ascertained etiology, of risk and protective factors, and
This identity is a fundamental tenet of
some disorders, such as central nervous neuropsychology) for developing new
medical sociology. We are not suggesting
system disorders, have often shifted to assessment and treatment approaches,
that psychiatrists or neurologists give up
the province of neurology. (Tertiary grounded in understanding of etiology
what really interests them, but a partial
syphilis is a good historical example of and pathophysiology.
reintegration of the two disciplines,
this shift.) Now, however, with the especially in undergraduate and graduate Our purpose is to discuss the future of
tools of modern neuroscience, a deeper medical training, as well as in research, psychiatry as clinical neuroscience and to
understanding of causal pathways to could strengthen both. The components specify strategies in several contexts to
of psychiatry and the components of enhance this future: (1) education and
Please see the end of this article for information neurology are often arbitrary and training, (2) health science policy, (3)
about the authors. historical rather than rational. Whereas institutional issues, (4) research, and (5)
Correspondence should be addressed to Dr. neurology has traditionally focused on clinical practice in medical schools and
Reynolds, University of Pittsburgh School of discrete anatomical lesions (e.g., stroke or training hospitals. We aim to present a
Medicine, Western Psychiatric Institute and Clinic, tumors), psychiatry or modern clinical synthesis of the key conceptual and social
3811 O’Hara Street, E-1135, Pittsburgh, PA 15213;
telephone: (412) 246-6414; fax: (412) 246-5300; neuroscience addresses dysfunction in issues facing psychiatry right now and to
e-mail: (reynoldscf@upmc.edu). anatomical circuits and connectivity. provide a tool for further discussion in

446 Academic Medicine, Vol. 84, No. 4 / April 2009


The Future of Psychiatry

Another strength is the systematic


evidence base now available to inform
psychiatric treatment, which is of a
relatively high order similar to, if not
better than, the rest of medicine in terms
of rigorously controlled randomized
clinical trials (RCTs), including those
testing theoretically based, disorder-
specific psychosocial treatments
(e.g., cognitive behavior therapy for
depression). Third, as highlighted by
the recent NIMH Strategic Plan, the field
is scientifically committed to both
optimizing treatment outcomes and
personalizing treatment for those living
with psychiatric disorders.6 This
commitment increasingly has inspired
investigating moderators of treatment
responses and creating models of care
organization (e.g., depression care
management) that allow evidence-based
Figure 1 The Future of Psychiatry at a Tipping Point. This concept map illustrates past streams of
practice to reach both specialty mental
influence on psychiatry, its current relationship with medicine, neurology, and public health, and
its future as clinical neuroscience and as a part of public-health-relevant prevention and disease
health and general medicine settings.
management strategies. These developments have also helped to
foster a growing emphasis on stepped-
care approaches with public health
many areas, both in psychiatry and in to synthesize a broad-based view of these relevance (e.g., the use of watchful
academic medicine more broadly. issues, to broaden participation of academic waiting before intervention and the use
medicine leaders in this conversation, and, of simple interventions before more
To explore these contexts and to provide above all, to make what we feel are strategic complex strategies) as well as integrated
a rationale for our views, we propose first recommendations for dealing with the multicomponent interventions that take
to present a Strengths, Weaknesses, tipping point where psychiatry now into account the burdens of coexisting
Opportunities, and Threats (SWOT) balances. We think, in short, that there is an medical, neurological, and psychosocial
analysis of the field of psychiatry. urgency to sustaining this conversation and challenges (e.g., care-giving burden).
Collectively, we bring to this task acting on it. We note several resources in Such interventions especially emphasize
approximately 200 years of experience in the literature of considerable value in this health-related quality of life. Selective and
all aspects of academic psychiatry: context from the surgeon general,3 the indicated preventive intervention for
research (basic and clinical), education IOM,4 and the APA.5 depression is also beginning to emerge as
(including leadership of programs in a feasible and effective strategy in primary
mentoring for academic careers), clinical care and specialty settings; such strategies
practice, and administration (medical Current Strengths of Psychiatry recruit individuals at high risk for
school dean and academic health center In our opinion, the assessment tools of psychiatric illness, many of whom are
[AHC] president, department chair, and psychiatry (e.g., the use of structured already experiencing presyndromal
large research group leader). All of us diagnostic instruments) and its treatment symptoms.7 Some preventive
have significant experience with the armamentarium (including maintenance interventions are psychosocial, such as
National Institutes of Health (NIH) as pharmacotherapy to prevent relapse and the use of problem-solving therapy to
reviewers, grantees, and National recurrence) are good, but they are far prevent or delay depression in people
Institute of Mental Health (NIMH) from excellent. Patients often improve living with macular degeneration8; others
national advisory council members; with substantially, but many do not recover are psychopharmacologic, such as
the Institute of Medicine (IOM); and as fully. The field has taken a largely antidepressant medications for
leaders of professional associations descriptive and categorical approach poststroke patients at risk for
(American Psychiatric Association to diagnosis, and now experts and depression.9
[APA], the American College of practitioners recognize the need to
Neuropsychopharmacology, and the incorporate multiple dimensions In addition, one of the greatest strengths
American College of Psychiatrists). We (e.g., severity, distress, impairment) into of psychiatry is the cadre of young people
emphasize that the views presented here their assessment procedures to better entering the field and its related basic and
are our own and do not necessarily reflect accommodate advances in relevant basic applied disciplines. Slightly more than
the official policies of any professional brain and behavioral sciences and to 4% of graduating seniors in the nation’s
organization with which we are affiliated. enhance clinical relevance. Indeed, this medical schools enter psychiatry.10
Our purpose is not to conduct a literature multidimensional assessment is a
review and analysis of the conceptual and fundamental goal of the Diagnostic and Finally, a critical and growing strength of
social issues facing psychiatry but, rather, Statistical Manual (fifth edition) task force. psychiatry as clinical neuroscience derives

Academic Medicine, Vol. 84, No. 4 / April 2009 447


The Future of Psychiatry

from the multiple and marked advances appropriately into undergraduate and enhancing the public health impact of
that are transpiring in the areas of graduate medical education. Psychiatry modern psychiatric treatment.
molecular, developmental, and systems has other weaknesses, too; it has paid too Psychiatry can also improve both
neuroscience. The expanding knowledge little attention to assessment and treatment strategies
of the neural substrates for the cognitive via deeper understanding of
and affective functions that are disturbed • inequalities in the delivery of mental genetics, pathophysiology,
in psychiatric disorders is creating an health services to vulnerable populations; functional neuroanatomy, and
increasingly more sophisticated and • the integration of mental health neuropsychopharmacology, allowing for
nuanced database for the generation of services into other areas of medicine, the development of more personalized
testable hypotheses about the biological from pediatrics to geriatrics; interventions. The opportunity to
underpinnings of psychiatric illness. develop and implement organization
Consistent with these advances, clinical • the real and perceived conflicts of models of mental health service delivery
neuroscientists are now witnessing the interest in relationships with industry; that have public health relevance will
early phases of the development of novel and further psychiatry’s reach and allow it to
pharmacological interventions centered • the unmet mental health needs of combat stigma against the mentally ill.
on pathophysiologically based illness medical students and physicians The pursuit of advocacy and consumer
models rather than on serendipitous generally (whose rates of suicide are health information initiatives through
discoveries. Psychiatrists are also now two to three times greater than in the partnerships with patients and
better able to estimate risk for mental general population12). families living with mental illness is
illness based on genetic information extraordinarily important to the
and to predict treatment response Finally, relative to most other specialties campaign to improve payment of mental
variability using pharmacogenetic in academic medicine, the number of health services via parity and, in a related
information. In this sense, the research-intensive departments of vein, to improve financial incentives for
traditional boundaries between psychiatry is relatively small, probably young people to enter the field. Finally,
psychiatry and neurology, between not more the 20% of the nation’s medical psychiatry has a duty to change the
mind and brain, are disappearing.11 schools, as judged by the geographic institutional culture of academic
distribution of NIH-sponsored research.6 medicine in a way that supports medical
This reflects a nexus of several challenges students and physicians seeking mental
Current Weaknesses of Psychiatry to the field: (1) too few psychiatrists who health services for themselves. For
Psychiatry’s assessment and treatment have completed research fellowships, (2) example, teaching medical students and
tools, though good, are limited by the too few mentors, (3) an overly rigid physicians to better recognize depression
lack of—and often internal resistance approach to graduate medical education in themselves and in their colleagues may
to—the clinical neuroscience perspectives with inadequate flexibility to allow the lead to decreased rates of physician
needed to bring the findings of integration of research training into disability and suicide—and increase the
psychiatric genetics, brain imaging, subspecialty clinical training, and (4) a likelihood that nonpsychiatrist physicians
cognitive and affective neuroscience, and failure to recruit a fair share of the best will recognize depression in their own
psychometric theory to defining etiology, and brightest medical students early patients.12
pathophysiology, and treatment-relevant enough into clinical neuroscience
phenotypes, and to personalizing research.13
treatment (i.e., which treatment for Current Threats to Psychiatry
which patient at what point in the illness Notwithstanding the many opportunities
trajectory?). In our opinion, optimizing Current Opportunities for available to psychiatry as clinical
treatment entails not only RCTs but also Psychiatry neuroscience, the field also faces
a greater emphasis on the identification Embedded within the strengths and challenges that threaten its future. Some
of biological and psychosocial variables weaknesses of psychiatry as a discipline of of these are financial in nature (e.g., lack
that predict or modify short- and long- clinical neuroscience are tremendous of parity in reimbursement policies and
term treatment response. As a field, opportunities to conduct research into Medicare’s discriminatory copayment
psychiatry is relatively new to this the causes of mental illness; to chart the requirement of 50%). Another relates to
enterprise, well behind many other developmental trajectories of mental the organization of medical practice;
medical specialties. We believe that the illness so as to determine when, where, structural barriers (e.g., the lack of
disciplinary separation of the two major and how to intervene; to develop mental electronic health records, decreasing
practice arms of clinical neuroscience, health treatments and approaches institutional support, and orientation to
psychiatry and neurology, is a conceptual responsive to diverse needs and acute rather than chronic care) impede
and structural impediment to scientific circumstances; and to strengthen the the implementation of evidence-based
and clinical progress in the care of people impact of treatments for mental illnesses mental health services in general
living with complex brain disorders. As a on public health. The tools of psychiatry’s medicine and pediatric practices. Social
discipline of clinical neuroscience, basic and behavioral sciences now permit realities, such as the persistence of
psychiatry needs to invest greater such progress. In addition, the field is stigma against the mentally ill, and
scientific effort into studies of the ripe with other opportunities to develop health/science policy (e.g., the inadequate
etiology and pathophysiology of major selective and indicated preventive funding of mental health research and the
brain disorders and to ensure that interventions for people at high risk for scanty support for mentoring), also
advances in these two fields are integrated mental illness across the lifecycle, thereby threaten the future of psychiatry. The

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The Future of Psychiatry

dearth of recruitment of excellent influence medical student choice for clinical neuroscience, such as loan
students and the attendant workforce psychiatry (and neurology) in graduate repayment programs and improved
implications (e.g., the paucity of child/ medical education. reimbursement schedules.
adolescent and geriatric psychiatrists, the
• Integrate the third-year medical school • Increase federal investment in (1)
low number of psychiatric trainees
clerkships in psychiatry and neurology research into the causes, diagnoses, and
embarking on research careers) also loom
rather than having two separate treatments of complex brain disorders
as threats to psychiatry’s future. Finally,
clerkships. and in (2) services to people with severe
the infrastructure needs of psychiatric
and persistent mental illness and other
and mental health research—from • Teach medical students how to
complex brain disorders.
basic laboratories to community- recognize depression in themselves and
based partnerships, especially with in their colleagues; encourage them to • Foster integrated approaches by the
disadvantaged, underserved people— use mental health services and, thereby, NIMH, Institute of Neurological
require ongoing, planned investment. combat the internal and external Disorders and Stroke, National
The capital available for that investment stigmas against mental illnesses. Institute on Drug Abuse, and National
is shrinking (the purchasing power of Institute on Alcohol Abuse and
the NIMH/NIH appropriations has • Train psychiatric residents in general
Alcoholism to complement the federal
decreased dramatically in the past five medical and pediatric settings, in
sponsorship of research in clinical
years) and underscores the vital role of addition to those in specialty mental
neuroscience.
the nation’s philanthropic community health settings, to convey mental health
and appropriate partnerships with expertise to their medical colleagues
Institutional issues
industry to ensure a robust future for and patients.
Several key issues require the attention of
psychiatry as clinical neuroscience. • Provide psychiatric residents in institutional leadership. We recommend
community settings with culturally the following strategies:
appropriate skills for dealing with
Strategies to Ensure the Future of patients who are disadvantaged and/or • Work toward the reintegration
Psychiatry as Clinical Neuroscience underserved. of undergraduate and graduate
On the basis of this SWOT analysis, we medical education in psychiatry and
• Foster greater cross-training during
think that the nation’s health policy neurology under the rubric of clinical
psychiatry and neurology residencies,
leaders, AHC and academic psychiatry neuroscience; offer certification by the
particularly in central (as apposed to
department leaders, and important American Board of Psychiatry and
peripheral) nervous system disorders.
gatekeepers such as the Liaison Neurology in clinical neuroscience with
Psychiatrists need to know much more
Committee for Medical Education and subspecialty qualification in psychiatry
about brain function, and neurologists
the Residency Review Committees should or neurology to recognize the divergent
need to know much more about the
consider the strategies listed below. We interests and group affiliations that are
neuropsychiatric dimensions of
organize these strategies into the domains key for professional identity.
their patients’ illnesses. (There is
of (1) education and training, (2) health
arguably more similarity between • Create endowments for both junior
science policy, (3) institutional issues, (4)
Parkinson disease and depression or and senior professors of clinical
research practice, and (5) clinical
schizophrenia than between Parkinson neuroscience so as to ensure
practice.
disease and myasthemia gravis or opportunities for initiating and
carpal tunnel syndrome.) maintaining academic career
Education and training
development.
Education, training, and mentoring are • Expand the education of psychiatry
obviously critical to ensuring recruitment residents in a disease-relevant • Create infrastructure to support core
and retention; therefore, we recommend understanding of molecular, laboratories in clinical neuroscience
the following strategies: developmental, and systems and related disciplines (1) to foster
neuroscience to ensure their ability to future integration across these
• Introduce medical students to the bring future advances in these areas disciplines and (2) to provide
excitement of clinical neuroscience in into clinical practice. interdisciplinary research and clinical
psychiatry during the first year of training.
medical school. Basic neuroscience, Health/science policy
• Remove barriers to the use of mental
psychiatry, and neurology faculty We believe that there are several critical
health services by medical students and
should coteach these courses, policy issues that demand action:
physicians.
integrating perspectives across their
• Pass and enforce legislation calling for
disciplines.
parity of coverage for physical and Research practice
• Recruit medical students into summer mental illness. New models of research practice should
research electives in psychiatry and include the following strategies:
• Abolish discriminatory Medicare
clinical neuroscience by providing
policies requiring 50% copayments for
mentoring and shadowing opportunities. • Develop broad programmatic
mental health services.
Integrate early clinical exposure to approaches to multidisciplinary
patients living with complex brain • Enhance financial incentives for research in clinical neuroscience. These
disorders into these experiences to medical students to choose careers in approaches should encompass (1)

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The Future of Psychiatry

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