neuroscience has increasingly become the royal road to the unconscious?….

Posted on Saturday 21 April 2012

I had a strong feeling of déjà vu when I was writing about today’s blog by NIMH Director Tom Insel [not for me to say…]. It’s because it’s almost the same as one he wrote in June last year after the APA Meeting. I blogged about it [one of those people…] right after Christmas and I even doctored a heroic poster from the old USSR to go with it. If you’ve got some  free time, compare the two. It’s kind of interesting:
Psychiatry: Where are we going?
NIMH: Director’s Blog
by Thomas Insel
June 03, 2011

At the recent annual meeting of the American Psychiatric Association [APA], a talk by Dr. Laura Roberts caught my attention. In her presentation on “living up to our commitments,” Dr. Roberts, the new chair of Psychiatry at Stanford, described a dire situation for psychiatry in 2011. While some of the most disabling and deadly medical problems, neuropsychiatric illnesses, have become the leading source of medical disability in this country, the discipline of psychiatry is often still struggling with issues of stigma, scandal, and self-doubt.

Consider these numbers. While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine. Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors [n = 698] applied for one of the 1097 post-graduate year one training positions in psychiatry. As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent. Indeed, over the past decade the number of psychiatry training programs has fallen [from 186 to 181] and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 2011.

Beyond these numbers, the profession is struggling with its identity, a theme echoed in other plenary talks at the APA meeting. Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems.

Is there a fix to these declining numbers? I think so. In fact, the change may be coming more quickly than most psychiatrists realize. Just as a new generation of chairs have taken over at many of the major academic departments [such as at Stanford, Pittsburgh, Yale, and Duke], a new generation of students is choosing to train in psychiatry. Over the past three years, NIMH has been running an annual “Brain Camp” for select psychiatry residents to give them a crash course in the most recent findings from cognitive science, neuroscience, and genetics. The residents we see at Brain Camp bring new perspectives. Many have PhDs in neuroscience. For today’s students intrigued with the mysteries of the mind, neuroscience has increasingly become the royal road to the unconscious. While these residents remain committed to the treatment of seriously mentally ill patients, today they are pursuing new venues in which to provide treatment such as in homeless shelters and jails, on battlefields, as well as globally in developing countries. While learning about the benefits of psychopharmacology and psychotherapies, they are also being taught to think critically about pharmaceutical company marketing messages and how to communicate thoughtfully with their patients in a multimedia-filled world.

A recent video module created by NIMH demonstrates the potential that a perspective in clinical neuroscience brings to psychiatric practice. “Translating Neural Circuits into Novel Therapeutics” describes recent findings elucidating the neurological basis of cognitive dysfunction in schizophrenia and how these findings may soon lead to new and better ways of treating one disabling aspect of the disorder. Each of the last three years, we have seen more MD-PhD students choosing psychiatry, suggesting that some of the best students interested in research are moving into this field. As just one example, at Yale, where a new curriculum stresses clinical neuroscience, 12% of the graduating medical school class chose to go into psychiatry this year (relative to the national average of 4%). The Yale success may reflect their focus on teaching medical students about psychiatry as a neuroscience discipline.

The scientific foundation of psychiatry has shifted from psychoanalysis and is moving to cognitive science and neuroscience. The new generation of academic leaders recognizes the need to integrate these new perspectives with traditional psychodynamic theories, creating new training programs. Some residents in this generation are bringing an extraordinary set of tools and talents to the profession. Imagine a new discipline, clinical neuroscience that brings the best science of brain and behavior to the compassionate care of those with serious mental illnesses. Who would not want to be part of this revolution? What better way to live up to our commitments?
I wonder what he’s talking about?…
    April 21, 2012 | 10:27 PM

    “some of the best students interested in research are moving into this field”

    Given the fact that much of the “research” in our field from the past 10-20 years is tainted beyond belief (making it impossible to determine whom to trust anymore), this is, quite possibly, a good thing.

    However, given the fact that the NIMH’s emphasis is on “Translating Neural Circuits into Novel Therapeutics” (instead of a greater understanding of what the heck we’re treating in the first place), I’m not so optimistic.

    Steve Lucas
    April 22, 2012 | 8:19 AM

    I am sure many young doctors, with the urging of pharma, will look at this link as the answer to all of our psychiatric problems. Forget the sample size, it will be ignored in the marketing, we have it all under control.

    Now all we need to do is check for LDL, A1c, and to see if you have an “undiagnosed” psychological problem but we have a drug for that.

    Think it won’t happen? Check out the April 23 & 30 2012 Newsweek article The Doctor Will See You – If Your Quick by Shannon Brownlee pg. 46 – 50 where an undiagnosed kidney cancer patient is asked if they are depressed.

    Steve Lucas

    April 22, 2012 | 1:16 PM

    In the software industry, “vaporware” is the term for features or improvement that are promised and heavily hyped but never seem to show up in the shipped software.

    Many, many companies have spent millions of dollars on vaporware. You would think the “fool me once” rule would apply, but their IT departments keep on buying software updates from the same vendors who’ve misrepresented their products in the past. There are several reasons for this. One is that if IT managers didn’t spend of time selecting software every year, they wouldn’t have jobs. Another is that the sales reps offer perks (fancy meals, etc.) and maybe kickbacks. All the software companies do this, so you might as well go with one as with the other.

    Lastly, there is always the hope the software, this time, will actually contain the promised improvements, run the way the sales rep says it will, and make the IT managers look really, really good.

    This has been going on for decades.

    April 22, 2012 | 4:52 PM

    Freud was a neurologist.

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