1 Boring Old Man

The Future of Psychiatry (= Clinical Neuroscience)
NIMH Director’s Blog
by Thomas Insel
April 20, 2012

Last week a short piece in the British medical journal, The Lancet, described an “identity crisis” in psychiatry. In the U.K., the number of medical students choosing psychiatry has dropped more than 50 percent since 2009 and over the past decade the number of psychiatrists has dropped by 26 percent while the number of physicians overall has increased more than 31 percent. Ninety-five percent of posts for junior physicians across all specialties are generally filled; but psychiatry posts, as of last summer, were running more than one third unfilled. Tom Brown, Assistant Registrar of Recruitment at the Royal College of Psychiatrists, U.K., told The Lancet: “Common perceptions within the medical profession include the view that psychiatry is just not scientific enough, is too remote from the rest of medicine, is often viewed negatively by other medical professionals, and is a specialty too often characterised by difficult doctor-patient relationships and limited success rates of therapeutic interventions.”

Meanwhile, psychiatry in the U.S. is undergoing a quiet resurgence which appears to run counter to the British experience. This might not have been apparent last month at match day, the day when medical students match with their post-graduate residencies. Match day is always a moment to track the popularity of different medical specialties. This year, slightly less than 4 percent of graduating students chose psychiatry, which is a bit lower than recent years. But this number hides an extraordinary trend: psychiatry has become the hot specialty for MD-PhD students who want to do research. The number of MD-PhD students choosing psychiatry has more than doubled in the past decade…

Why are they now selecting psychiatry? I asked this question at Brain Camp a couple weeks ago. Each year, NIMH runs a 4-day intensive Brain Camp for some of the top physicians in their second year of psychiatric residency training. The faculty, including Nobel laureates and other distinguished scientists, describe recent insights from neuroscience relevant to the problems facing psychiatric residents. The residents, who are still at a very early stage of their training, are challenged with charting the future of psychiatry. The result is one of the most inspiring 4 days of the year for all of us who attend.

This year, 11 of the 17 psychiatric residents at Brain Camp were MD-PhDs. Many had been neuroscience majors in college, had published high impact papers in medical school, and were continuing to do research during their clinical training. Prior to residency, all 17 were medical students who had been at the top of their class and could have gone into any specialty. When I asked them why they had chosen psychiatry instead of another specialty, I heard various reasons but they all agreed that psychiatry is the specialty where they can have the greatest impact. To paraphrase, one student said, “The questions are profound, the patients are fascinating, and the tools are finally available to make unprecedented progress.” Another told me confidently, “This is the place to make a mark”…

This year Brain Camp was largely focused on neuromodulation—using cognitive training and repetitive transcranial magnetic stimulation (rTMS) — to alter symptoms of depression and anxiety by modulating specific brain circuits. For this new generation, psychiatry already is clinical neuroscience. So maybe there is an identity crisis for psychiatry in the U.S. as well as the U.K. But the U.S. version seems filled with hope and excitement, with many of the best and brightest now deciding that they can bring new approaches to help people challenged by mental illness.

He is personable, well-spoken, looking like a boy made up to play a 60 year old in a school play. His NIMH has not been one to follow the researchers but rather one to have programs and tracts with a heavy focus on the translational meme. To my knowledge, he’s been personally clear of sleazy connections with PHARMA, though he’s certainly been an ally. His personal morality might be questioned eg favored researchers [Trivedi, Rush, Nemeroff] and his helping Charlie Nemeroff get the job at Miami after being disgraced at Emory. But Dr. Insel is an active force in shaping the directions of psychiatry in his own image – his beloved Clinical Neuroscience – as in the title for this blog.

In his blog, he reports that there’s a further fall in people coming into psychiatry [already filling with about 40% Foreign Medical Graduates], and more than ever they are aiming for research careers, so the decline in clinicians who actually see patients continues. Who would want to look at seeing patients for 15 minute medication checks as a career? I’m not complaining about the MD/PhDs. We could certainly use better trained Clinical Neuroscientists than we’ve had in the past. But Insel does not attend to the problem of the waning number of psychiatric clinicians, the fate of practicing psychiatrists, or for that matter the fate of the patients we serve. He instead focuses on those who follow in his own footsteps who he refers to in the blog post as the "elite" and then moves to his signature comment…

^{So maybe there is an identity crisis for psychiatry in the U.S. as well as the U.K. But the U.S. version seems filled with hope and excitement, with many of the best and brightest now deciding that they can bring new approaches to help people challenged by mental illness.}

As a kid, I hated it when my parents or other adults would talk about the past nostalgically – about things being better. "We carried our own water" was particularly annoying. Both sets of Grandparents got their "drinking water" from springs, meaning that I was often sent with jugs to obtain the precious commodity. I didn’t think that was better. I liked the idea that potable water came out of our faucets at home. I had an even stronger affection for indoor toilets. My parents had lived through the Depression and World War II, yet those were the "good old days"? I knew better. "We made our own …" was spoken with reverence. Well I’d bathed with that "home-made" soap at grandma’s house, and was less than impressed. There was a derogatory term – "new-fangled contraption" – that addressed the compliant about modernity. Corny love songs were better than rock and roll? slacks better than blue jeans? long dresses better than miniskirts? Well, that wasn’t going to happen to me. I wasn’t going to get to be an old man with disdain for the modern ways. I think back then I felt it was a contempt for "my time," so I wasn’t going to put my childrens’ "time" down like the generation before me. If the past was so great, why were they eating from t.v. trays so they could watch the news on the "new fangled contraption" in the den? But it didn’t work out like I planned. I hate rap music, vampire movies, gratuitous sex, direct-to-consumer ads, and South Park; I configure my computer to look like Windows 3.0; and the ring on my iPhone sounds like my Grandma’s.

In a more serious vain, I lament the loss of the clinic, and with it, the disappearance of the clinician. Notice that #4. ["the teaching of medicine to students at the bedside "] is marked as obsolete. In psychiatry, there’s no bedside at which to either teach or learn, as the hospitals are gone. There’s really no clinic, outside the 15 minute "med-checks." And I’m afraid that the clinicians are also disappearing. In Insel’s case, he never was one – so he may not be attuned to what’s being lost. I know in my case, I chose being a clinician who "specializes in clinical work" over  being "one engaged in laboratory or experimental studies" because I enjoyed it more, but also because I respected it more. But I did both and actually enjoyed both. But I was awed by clinicians and wanted to be one – and that’s where I ended up putting my efforts. I actually saw psychiatry as essentially being mostly for clinicians, at least my version [I’ll spare you a long lecture/diatribe about that].

I don’t personally think that mental health treatment has progressed to the point where clinicians are expendable: diagnosis from look-up tables [DSM-5] rather than experience; treatment by algorithm rather than by bringing what is known about all people and brains to bear on what is known about this particular patient and creating something specific. It’s not Insel’s neuroscience I’m complaining about. It’s his using the term clinical – something he knows nothing about and doesn’t seem to value, even from afar. It’s pretty clear that the current trajectory that he’s championing will result in a growing class of neuroscientists [like him] and the clinician psychiatrists [like me] will disappear – replaced by primary care physicians with "book learning" using "new-fangled contraptions."