not for me to say…

Posted on Saturday 21 April 2012

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.

Dr. Insel apparently says proudly that he’s never spent a moment as a clinician since finishing his residency [1980NIMH1994Yerkes1999Translational Program2002NIMH Director]. His career began literally at the time of the DSM-III revolution in psychiatry and has spanned the era. His early research was using SSRI’s to treat OCD, then later on the effects of the hormones Oxytocin and Vasopressin in animal bonding. Both moves from the NIMH and from Yerkes were because of non-contract renewals. He was a surprise pick as NIMH Director, a choice apparently heavily supported by his boss, Emory Chairman Dr. Charles Nemeroff.

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.
…what I call his future-think. The hope is in the future. And it is a specific future – the future of neuroscience and the treatments that will come down the line – like transcranial magnets, new medications strategies, implanted brain wires, etc. There can be little question about the neuroscience part of Dr. Insel’s equation. It’s the clinical and clinician parts that are missing in action the Future of Psychiatry (= Clinical Neuroscience).
World English Dictionary

clinic  [ˈklɪnɪk]
— noun
  1. a place in which outpatients are given medical treatment or advice, often connected to a hospital
  2. a similar place staffed by physicians or surgeons specializing in one or more specific areas: eye clinic
  3. [British] a private hospital or nursing home
  4. obsolete  the teaching of medicine to students at the bedside
  5. [US] a place in which medical lectures are given
  6. [US] a clinical lecture
  7. chiefly  [US], [Canadian] a group or centre that offers advice or instruction: a vocational clinic
[from Latin, clÄ«nicus one on a sickbed; from Greek, from klinÄ“  bed]

clinician  [klɪˈnɪʃən]
— noun
    a physician, psychiatrist, etc, who specializes in clinical work as opposed to one engaged in laboratory or experimental studies
[from French, clinicien; from Latin, clinicus – see clinic]

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."

So, I just couldn’t bring off my childhood resolution after all. I didn’t want to grow old and be one of those boring old men who said that what they were and how they learned the hard way to be it was the better way of doing things. As a young guy, I thought it was just old people lamenting the lost narcissism of their youth. The difference from then to now? I guess that’s not for me to say, but it’s not for Tom Insel to say either…
    April 21, 2012 | 12:00 PM

    I just posted what my vision of the profession might look like. If psychiatrists want to help people get well, they can find out what’s going on in people’s lives.

    Life situations cause brain chemistry changes, not the other way around. People can study the secondary effects all the want, but the chemistry will never make sense or be resolvable without looking at the root causes.

    April 21, 2012 | 1:52 PM

    Children who experience severe forms of abuse are around three times as likely to develop schizophrenia and related psychoses in later life compared with children who do not experience such abuse, according to a study that has brought together psychiatric data from almost 80,000 people.

    One of my uncles was extremely abused as a child. It took two tours as a helicopter machine gunner in Viet Nam to make him snap, though. It seems to me that having to dissociate as a child would create entire mechanisms that would be maladapted in adulthood. To be thrown into an adult world that is as or more pathological than the family that abused you as one is becoming an adult socially, but the brain is still developing could conceivably wire a person for psychosis in an attempt to deal with inescapable pain and cruelty.

    April 21, 2012 | 3:56 PM

    I posted about Insel’s latest blob post as well. Friday Funny: I have something to say to Thomas Insel

    April 21, 2012 | 3:59 PM

    So you did! LOL

    April 21, 2012 | 4:05 PM

    fyi “brain power – psychiatry turns to neuroscience”

    Nancy Wilson
    April 21, 2012 | 6:01 PM

    Thomas Insel, all dressed up and nowhere to go.

    Columnist Steve Blow has a plan….

    April 21, 2012 | 8:30 PM

    I’m still going to see some hope in neuroscience. Whether the author of that neuroscience article gave a dumbed down explanation or was given one

    “Later I print the scans and hang them on my refrigerator door. Occasionally a visitor asks me about them. I say they show a neural network we all rely upon to deal with emotional conflict. I point to the activated red spot and the dampened blue blobs and explain that they show how people cope with anxiety.”

    To say that the tests represents “emotional conflict” writ large would be a gross characterization. To say that the way neural networks respond to that particular test demonstrates how the brain deals with an “emotional conflict” that is already a generalization is beginning to go down the rabbit hole.

    If the conflict were between buying medication for severe pain or paying the electric bill, I’m guessing we would see a huge difference in neural activity from what is seen in the labeled faces test.

    Melissa Raven
    April 21, 2012 | 11:40 PM

    Insel’s vision of clinical neuroscience as the future of psychiatry is like the drunk searching for lost keys under a lamp-post because the light is good there but bad where the keys were lost.
    It’s also like one of Escher’s staircase lithographs. ‘Ascending and Descending’ [the ‘Penrose stairs’] is particularly relevant because it is mounted on an impressive edifice Here it is in LEGO: Lots of activity, lots of ‘progress’ in a rarified atmosphere far removed from the everyday realities that psychiatrists attempt to deal with.

    April 21, 2012 | 11:47 PM

    Escher in Leggo® – priceless!…

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