JAMA: PsychiatryViewpointPublished online March 11, 2015.In 2012, Thomas Insel, director of the National Institute of Mental Health, wrote an essay entitled The Future of Psychiatry ( = Clinical Neuroscience), echoing a familiar trope in our field. The themes he described then are even more relevant today. Technologic advances have enhanced our ability to study the brain, and new findings have reshaped the fundamental way in which we understand psychiatric illness. For example, although depression was once characterized as simply a monoaminergic deficit, new research is expanding our understanding of depression across multiple levels of analysis—from circuits, to neurotransmitters, to synaptic plasticity, to second messenger systems, to epigenetic and genetic differences.
To date, however, these advances seem largely limited to the pages of our leading research journals. We have not yet experienced a paradigm shift in the way most physicians approach patient care or in the way we communicate about our field with each other and with the lay public. Given how much progress has already been made, why does this transition remain a thing of the future? What barriers prevent our field from embracing a new identity today?…
Funding/Support: This study was supported by grant 3R25MH101076-02S1 [PI: Jane Eissen MD] from the National Institute of Mental Health to develop the National Neuroscience Curriculum Initiative [Drs. David A. Ross, Michael J. Travis, and Melissa R. Arbuckle].
The overarching goal is that residents will incorporate a modern neuroscience perspective as a core component of every formulation and treatment plan and bring the bench to the bedside.
CHANGING PSYCHIATRY, TODAYThe diseases that we treat are diseases of the brain. The question that we need to address is not whether we integrate neuroscience alongside our other rich traditions but how we work as a field to overcome the barriers that currently limit us. Ultimately, the most powerful force will be the improved translation of research into more refined explanatory models of psychiatric pathology and into novel therapeutics. To ensure that our field is ready to embrace new findings as they emerge, we need to begin the process of culture change today by enhancing communication and collaboration between researchers and practitioners.
In this regard, the struggle of residency programs to implement robust neuroscience curricula may be seen as emblematic: if we cannot succeed in changing the conversation within the confines of our most distilled educational setting, how can we effect change more broadly? One lesson may be that it is not possible to address this challenge at an individual [or program] level. Just as cutting-edge research requires a team-based, collaborative approach, so too does cutting-edge education.
We need to begin by facilitating partnerships between the distinct communities of scientists and educators. The more sophisticated and nuanced our science becomes, the more critical it is to have individuals who can translate this work to make it accessible to students at all levels. It is imperative to have skilled educators who can craft classroom experiences that are consistent with the extensive literature on how adults learn. In addition to core content, learning objectives should explicitly address both attitudes toward neuroscience and behavioral skills, such as the ability to incorporate neuroscience data into patient formulations and the ability to communicate effectively with a lay audience…
"To ensure that our field is ready to embrace new findings as they emerge, we need to begin the process of culture change today by enhancing communication and collaboration between researchers and practitioners" strikes me as old news. It has been the Mantra from on high for a long time. I would suggest an alternative more based in the reality of our recent past. The neuroscience of today isn’t likely to be the neuroscience of next year. One need only read the various iterations of Dr. Insel’s versions of this paper to see that. The problem has been that psychiatrists have not been skilled in evaluating the information presented to them. One example is Clinical Trial articles. They poured into our literature for 15 or 20 years and had an enormous impact on clinical practice, and the average psychiatrists had no ability to read them critically – and they really needed to be read critically. A course on clinical trial methodology and analysis including a close reading of examples would be a stellar idea. We’ve been inundated with neuroimaging papers, but few psychiatrists not involved in that kind of research understand the fMRIs, the measurements, or the anatomy being presented. Genomic studies abound, but their techniques and complexities aren’t slightly transparent. Rather than being "ready to embrace new findings as they emerge", tomorrow’s psychiatrist needs to know how to critically evaluate new findings as they emerge. We were carried down some dark roads by embracing new findings somewhat blindly, and the results have not done us proud at all. In my Internal Medicine Residency, that’s the kind of exposure to basic techniques we received in the advanced subspecialty rotations. It should be the same in psychiatry.
“A course on clinical trial methodology and analysis including a close reading of examples would be a stellar idea.” Yes, it damn well would. At the introductory postgraduate level, we might also benefit from a brief review of the difference between science and technology, the difference between science and magic, and so on.
However, I am happy to report that critical thinking– at least on some level– and ethics is actually being taught in MA programs, at least to MFT interns, psych assistants and social workers. And there are a lot of us out there.
Maybe it’s different in med school or psychiatric training programs, but in our neck of the woods, NNCI or whoever they’re calling themselves, would seem comically out of touch. I mean, it’s not like we all sit around wearing berets and talking about Foucault….
Oh, wait a minute– Yeah, we actually do that sometimes, sorry. (And it’s really annoying, I know.) My point is that it seems the ship is sailing in the opposite direction… Somatic therapy, mindfulness, the recovery movement, etc. There’s a lot of excitement about epigenetics, particularly the bits that can happen just as a result of human experience. But my psychopharm professor wasn’t raving about all the wonders neurobiology would be bringing us any day now. No one was beating that particular drum very hard.
Matthew Jansky, MA, MFTI #66278
I could not help but think of how the yellow brick road concept rules our society. Computers come to mind first. If we just spend a little more money and add a mandate we can show the world just how great they really are and improve the system. EMR’s will some day be a part of medical practice, but today we see them as an experiment in progress.
Imaging is another yellow brick project, with the right scan we can determine exactly what is wrong with a person. Today many doctors never physically touch a patient and never render a diagnosis with out a scan. The whole concept of a physical exam has been moved to the back burner in favor of technology.
Medicine is driven with the concept that the sun will come out tomorrow, but has forgotten that a kind word, a look see, and a simple conversation may in fact solve or identify the problem. What we do have is a world driven by computers and test and the doctor patient relationship rarely exist.
Med checks exist in all types of medicine and testing is based on insurance coverage.
Steve Lucas
If the gestalt psychiatry is wrong than how could the neuroscience be right? That is interpreting the results of imaging?
“Neuroethics Debates by Emory Neuroscience Graduate Students ”
from the Neuroethics Blog Emory UN
http://www.theneuroethicsblog.com/2012/01/neuroethics-debates-by-emory.html
Neuroscience is pretty young and enamored with its technologies. I think it better not to embrace whatever current and vogue model of the workings of the brain seems shiny, and convenient. Though a phenomenal amount of knowledge about the brain’s working has been gained, I think we haven’t gotten much past the clockwork understanding— the computer is just another metaphor that doesn’t help us understand how the brain/mind/body/etc. works and what’s going on when it apparently isn’t working well.
Perhaps Clinical Neuroscience is an innovative, faith-based field?
Mickey, thank you for yet another excellent post. I fully agree with the sentiments you expressed in reaction to this article. I’m having trouble moving on from this one because I keep coming back to one question: how can these authors be so oblivious to the scientific and practical limitations of their paradigm? This question is like a thorn in my side that won’t come out.
DSM diagnoses are not valid, there are few diagnostically or clinically useful biological tests, and psychiatric treatments have advanced little in decades despite massive investment in biomedical research. It’s 2015, and Insel’s predicted era of “biodiagnostics” and “treatment of core pathology” has obviously not arrived. Because these realities have been publicly acknowledged by psychiatrists at the highest levels of APA/NIMH like Insel and David Kupfer. I assumed they were more or less accepted in academic psychiatry as the “state of the field.” The “future think” (faith) is still there, and this is a problem, but at least the faithful have usually been willing to acknowledge that the paradigm still isn’t ready for prime time. Even an ideological cheerleader like Insel who is banking everything on an imagined future with biological “cures” doesn’t seem willing to advise practicing psychiatrists to incorporate neuroscience into their patients’ treatment plans just yet. I even suspect Insel would walk back the timeline on his figure now that he has thrown the DSM under the bus in favor of RDoC, an initiative he has said will take decades to bear fruit.
Such was my perception of the thinking at the highest level of academic psychiatry until I read your blog post. Now I don’t know what to think. The authors of this JAMA: Psychiatry commentary apparently believe the midpoint of Insel’s figure is here, at least close enough to begin incorporating neuroscience into patient care. They are not simply putting the cart before the horse; they are advising cart riders to fasten their seatbelts and start their engines. This seems to me like more than just future think on steroids. It seems as though the authors are operating without an adequately reality-based understanding of the state of their science and its clinical applicability. If so, this is deeply troubling. However, I’m not sure if I’m interpreting their article correctly. Mickey, I’d appreciate your thoughts on this issue if you’re able to share them as I’m struggling to understand the implications of this article. Is it just the latest example of future think, or is it something more?
Dear 1bom
here’s the thing. I read your blog mostly because I agree with you, but agreeing with you isn’t very comforting (I guess that’s part of your point).
The trouble is this: the subject must have direction, for various reasons. Clinical care is deeply rewarding, and the skills required are things that can only be taught to an extent. In addition, clinical care (as I see it, at least) is more about judgement and common sense than about a paradigm or a theory (Neuroscience or psychological or social). If that’s so, we’re faced with the finding that everything we know right now is imperfect. I don’t think neuroscientists have a sufficient hold on brain matters to guide psychiatric treatment at the current time. I don’t think the psychological treatments can be more than frameworks to help people,and I find it hard to believe that any particular psychological treatment is better or worse (although in this particular field, my own training is so rudimentary that this is no more than a hunch).
So where do we go from here? that’s what bothers me, because I’m interested in research, and I do think the subject needs a direction. ok, not one direction, perhaps, but I’d like to consider one direction and move on it. neuroscience seems the “cool” thing to do right now, but it’s too full of imponderables. the rest seems incredibly difficult to pin down because of the client-therapist factors.
In that case, what’s the solution? where does psychiatry go? you might argue that it doesn’t need to go as such. but surely improvements are necessary, and improvements must come from a better understanding of how things work?
there are times when the neuroscience side seems most attractive not because it’s likely to be most productive, but because this potentially blind alley at least has a single direction, clear outcomes, and precision. the others seem like a mess (not necessarily a bad thing) where it’s client-therapist dyads that need to be studied, I sometimes feel.
Maybe i’m naive. maybe i’ve not thought things through. But as someone with six years in psychiatry (three in training), I find myself thinking about this too frequently for comfort. clinical care involves basing what i do on common sense, yes, but also having to justify my seemingly unpopular care decisions to friends who are biologically oriented (guideline so-and-so and trial so-and-so say that this is the treatment of choice–something i can’t answer beyond saying “i don’t think that’s so”). I’d like not to be so uncomfortable in my skin, but equally I’d like to be able to prove/disprove my notions. As things stand, it seems that those opportunities don’t exist in academic psychiatry. And that’s a misfortune, as I see it. So while I do enjoy your posts about what’s going on now, I find myself more anxious about the future each time you write. I don’t mind it… just saying. :-).
The comments reminded me of my undergraduate and graduate programs in business. In my undergraduate program all of the students worked with many using their GI benefits and many being Viet Nam veterans. A number of the instructors were attorneys and enjoyed the give and take of classroom discussions.
My graduate program had a work requirement along with a requirement that you were or had been a supervisor. We were sharks and we were hungry.
Problems arose with those instructors who were academics and had no or failed work experience. They talked about the way things should be, we talked about the way things were, and the solutions employed to over come these issues.
I see much the same in psychiatry where leadership has little or no practical experience other than that received in training. Removed from day to day patient interaction their whole professional experience has focused on grants, tenure, and political advancement in various organizations. This is a very different skill set than that used in the office of a practicing mental health professional.
Today, in every field, we all face those who have done very well promoting an image of professionalism and expertise all the while they are really only shells with no real substance. A common tool to deal with detractors is to divert attention from the substance of an argument to the number of authored papers, or simply claim a position of superior knowledge.
Psychiatry seems to suffer from a large number of those who can effectively use their knowledge to manipulate a situation to their advantage.
Steve Lucas
It’s interesting that the scientifically sophisticated (sarc alert) bio/bureaucrat crowd struggles to grasp how science evolves in much the manner of a species…and it sure isn’t based on some top down central planning paradigm.
Some day the next great advance in behavioral medicine will happen based on either an accident in the lab or some genius doing his/her own thing on his/her own terms and it will have nothing to do with NIMH directives. Case in point would be how lithium was discovered as a mood stabilizer.
But then at that point they’ll take credit for it anyway saying it come under the umbrella of their vision.