Rubin, Eugene H. MD, PhD; Zorumski, Charles F. MD
Psychiatry is in the midst of a crisis fueled by a fragmented and inefficient system of care delivery and a disconnect between the state of research and the state of psychiatry education and practice. In our opinion, psychiatry will need to embrace at least two significant paradigm shifts in order to deal with these problems. One shift will involve the manner in which psychiatric care is delivered. The other will affect how psychiatric disorders are conceptualized and how psychiatry is taught. We believe that these paradigm shifts will be as transformative as the paradigm shift in the 1970s when the field moved away from the dogmatic dictums of psychoanalysis to the evidence-based approaches of the medical model.
Sloppy diagnoses and inappropriate polypharmacy
Psychiatric diagnosis is currently based on a reliable but, for the most part, only partially validated criteria-based system that was developed in the 1970s.1,2 This system has undergone relatively minor revisions over the past 40 years. Although the number of recognized disorders has increased and diagnostic criteria have evolved, understanding of the pathophysiological mechanisms underlying mental disorders is lacking. Together with the absence of meaningful biomarkers, this results in many patients receiving multiple descriptive diagnoses and multiple symptom-driven treatments. Diagnoses today are based on clinical interviews much like they were when the disorders were first described. Furthermore, the criteria for some disorders (e.g., bipolar disorder and personality disorders) have broadened over time, resulting in vague (and often poorly validated) subtypes.3
Most psychiatrists are aware of increasing problems in psychiatric diagnoses and treatments. When psychiatrists evaluate patients in inpatient, outpatient, or emergency settings, they often find that the patients have previously been diagnosed with a large number of different psychiatric disorders. It is common to encounter a patient who has been diagnosed at various times with major depression, bipolar disorder, schizoaffective disorder, schizophrenia, polysubstance dependence, borderline personality disorder, and one or more anxiety disorders, particularly posttraumatic stress disorder. Even when records from prior caregivers are available, it is often difficult to determine the longitudinal history and relationship among symptoms and the course of illness. Information in the medical record is typically confusing, fragmented, and contradictory. Hospitalizations are often brief and occur in various locations under the care of different physicians; in many cases, treating teams do not have time to integrate prior information into reliable diagnostic formulations. Treatment plans are based on symptomatic presentation, and outpatient follow-up is often limited or nonexistent. Despite this, acute, at least short-term, symptomatic improvement is the norm.
An overreliance on polypharmacy adds to the confusion. It is not unusual for patients with severe illnesses to be prescribed multiple concurrent antipsychotic agents, mood stabilizers, antidepressants, and sleeping/anxiolytic medications. Patients may also take medications for pain and for a variety of comorbid medical disorders including heart disease, hypertension, hypercholesterolemia, diabetes, and asthma. Some of these medical disorders are the result of, or are exacerbated by, psychotropic medications.4 Often, it is not clear whether patients are taking all of their daily medications “as prescribed” or whether side effects and drug–drug interactions are influencing clinical presentations. In addition, many psychiatric patients abuse street drugs and/or alcohol. The use of substances like marijuana, cocaine, methamphetamine, and heroin leads to further confusion in diagnosis and management. Nicotine dependence is also common, particularly in individuals with chronic disorders, and adds to the overall burden of those illnesses.
The mental health care system
Many factors contribute to the current problems in psychiatric care. Responding to financial pressures, both the public and private health care sectors have substantially decreased the length of hospitalization for even the sickest patients. These same pressures have led to the closing of state-funded psychiatric hospitals and outpatient programs. Cutbacks in funding have also resulted in diminished community resources to assist persons with psychiatric and addictive disorders.
Patients with acute exacerbations of major illnesses such as mania and schizophrenia may be discharged from the hospital after brief inpatient stays, typically lasting only several days. Such patients are frequently rehospitalized within weeks, often in a different hospital under the care of a different treatment team, contributing to the cycle of diagnostic and therapeutic uncertainty. In efforts to keep lengths of stay short, well-intentioned treatment teams add medications to an already complicated regimen. It can take weeks for the brain to respond to changes in medications, but hospital stays are brief, continuity of care is variable, and, therefore, there is limited ability to adjust medications in a rational manner. Although physicians can sedate patients and relieve the effects of acute agitation or intoxication/withdrawal during a brief hospitalization, the overall impact of such strategies on the core features of psychosis and mood disorders is less than optimal. Furthermore, these rapid management approaches have little impact on the underlying and persistent neural changes associated with drug dependence syndromes that often contribute to exacerbations. A disconnect between psychiatric and substance abuse care unnecessarily compounds this problem. Patients with severe chronic psychiatric disorders and substance dependence disorders may benefit from comprehensive, longer-term hospitalization. Unfortunately, such programs are beyond the financial resources of most patients.
When patients with limited insurance are discharged, they have few, if any, outpatient options for treatment. Even when options exist, weeks or months may pass before patients can be seen by a psychiatrist. During that interval, patients often run out of medications. They may not be able to afford refills, or they may be too disorganized to purchase medications on their own. Their symptoms then escalate and lead to another brief hospitalization, too often in a different care setting with different providers. Our observations are based on experiences in a major midwestern metropolitan area. Given the more limited access to care in rural areas, we suspect that the problems we outline are even worse in those areas.
A disconnect between scientific advances and psychiatry education
The National Institute of Mental Health has created the Research Domain Criteria project to encourage research aimed at elucidating the neural circuitry and molecular and cellular factors underlying psychiatric symptoms and disorders.5 In addition, the American Psychiatric Association is developing the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM) that attempts to set the stage for incorporation of neurobiologic advances into diagnostic thinking.6 Although there have been many neuroscientific advances in psychiatry since the publication of the DSM-IV, these advances have not yet led to major changes in understanding or treating psychiatric disorders. We believe this is about to change.
Findings from recent research in systems neuroscience, network biology, cellular and molecular neurosciences, genetics, and epigenetics are beginning to demonstrate relationships between certain neurodegenerative disorders and abnormalities in specific functional brain systems. For example, Alzheimer disease seems to involve initial deterioration in a specific brain system, the default mode network.7,8 Another form of dementia, behavioral variant frontotemporal dementia, seems to involve initial attack on a specific system involved in emotional regulation.9 Defects arising from dysfunction in these brain networks account for early symptoms of the disorders. Furthermore, pathological accumulations of different proteins (e.g., amyloid, tau, TDP-43, and FUS) have been associated with these illnesses and provide targets for innovative therapies.10,11 These advances serve as models for thinking about the neural processing defects associated with primary psychiatric disorders.
Functional neural circuits underlying cognition, emotion, and motivation are currently being mapped with a high level of precision, and animal studies are providing insights into the synaptic and molecular underpinnings of these systems. A large, federally funded initiative called the Human Connectome Project has been recently launched with the explicit goal of defining functional neuronal systems in the brain using state-of-the-art neuroimaging and physiological recording methods. Mental processing and behavioral symptoms are increasingly being described in terms of specific brain systems. Over time, the causes of brain system malfunctions will be better understood at molecular and synaptic levels. Research examining environment/gene interactions and the inheritance of environmental influences (epigenetics) is changing the way we understand the development of normal and abnormal human behavior.12 Genetic and environmental factors lead to molecular changes that, in turn, alter functional brain systems.
Importantly, psychiatric disorders are now being linked to defects and changes in specific neurocircuits.13 To date, however, psychiatry has not been successful in incorporating the language of neural circuits and systems neuroscience into clinically meaningful terminology or psychiatry education.14,15 Rather, archaic concepts about monoaminergic neurotransmitter systems and “chemical imbalances” continue to dominate discussions about pathophysiology. The potential benefits and limitations of emphasizing clinical neurosciences as a major direction for psychiatry's future have been addressed by others.15–17
Mental health care delivery
There is little doubt that the mental health system is broken. Large segments of the population, particularly those in inner-city and rural areas, have marginal access to quality care. Psychiatry is a shortage specialty, and, to make matters worse, the number of psychiatrists per 100,000 persons in the United States will be decreasing over upcoming decades.18–20 This trend is unlikely to reverse in the foreseeable future. Thus, to reach the large numbers of patients suffering from psychiatric illnesses, health care systems will have to change and take advantage of collaborative and integrative models and new technologies.21,22 The practice of psychiatry must adapt.
A recent comprehensive review examines in detail various models that integrate behavioral care with primary care as well as related pragmatic issues including financial and structural considerations.23 We believe that primary care physicians, together with non-MD professionals working within primary care teams, could form the core of an efficient system for addressing the mental health care needs of many patients. Repairing the mental health system in the United States will require increased numbers of primary care physicians and better collaboration of psychiatrists and other mental health professionals with primary care teams. We believe that every primary care team should include a professional with a mental health background. Such individuals would help primary care teams recognize psychiatric disorders and initiate evidence-based treatments for persons suffering from common and milder psychiatric disorders including depression, anxiety disorders, personality disorders, and substance use disorders. These primary care mental health specialists would also provide the conduit for collaboration with psychiatrists who are part of affiliated and integrated mental health care teams. Patients who did not respond to primary-care-administered interventions in a timely fashion would be referred to the mental health care team for more intensive psychiatric care. After stabilization, patients would be referred back to the primary care team for longer-term follow-up. This collaborative approach would increase the recognition of disabling psychiatric illnesses and encourage primary care teams to treat patients with common and milder psychiatric illnesses or illnesses that are in remission. For this approach to work, financial, technological, and administrative systems that align the incentives of the various care teams must be implemented. The use of screening instruments for psychiatric illnesses would aid primary care teams in identifying patients with psychiatric disorders. Quality-of-care measurements would aid in evaluating the success of newly implemented approaches.23–25 Primary care teams would also benefit from increased hands-on training in psychiatry, something that is lacking in the majority of general medicine residency programs. Ideally, this training should be provided in collaborative care interactions that can be translated readily into community-based outpatient practices.
In the model just described, psychiatrists would be part of mental health care teams that are each affiliated with several primary care teams. Patients with severe symptoms (e.g., patients with unstable psychotic symptoms and patients demonstrating disruptive or suicidal behaviors) would be primarily managed by the mental health care team. To oversee the complexities of each patient's care, psychiatrists would work closely with team members and maintain a relationship with each patient. Informal and formal communication among team members, sometimes facilitated by technology, would aid each member of the team in delivering personalized treatment. Telepsychiatry would be used to deliver care to selected patients, particularly those in difficult-to-reach rural areas. Efficient, evidence-based treatments might include individual therapy, group therapy, Internet-based therapy, and computer-based treatments as well as medications and brain stimulation approaches. A major focus of this care would include strategies targeting the disabling cognitive dysfunction that accompanies major psychiatric illnesses. Some health care organizations have successfully implemented many of these approaches, and their efficacy is being tested in systematic clinical trials.23,26,27 The PROSPECT study is one example of an integrative system that reduces depression and suicidal ideation in elderly patients.28
Our educational system continues to focus largely on training psychiatrists in individual patient management and psychotherapy. Many psychiatry residents and medical students entering psychiatry continue to view psychiatry as a specialty practiced in settings where the psychiatrist sees a small number of self-pay patients several times a week over several years. Although some will elect such practices, it is our hope that the majority of psychiatry residents entering the clinical arena will embrace a delivery system that responds to society's need for treating a large number of ill patients. Otherwise, there will be an insufficient number of psychiatrists to respond to the country's mental health needs, and services will be increasingly fragmented and marginalized.
In this collaborative/integrative care model, we envision psychiatrists using their expertise in diagnosis and evidence-based therapies to direct mental health care teams. Psychiatrists must avoid becoming assembly-line prescription writers; inappropriate polypharmacy is costly, ineffective, and dangerous and must be eliminated.16,20 As new therapies targeting specific abnormal pathophysiology become defined, psychiatrists and other members of mental health care teams must integrate these treatments with evidence-based psychotherapies, rehabilitative strategies, and lifestyle interventions. Optimizing care will require psychiatrists to stay up-to-date with rapidly advancing research. Future diagnostic approaches will include the use of neuroimaging and biomarkers. Knowledge of systems and molecular neuroscience will be necessary for psychiatrists to interpret clinically relevant research and to implement and oversee state-of-the-art pharmacological, neurostimulation, and rehabilitative interventions, particularly interventions targeting cognitive dysfunction.
Implications for training
Advances in neuroscience are leading rapidly to a time when psychiatric diagnoses will be redefined according to perturbations in specific brain systems.29 This paradigm shift has the potential to lead to truly innovative treatments as well as improved predictions of treatment responsitivity (“neuroprognosis”).30 As we have already mentioned, current work involving Alzheimer disease serves as an illustrative model. Biomarkers, including polypeptides in CSF, together with brain amyloid imaging, will soon allow identification of people with presymptomatic Alzheimer disease.31 A number of therapeutic approaches are being developed that are based on the molecular pathophysiology underlying this illness. To date, trials of these therapeutic approaches have not been successful, but it is reasonable to believe that treatments will be developed soon that may prevent or substantially delay the clinical manifestations of this illness when such treatments are administered during the presymptomatic phase. Effective management of presymptomatic patients with Alzheimer disease will likely also require strategies that enhance and preserve cognitive function, including declarative memory, working memory, and attention. Such approaches may be Internet- or technology based and can serve as models for similar efforts with primary psychiatric diagnoses.
Although our understanding of primary psychiatric illnesses (e.g., schizophrenia and bipolar disorder) is not yet at the level of our understanding of Alzheimer disease, progress is being made. In the not-too-distant future, we will likely be able to elucidate specific brain systems that are dysfunctional in these illnesses. Once these systems are identified, uncovering the synaptic and/or molecular causes of the malfunctioning will advance. Also, many psychiatric illnesses likely involve abnormal development of neural networks, and presymptomatic diagnoses of various illnesses might be possible by imaging the brain in high-risk individuals during childhood and adolescence. Recent studies describing the developmental trajectory of neural connectivity systems using brief resting BOLD fMRI scans in children and adolescents suggest the feasibility of such an approach.12
If such advances come to pass, psychiatrists will have to become clinical cognitive neuroscientists.32 Currently, many—if not most—psychiatrists and departments of psychiatry are unprepared for this. The language of psychiatry-related sciences is changing rapidly, yet medical schools and residency programs often include little meaningful discussion about how brain systems contribute to psychiatric illnesses and how treatments, both pharmacological and psychotherapeutic, alter network function. If advances are to be made in diminishing the impact of psychiatric illnesses, we believe this situation must change.
We would encourage medical school educators to integrate psychiatric systems neuroscience into the first-year neuroscience curriculum. Also, in the first year's introduction to medicine/practice of medicine courses, we would recommend that medical students be exposed to integrative care involving mental health professionals working in teams with internists and pediatricians. We would urge internal medicine and pediatrics programs to work with psychiatry programs to develop integrated care clinics. Residents and medical students would rotate through these clinics as part of their medicine, pediatrics, and psychiatry experiences. Psychiatry residency programs would benefit by including basic and clinical training in systems and molecular neurosciences and by being ready to apply this knowledge to patient care. It is likely that some psychiatry educators will enthusiastically embrace the advances in clinical neuroscience and integrated care training; others will argue that teaching such approaches is premature. We believe that science will drive the field.
Changes in psychiatry education are essential for resolving the current crisis. We hope that a critical mass of psychiatry educators will champion the new directions in health care delivery and in psychiatry didactics. At Washington University in St. Louis, we have seen an increasing number of MD-PhD students with research expertise in systems neuroscience choose psychiatry for residency training. These individuals and those at other institutions offer tremendous hope for the future. We firmly believe that psychiatry is at the brink of major paradigm shifts that will improve our abilities to diagnose and treat those who suffer from some of the most common, painful, and disabling illnesses that inflict humans.
The authors wish to thank Dottie Kinscherf for editorial assistance.
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The authors receive royalties from the publication of two books, Demystifying Psychiatry and Psychiatry and Clinical Neuroscience: A Primer, which are listed in the reference list. Dr. Zorumski is a consultant for Sage Therapeutics. Dr. Rubin receives research support from the National Institute on Aging and the National Heart Lung and Blood Institute. Dr. Zorumski receives research support from the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of General Medical Sciences, the National Institute of Neurological Disorders and Stroke, and the Bantly Foundation. None of these foundations or institutes had any role in the writing of this manuscript or in the decision to submit the paper for publication.