It is universally accepted within the scientific community that human behavior emerges from the brain in interaction with the environment.1 Yet, within psychiatry there have been long-standing debates about whether psychiatrists ought to expand their knowledge of neuroscience and neuropsychiatry, and, if so, to what extent.2–5 The advent of functional neuroimaging along with advances in genomics have led to rapid expansion in our understanding of the relationships between brain and behavior and increasing recognition of the importance of neurobiology to psychiatry. We wrote this article to argue that although there is growing consensus that the field of psychiatry would benefit from expanded knowledge of neuroscience,6,7 numerous changes will be required to accomplish the integration of neuroscience knowledge and neuropsychiatric skills into general psychiatric practice. We define this integration as the ability to use both a sophisticated understanding of neuroscience to enhance psychological and humanistic approaches to patients as well as an appreciation of patients’ experience to drive neuroscientific thought.
We first summarize arguments for more integration of neuroscience knowledge and neuropsychiatric skills into general psychiatric practice. Then, we make recommendations for how to overcome factors that impede this integration, focusing on nine topics concerning the individual psychiatrist, the system of psychiatric care, and psychiatry residency education.
The Case for Integrating Neuroscience Knowledge and Neuropsychiatric Skills Into Psychiatry
Knowledge of neuroscience and neuropsychiatry provides general psychiatrists with expanded approaches for diagnosis, formulation, and treatment and prepares psychiatrists to understand and use future neuroscience developments that will inform their practices.
To make accurate diagnoses, psychiatrists should be familiar with the myriad diseases, common and rare, that can masquerade as “psychiatric” conditions.8 Examples abound: sleep apnea causing depression; brain tumor presenting as apathy; autoimmune limbic encephalitis manifesting as catatonia; frontotemporal dementia heralded by compulsive behavior.
The psychiatric clinical formulation is a synthesis of social, psychological, and biological factors contributing to a patient’s presentation. To traditional biological elements (such as genetics, medication and substance effects, medical conditions, and neurological deficits),9 neuroscientific knowledge adds consideration of a patient’s cognitive substrate and the focal or network brain localization of symptoms, all of which contribute to subjective experience, behavior, and mental status. For example, a businessman’s social anxiety holds back his career; effective coping strategies are generated only after the psychiatrist realizes that the patient has mild prosopagnosia, an underrecognized, common condition that affects facial recognition and contributes to social avoidance.10
Neuroscientific thinking allows behavior to be conceptualized in categories that are closer to what is known about brain functioning. For example, the term ego function is a psychological construct that does not map onto brain anatomy, whereas executive functions include planning and organizing behaviors that involve frontal, parietal, and cerebellar circuitry. Additionally, our understanding of insight benefits from knowledge of cortical neglect, in which patients lack awareness of deficits. Other psychiatric concepts have been refined by using knowledge of brain functioning, including memory, social cognition, addictive behavior, and perceptual disturbances.
Beyond contributing to formulation of pathology, expanded knowledge of neuroscience and neuropsychiatry helps clinicians understand the neuroplastic (synaptic changes and neuronal remodeling) and epigenetic mechanisms (environmentally induced changes in DNA expression) by which life experience may contribute to shaping an individual’s brain and physiology. Conversely, an individual’s life experience is affected by normal variations in brain-based mental functions such as orienting in space, cognitive processing speed, initiating behavior, planning, and persistence. Factoring in neuropsychiatric and cognitive variables facilitates individualized patient formulation.
Individualized treatment follows from individualized diagnosis and formulation. For example, pharmacologic treatment could be altered on the basis of genetic features in addition to underlying medical conditions. Neuromodulatory treatments, including repetitive transcranial magnetic stimulation, deep brain stimulation, or transcranial direct current stimulation, can be directed to sites within neural networks believed to be associated with pathology.11 Psychosocial rehabilitation is ideally adapted to a patient’s cognitive abilities, such as insight, motivation, and executive functioning. A neuropsychiatrically informed psychotherapy recommendation considers these same features along with less widely appreciated abilities such as the patient’s comprehension of emotional communication and social cues.
Preparing for the future
Knowledge of neuroscience will allow psychiatrists to take advantage of emerging research for use in diagnosis, formulation, and treatment. The recent pace of discovery leads us to expect much progress. Examples of advances include new diagnoses (anti-N-methyl-D-aspartate receptor encephalitis), new investigative tools (amyloid imaging, diffusion tensor imaging, genome sequencing, microarray analysis), and new understandings of neural function (cerebellum in cognition, hypothalamic hypocretin/orexin system in sleep).
Neuroscience research also has advanced knowledge of mechanisms that underlie common psychiatric disorders. Our knowledge of schizophrenia now includes gene–environment interaction causing dysfunctional frontal–subcortical circuits, multiple gene-based phenotypes, and glutamatergic dysfunction. Posttraumatic stress disorder is understood to involve abnormal frontolimbic fear signal processing. Identification of dysfunctional neural networks in obsessive compulsive disorder and depression has suggested treatment with deep brain stimulation, whereas ketamine studies have revealed the importance of glutamate in depression.
The argument for expansion of neuroscience knowledge and neuropsychiatric assessment skills has been further bolstered by two important developments—required clinical neuroscience competencies in residency training12 and adoption, by the National Institute of Mental Health, of research domain criteria (RDoC) as an organizational schema to guide neuroscientific inquiry into psychiatric disorders.13
The need for a working knowledge of neuropsychiatry has become more acute with the advent of accountable care organizations (ACOs) in the United States. ACO psychiatrists will be expected to assume expanded responsibility for management of patients with complex neuropsychiatric disorders.14–16
Overcoming Factors That Impede Integration
Educational initiatives at all levels of medical training will be the most fundamental instruments of change. In addition, advocacy efforts by psychiatrists and medical and psychiatric organizations will be required to transform the current system of psychiatric care. The path to neuroscience integration into psychiatry will be difficult because the obstacles to moving forward are deeply entrenched and mutually reinforcing.
We present nine factors that impede integration of neuroscience knowledge and neuropsychiatric skills into psychiatry. We have placed each of these factors under one or another of three overarching areas: the individual psychiatrist, the system of care, and psychiatry residency education. Each of the nine factors is followed by one or more recommendations, some of which apply to more than one factor.
The individual psychiatrist
The integration of neuroscience and neuropsychiatric knowledge into psychiatric thinking and practice involves different challenges for established practitioners than for early-career psychiatrists, whose exposure to neuroscience may have begun as early as high school.17
Challenges for practitioners in learning more neuroscience and neuropsychiatry.
These are complex fields, but additional factors contribute to what some refer to as “neurophobia.”18,19 Two of these factors are a paucity of quality teaching20 and difficulty attaining clinical experience with the myriad of neuropsychiatric disorders, some of which are comparatively rare. Neuroscience literacy topics (see List 1) are often not included in continuing medical education (CME) offerings for psychiatrists. Moreover, neuropsychiatric skills require clinical practice to learn to recognize patterns of disease presentation and to avoid cognitive errors such as premature diagnostic closure.21 In seeking the requisite exposure to neuroscience material and clinical experience, even a highly motivated clinician may encounter practical obstacles, including competing commitments, lack of institutional support or funding, limited library resource access, or few opportunities for interdisciplinary collaboration.22
Quality educational materials for teaching neuroscience within CME programs are needed for practitioners with varying levels of knowledge. Ideally, general psychiatrists would have opportunities to observe, possibly by electronic means, neuropsychiatric exams performed by expert clinicians. Advocacy by psychiatric and medical organizations is needed to prioritize neuroscience education and muster the institutional and financial resources to develop necessary teaching materials and innovative technologies. Public positions by thought leaders in support of expanding neuroscience literacy for psychiatrists, along with requiring neuroscience and neuropsychiatry modules for maintenance of certification and CME, are ways to increase the priority of neuroscience learning for clinicians. Were medical and psychiatric leaders and organizations to embrace the concept of psychiatry as a clinical neuroscience,23 the need to increase the neuroscience knowledge and neuropsychiatric skills of the current workforce would acquire more urgency.
Beliefs about neuroscience and psychiatry.
The degree to which a psychiatrist pursues neuroscience education can be influenced by beliefs that may be unarticulated yet powerful. Some examples follow.
- Belief 1. We will never understand how brain gives rise to mind.
- Belief 2. Psychology-based and neuroscience-based thinking are equally valid ways of knowing, but fundamentally at odds. Knowledge about brain function adds little to the understanding of psychological concepts or subjective human experience.
- Belief 3. Knowing more neuroscience will not change current psychiatric treatment, and therefore knowledge expansion into this area is not yet a worthwhile endeavor.24 Psychiatry’s biopsychosocial model and the Diagnostic and Statistical Manual of Mental Disorders (DSM)25 provide sufficient framework to understand most patients.26
- Belief 4. Neurobiology is reductionistic and may be used to oversimplify, morally excuse, or eschew responsibility for problematic behavior. Genetic and neuroscience principles undermine the notions of free will and personal responsibility that form the basis for psychological theories of behavioral change.27
- Belief 5. There is a “neurocentric” overemphasis on neuroscientific explanations for behavior at the expense of psychological and social components.28 Functional imaging, the basis for many behavioral neuroscientific findings, is a limited tool that is also vulnerable to misuse and misinterpretation.29 “Neuroskeptics”30 hold that functional neuroimaging localizes mental functions to brain areas but adds little to the understanding of human behavior.
Although these beliefs may slow the integration of neuroscience and neuropsychiatry knowledge into psychiatric thinking, they also serve to illuminate crucial areas of uncertainty that merit further investigation and discussion.
The emergence of a neuroscience paradigm for psychiatry will depend on the field giving thoughtful consideration to beliefs such as those discussed above. Active debate about the benefits and limitations of neuroscience for psychiatry should be featured in fora such as publications, conferences, and grand rounds. Historians of science offer a useful perspective: A new paradigm is not necessarily adopted because it has already solved problems that a scientific field is facing but, rather, because it offers the hope of finding solutions in the future to some of the problems that older paradigms have failed to solve.31
The system of psychiatric care
More than a decade into the 21st century, the U.S. health care system continues to operate under the Cartesian notion that the body and mind are separate. “Mental” patients are managed differently than “medical” patients. Differential treatment reinforces the notion that mental disease is not brain disease and that the purview of psychiatrists is unlike that of medical practitioners, for whom the body is central. The current system of care includes conceptual and practical barriers to bridging this gap between mind and body.
A generation of psychiatrists was trained during an era when psychological and psychoanalytic theories were predominant and neurological theories of behavior were eschewed.32 In the 1970s the requirement for psychiatrists to have a medical internship was even temporarily eliminated.33 Even today, psychiatrists often do not take primary medical responsibility for their patients and may be required to obtain medical clearance to admit patients to psychiatric units.34 Frequently, psychiatrists are consulted to manage a patient’s behavioral problems rather than also to contribute a neuropsychiatric formulation. These realities reinforce the notion that it is possible for a psychiatrist to care for a patient’s “psyche” without having to focus on the “soma” or on complex psychobiological interactions.35 Within teaching hospitals, this contributes to psychiatry trainees having fewer opportunities to manage complex neuropsychiatric conditions, thus perpetuating Cartesian thinking.
Overemphasis on the DSM.
Contributing to the relative exclusion of neuroscience from psychiatric thinking is reliance on the DSM,25 a diagnostic manual that does not require psychiatrists to consider neurobiology when making diagnoses.36 The DSM’s psychiatric diagnoses derive from symptom descriptions and are not intended to indicate etiology or neurobiology. The DSM has facilitated research and is central to psychiatric treatment guidelines and billing, but exclusive reliance on the DSM is a system barrier to integrating neurobiological thinking into clinical practice.
To expand psychiatric diagnostic thinking beyond the DSM, neuroscience literacy (see List 1) and neuropsychiatry skills need to be core areas for mastery in medical school, residency, and CME courses. In teaching settings, it is important to elucidate brain–behavior relationships in psychiatric formulations and encourage familiarity with RDoC, which organizes observations around an evolving understanding of key neurologically correlated functional domains. Psychiatric thought leaders, department chairs, and residency directors are positioned to promote an understanding of the limitations of the DSM within a broader neuroscientific context.
Overemphasis on psychopharmacology.
Given the efficacy of psychopharma cologic treatments, many psychiatrists have come to rely primarily on them. System forces contributed to this evolution in psychiatric practice: reimbursement rules, shortened hospital stays, lower cost of drug treatment, increased availability of nonmedically trained therapists, and investment in research and product promotion by the pharmaceutical industry. Some psychiatrists equate psychopharmacologic mechanisms with the neurobiology of mental illness. Although neurotransmitter biology is a crucial aspect of neurological functioning, it is not sufficient for conceptualizing mental phenomena and generating comprehensive treatment strategies that include nonpharmacological interventions.
Increasing neuroscience literacy (see List 1) for psychiatrists at all levels of expertise is central to expanding the concept of “biological psychiatry” beyond an understanding of the role of neurotransmitters. Trainees should be exposed to emerging research into the complex brain mechanisms that underlie nonpharmacological treatment approaches such as psychotherapy and neuromodulation.
Physical separation of psychiatry from medicine.
For centuries, the care of mental patients has been delivered in locations apart from medical patients. Even now, psychiatry emergency rooms and inpatient units are typically located away from medical and surgical units and further differentiated by locked doors and monitored access, although these measures are often necessary. Psychiatric inpatient unit staffing and/or licensing may also preclude treating medically ill individuals. This physical division reinforces the problematic notion that it is always possible to make a clear distinction between psychiatric and medical patients.37,38
The establishment of more clinical settings for treatment of patients with neuropsychiatric conditions could move the field toward reversing the conceptual separation of psychiatry from medicine and decrease the isolation of psychiatric units within institutions. ACOs also will bring psychiatrists into closer collaboration with primary care colleagues; psychiatrists’ involvement in ACO planning will aid in establishing outcome measures and protocols that could ultimately lower the cost of care for patients with neuropsychiatric disorders.
Different systems of reimbursement.
In the United States, psychiatric and medical reimbursements have been handled differently, despite legislative action in favor of parity and despite scientific recognition that many major psychiatric disorders are brain based.37 Examples of differential treatment include per diem flat rates for inpatient treatment, requirements for service preauthorization, and use of claim management companies for psychiatric and addiction services that are different from those for medical and surgical services.
Reimbursement rates for mental health services have favored shorter visits with multiple, uncomplicated patients. Thus, there are financial disincentives to the time-intensive evaluation and management of complex neuropsychiatric patients. Some states, faced with limited resources, deny publicly funded psychiatric care to those patients whose behavioral symptoms occur in the setting of a neurological condition (e.g., HIV, traumatic brain injury).39
Advocacy for equitable reimbursement to psychiatrists is needed for true medical/psychiatric parity. The change in payment model inherent in the Accountable Care Act may allow psychiatrists to be compensated on the basis of savings that will accrue to an ACO when psychiatrists manage psychiatrically complex patients whose medical care is compromised by their behavioral symptoms. In addition, the creation of financial incentives by third-party payers could encourage psychiatrists to treat patients who are more complex.
Separate handling of psychiatric records.
In many institutions, psychiatric records are segregated from other parts of the electronic health record.40,41 Access to all or part of the psychiatric record may be restricted to mental health clinicians, thereby limiting the availability of information about a patient’s psychiatric workup, diagnosis, and treatment. This is a barrier to integrative thinking. Although different safeguards for psychiatric records, especially psychotherapy notes, have been created to protect patient confidentiality, separation of documentation contributes to the assumption that psychiatric illness is fundamentally different from medical illness and also implies that these records do not contain information vital to patient care. Limited access effectively undermines the psychiatrist’s contribution and may act as a further disincentive for psychiatrists to expand their thinking into the arena of neuropsychiatry.
Psychiatric evaluations and consultation documentation should be made accessible to nonpsychiatric physicians within the umbrella of the Health Insurance Portability and Accountability Act while continuing to treat psychotherapy records as highly privileged.
Psychiatry residency education
For half a century, leading figures in neurology and psychiatry have advocated increased neuroscience training for psychiatrists,42 yet surprisingly little educational reform has ensued. Two months of neurology and four months of medical training are required during the psychiatry internship year. However, competency outcomes in neurology and medicine have not been specified, nor have there been consistent attempts to integrate this material into the rest of residency training. Only recently has competency in clinical neuroscience been required.12
The milestones project of the Accreditation Council for Graduate Medical Education (ACGME) is beginning to move residency training from required timed rotations and content toward achievement of measurable milestones, including milestones in clinical neuroscience. This is an important step toward integrating neuroscience into psychiatry education, but barriers remain. Given the complexity of this teaching endeavor, questions arise as to whether psychiatry departments currently are equipped to deliver effective residency training in clinical neuroscience.
Faculty and curricula.
A recent survey of program directors by the American Association of Directors of Psychiatry Residency Training indicated that inadequate faculty resources presented a moderate barrier for many residencies despite the presence of neuropsychiatry faculty in 73% of their programs and neuroscience researchers in 81% of their institutions.43 The dearth of available curricula and time limitations were cited as other important barriers.
Building a cadre of neuroscientifically informed psychiatric educators for the future will require department chairs to consider clinical neuroscience literacy as a desirable attribute in hiring core faculty. In addition, telemedicine and video teleconference capacity are underused resources that could expand the impact of the limited pool of experienced neuropsychiatry educators. Creating educational collaboration with experts from allied fields such as behavioral neurology, neuropsychology, and neuroradiology is essential to expanding the breadth and depth of teaching faculty for residency training and psychiatry faculty development.
Efforts to address the dearth of neuroscience curricula would be bolstered by support from national psychiatry organizations. Curricula, including those that leverage emerging technologies, are needed both for neuroscience content and for neuropsychiatry skills. Encouraging residents’ research on neuroscience and neuropsychiatry topics would increase their expertise and help build future educators. Training environments that allow residents to treat a broad range of neuropsychiatric conditions are needed; these should provide active supervision and consultation with experts in relevant clinical neurosciences as well as related psychiatry subspecialties (such as geriatric psychiatry and psychosomatic medicine).
Residency programs may have difficulty finding time for clinical neuroscience milestones material in already-crowded curricula. Over the past 15 years, general psychiatry training requirements in addiction and geriatric psychiatry were increased at the expense of in-depth, longitudinal inpatient experiences.44 The challenges of finding additional curriculum time will only increase. The ACGME and the American Board of Psychiatry and Neurology have considered a proposal to allow substitution of fellowship training for the fourth year of psychiatry residency, as is permitted for child and adolescent psychiatry. In addition, in response to projected shortfalls in federal funding, a 2011 Macy Foundation report45 recommended maximizing the efficiency of graduate medical education, a process that would lead to shortening the length of training in many cases. Although increasing the number of years required for psychiatry training would enhance educators’ ability to provide clinical neuroscience and neuropsychiatry training, this solution is clearly unrealistic at this time.
The current requirement of two months of neurology training is inadequate to achieve the clinical neuroscience milestones. Clinical neuroscience and neuropsychiatry need to be integrated into every subspecialty curriculum within general psychiatry training.46,47 Lecture-based neuroscience teaching is also essential. Encouraging residents to consider neuropsychiatry fellowship training and removing obstacles to the establishment and accreditation of combined neurology–psychiatry residency training programs could help address the shortage of qualified educators in this area.
The Contributions of Neuroscience and Neuropsychiatry to Understanding the Whole Person
We have outlined factors that complicate the integration of neuroscience and neuropsychiatric knowledge into psychiatric practice and have recommended actions to help move the field of psychiatry toward increased neuroscience literacy and neuropsychiatric skill. Ultimately, the success of our recommendations will depend on the commitment of leaders in psychiatric and medical organizations to implement them.
Psychiatry has traditionally concerned itself with what is individual and personal—namely, life experiences and the construction of meaning. Brain function is also an important aspect of individuality. In this era of rapidly advancing scientific information about the brain, it is now possible for psychiatrists to integrate knowledge of neuroscience into their understanding of the whole person by asking, What person has this brain? How does this brain make this person unique? How does this brain make this disorder unique? What treatment will help this disorder in this person with this brain?
Acknowledgments: This Perspective was a project of the Neuropsychiatry Committee of the Group for Advancement of Psychiatry. The authors acknowledge Colin J. Harrington, MD, of Rhode Island Hospital, Alpert Medical School of Brown University, Departments of Psychiatry and Human Behavior and Medicine, for help in formulating the early stages of this Perspective.
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