The Future of Psychiatry

The Future of Psychiatry as ClinicalNeuroscience

Charles F. Reynolds, III, MD, David A. Lewis, MD, Thomas Detre, MD,Alan F. Schatzberg, MD, and David J. Kupfer, MD

Abstract

Psychiatry includes the assessment,treatment, and prevention of complexbrain disorders, such as depression,bipolar disorder, anxiety disorders,schizophrenia, developmental disorders(e.g., autism), and neurodegenerativedisorders (e.g., Alzheimer dementia). Itscore mission is to prevent and alleviatethe distress and impairment caused bythese disorders, which account for asubstantial part of the global burden ofillness-related disability. Psychiatry isgrounded in clinical neuroscience. Itscore mission, now and in the future, isbest served within this context becauseadvances in assessment, treatment, andprevention of brain disorders are likely tooriginate from studies of etiology andpathophysiology based in clinical andtranslational neuroscience. To ensure itsbroad public health relevance in thefuture, psychiatry must also bridgescience and service, ensuring that thosewho need the benefits of its science arealso its beneficiaries. To do so effectively,psychiatry as clinical neuroscience muststrengthen its partnerships with thedisciplines of public health (includingepidemiology), community andbehavioral health science, and healtheconomics.The authors present a Strengths,Weaknesses, Opportunities, and Threats(SWOT) analysis of psychiatry andidentify strategies for strengthening itsfuture and increasing its relevance topublic health and the rest of medicine.These strategies encompass newapproaches to strengthening therelationship between psychiatry andneurology, financing psychiatry’s mission,emphasizing early and sustainedmultidisciplinary training (research andclinical), bolstering the academicinfrastructure, and reorganizing andrefinancing mental health services bothfor preventive intervention and cost-effective chronic disease management.

Acad Med. 2009; 84:446–450.

Editor’s Note: A commentary on this article appearson pages 413 and 418.

sychiatry is the medical specialty that seeks to help (i.e., assess and treat)people and families living with complexbrain disorders including depression,bipolar disorder, anxiety disorders,schizophrenia, substance abusedisorders, developmental disorderssuch as autism, and neurodegenerativedisorders such as Alzheimer dementia.Traditionally, disorders falling intothe province of psychiatry have beenthose of unknown etiology, and, asresearchers have ascertained etiology,some disorders, such as central nervoussystem disorders, have often shifted tothe province of neurology. (Tertiary syphilis is a good historical example of this shift.) Now, however, with thetools of modern neuroscience, a deeperunderstanding of causal pathways tomajor neuropsychiatric illness isevolving, thus rendering artificial theboundary between psychiatry andneurology.

The artificiality of thisboundary has profound implicationsfor psychiatry’s future. Our thesis isthat the two disciplines, which wereonce united, should be, at leastpartially, reintegrated as clinicalneuroscience (Figure 1). That said,we also acknowledge that whereaspsychiatrists and neurologists share acommon interest in the central nervoussystem, their interests can and often dodiverge, resulting in group affiliationsthat are key for professional identity.This identity is a fundamental tenet of medical sociology. We are not suggestingthat psychiatrists or neurologists give upwhat really interests them, but a partialreintegration of the two disciplines,especially in undergraduate and graduatemedical training, as well as in research,could strengthen both. The componentsof psychiatry and the components of neurology are often arbitrary andhistorical rather than rational. Whereasneurology has traditionally focused ondiscrete anatomical lesions (e.g., stroke ortumors), psychiatry or modern clinicalneuroscience addresses dysfunction inanatomical circuits and connectivity.These, as we illustrate below, aredifferences of degree—not absolutes.According to the World HealthOrganization, neuropsychiatricdisorders account for at least 20% of the global burden of illness-relateddisability, and all represent complexdisorders of brain function.

Psychiatry,like neurology, rests on a foundation of clinicalneuroscience.Italsoencompassesandisinformedbyabroadrangeofbasicbiologicalandsocialsciencesandhasatitsdisposalmanytools(e.g.,brainimaging,genetics,neuropsychopharmacology,neurophysiology, epidemiological modelsof risk and protective factors, andneuropsychology) for developing newassessment and treatment approaches,grounded in understanding of etiology and pathophysiology.Our purpose is to discuss the future of psychiatry as clinical neuroscience and tospecify strategies in several contexts toenhance this future: (1) education andtraining, (2) health science policy, (3)institutional issues, (4) research, and (5)clinical practice in medical schools andtraining hospitals. We aim to present asynthesis of the key conceptual and socialissues facing psychiatry right now and toprovide a tool for further discussion in

Please see the end of this article for informationabout the authors.Correspondence should be addressed to Dr.Reynolds, University of Pittsburgh School ofMedicine, Western Psychiatric Institute and Clinic,3811 O’Hara Street, E-1135, Pittsburgh, PA 15213;telephone: (412) 246-6414; fax: (412) 246-5300;e-mail: (reynoldscf@upmc.edu).

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many areas, both in psychiatry and inacademic medicine more broadly.To explore these contexts and to providea rationale for our views, we propose firstto present a Strengths, Weaknesses,Opportunities, and Threats (SWOT)analysis of the field of psychiatry.Collectively, we bring to this taskapproximately 200 years of experience inall aspects of academic psychiatry:research (basic and clinical), education(including leadership of programs inmentoring for academic careers), clinicalpractice, and administration (medicalschool dean and academic health center[AHC] president, department chair, andlarge research group leader). All of ushave significant experience with theNational Institutes of Health (NIH) asreviewers, grantees, and NationalInstitute of Mental Health (NIMH)national advisory council members; withthe Institute of Medicine (IOM); and asleaders of professional associations(American Psychiatric Association[APA], the American College of Neuropsychopharmacology, and theAmerican College of Psychiatrists). Weemphasize that the views presented hereare our own and do not necessarily reflectthe official policies of any professionalorganization with which we are affiliated.Our purpose is not to conduct a literaturereview and analysis of the conceptual andsocial issues facing psychiatry but, rather,to synthesize a broad-based view of theseissues,tobroadenparticipationofacademicmedicineleadersinthisconversation,and,aboveall,tomakewhatwefeelarestrategicrecommendationsfordealingwiththetippingpointwherepsychiatrynowbalances.Wethink,inshort,thatthereisanurgencytosustainingthisconversationandactingonit.Wenoteseveralresourcesintheliteratureofconsiderablevalueinthiscontextfromthesurgeongeneral,

theIOM,

andtheAPA.

Current Strengths of Psychiatry

In our opinion, the assessment tools of psychiatry (e.g., the use of structureddiagnostic instruments) and its treatmentarmamentarium (including maintenancepharmacotherapy to prevent relapse andrecurrence) are good, but they are farfrom excellent. Patients often improvesubstantially, but many do not recoverfully. The field has taken a largely descriptive and categorical approachto diagnosis, and now experts andpractitioners recognize the need toincorporate multiple dimensions(e.g., severity, distress, impairment) intotheir assessment procedures to betteraccommodateadvancesinrelevantbasicbrainandbehavioralsciencesandtoenhanceclinicalrelevance.Indeed,thismultidimensionalassessmentisafundamentalgoalofthe

Diagnostic andStatistical Manual

(fifthedition)taskforce.Another strength is the systematicevidence base now available to informpsychiatric treatment, which is of arelatively high order similar to, if notbetter than, the rest of medicine in termsof rigorously controlled randomizedclinical trials (RCTs), including thosetesting theoretically based, disorder-specific psychosocial treatments(e.g., cognitive behavior therapy fordepression). Third, as highlighted by the recent NIMH Strategic Plan, the fieldis scientifically committed to bothoptimizing treatment outcomes andpersonalizing treatment for those livingwith psychiatric disorders.

Thiscommitment increasingly has inspiredinvestigating moderators of treatmentresponses and creating models of careorganization (e.g., depression caremanagement) that allow evidence-basedpractice to reach both specialty mentalhealth and general medicine settings.These developments have also helped tofoster a growing emphasis on stepped-care approaches with public healthrelevance (e.g., the use of watchfulwaiting before intervention and the useof simple interventions before morecomplex strategies) as well as integratedmulticomponent interventions that takeinto account the burdens of coexistingmedical, neurological, and psychosocialchallenges (e.g., care-giving burden).Such interventions especially emphasizehealth-related quality of life. Selective andindicated preventive intervention fordepression is also beginning to emerge asa feasible and effective strategy in primary care and specialty settings; such strategiesrecruit individuals at high risk forpsychiatric illness, many of whom arealready experiencing presyndromalsymptoms.

Some preventiveinterventions are psychosocial, such asthe use of problem-solving therapy toprevent or delay depression in peopleliving with macular degeneration

; othersare psychopharmacologic, such asantidepressant medications forpoststroke patients at risk fordepression.

In addition, one of the greatest strengthsof psychiatry is the cadre of young peopleentering the field and its related basic andapplied disciplines. Slightly more than4% of graduating seniors in the nation’smedical schools enter psychiatry.

Finally, a critical and growing strength of psychiatry as clinical neuroscience derives

Figure 1

The Future of Psychiatry at a Tipping Point. This concept map illustrates past streams ofinfluence on psychiatry, its current relationship with medicine, neurology, and public health, andits future as clinical neuroscience and as a part of public-health-relevant prevention and diseasemanagement strategies.The Future of PsychiatryAcademic Medicine, Vol. 84, No. 4 / April 2009

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from the multiple and marked advancesthat are transpiring in the areas of molecular, developmental, and systemsneuroscience. The expanding knowledgeof the neural substrates for the cognitiveand affective functions that are disturbedin psychiatric disorders is creating anincreasingly more sophisticated andnuanced database for the generation of testable hypotheses about the biologicalunderpinnings of psychiatric illness.Consistent with these advances, clinicalneuroscientists are now witnessing theearly phases of the development of novelpharmacological interventions centeredon pathophysiologically based illnessmodels rather than on serendipitousdiscoveries. Psychiatrists are also nowbetter able to estimate risk for mentalillness based on genetic informationand to predict treatment responsevariability using pharmacogeneticinformation. In this sense, thetraditional boundaries betweenpsychiatry and neurology, betweenmind and brain, are disappearing.

Current Weaknesses of Psychiatry

Psychiatry’s assessment and treatmenttools, though good, are limited by thelack of—and often internal resistanceto—the clinical neuroscience perspectivesneeded to bring the findings of psychiatric genetics, brain imaging,cognitive and affective neuroscience, andpsychometric theory to defining etiology,pathophysiology, and treatment-relevantphenotypes, and to personalizingtreatment (i.e., which treatment forwhich patient at what point in the illnesstrajectory?). In our opinion, optimizingtreatment entails not only RCTs but alsoa greater emphasis on the identificationof biological and psychosocial variablesthat predict or modify short- and long-term treatment response. As a field,psychiatry is relatively new to thisenterprise, well behind many othermedical specialties. We believe that thedisciplinary separation of the two majorpractice arms of clinical neuroscience,psychiatry and neurology, is a conceptualand structural impediment to scientificand clinical progress in the care of peopleliving with complex brain disorders. As adiscipline of clinical neuroscience,psychiatry needs to invest greaterscientific effort into studies of theetiology and pathophysiology of majorbrain disorders and to ensure thatadvances in these two fields are integratedappropriately into undergraduate andgraduate medical education. Psychiatry has other weaknesses, too; it has paid toolittle attention to• inequalities in the delivery of mentalhealthservicestovulnerablepopulations;• the integration of mental healthservices into other areas of medicine,from pediatrics to geriatrics;• the real and perceived conflicts of interest in relationships with industry;and• the unmet mental health needs of medical students and physiciansgenerally (whose rates of suicide aretwo to three times greater than in thegeneral population

).Finally, relative to most other specialtiesin academic medicine, the number of research-intensive departments of psychiatry is relatively small, probably not more the 20% of the nation’s medicalschools, as judged by the geographicdistribution of NIH-sponsored research.

This reflects a nexus of several challengesto the field: (1) too few psychiatrists whohave completed research fellowships, (2)too few mentors, (3) an overly rigidapproach to graduate medical educationwith inadequate flexibility to allow theintegration of research training intosubspecialty clinical training, and (4) afailure to recruit a fair share of the bestand brightest medical students early enough into clinical neuroscienceresearch.

Current Opportunities forPsychiatry

Embedded within the strengths andweaknesses of psychiatry as a discipline of clinical neuroscience are tremendousopportunities to conduct research intothe causes of mental illness; to chart thedevelopmental trajectories of mentalillness so as to determine when, where,and how to intervene; to develop mentalhealth treatments and approachesresponsive to diverse needs andcircumstances; and to strengthen theimpact of treatments for mental illnesseson public health. The tools of psychiatry’sbasic and behavioral sciences now permitsuch progress. In addition, the field isripe with other opportunities to developselective and indicated preventiveinterventions for people at high risk formental illness across the lifecycle, thereby enhancing the public health impact of modern psychiatric treatment.Psychiatry can also improve bothassessment and treatment strategiesvia deeper understanding of genetics, pathophysiology,functional neuroanatomy, andneuropsychopharmacology, allowing forthe development of more personalizedinterventions. The opportunity todevelop and implement organizationmodels of mental health service delivery that have public health relevance willfurther psychiatry’s reach and allow it tocombat stigma against the mentally ill.The pursuit of advocacy and consumerhealth information initiatives throughpartnerships with patients andfamilies living with mental illness isextraordinarily important to thecampaign to improve payment of mentalhealth services via parity and, in a relatedvein, to improve financial incentives for young people to enter the field. Finally,psychiatry has a duty to change theinstitutional culture of academicmedicine in a way that supports medicalstudents and physicians seeking mentalhealth services for themselves. Forexample, teaching medical students andphysicians to better recognize depressionin themselves and in their colleagues may lead to decreased rates of physiciandisability and suicide—and increase thelikelihood that nonpsychiatrist physicianswill recognize depression in their ownpatients.

Current Threats to Psychiatry

Notwithstanding the many opportunitiesavailable to psychiatry as clinicalneuroscience, the field also faceschallenges that threaten its future. Someof these are financial in nature (e.g., lackof parity in reimbursement policies andMedicare’s discriminatory copaymentrequirement of 50%). Another relates tothe organization of medical practice;structural barriers (e.g., the lack of electronic health records, decreasinginstitutional support, and orientation toacute rather than chronic care) impedethe implementation of evidence-basedmental health services in generalmedicine and pediatric practices. Socialrealities, such as the persistence of stigma against the mentally ill, andhealth/science policy (e.g., the inadequatefunding of mental health research and thescanty support for mentoring), alsothreaten the future of psychiatry. The

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