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
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: (firstname.lastname@example.org).
Academic Medicine, Vol. 84, No. 4 / April 2009