Post by Former NIMH Director Thomas Insel: The Future of Psychiatry (= Clinical Neuroscience)

By Thomas Insel on April 20, 2012

Last week a short piece in the British medical journal, The Lancet, described an “identity crisis” in psychiatry. In the U.K., the number of medical students choosing psychiatry has dropped more than 50 percent since 2009 and over the past decade the number of psychiatrists has dropped by 26 percent while the number of physicians overall has increased more than 31 percent. Ninety-five percent of posts for junior physicians across all specialties are generally filled; but psychiatry posts, as of last summer, were running more than one third unfilled.

Tom Brown, Assistant Registrar of Recruitment at the Royal College of Psychiatrists, U.K., told The Lancet: “Common perceptions within the medical profession include the view that psychiatry is just not scientific enough, is too remote from the rest of medicine, is often viewed negatively by other medical professionals, and is a specialty too often characterised by difficult doctor-patient relationships and limited success rates of therapeutic interventions.”

Meanwhile, psychiatry in the U.S. is undergoing a quiet resurgence which appears to run counter to the British experience. This might not have been apparent last month at match day, the day when medical students match with their post-graduate residencies. Match day is always a moment to track the popularity of different medical specialties. This year, slightly less than 4 percent of graduating students chose psychiatry, which is a bit lower than recent years. But this number hides an extraordinary trend: psychiatry has become the hot specialty for MD-PhD students who want to do research.

The number of MD-PhD students choosing psychiatry has more than doubled in the past decade. This year, 50 percent of the students who matched with the Yale psychiatry residency were MD-PhDs. At Columbia, 20 percent of psychiatric residents in recent years have been MD-PhDs. In other psychiatry residency programs, while the number of applicants has not increased, the number of MD-PhDs has. Why is this important? Getting into an MD-PhD training program is even more competitive than getting into medical school. The training includes intensive research experience, and many (but not all) graduates go on to do independent research either in the clinic or in a laboratory setting. In the past, most of these elite students have chosen a medical specialty such as oncology or a high paying surgical specialty such as ophthalmology.

Why are they now selecting psychiatry? I asked this question at Brain Camp a couple weeks ago. Each year, NIMH runs a 4-day intensive Brain Camp for some of the top physicians in their second year of psychiatric residency training. The faculty, including Nobel laureates and other distinguished scientists, describe recent insights from neuroscience relevant to the problems facing psychiatric residents. The residents, who are still at a very early stage of their training, are challenged with charting the future of psychiatry. The result is one of the most inspiring 4 days of the year for all of us who attend.

This year, 11 of the 17 psychiatric residents at Brain Camp were MD-PhDs. Many had been neuroscience majors in college, had published high impact papers in medical school, and were continuing to do research during their clinical training. Prior to residency, all 17 were medical students who had been at the top of their class and could have gone into any specialty. When I asked them why they had chosen psychiatry instead of another specialty, I heard various reasons but they all agreed that psychiatry is the specialty where they can have the greatest impact. To paraphrase, one student said, “The questions are profound, the patients are fascinating, and the tools are finally available to make unprecedented progress.” Another told me confidently, “This is the place to make a mark.”

These brilliant young scientists have mostly come from a neuroscience background. They are but a few of the gifted and committed trainees currently in the pipeline who have been attracted to psychiatry in the U.S. They see psychiatry as the natural application of their interest in how the brain works. They want to transform psychiatry into clinical neuroscience, not with less of a commitment to clinical excellence but with a great commitment to developing a new scientific basis for clinical care. This year Brain Camp was largely focused on neuromodulation—using cognitive training and repetitive transcranial magnetic stimulation (rTMS)—to alter symptoms of depression and anxiety by modulating specific brain circuits. For this new generation, psychiatry already is clinical neuroscience.

So maybe there is an identity crisis for psychiatry in the U.S. as well as the U.K. But the U.S. version seems filled with hope and excitement, with many of the best and brightest now deciding that they can bring new approaches to help people challenged by mental illness.

References

Lancet. 2012 Apr 7;379(9823):1274.