[Summary] Integrating neuroscience into psychiatric residency training (Insel 2015)
TLDR; Even though neuroscience is not fully actionable, psychiatry residents need to learn it because brain science will yield much more effective diagnoses and treatments in the future.
TLDR; Even though neuroscience is not fully actionable, psychiatry residents need to learn it because brain science will yield much more effective diagnoses and treatments in the future. Psychiatry will shift away from using only subjective, observable signs and classifications (eg DSM) toward more objective and biologically based diagnoses and treatments.
“When the residents of today are the seasoned clinicians of midcentury, they may find it difficult to believe we ever divorced psychiatry from brain science.”
Psychiatry, and understanding/treating mental activity, is profoundly changing from being focused on psychology and pharmacology to neuroscience and cognitive science.
“There are few areas of medicine undergoing the profound changes we see in psychiatry today. Over the past decade, the fundamental sciences underlying psychiatry have begun to shift from psychology and pharmacology to neuroscience and cognitive science. As the tools of neuroscience have progressed, we can begin to understand the disorders of the mind by studying the brain. The two related disciplines of systems neuroscience and cognitive science hold particular promise for revealing how brain activity is converted to mental activity and behavior.”
Although neuroscience is not fully actionable it will transform diagnosis and treatment in the future.
“Neuroscience and cognitive science may not yet be actionable in the clinic, but they will likely have a transformative effect in the near future in two major areas.”
Diagnoses will shift from subjective, observable signs, to objective and biologically based.
“First, we will see major changes in diagnosis. Psychiatric diagnosis, in contrast to diagnosis in most areas of medicine, relies solely on observable signs and subjective symptoms. Our diagnostic criteria are consensus definitions of symptoms that cluster together. While this approach offers reliability and clear communication, it lacks biological validity and therefore cannot provide the necessary precision for selecting treatments. Over the next five years, data from genomics, systems neuroscience, and cognitive science should help us to transform diagnostics by augmenting subjective reports with objective measures.”
We may need to break from old classifications (such as DSM and “major depressive disorder”) to find more distinct problems and treatments.
“What we call major depressive disorder or schizophrenia today may soon be viewed as several distinct disorders, each requiring a different treatment. This precision medicine approach requires that we break free of the current symptom-based categories and allow the data to direct us to a new classification.”
Treatments will also become more specific and targeted, as opposed to current day where many psychiatric medications were accidentally discovered to help relieve symptoms.
“The second major transformation will be in therapeutics. Psychiatry for much of the past four decades has been guided by the serendipitous discoveries of medications that reduced psychosis or relieved depression. Based on the efficacy of these drugs, we assumed that mental disorders were ‘‘chemical imbalances’’. Systems neuroscience teaches us that anatomy really matters and that mental disorders can be addressed as circuit problems. Rather than drugs to change chemicals everywhere (with unavoidable side effects), treatments can begin to focus on tuning specific circuits involved in mood regulation or cognitive control. How will we tune neural circuits? Both invasive (deep brain stimulation) and non-invasive (trans-cranial magnetic stimulation) tools have been developed for neuromodulation. It seems likely that psychotherapy that involves learning and skill building also alters regional brain function, tuning circuits through the brain’s remarkable neuroplasticity.”
Just as oncologists are learning about genes for more effective diagnosis and treatment, psychiatry residents need to start learning neuroscience to be prepared for the future.
“If patients are to benefit from the latest science, residents need to be taught the state of the art and prepared for the future. I appreciate that genomics and neuroimaging have yet to yield a biomarker or really any finding that would be essential today for clinical practice. But just as oncologists are learning about the genes for the control of cell division, psychiatrists need to know the basics of brain function and the fundamentals of cognitive science so they are prepared to use the tools of the future.”
The National Neuroscience Curriculum Initiative was started by neuroscientist-psychiatrists to help bridge the gap.
“In the U.S., a group of neuroscientist-psychiatrists have created a website with lectures, videos, and discussion groups to fill this gap. The National Neuroscience Curriculum Initiative (www.nncionline.org) is a useful resource for trainees anywhere who want to learn about the neuroscience relevant to psychiatry (Ross et al., 2015). This online set of teaching modules is grounded in principles of adult learning and innovative teaching methods. And it is updated regularly based on new science and feedback from residents”
Shifting the perspective to name “mental” disorders as “brain” disorders is already a good start to create a future of psychiatry that is more scientific and effective.
“Just the formulation of mental disorders as brain disorders will be an important shift in perspective. When the residents of today are the seasoned clinicians of midcentury, they may find it difficult to believe we ever divorced psychiatry from brain science. What is exciting is to realize that residents today can be the vanguard of change to create a future with a far more scientific and more effective discipline.”