Neuropsychiatry: Psychiatry’s Future?
Recently, a British journal[i],[ii] takes on the thorny issue of (as the authors see it) the artificial and deleterious divide between neurology and psychiatry. The special article by TJ Reilly, “The Neurology-Psychiatry Divide: A Thought Experiment,” takes a brief and whimsical approach to describing the differentiators to a Martian who has no knowledge of the history, while the longer, and impressively academic, editorial piece traces the history of the separation to make the same argument: All future psychiatrists should be neuropsychiatrists, according to a Psychiatrist article[iii]. There are several suggestions of differences between UK and US training (e.g., Reilly states UK training in either specialty may exclude any exposure to the other specialty) and practice (e.g., the treatment of conversion disorder in the UK is apparently the sole province of neurologists). Nonetheless, the similarities may be greater than the differences across the pond.
Neurology, as the study of the nervous system through its structure and functions and any ensuing abnormalities, will by definition attract a different type of professional than psychiatry, a medical specialty that addresses mental and behavioral disorders.
However, training isn’t the real issue. Neurology, as the study of the nervous system through its structure and functions and any ensuing abnormalities, will by definition attract a different type of professional than psychiatry, a medical specialty that addresses mental and behavioral disorders. The focus differs; the day-to-day differs; and so the professional differs.
To illustrate, as a medical student, I asked every one of my attendings and supervising residents how they decided on their specialty. A very unhappy and extremely bright internal medicine resident (who I later learned went into anesthesiology) gave me this sage wisdom: “You need to decide what the bread and butter is and how much you like that, because no matter how exciting the rotation in a tertiary care hospital, you’re going to do a whole lot of the bread and butter.” While psychiatrists can never know too much neurology, and vice versa, the bread and butter of these two specialties is very different. I was irresistibly drawn to patients struggling with depression, anxiety and psychosis, and continue to have no desire to treat headaches, seizure disorders or neurodegenerative diseases. Both authors have failed to appreciate the key factor that these specialties draw from different personality structures and skill sets.
Specialty delivers value
While there are undoubtedly exemplary clinicians who can and do cover the spectrum of brain, mind, behavioral and nervous system syndromes, neuropsychiatry remains but one option to channel the burgeoning neuroscientific advances for the betterment of our patients. It is true that US psychiatry took a huge step away from medicine in the early 20th century (the heyday of psychoanalysis), but it is equally important to remember and reinforce that psychiatry is a medical specialty – especially in the 21st century – and neurology is not the only other medical specialty to cope with psychiatric symptoms. It would be equally beneficial if every new psychiatrist were also a primary care physician, cardiologist, dermatologist or endocrinologist – to name just a few. However, the area under the bell curve is too great – otherwise all physicians should be generalists and treat everything. We have long since recognized the need for specialization for just this reason.
Both authors have failed to appreciate the key factor that these specialties draw from different personality structures and skill sets.
Another option is psychosomatic medicine, a psychiatric subspecialty applying all the traditional psychiatric skills and medical expertise of fellowship training to work effectively at the interface of psychiatry and medicine. Often in a consultative or integrative role, these psychiatrists truly have the big picture (beyond merely neurology), sorting out delirium, dementia, depression, primary or secondary psychosis; managing behavior caused by and/or interfering with medical treatment; working with (inpatient or outpatient) staff to develop more productive treatment plans, etc.
As the science of the brain continues to evolve and become more sophisticated, the future psychiatrist may look more like today’s neuropsychiatrist, but it is unlikely the future neurologist will follow suit. If for no other reason, both specialties will remain relevant.
[i]Reilly TJ. Special Article: The neurology-psychiatry divide: a thought experiment. BJPsych Bulletin 2015; 39:134-5.
[ii]Fitzgerald M. Editorial: Do psychiatry and neurology need a close partnership or a merger? BJPsych Bulletin 2015; 39:105-7.
[iii]Fitzgerald M. All future psychiatrists should be neuropsychiatrists (letter). Psychiatrist 2013; 37:309.