OK, so I’m writing this as fast as I can in between seeing patients, so I definitely would like your feedback on the articles I recently encountered and which I also have to read in between seeing patients. First, take a look at a couple of items that tend to complement each other (I hope!). See the tweets below:
Let me complain a little about the clinical neuroscience article in JAMA Psychiatry. OK so I get it that neuroscience may be the wave of the future in psychiatry–when there are practical interventions we can apply that will be safe and effective for our patients. They also need to be applicable just in time and not cost 10 gazillion dollars.
And tell me what you think of the authors’ statement: “The diseases that we treat are diseases of the brain.” The italics are mine. I have a problem with every symptom or behavior I see as a consulting psychiatrist in the general hospital being considered classifiable as a disease. It seems to run counter to what I was taught as a resident about the perspectives of psychiatry [1,2]. A disease I often encounter is delirium. Many of my colleagues would also think of schizophrenia or bipolar disorder as diseases. What happens to the life story perspective? Is that containable in the clinical neuroscience paradigm. Well, maybe, but I have a little trouble with it.
You might recall I had an issue with this idea that all psychiatric disorders are brain disorders about which I wrote the post “Just A Giant Bowl of Doodoo.” In it I quoted past American Psychiatric Association president Dr. Jeffrey Lieberman:
Our understanding of the relationship between the brain and mental disorders may have been slow to develop, but recent advances in research have shown us that they are biological in nature and caused by genetics and environmental factors. Patients are not responsible for their mental illness, and psychiatrists are doing their best to recognize and treat mental disorders and help patients as best we can within the limits of our knowledge. For this noble mission, we have nothing to be defensive about.
Really, we’re not at all responsible for our mental illnesses–every mental illness–every behavior? Then why bother with mindfulness?
And you really lose me when you start talking about forcing psychiatrists to use neuroscience–especially before it’s really usable:
Last, we should work with regulatory organizations to formally incorporate neuroscience into our training and certification processes. Such an approach could include revision of the program requirements and milestones for psychiatry and greater incorporation of neuroscience content into the American Board of Psychiatry and Neurology certification process for psychiatrists.
Hang on. The authors mention that the ACGME Milestones program for evaluating residents is really inadequate for integrating neuroscience into the training program even though we’re forced to evaluate residents about it. And who’s on the advisory board for Milestones? One is Dr. Larry Faulkner, MD, the President and CEO of the American Board of Psychiatry and Neurology (ABPN). You remember Dr. Faulkner; I wrote him a letter about the Maintenance of Certification (MOC). His reply was only mildly patronizing, to which my response was predictable.
If you ever take a look at the Milestones, they’re basically foreshadow the MOC.
So another article about neuroscience was about someone I never heard of in medical school or residency, Nicolaas Tinbergen. It’s actually readable and I’m intrigued by the author’s approach. Martin Brune even mentions an iphone app called the ginger.io which my department chair recently mentioned. It “…captures variation in a number of patterns, including movement, as detected by a phone’s motion sensor, and texting frequency, to generate information relevant to things like energy level and social connection.”
This piece of technology seems to resonate with Brune’s observation that paying greater attention (mindfully?) to the nonverbal behaviors of patients might be more valuable than using psychiatric rating scales to measure their progress in psychotherapy.
It seems like every time we wander off to the brain, we wander back to the mind. Gotta go now. Tell me what you notice.
1. McHugh, P. R., M.D., and P. R. Slavney, M.D. (1998). The Perspectives of Psychiatry, The Johns Hopkins University Press.
2. Chisolm, M. S., MD, and C. G. Lyketsos, MD, MHS (2012). Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry, The Johns Hopkins University Press.