May 28, 2014

Reintegrating Psychiatry and Neurology Is Long Overdue: Part 2

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Henry A. Nasrallah, MD

Saint Louis University School of Medicine, St. Louis, Missouri


In my previous blog entry, I explained why the splitting of neurology and psychiatry is no longer conceptually justified. At the practical level, there are numerous advantages and very few drawbacks to reuniting neurology and psychiatry into a single discipline of clinical brain disorders. Using the academic tripartite mission, I’ll describe the expected benefits.

Research. All clinical knowledge has to be discovered before it is taught and applied to patient care, so the positive impact on research must be highlighted first. Neurology and psychiatry have separately conducted their own studies with barely any collaboration with each other. Thus, there has been a dearth of testable hypotheses that integrate both the hardware (brain) and software (mind). A tragically high number of investigative opportunities were lost by failing to collaborate. Every neuroscience discovery has implications for ordinary brain functions as well as higher brain functions. By reuniting and integrating the 2 specialties into 1 department, disruptive translational neuroscience discoveries are more likely to emerge, substantively changing the current models of conceptualizing, diagnosing, and treating brain disorders.

Teaching and Training. The training for future clinical neuroscience practitioners must integrate the current neurologic and psychiatric training methods in order to assess and manage every patient with any brain disorder in a 360° approach. Every graduate of an integrated department would concurrently conduct neurologic-psychiatric history and examination and amalgamate the findings into a 360° diagnostic and treatment plan. Trainees would become adept at (1) recognizing and localizing the primary and secondary brain “lesions” that produce the patients’ physical and mental symptoms and (2) consistently looking at the consequences of a neurologic lesion on sensory and motor functions and concomitantly on cognitive behavior, thought, emotions, mood, and behavior. Here is one example of how the current un-integrated training overlooks important findings: patients with first-episode psychosis are rarely given a full neurologic exam by a psychiatry resident. Yet, researchers have consistently found that a substantial proportion of drug-naïve patients with first-episode psychosis have hypokinesia, dyskinesias, and dystonias. Because they are not documented in clinical settings, those movement disorders are attributed to iatrogenic effects of antipsychotics following the initiation of pharmacotherapy. Such undetected findings have neurobiological, diagnostic, and treatment implications. Trainees of an integrated program will develop a multidimensional view of the brain and all of its neuropsychiatric dysfunctions and their effects on patients’ functional outcomes.

Clinical Care. The salutary effects of integrating neurology and psychiatry on patient care are a genuine no-brainer. Every patient with a brain disorder (including mental symptoms) deserves a comprehensive 360° evaluation and management. Clinical and functional outcomes will be optimized with a neuropsychiatric approach. Another important benefit to psychiatric patients under the integrated model is the reduction in the stigma of mental illness. When the mind is recognized as a neurologic component of the brain, the ignorant discrimination toward psychiatric disorders will gradually disappear.

In medical schools, another important benefit of combining neurology and psychiatry is the improved fiscal integrity of the unified department. Neurology is associated with many well-reimbursed procedures (eg, EEG, EMG, lumbar puncture, botulinum toxin injections), while psychiatry is not. Thus, a combined department is more likely to have a healthier bottom line than a psychiatry department. In addition, due to economy of scale (eg, 1 chair instead of 2, 1 set of committees, 1 set of clinic receptionists and staff), the overhead is lower, and the faculty have more time to see patients, teach, mentor, or write research grant applications.

In conclusion, there are conceptual, academic, and practical benefits of reintegrating the 2 currently separate neuroscience disciplines of neurology and psychiatry. Reintegration is what Saint Louis University School of Medicine boldly initiated 7 years ago. This model should be given serious consideration by medical school deans and adopted by all medical schools, leaving behind the archaic, old-fashioned model of sequestering brain and mind disorders in separate departmental silos. Our patients with brain disorders deserve better because every “neurologic” disorder is associated with psychiatric sequelae and every “psychiatric” disorder has neurologic underpinnings. The remarkable neuroscience revolution will thrive further with an integrated model of brain disorders.

Financial disclosure:Dr Nasrallah is a consultant for Boehringer-Ingelheim, Genentech, Gruenthal, Janssen, Lundbeck, Merck, Otsuka, Roche, and Sunovion; has received grant/research support from Roche, Forest, and Otsuka; has received honoraria from Boehringer-Ingelheim, Forum, Genentech, Gruenthal, Janssen, Lundbeck, Merck, Otsuka, Roche, and Sunovion; and is a member of the speakers/advisory boards for Janssen, Otsuka, Genentech, Forum, Merck, and Sunovion.

Category: Medical Conditions , Mental Illness , Psychosis
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14 thoughts on “Reintegrating Psychiatry and Neurology Is Long Overdue: Part 2

  1. I agree with the idea of integrating psychiatry and neurology into one discipline. I do wonder how psychiatrists already out of training can acquire the training to practice in the proposed combined field.
  2. So why does “neuro-” always come before “psychology” and “psychiatry”? In collapsing disciplines, I’m afraid for the mind and for nonscientific skills in understanding and treating subjectivity. Neuroloogists, psychologists, and psychiatrists have some overlapping territory, but only some. It’s not neurologists, anyway, but rather neuroscientists who are discovering the overlap. I certainly would not want to be treated by a neuroscientist.
  3. When I was in Med School I disliked neurology second only to genetics. Pharmacology was 3rd and I wasn’t much good at any of them. In Psych training I still disliked neurology and pharmacology. Now, in private practice, I’m thinking about and using neurology and pharmacology constantly and loving them both (still not much good at them!). All these fields are truly complementary and valuable when brought together. But that doesn’t mean the sub-specialties should be abandoned – each field is too vast in it’s own right to think any one person can be an expert at them all – but more common basic education and ground-level training would be great.
  4. When the cognitive action of the spoken word and
    the non-verbal features of relating that constitute human connection can be empirically validated as instruments of neurological change and remediation, then is the time to combine depts.
  5. As an older analytically trained therapist, I recognized in about 1985 that I was not treating my patients as well as I should be or could. I went back and got a D. Pharm, and have made a second career out of learning as much as I can about the treatment of mental illness with medication as well as Cognitive Behavioral Interventions, and other ways to address the illnesses I used to treat without these therapies. It was a good choice for me. I can not imagine feeling good about how I do my job without at least considering medications, and educational therapies as well as traditional analytic skills. Putting neurology and psychiatry back together seems like a logical step to me. Obviously, far greater emphasis would have to be given to pharmacology and behavioral therapies, as well as newly emerging treatments such as magnetic brain stimulation, bio-feedback and others. But understranding the genetic and neurochemical issues in mental illness seems to me to be essential to treating patients as efficaciously as possible.
  6. Epigenetics is currently addressing this issue. The brain changes constantly, and not just the chemistry, the structure as well. We are now understanding more about how traditional therapies work. See Stephen Stall for an excellent review of this in his recent book, Psychopharmacology.
  7. Psychiatrists by training and therefore practice are mostly psychopharmacologists nowadays. They have 15-minute hours and still earn less than any other medical specialist, and they are nearly as stigmatized in the medical profession as the patients they treat are in general. I doubt there will be much support from neurology for joining forces with psychiatry.
  8. It is general that people are afraid of “mental“ illnes may be even Neurologist are afraid of“Knitting” together withe psychiatrists ,not to become as they,
  9. As a Brazilian psychiatry, working very close to primary care in the Brazilian Collaborative Care system, I think the really important point would be thinking in mental health terms.
    It seems form what has been written that all that matters is the brain. I have never treated a brain in my 30 years of practice, althought I have treated hundreds of people with all types of problems, including pain, cancer, depression, psychoses, strokes and so on.

    We need good doctors, that can treat people well, and not treat disorders. The ICD-11-PC has just 28 categories, because they are the ones needed to treat more than 80% of the people with mental health problems all over the world.

    Mental Health Treatment Gap is over 50%, reaching even 80% to some disorders, all over the world. I really do not think the answer to that will be with more neuroscientist… we need good doctors.

    Mental Health is much more than NeuroScience…

  10. Even uniting with neurology is retrogressive. In the modern world – and its foreseeable future – multi-system, multi-comorbidity, and chronicity may make post-medieval entities such as psychiatry null and void. Psychiatrists are trained as doctors, though many act as supernumerated psychologists, and psychiatry should be a sub-speciality of general medicine. Stigma starts at home, as ‘they’ say.
    [Comment from Tim 6/5/14]
  11. I am a portuguese psychiatrist and I agree on the essential of this issue. Theoretically and empirically I think that neurosciences, mainly the cognitive neurosciences, are the integrative mean of the domains of neurology and psychiatry. However, I think that we are not in nowadays as we were in the times where these two medical specialities were joined together. We have not only a lot of knowledge that comes from neurosciences as well a lot of knowledge that comes from phenomenology of the mind and of the relationship. This having been said, I agree on this: psychiatry need to deepen its roots in neuroscience, and neurology its roots in subjectivity. This is a big job for both before they can enter in a dialogue in order to define a common program for a new medical speciality.
  12. Dear Professor, I am happy that you start this topic.
    I am a neuropsychiatrist from Bosnia.
    The curriculum of specialization has changed in our country just last year, and these two specializations were separated.
    Unfortunately, in my opinion totally unhappy.
    Now specialization in psychiatry in general does not include any month of neurology.
    I believe that the changes were necessary. But my opinion is that specialization in psychiatry includes one year of neurology, and 3 years psychiatry . Best regards

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