Friday, October 14, 2016

National Neuroscience Curriculum Initiative - a brighter future for psychiatry






As any reader of this blog probably knows, I am a big proponent of neuroscience education for psychiatrists and always have been.  I have suggested in the past that it would take broad collaboration.  I posted some examples of an NIMH initiative on neuroscience  education.  I teach neuroscience (also known as neurobiology) myself and that has led me to be acutely aware of the lack of educational resources on the field.  That background is what has made this the happiest day at a CME conference that I have ever spent.  I am currently at the University of Wisconsin 4th Annual Update and Advances In Psychiatry - a conference that has really been in place for the past 41 years.  After watching a comprehensive update on eating disorders I settled in to listen to Melissa Arbuckle, MD, PhD; Professor of Clinical Psychiatry, Director of Residency Training; Department of Psychiatry, Columbia University Medical Center.  The title of her presentation was Discussing the Neuroscience of Mental Illness with Your Patients.  I turned to the section in the syllabus and there was one page with a case report on the front and a crude drawing of the brain (two views) on the back.  Being a traditional conference guy who likes a ton of technical information, no audience participation, and no role playing - I was prepared to be disappointed.

I was not prepared for what would transpire in the next 90 minutes.  I have posted here many times why I thought that every psychiatrist should know neuroscience and ways to do it, specifically the need for widespread collaboration due to a lack pf neuroscience manpower in most departments.  Dr.  Arbuckle started out explaining what the National Neuroscience Curriculum Initiative was.  It was started by a collaboration of like minded residency directors  to come up with a program to teach neuroscience to psychiatry residents.  She showed the explosion in neuroscience papers in psychiatry just over the past decade.  She referred to an article in JAMA Psychiatry (1) with her collaborators on why neuroscience needs to be integrated into psychiatry right now.  She discussed the New York Times editorial that showed up three weeks later with the criticism of their viewpoint (2).  Although she did not mention it, like a lot of articles it as written form the perspective of a psychiatric identity crisis.  Whenever I see that term it seems like the authors are firmly behind the curve and don't seem to understand what neuroscience encompasses.  Dr. Arbuckle said that the article was critical of the criticism that the brain was the basis of human behavior.  Quoting the article:

"Indeed an article in May in one of the most respected journals in our field JAMA Psychiatry echoed this view: "The diseases we treat are diseases of the brain."........ Even if this premise were true - and many would consider it reductionist and simplistic - an undertaking as ambitious as unraveling the function of the brain would likely take many years."  The author is a psychiatrist and goes on to say that he is all for neuroscience and even talks about some recent research techniques he (implicitly) just doesn't think psychiatrists should study it?  He also seems to conflate psychotherapy as being independent of neuroscience when in fact we have known just the opposite since since Kandel's 1979 seminal lecture Psychotherapy And The Single Synapse.  

I am equally incredulous when people seem to argue about the importance of neuroscience in psychiatry.  I find reductionism and reductionist approaches to be perfectly understandable and acceptable.  It is an interesting form of rhetoric to use these terms pejoratively.  Most people go into medicine because they want to know how things work.  If they did not enter with that goal, it soon becomes apparent that knowing mechanisms whether they are theoretical or not is an important aspect of studying medicine.  Some of the first mechanisms I studied in medical school involved cholera and diphtheria toxin. How is it possible to determine these mechanisms and recent significant epigenetic mechanisms without taking a reductionist approach?

The exercise that Dr. Arbuckle introduced to the audience was the diagnosis and treatment of complex cases.  The case vignette involved a young woman with borderline personality disorder.  The task for the audience was to pair up and role play discussing the relevant neuroscience concepts of treatment with the patient using the brain diagram as an aid.  Eliciting responses from 300 people in a room slows things down.  After the audience was done, she showed a film of an expert presenting this information to a patient and what presentation materials might be available.  It went very well and it presented the rationale for dialectical behavior therapy and not a medication.  It was a clear example of a neuroscience based discussion that provides a rationale for psychotherapy.  There are numerous materials on the web site (9 modules, 56 sessions, 40 authors) and wide scale participation is encouraged.

The information up to that point was quite exciting.  Dr Arbuckle had plenty of enthusiasm in her closing remarks.  In those remarks she pointed out the goal of "getting the entire field up to speed" in neuroscience.  She pointed out that everything on the site is free but at some point they may ask physicians to pay for CME.  She said that she realizes that this is literally "changing the world and that is what we are going to do."        

This was the most exciting commentary from a psychiatrist about teaching the entire field and the future of psychiatry that I have ever heard.  I have never been this impressed by any development in the field during my career.  And I am a psychiatrist who is as pro-neuroscience as anybody.  How is it that I am just hearing about this initiative right now and only because I am attending a conference?  That is why I am posting my experience here and a link to the NNCI web site and materials.

Dr. Arbuckle and her collaborators are one of the few bright spots for the future of psychiatry.

But they are very bright.


George Dawson, MD, DFAPA


References:


1:  Ross DA, Travis MJ, Arbuckle MR. The future of psychiatry as clinical neuroscience: why not now? JAMA Psychiatry. 2015 May;72(5):413-4. doi: 10.1001/jamapsychiatry.2014.3199. PubMed PMID: 25760896.

2: Friedman RA.  Psychiatry's Identity Crisis.  New York Times July 17, 2015. p SR5.


Attribution: 

The graphics at the top are two slides from one of my lectures.  I like to present data on the unique aspects of every individual brain and why that can happen.  The slides are not from the NNCI program and I am not affiliated with that program.  Click on each slide to enlarge.








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