Making a practical case for marrying psychiatry and neurology

Historically and recently, leaders within psychiatry have expressed disdain over the public’s misunderstanding of the specialty. ¹ There are many factors—cultural and sociopolitical influences, for example—that contribute to a generalized suspicion of the intent and the abilities of psychiatry. Few observers, however, have focused on how a lack of cohesion within the discipline might be an important, underappreciated influence in the misconceptions and mistrust.

One way to view the recent publication of the DSM-5 is as further positive application of evidence-based medicine and an indicator of the flexible, progressive adaptability of psychiatry. Indeed, Gawande has demonstrated the benefit of implementing a high degree of standardization in terms of maximizing economic efficiency and minimizing medical error. ²

Yet critics of psychiatry use the DSM-5 to substantiate their claim that the field is still murky and unsure of itself. Major changes in classification and diagnostic criteria might support a Szaszian fallacy that we somehow create mental illness and simply fit individuals into the framework at our whim. In the midst of what is, at best, lateral movement in psychiatry, the extremism of critics of the specialty, such as Peter Breggin, might gain undeserved credence. Furthermore, the merits of these critics’ arguments remain largely unchallenged in the public arena.

It is worth noting 2 additional factors within psychiatry that contribute to its stagnation:

• Knowledge and practice are grossly misaligned. What practitioners know and what they do are quite different, and the best way to treat mental illness often takes a back seat to tradition or convenience. Consider neuroimaging, which has illustrated structural and functional changes in the brain that have contributed to the phenomenology of schizophrenia. Schizophrenia is considered a clinical diagnosis, but the value of imaging in predicting prognosis, progression, response to treatment, etc. is well known. Yet neuroimaging is underutilized and the cost-benefit analysis of this modality remains unexplored. Likewise, cognitive testing, an important tool in the diagnosis and prognosis of schizophrenia, is not standard practice. These are good reasons why psychiatry shouldn’t shy from the push toward medicalization: Incorporating imaging and genetic analysis into practice will go a long way toward building legitimacy.
• Mental illness is stigmatized within. The stigma of mental illness that psychiatry must overcome is rooted in ignorance and misunderstanding. However, psychiatry itself has done little to eliminate the stigma of mental illness among its practitioners. This is apparent in the punitive, non-progressive nature of most state programs for impaired physicians. ³ This type of “individual discrimination” described by Carl Hart ⁴ undoubtedly permeates the residency match and ranking process, even in psychiatry. How can any headway be made in curbing societal intolerance of, say, addiction when it thrives in the academic environment?

A marriage that will dispel ignorance

In light of the continued undervaluation and ignorance of psychiatry, we can start by heeding the Buddhist teaching that change must come from within. To undertake change means to consolidate information and begin to change the inner workings, practices, and structure of the field itself. It means taking seriously the Research Domain Criteria outlined by Thomas Insel, MD, Director of the National Institute of Mental Health. ⁵