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The relevance of translational neuroscience in psychiatry residency training
Asian Journal of Psychiatry 17 (2015) 131–132
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Discussion
The relevance of translational neuroscience in psychiatry residency training Commentary on ‘‘Torous et al. A proposed solution to integrating cognitive–affective neuroscience and neuropsychiatry in psychiatry residency training: The time is now’’ Sri Mahavir Agarwal, Ganesan Venkatasubramanian * Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
A R T I C L E I N F O
Article history: Received 28 August 2015 Accepted 28 August 2015 Keywords: Psychiatry Training Translational neuroscience Brain stimulation
1. Commentary In psychiatry, the critical influence of residency training in shaping one’s outlook toward the specialty cannot be overstated. It determines, to a large extent, conceptualization of mental phenomena/related disorders as well as formulation of specific treatment approaches. The psychiatry–neurology dualism that pervades most residency programs across the world has had an adverse impact on psychiatry training. This distinction between specialties largely stemmed from the fact that the pathophysiological processes that led to psychiatric symptoms were unknown at that point in time making them ‘‘functional’’. However, passage of time and lack of concerted attempts toward updating this understanding has resulted in the hitherto unknown being misunderstood as eternally unknowable or non-existent. This has led to cementing of psychiatric disorders as disorders of the ‘‘mind’’, clearly distinct from disorders of the ‘‘brain’’; so much so that several decades of dedicated and fruitful research into the biological basis of symptoms has largely failed to change this
* Corresponding author at: Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India. E-mail address: [email protected] (G. Venkatasubramanian). http://dx.doi.org/10.1016/j.ajp.2015.08.015 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
perception. The average resident in psychiatry is therefore less likely to explore brain based explanations of psychiatric symptoms because they are prejudged to be functional. This is at odds with the current level of knowledge where several concrete examples exist neatly tying region or circuit level activity, or lack thereof, to clinical symptoms. Hence, advances in understanding are slow to permeate through an uninitiated audience; application of this knowledge in routine patient care is slower still. On one hand, this projects psychiatry as a branch not in tune with times, while on the other it exposes it to attacks which question its very basis as a medical branch since it appears not to be rooted firmly in biology. It is in this context that the article by Tourus et al. in the current issue assumes significance. The authors impress upon the reader the need for psychiatric residency to be informed by cognitive– affective neuroscience and neuropsychiatry. With regards to the barriers that impede psychiatry residents from being trained suitably in neurosciences and neuropsychiatry, the authors point to the absence of suitable faculty as a core problem. This again, in our opinion, is a manifestation of the mold psychiatry has cast itself in over the last few decades. Absence of focus on neurosciences has resulted in faculty who are themselves not suitably trained to impart the necessary skills to residents, starting a vicious circle that needs to be broken urgently. The inclusion of brain circuits and anatomical regions related discussions in routine case discussion is
132
S.M. Agarwal, G. Venkatasubramanian / Asian Journal of Psychiatry 17 (2015) 131–132
a novel idea with significant advantages. This approach introduces the concept of neuroscience based causality as well as promotes thinking toward targeted, logical, evidence based strategies that reverse the identified neuropsychiatric deficit. Moreover, such an approach brings the robustness of identifying anatomical and functional neural correlates to the discussion which complements the richness of personalized and phenomenology based approach that is so unique to psychiatry. While similar views have been expressed earlier (Benjamin, 2013; Coverdale et al., 2014), the article’s merit lies in proposing a solution which is ready to work out of the box and which merges seamlessly into the mores and routine of clinical residency. For instance, the description of case study in the article is illustrative of how useful such an approach can be toward both increasing a resident’s understanding of brain processes behind symptoms and facilitating a more informed approach to the management of psychiatric disorders. Moreover, such a method of discussion is likely to encourage residents to learn more about how current modalities of treatment work and help them become more receptive to the latest advances in neurotherapeutics. It will also help them recognize and stay alert to new techniques in future that may potentially improve symptoms. The emergence of various invasive and non-invasive brain stimulation modalities for treating psychiatric disorders over the last few years highlights the challenge in front of us. Application of these techniques assumes thorough understanding of the anatomical and functional basis of effects produced and the brain circuits or regions they act upon. Evidence for the efficacy of techniques like transcranial magnetic stimulation (TMS) (Lefaucheur et al., 2014) and transcranial direct current stimulation (tDCS) (Agarwal et al., 2013; Tortella et al., 2015) in treating psychiatric disorders is fast accumulating. Given the efficacy, safety profile and the interest these techniques have generated in the scientific community, it is likely that they will gradually become commonplace and a psychiatrist will be expected to, at the very least, understand how they work. The authors highlight this in their article and sound a timely warning in saying: ‘‘If psychiatrists do not embrace
opportunities to become specialists in neuromodulation, the void could be filled by other clinical experts in brain functioning.’’ Constant updating of ‘‘knowledge’’ and converting this into ‘‘wisdom’’ that facilitates application is a prerequisite for any scientific field. It is therefore necessary for young psychiatrists to learn to assimilate and apply the knowledge that progress in translational neuroscience makes available to them. That is unlikely to happen unless they are well trained in the nuts and bolts of brain based approach to psychiatry. It is quite possible that in the coming years our understanding might improve further paving the way for identification of psychiatric disease processes at the level of individual neurons and synapses. If psychiatrists are to stay relevant in this ever changing scheme of translational neuroscience, the time to overhaul our training is, as the article by Tourus et al. puts it, right now!
References Agarwal, S.M., Shivakumar, V., Bose, A., Subramaniam, A., Nawani, H., Chhabra, H., Kalmady, S.V., Narayanaswamy, J.C., Venkatasubramanian, G., 2013. Transcranial direct current stimulation in schizophrenia. Clin. Psychopharmacol. Neurosci. 11, 118–125. Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuroscience. Int. Rev. Psychiatry 25, 265–275. Coverdale, J., Balon, R., Beresin, E.V., Louie, A.K., Tait, G.R., Goldsmith, M., Roberts, L.W., 2014. Teaching clinical neuroscience to psychiatry residents: model curricula. Acad. Psychiatry 38, 111–115. Lefaucheur, J.P., Andre-Obadia, N., Antal, A., Ayache, S.S., Baeken, C., Benninger, D.H., Cantello, R.M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di Lazzaro, V., Filipovic, S.R., Hummel, F.C., Jaaskelainen, S.K., Kimiskidis, V.K., Koch, G., Langguth, B., Nyffeler, T., Oliviero, A., Padberg, F., Poulet, E., Rossi, S., Rossini, P.M., Rothwell, J.C., Schonfeldt-Lecuona, C., Siebner, H.R., Slotema, C.W., Stagg, C.J., Valls-Sole, J., Ziemann, U., Paulus, W., Garcia-Larrea, L., 2014. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin. Neurophysiol. 125, 2150–2206. Tortella, G., Casati, R., Aparicio, L.V., Mantovani, A., Senco, N., D’Urso, G., Brunelin, J., Guarienti, F., Selingardi, P.M., Muszkat, D., Junior Bde, S., Valiengo, L., Moffa, A.H., Simis, M., Borrione, L., Brunoni, A.R., 2015. Transcranial direct current stimulation in psychiatric disorders. World J. Psychiatry 5, 88–102.
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Discussion
The relevance of translational neuroscience in psychiatry residency training Commentary on ‘‘Torous et al. A proposed solution to integrating cognitive–affective neuroscience and neuropsychiatry in psychiatry residency training: The time is now’’ Sri Mahavir Agarwal, Ganesan Venkatasubramanian * Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
A R T I C L E I N F O
Article history: Received 28 August 2015 Accepted 28 August 2015 Keywords: Psychiatry Training Translational neuroscience Brain stimulation
1. Commentary In psychiatry, the critical influence of residency training in shaping one’s outlook toward the specialty cannot be overstated. It determines, to a large extent, conceptualization of mental phenomena/related disorders as well as formulation of specific treatment approaches. The psychiatry–neurology dualism that pervades most residency programs across the world has had an adverse impact on psychiatry training. This distinction between specialties largely stemmed from the fact that the pathophysiological processes that led to psychiatric symptoms were unknown at that point in time making them ‘‘functional’’. However, passage of time and lack of concerted attempts toward updating this understanding has resulted in the hitherto unknown being misunderstood as eternally unknowable or non-existent. This has led to cementing of psychiatric disorders as disorders of the ‘‘mind’’, clearly distinct from disorders of the ‘‘brain’’; so much so that several decades of dedicated and fruitful research into the biological basis of symptoms has largely failed to change this
* Corresponding author at: Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India. E-mail address: [email protected] (G. Venkatasubramanian). http://dx.doi.org/10.1016/j.ajp.2015.08.015 1876-2018/ß 2015 Elsevier B.V. All rights reserved.
perception. The average resident in psychiatry is therefore less likely to explore brain based explanations of psychiatric symptoms because they are prejudged to be functional. This is at odds with the current level of knowledge where several concrete examples exist neatly tying region or circuit level activity, or lack thereof, to clinical symptoms. Hence, advances in understanding are slow to permeate through an uninitiated audience; application of this knowledge in routine patient care is slower still. On one hand, this projects psychiatry as a branch not in tune with times, while on the other it exposes it to attacks which question its very basis as a medical branch since it appears not to be rooted firmly in biology. It is in this context that the article by Tourus et al. in the current issue assumes significance. The authors impress upon the reader the need for psychiatric residency to be informed by cognitive– affective neuroscience and neuropsychiatry. With regards to the barriers that impede psychiatry residents from being trained suitably in neurosciences and neuropsychiatry, the authors point to the absence of suitable faculty as a core problem. This again, in our opinion, is a manifestation of the mold psychiatry has cast itself in over the last few decades. Absence of focus on neurosciences has resulted in faculty who are themselves not suitably trained to impart the necessary skills to residents, starting a vicious circle that needs to be broken urgently. The inclusion of brain circuits and anatomical regions related discussions in routine case discussion is
132
S.M. Agarwal, G. Venkatasubramanian / Asian Journal of Psychiatry 17 (2015) 131–132
a novel idea with significant advantages. This approach introduces the concept of neuroscience based causality as well as promotes thinking toward targeted, logical, evidence based strategies that reverse the identified neuropsychiatric deficit. Moreover, such an approach brings the robustness of identifying anatomical and functional neural correlates to the discussion which complements the richness of personalized and phenomenology based approach that is so unique to psychiatry. While similar views have been expressed earlier (Benjamin, 2013; Coverdale et al., 2014), the article’s merit lies in proposing a solution which is ready to work out of the box and which merges seamlessly into the mores and routine of clinical residency. For instance, the description of case study in the article is illustrative of how useful such an approach can be toward both increasing a resident’s understanding of brain processes behind symptoms and facilitating a more informed approach to the management of psychiatric disorders. Moreover, such a method of discussion is likely to encourage residents to learn more about how current modalities of treatment work and help them become more receptive to the latest advances in neurotherapeutics. It will also help them recognize and stay alert to new techniques in future that may potentially improve symptoms. The emergence of various invasive and non-invasive brain stimulation modalities for treating psychiatric disorders over the last few years highlights the challenge in front of us. Application of these techniques assumes thorough understanding of the anatomical and functional basis of effects produced and the brain circuits or regions they act upon. Evidence for the efficacy of techniques like transcranial magnetic stimulation (TMS) (Lefaucheur et al., 2014) and transcranial direct current stimulation (tDCS) (Agarwal et al., 2013; Tortella et al., 2015) in treating psychiatric disorders is fast accumulating. Given the efficacy, safety profile and the interest these techniques have generated in the scientific community, it is likely that they will gradually become commonplace and a psychiatrist will be expected to, at the very least, understand how they work. The authors highlight this in their article and sound a timely warning in saying: ‘‘If psychiatrists do not embrace
opportunities to become specialists in neuromodulation, the void could be filled by other clinical experts in brain functioning.’’ Constant updating of ‘‘knowledge’’ and converting this into ‘‘wisdom’’ that facilitates application is a prerequisite for any scientific field. It is therefore necessary for young psychiatrists to learn to assimilate and apply the knowledge that progress in translational neuroscience makes available to them. That is unlikely to happen unless they are well trained in the nuts and bolts of brain based approach to psychiatry. It is quite possible that in the coming years our understanding might improve further paving the way for identification of psychiatric disease processes at the level of individual neurons and synapses. If psychiatrists are to stay relevant in this ever changing scheme of translational neuroscience, the time to overhaul our training is, as the article by Tourus et al. puts it, right now!
References Agarwal, S.M., Shivakumar, V., Bose, A., Subramaniam, A., Nawani, H., Chhabra, H., Kalmady, S.V., Narayanaswamy, J.C., Venkatasubramanian, G., 2013. Transcranial direct current stimulation in schizophrenia. Clin. Psychopharmacol. Neurosci. 11, 118–125. Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuroscience. Int. Rev. Psychiatry 25, 265–275. Coverdale, J., Balon, R., Beresin, E.V., Louie, A.K., Tait, G.R., Goldsmith, M., Roberts, L.W., 2014. Teaching clinical neuroscience to psychiatry residents: model curricula. Acad. Psychiatry 38, 111–115. Lefaucheur, J.P., Andre-Obadia, N., Antal, A., Ayache, S.S., Baeken, C., Benninger, D.H., Cantello, R.M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di Lazzaro, V., Filipovic, S.R., Hummel, F.C., Jaaskelainen, S.K., Kimiskidis, V.K., Koch, G., Langguth, B., Nyffeler, T., Oliviero, A., Padberg, F., Poulet, E., Rossi, S., Rossini, P.M., Rothwell, J.C., Schonfeldt-Lecuona, C., Siebner, H.R., Slotema, C.W., Stagg, C.J., Valls-Sole, J., Ziemann, U., Paulus, W., Garcia-Larrea, L., 2014. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin. Neurophysiol. 125, 2150–2206. Tortella, G., Casati, R., Aparicio, L.V., Mantovani, A., Senco, N., D’Urso, G., Brunelin, J., Guarienti, F., Selingardi, P.M., Muszkat, D., Junior Bde, S., Valiengo, L., Moffa, A.H., Simis, M., Borrione, L., Brunoni, A.R., 2015. Transcranial direct current stimulation in psychiatric disorders. World J. Psychiatry 5, 88–102.