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March 12, 2020

The Convergence of Neurology and Psychiatry: The Importance of Cross-Disciplinary Education

Author Affiliations
  • 1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2McLean Hospital, Harvard Medical School, Boston, Massachusetts
  • 3Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
JAMA. 2020;324(6):554-555. doi:10.1001/jama.2020.0062

The collaboration between neurology and psychiatry, 2 medical specialties that share the same organ, has wavered throughout history. Hippocrates viewed mental disorders as arising from the brain. However, focus during the Middle Ages and later cartesian mind-body dualism separated most disorders of the mind from the province of medicine. The fields converged in the 19th century with the advent of natural sciences and the emergence of neuropathology. Broca, Wernicke, Charcot, Alzheimer, Kraepelin, and Freud were all pioneering physicians who practiced both fields.

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    4 Comments for this article
    They're mostly separate with reason
    Richard Lunsford, MD | Hospital
    If you watch how psychiatrists go about their day vs. how neurologists go about their day on ward rounds, how they assess and approach their patients, it's plain to see for most there's a difference.

    A psychiatrist already likely finds a number of print publications in his mailbox, and multiple profession-related e-mails about psychiatry and general medical issues in his or her e-mail inbox most every day, more than all but the most brilliant fanatics could keep up with.

    Trying to turn these professions into each other would be a mistake. Some limited 'cross-pollination' is gainful, but how
    many dually trained psychiatrists/neurologists do we see? How many practitioners of the one are eager to practice the other in a big way? It's fine that some may wish to delve into both, but don't inflict it on everyone.

    Psychiatrists will continue to treat often-subjectively reported symptoms such as depression with suicidal ideation or paranoia and 'hearing voices' based on patient report and/or observed behavior, without regard to whether imaging studies show a lesion.
    Duration of Training
    Murli Mishra, Ph.D. | St. George's University School of Medicine, Grenada; Jackson Memorial Hospital, Miami, FL
    I read this article with great interest. I personally know medical students who would prefer dual training over specializing only in Neurology or Psychiatry. However, there are others who would prefer to specialize only in one of these fields. Most medical students interested in dual residency program abstain from pursuing it in reality because of one common reason: duration of a dual residency program. There are many students who apply to Neurology and to Psychiatry residency programs (i.e. 4 year programs in USA) but avoid applying to Neurology + Psychiatry combined residency program (i.e. 6 year programs in many US schools that offer the opportunity). My comment may involve potential bias as it is based on my discussion with 3 medical students in the past few months who are planning to apply to both Neurology and Psychiatry residencies. I decided to comment based on the assumption that many other medical students share similar concerns.

    If we could somehow combine Neurology and Psychiatry curricula into a 4 year program, probably we will see a boost in number of applicants. There are multiple tracks possible for such programs. For example, first year training can still be general medicine training followed by 3 years of neuropsychiatry training. Those 3 (out of 4) years can be a combination of 1.5 years Neurology and 1.5 years Psychiatry training. Alternatively, it could be 2 years of Neurology and 1 year of Psychiatry training or vice versa depending on the interests of trainee or goals of institute.

    We can still enjoy the structured independent Neurology and Psychiatry residency training programs available across USA. Reducing the duration of dual Neurology + Psychiatry residency programs can boost the interest of students that may help to merge the two fields in the future.
    Separation is Hard to Justify
    Shelley Enger, PhD, MPH | Unaffilated
    I am an epidemiologist and caregiver for someone with a serious brain disorder. I think that the dichotomy of psychiatry and neurology has hindered, and continues to hinder, progress in the treatment of brain disorders.

    Many neurological disorders have psychiatric symptoms, and neurological and psychiatric conditions often co-occur. By treating brain and mind separately, couldn't we be missing critical clues about the underlying causes of these conditions that could lead to more effective treatments or to more effective use of current treatments from either specialty?

    Mental illness and death by suicide among the young and middle-aged is epidemic.
    We need to better understand how brain biology is changed in ways that hijack innate self-preservation instincts and create anti-survival behavior. How can we do this if brain and mind are studied and treated separately?

    Chronic fatigue syndrome has shown us that if a brain disorder can only be diagnosed from symptoms, we probably just don’t have the technology yet to visualize the brain structure or biochemistry that causes or occurs with the disorder. Imaging has already established that significant biological changes occur in the bipolar brain, and yet it is still treated exclusively in the behavioral health domain. Where does psychiatry end and neurology begin?

    Common sense suggests that separation of psychiatry and neurology leads to blind spots in both fields.
    Commonality of the Brain in our Specialties
    Blake O'Lavin, MD | Partially Retired General Neurologist
    Sharing postgraduate training in neurology and psychiatry has been desirable for the last 3 decades and, as the author advocates, is even more so now as our brain science advances. Unfortunately, both specialties are fragmenting themselves into sub-specialities with 1 and 2 year fellowships with certification exams and maintenance requirements. Only if a combined training program can be kept to 4 or 5 years will it become attractive. Neither speciality rewards financially enough to delay practice much past age 30.