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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. Published online March 12, 2020. 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.

The emphasis in psychiatry on the brain diminished in mid-20th century and resulted from the post-World War II dominance of psychoanalysis, together with the inability to identify the neuropathology in major psychiatric disorders. Reflecting the separation of neurology and psychiatry, the Archives of Neurology and Psychiatry, first published in 1919, divided in 1960 into the Archives of Neurology and Archives of General Psychiatry, the forbearers of JAMA Neurology and JAMA Psychiatry.1,2

Over the past half century, advances in basic and clinical neuroscience, including neuroimaging, network connectomics, molecular genetics, epigenetics, and neuroplasticity have blurred the boundaries between the 2 disciplines and have led to efforts for renewed convergence. Defining neurology as the study of the brain and psychiatry as the study of the mind is no longer tenable. Brain circuits do not distinguish between neurologic and psychiatric disorders; clearly, practitioners at the mind-brain interface should develop diagnostic and therapeutic expertise across the clinical neurosciences. Currently however, shared learning between neurology and psychiatry is limited in medical school and in residency training at most US educational programs. Training accreditation, made by a board that is shared by neurology and psychiatry, has resulted in suboptimal lengths of neurology training in psychiatry and of psychiatry training in neurology. There is little, if any, training in neurosurgery for psychiatry residents and vice versa.

Recent approaches to develop biomarker-based classifications in psychiatry, such as the research domain criteria3 and identification of biotypes in psychotic disorders,4 are advancing a biological basis for major psychiatric disorders. Novel teaching approaches, such as the National Neuroscience Curriculum Initiative,5 clinical-pathological conferences, and neurobiopsychosocial formulations applied to both psychiatric and neurologic conditions,6 are promising developments. Brain-behavior relationships are bidirectional and cut across both disciplines; psychosocial factors are critical for developing patient-centered treatment plans. The subspecialties of behavioral neurology and neuropsychiatry, open to both neurologists and psychiatrists, have emerged at the intersection of clinical neuroscience.7

At a 2005 conference on “The Convergence of Neuroscience, Behavioral Science, Neurology and Psychiatry,”8 a consensus emerged on “the importance of cross-disciplinary education at every level from the aspiring college student interested in brain science to exploring new models for postgraduate education in the clinical and basic neurosciences.” It was noted that “Although revolutionary changes were advanced by some, most participants favored incremental change.” In 2017, Heckers9 asserted “the training of psychiatrists in the US is still brainless” and advocated for “neuroscience literacy to become as crucial for good psychiatric practice as empathy already is.” In 2019, Josephson1 announced plans to share relevant articles between JAMA Neurology and JAMA Psychiatry and stated “never before have neurology and psychiatry so needed publications that recognize the rich partnership between the fields—one that was once a historical footnote but now appears to be an exciting future.”

However, incremental changes have proven insufficient. Educational efforts at both the medical school and residency levels have remained short sighted. Both neurologists and psychiatrists need strong training in core principles of clinical neuroscience (traditionally stronger in neurology), as well as listening, and interview skills and psychosocial determinants of illness (emphasized more in psychiatry). A substantial reconfiguration of training is needed in both medical school and during residency. A strengthened curriculum of clinical neuroscience education in the fourth year of medical school (for those already planning a clinical neuroscience–related residency) could permit an enriched student experience in neurology, psychiatry, and neurosurgery. Rotations would include child neurology and psychiatry and electives in subspecialty areas such as neuroradiology, neuropathology, neuromodulation, and allied subspecialty outpatient clinics. Emphasis on outpatient engagement would be important because much of hospital-based clinical education deals with the most difficult and unusual patients.

A substantial transformation is also needed in joint training in neurology and psychiatry residency programs. After a required year or less of general medicine, the following 2 years of clinical neuroscience could encompass both fields with special attention to areas of overlap. The following 2 years could differentiate into neurology and psychiatry specialization followed by further fellowship-based subspecialization as desired. This continues a cross-disciplinary clinical thread spanning the entirety of residency, including longitudinal relationships with patients and peers. Such subspecialization could include joint fellowships (eg, neuropsychiatry and behavioral neurology training), an important area of training for both fields. The interdependence of mental, medical, and social health could be emphasized. Integrative department structures, teaching conferences, clinical-pathology correlations, and didactics could be critical program components.

This model could serve to shift the fields from a lesion-based model toward a network-based one, from a unidirectional framework toward a bidirectional framework of interactions, from exclusive reliance on categorical diagnoses toward transdiagnostic dimensional perspectives, from silo-based approaches toward interdisciplinary ones, and from biologically isolated methodologies toward integration of neuroscience with psychosocial and cultural factors.7 These changes may lead to an increased number of medical students drawn to these specialties and could potentially create new leadership and more fundamental knowledge. This model is presented in the context of the mutual challenge given that psychiatric and neurologic disorders are highly prevalent, expensive to society, and among the most disabling illnesses in all of medicine throughout the world per estimates from the World Health Organization.

Institutional, structural, and cultural changes must occur to accommodate this reconfiguration. Barriers to change include persistent mind-body dualism, the complexities and uncertainties of psychiatry that have yet to translate into clinical practice, public and professional stigma (within psychiatry and neurology as well), and the lack of parity in reimbursement and federal funding. Rigid educational traditions set more than a century ago, engrained cartesian concepts, and protective instincts regarding professional turf remain challenges. The time for change is now. Open debate followed by actionable suggestions is needed. Novel experimental approaches are encouraged. Rather than further contracting into separate fields, the convergence of neurology and psychiatry should span the unique intersections of humanity, philosophy, and science.

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Article Information

Corresponding Author: Matcheri S. Keshavan, MD, Harvard Medical School, Beth Israel Deaconess Medical Center, 75 Fenwood Rd, Boston, MA 02115 (keshavanms@gmail.com).

Conflict of Interest Disclosures: None reported.

Published Online: March 12, 2020. doi:10.1001/jama.2020.0062

Additional Contributions: We are grateful to David Perez, MD, for his substantive and helpful input in writing this article.

Josephson  SA.  100 years of JAMA Neurology and the journey back to the beginning.  JAMA Neurol. 2019;76(11):1279-1280. doi:10.1001/jamaneurol.2019.3056PubMedGoogle Scholar
Öngür  D.  Celebrating the 100th anniversary of the Archives of Neurology and Psychiatry JAMA Psychiatry. 2019;76(11):1115-1116. doi:10.1001/jamapsychiatry.2019.3127PubMedGoogle ScholarCrossref
Insel  T, Cuthbert  B, Garvey  M,  et al.  Research domain criteria (RDoC): toward a new classification framework for research on mental disorders.  Am J Psychiatry. 2010;167(7):748-751. doi:10.1176/appi.ajp.2010.09091379PubMedGoogle ScholarCrossref
Clementz  BA, Sweeney  JA, Hamm  JP,  et al.  Identification of distinct psychosis biotypes using brain-based biomarkers.  Am J Psychiatry. 2016;173(4):373-384. doi:10.1176/appi.ajp.2015.14091200PubMedGoogle ScholarCrossref
Ross  DA, Arbuckle  MR, Travis  MJ, Dwyer  JB, van Schalkwyk  GI, Ressler  KJ.  An integrated neuroscience perspective on formulation and treatment planning for posttraumatic stress disorder: an educational review.  JAMA Psychiatry. 2017;74(4):407-415. doi:10.1001/jamapsychiatry.2016.3325PubMedGoogle ScholarCrossref
Torous  J, Stern  AP, Padmanabhan  JL, Keshavan  MS, Perez  DL.  A proposed solution to integrating cognitive-affective neuroscience and neuropsychiatry in psychiatry residency training: the time is now.  Asian J Psychiatr. 2015;17:116-121. doi:10.1016/j.ajp.2015.05.007PubMedGoogle ScholarCrossref
Perez  DL, Keshavan  MS, Scharf  JM, Boes  AD, Price  BH.  Bridging the great divide: what can neurology learn from psychiatry?  J Neuropsychiatry Clin Neurosci. 2018;30(4):271-278. doi:10.1176/appi.neuropsych.17100200PubMedGoogle ScholarCrossref
Hager  M, ed.  The Convergence of Neuroscience, Behavioral Science, Neurology and Psychiatry, Proceeding of a Conference Chaired by Joseph B. Martin. Penguin Books; 2005.
Heckers  S.  Project for a scientific psychiatry: neuroscience literacy.  JAMA Psychiatry. 2017;74(4):315. doi:10.1001/jamapsychiatry.2016.3392PubMedGoogle ScholarCrossref
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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.