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All future psychiatrists should be neuropsychiatrists

  • Michael Fitzgerald (a1)
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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1 Conn, R, Cavanna, AE. A meeting point for neurology and psychiatry? Psychiatrist 2013; 37: 147–8.
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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All future psychiatrists should be neuropsychiatrists

  • Michael Fitzgerald (a1)
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eLetters

Why some psychiatrists should continue to directly provide psychological therapies

Mohsin Khan, Foundation Year Two Doctor
13 October 2013

Fitzgerald (1) suggests that psychiatrists should not directly providepsychological therapies. There are a number of reasons why a subset should.

First, specialist experience in delivering psychological therapies may strengthen the skill of a psychiatrist in choosing when and how to usepsychopharmacology. A psychiatrist's experience in administering both psychotherapy and psychopharmacology may improve their ability to judge when to commence, combine or cease either treatment (2). Indeed, the 'New Ways of Working for Psychiatrists' report (3) predicted an increase inthe 'need for support from consultant psychiatrists in psychotherapy' for service users with complex problems.

Second, some service users may need difficult risk assessments while receiving psychotherapy. The different career path of a psychiatrist to that of a psychotherapist may make them better suited to make these assessments.

As for the financial cost of psychiatrists providing psychotherapy being 'prohibitive' (1), Layard et al (4) have argued that the implementation of NICE guidelines requiring psychological therapies may beself-financing when the effect of depression and anxiety disorders upon the wider economy is taken into account.

References:

1. Fitzgerald M. All future psychiatrists should be neuropsychiatrists.The Psychiatrist 2013; 37:309

2. Royal College of Psychiatrists and Royal College of General Practitioners. Psychological therapies in psychiatry and primary care - College Report CR 151. 2008

3. Department of Health. New Ways of Working for Psychiatrists: Enhancing effective, person-centred services through new ways of working in multidisciplinary and multi-agency contexts. 2005

4. Layard R, Bell S, Clark D, et al. The Depression Report A New Deal for Depression and Anxiety Disorders. The Centre for Economic Performance's Mental Health Policy Group, LSE. 2006

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Conflict of interest: None declared

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Psychiatrists as neurologists... or biologists?

Philip Timms, Consultant Psychiatrist
13 October 2013

Michael Fitzgerald thinks that "All future psychiatrists should be neuropsychiatrists" (1) - and, what's more, should only concern themselves with diagnosis and prescribing, leaving psychological treatments to non-psychiatrists. I disagree. Don't get me wrong. I enjoy "hunt the lesion" as much as anyone I know. And I've valuedmy medical-school level neurology on the few occasions when it has come inreally handy. But to hive off all psychological interventions to other professions is where I take issue. Let's look at the two "core" tasks he suggests and try to take the psychology out of them.

In spite of the golden dawn promised over the course of my career, there are still no physical investigations that usefully inform the most common issues of psychiatric diagnosis. The main instrument of investigation continues to be conversation. William Osler stated one of the fundamental principles in this area - "Listen to your patient, he is telling you the diagnosis". This sounds simple, but it clearly is not. Thepatient will only tell the doctor the necessary information if the patientfeels that they are being taken seriously and listened to (2). Some of us are born listeners of this sort, most of us are not. It is a psychologicalskill that we can acquire - but, I have found, one that needs psychological understanding and training. So, diagnosis is not just about working through questionnaires and searching for physical signs, but abouta more subtle and interactive process of building trust and establishing aclear dialogue.

What about prescription? The fact is that even if I aspire only to bea humble manipulator of neurochemicals and pharmaceuticals, psychology andculture keep getting in the way. Apparently straightforward conversations about pharmacological treatments are actually highly loaded psychological interactions which demand psychological skills to negotiate successfully. Which may be why adherence to medication is poor across all areas of medicine (3). And when you bear in mind the limited effectiveness of most biological treatments (again, not unlike the rest of medicine), the prescriber is burdened with the purely psychological task of supporting the patient through the difficult task of trying one drug (or combination)after another to achieve a worthwhile result.

So, the retreat to a bio-pharmacological bunker might be attractive to those who like the spurious certainty of diagnostic and treatment algorithms. It might suit others who prefer to focus on one domain rather than straddle several. However, it just won't work therapeutically. If you separate off psychological skills and social understanding from the training of psychiatrists, we will be training a generation of idiot savants, good only for delivering simplistic (and ever-changing) diagnostic labels, or for prescribing medications that their patients don't take.

References:

1. Fitzgerald M. All future psychiatrists should be neuropsychiatrists.The Psychiatrist. 2013; 37:309. 2. Ley P. (1997) Communicating with patients: improving communication, satisfaction and compliance. Nelson Thornes Ltd.

3. Osterberg L, Blasche K. Adherence to medication. N. Engl J Med 2009; 353: 487-497.

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Conflict of interest: None declared

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