Why is more neuroscience needed within psychiatric training?

Balancing the importance of neuroscience and other biological factors within the biopsychosocial model for best practice has been a controversial topic, subject to much debate. Some argue that psychiatric disorders are primarily disorders of the brain, with ideologies and social practices being woven around core biological concepts, and therefore propose that psychiatrists regain a primarily neurological focus.^{Reference Mitchell and Agrawal4,Reference Berrios and Marková8} Others suggest that psychosocial factors should receive more focus in research and practice, arguing that, since the Decade of the Brain in the 1990s, neuroscience has received much investment without delivering significant results or changes in practice.^{Reference Kingdon9} Most support an approach that develops all aspects of the biopsychosocial model, conceptualising neuroscience in the context of its psychological and environmental interactions.^{Reference Hill10,Reference Bolton11} Equal emphasis on all aspects of biopsychosocial care in training is key for developing global understanding and retention of multimodal learning.^{Reference Bolton11,Reference Prosser, Helfer and Leucht12} It allows for individualised person-centred care, a highlight of the new RCPsych curricula, in which a person's needs and values are best met, leading to improvement in patient experience, outcomes, clinicians’ work satisfaction and reduced work-related stress.^{Reference Boardman and Dave13–15} This concept has recently been expanded by Gómez-Carrillo et al (2023), who suggest that neuroscience should be integrated into psychiatry using a cultural ecosystems approach rather than using pre-existing brain-centric models, promoting sociocontextual and more systemic thinking.^{Reference Gómez-Carrillo, Kirmayer, Aggarwal, Bhui, Fung and Kohrt16}

There is of course acknowledgement that most psychiatric disorders have a direct neural component. In these cases, it is crucial for psychiatrists to have sufficient neuroscientific knowledge and skills to facilitate accurate diagnosis, provide meaningful explanations to patients, enable shared decision-making and manage the interface with medical colleagues, leading to better patient outcomes.^{Reference O'Loughlin1} The huge surge in research concerning the neuroscientific aspects of psychiatric symptoms and diagnoses in the past few decades has advanced the understanding of depression, psychosis and dementia,^{Reference Kanner17–Reference Arvanitakis, Shah and Bennett19} the detection and management of autoimmune encephalitis,^{Reference Uy, Binks and Irani20} as well as having led to emerging pioneering treatments such as deep brain stimulation.^{Reference Mahoney, Koch-Gallup, Scarisbrick, Berry and Rezai21} We have observed improved understanding of the interactions between core neurological and psychiatric conditions, such as depression and anxiety in both epilepsy and multiple sclerosis, and psychosis in Parkinson's disease.^{Reference Agrawal and Rickards22–Reference Creese, Politis, Chaudhuri, Weintraub, Ballard and Aarsland24} Neuropsychiatry is often considered the bridging discipline for psychiatry and other brain-based specialties, fostering the integration of neuroscience into patient care, training and research.^{Reference Lishman2–Reference Mitchell and Agrawal4,Reference Sachdev25} In the future, increased patient needs may overwhelm neuropsychiatry's specialist capacity, where there is already considerable regional variation, resulting in general adult psychiatrists needing to be better equipped to manage these issues (in conjunction with neurology colleagues).^{Reference Mitchell and Agrawal4,Reference Molina-Ruiz, Nakagami, Mörkl, Vargas, Shalbafan and Chang26}

The understanding of neuroscience, as well as other medical topics, remains lacking within the profession worldwide, with some psychiatrists and other clinicians previously described as being ‘neurophobic’ and ‘medically deskilled’.^{Reference Bullmore, Fletcher and Jones27–Reference Goodwin and Geddes29} Anecdotally we are aware that many psychiatrists in the UK, including trainees, currently feel overwhelmed and lacking in confidence when it is necessary to integrate neuroscientific principles into their clinical practice. With the absence of expectation that neuroscience knowledge and skills should be kept up to date after the MRCPsych has been completed, often combined with the geographical divide between mental and physical healthcare, essential competencies can be lost. The presence of role models and the development of a culture within the profession would be beneficial but can only be developed over time within the construct of RCPsych training and professional development initiatives. Any step forward should of course not minimise the existing emphasis on psychosocial sciences.

In the literature, trainees and training directors have repeatedly called for more neuroscience within psychiatry training, with studies from the UK, USA, Canada and Australia all revealing similar views.^{Reference Schon, MacKay and Fernandez30–Reference Rego, Eratne, Walterfang and Velakoulis33} The recent survey by Molina-Ruiz et al (2023) of early career psychiatrists from 35 countries again reported a strong preference for more neuroscience training, as well as a better relationship between neurology and psychiatry: 72% acknowledged the extent of regional variation, in part due to political and economic factors, posing the question of how increased training can be practically implemented given current constraints.^{Reference Molina-Ruiz, Nakagami, Mörkl, Vargas, Shalbafan and Chang26} Similarly in the UK, in an unpublished survey of 822 psychiatry trainees (54% core trainees, 46% higher trainees) undertaken by the RCPsych Faculty of Neuropsychiatry in 2012, 75.2% expressed an interest in wanting more neuropsychiatry training even though only 25% wished to pursue neuropsychiatry as a career choice, highlighting the acknowledged relevance of neuroscientific skills for all psychiatrists regardless of intended subspecialty.

How might psychiatry training be modified to integrate more neuroscience?

Proposals for better integration of neuroscience into psychiatry training date back 50 years, with previous calls for neuropsychiatrists to lead on this issue.^{Reference O'Loughlin1,Reference Mitchell and Agrawal4,Reference Hill10,Reference Schon, MacKay and Fernandez30–Reference Roffman, Simon, Prasad, Truman, Morrison and Ernst32,Reference Benjamin34,Reference Arciniegas and Kaufer35} Box 1 illustrates some of the global initiatives to date, mostly aimed at improving resources for those wishing to improve their neuroscientific knowledge and skills in their own time and having an existing specialist interest in the subject. Although these measures have been successful to an extent, this article argues that without fully embedding neuroscience within the curriculum, they may not engage and be inclusive for all learners regardless of subspecialty, particularly those not naturally neurologically inclined.

Efforts thus far have been limited by several barriers, noted both in the UK and internationally. Particular obstacles have been a paucity of leading experts who might teach and impart knowledge, regional disparities challenging reliable clinical exposure, limited specified requirements within the psychiatry curriculum and a lack of drive among some general psychiatrists to continue to develop and embed neuroscientific skills into practice.^{Reference Sachdev25,Reference Arbuckle, Travis, Eisen, Wang, Walker and Cooper38,Reference Nasrallah42,Reference Schildkrout, Benjamin and Lauterbach43}

Developments in online learning potentially offer a solution. A ‘blended’ learning regime (a combination of face-to-face opportunities with online teaching and resources made necessary by the COVID-19 pandemic) has become the accepted norm and complements the emergence of hybrid working.^{Reference Dhawan44} There are fewer time constraints on teachers and learners and a variety of andragogic methods available with guidance for best practice.^{Reference Dhawan44,Reference Daniel, Gordon, Patricio, Hider, Pawlik and Bhagdev45} More centralised learning is now possible, with the option of creating regional hubs to direct learning opportunities and offer appraisal. Learners who do not have neuropsychiatrists in their training location can now access hybrid teaching sessions, clinical exposure opportunities, remote supervision and an array of online learning resources.^{Reference Schildkrout, Benjamin and Lauterbach43} Work undertaken by the National Neuroscience Curriculum Initiative (NNCI) and Gatsby Project (Box 1), as well as other independent groups, can be utilised, further developed and used to inspire additional initiatives.^{Reference Arbuckle, Travis, Eisen, Wang, Walker and Cooper38,Reference Burns39} Developing a culture of engagement and interactivity is key, with senior psychiatrists and educators reinforcing these links. Advocacy within overarching psychiatric and medical organisations is a crucial component to prioritise neuroscience education and set expectations for the level of knowledge and skills required, with endorsement and support of the new learning opportunities available.^{Reference Schildkrout, Benjamin and Lauterbach43}

Suggested template for the reintegration of neuroscientific principles into psychiatric training, continued learning and clinical practice

Considering international successes, barriers and developments to date, a template is suggested below for how neuroscience can be best integrated into life-long learning for psychiatrists. Although the UK is used as a case example, integration principles and strategies can be similarly applied internationally.

Consideration of learning opportunities at all stages of training

All levels of training must be considered to better integrate neuroscientific knowledge and skills into psychiatric practice. Suggestions for integrating neuroscience training at various career points are listed in Table 1.

Table 1 Options along the UK psychiatry training pathway

MRCPsych, Royal College of Psychiatrists’ membership examination; U, undergraduate; FY, foundation years; CT, core psychiatry training; ST, higher/specialist psychiatry training; CPD, continuing professional development for those not in training.

Combining teaching for brain-based specialties as early as medical school might affect how all clinicians view mental health within medicine as a whole, with previously reported success in combining neurology and psychiatry placements.^{Reference Glick, Armstrong, Waterman, Hundert and Hyman47,Reference Ogur, Hirsh, Krupat and Bor48} As well as joint placement options, integrating teaching across Foundation Years is another option for establishing collaboration across disciplines.

Local psychiatry teaching programmes (often referred to as MRCPsych courses) provide a key opportunity for scaffolding the knowledge and skills of core trainees, with neuroscientific teaching potentially involving expert-delivered sessions online across regions, thereby improving consistency and removing geographical disparities.^{Reference Vassilas and Berrisford49} Additional eLearning and external courses or conferences could be highlighted in MRCPsych courses for those who wish to develop skills further, endorsed by local training directors. Offering ‘neuro case discussion groups’ to core and specialist psychiatry trainees, where case formulations with a neurological (or biological) component are developed, would be possible. Appropriate supervision can be offered virtually where there is a paucity of experts.^{Reference Benjamin34,Reference Torous, Stern, Padmanabhan, Keshavan and Perez37} Such groups might highlight how best to integrate all perspectives (from biological to psychosocial), validating each other to advance the holistic and global perspective of the clinical case discussed.^{Reference Kendler, Parnas and Zachar50} Close collaboration between psychiatrists, other clinicians in the field of neuroscience and non-clinical researchers might further support this process, as well as offering mentorship and promoting further academic opportunities.^{Reference Posporelis, Sawa, Smith, Stitzer, Lyketsos and Chisolm51} Neuropsychiatric, neurological or medical placements could also be optimised at all trainee levels, with additional options of special interest or taster sessions, thereby creating opportunities for wider clinical exposure with local trainer endorsement.^{Reference Benjamin34,Reference Agrawal, Fleminger, Ring and Deb52} Joining neuropsychiatry patient assessments or group sessions remotely might be another option, with appropriate consent and organisational support.

Learning opportunities need not be limited to training levels but should support CPD for all clinicians. Regular neuroscientific sessions within a trust's academic programmes can be optimised, with local programmes supporting trainees to attend other regional programmes (e.g. at regional neuroscience centres) remotely if these sessions are unavailable. Additional online national options can keep neuroscientific knowledge and skills up to date, as well as applying these to clinical practice, as seen in recent initiatives such as the introduction of Dean's Grand Rounds and the Enhancing Generalist Skills programme (‘enhance’).^53,54 Formalised credentialling for neuropsychiatry may open the route for an accredited path to acquiring neuropsychiatry and neuroscience experience in the future.

Any proposed changes, of course, need to fit into the existing RCPsych curricula,⁴⁶ which state that all neuroscience training or exposure within psychiatry should be considered with an equal emphasis on psychosocial aspects of care, all part of a holistic psychosocial model. As the current focus is tailoring education to individual need, the option of introducing additional mandatory neuroscience requirements does not appear viable. The focus therefore needs to be on optimising opportunities, making them easier to access, of sound quality and thereby more appealing. An eventual change in attitude, expectation and culture is the overall aim, with trainees wanting to embed the knowledge and skills learned for exams into their life-long practice. We believe that this can be achieved in time, with senior psychiatrists leading by example, ideally with RCPsych endorsement, routinely considering neuroscientific principles within their clinical practice and demonstrating how others might do the same.