Neuroskeptic has launched the “mother of all blog posts” against my article, published earlier this week.
Neuroskeptic is skeptical that there is a “War Between Neuroscience and Psychiatry.” I fully agree. There is NOT a war and I regret the first title that was published with my piece. I did not choose “War Between Neuroscience and Psychiatry” and was grateful when the editors changed the title to “Why Psychiatry Needs Neuroscience” at my request.
I’m thrilled that Neuroskeptic was so engaged by my piece. My goal was to break down the false dichotomy between neuroscience and psychiatry with arguments like “what organ do psychiatrists treat if not the brain? And what framework could possibly be more relevant than neuroscience to understanding brain dysfunction?”
And yet, Neuroskeptic missed the point. In their (I will use the pronoun “they” since we don’t know who Neuroskeptic is or what their credentials are) article, Neuroskeptic undermines and ignores the very real struggle that I, as a clinical neuroscientist, am drawing attention to.
For example, they argue that “it’s naïve to think that we will understand the brain well enough for [a neuroscience framework] to work.” May I ask Neuroskeptic what disease process we do have an exhaustive knowledge of?
In medical school and residency, I recall learning many unknowns about heart physiology, perhaps the best “figured out” of organs. And yet no rational person would suggest that cardiologists should abandon heart physiology and statins for humorism and bloodletting. So why should psychiatrists turn away from neuroscience simply because we do not have a unifying theory of neuroscience?
Another example Neuroskeptic used to minimize the relevance of neuroscience to clinical care was drug discovery: “The big discoveries in psychiatric medications were driven by serendipity, not through mechanism-based research.”
Well, that’s true for many medicines. I suggest Neuroskeptic learn about the history of antibiotics beginning with the serendipitous discovery of penicillin. Or perhaps chemotherapy medications. Or perhaps even aspirin. Serendipity and data-science can both be our clinical allies.
Because we have studied and now know penicillin’s precise mechanism of action, we can manipulate the penicillin molecule to be more effective (e.g. piperacillin, ampicillin, etc). Clinical outcome studies of penicillin’s efficacy in different bacteria have allowed us to predict which bacteria penicillin can effectively kill, yielding a serious clinical tool to guide antibiotic therapy in patients. Further applying a physiological framework to evaluate moments when penicillin is not fully effective has allowed scientists to develop molecules like sulbactam and clavulanic acid, both of which act on specific bacterial pathways to amplify penicillin’s effect. This could only have been accomplished because we understand penicillin’s mechanism of action and the bacteria penicillin targets.
Medicine embraces but does not rely on serendipity.
Data-driven frameworks like the neuroscience framework I wrote about similarly allow clinicians to embrace serendipity while they develop testable hypotheses to evaluate and improve patient care. Something Neuroskeptic ought to know.
Such missteps tell me that Neuroskeptic isn’t a clinician (though in the absence of data, I may be wrong).
Without clinical experience, how could Neuroskeptic know the difficulty clinicians like myself have in convincing my colleagues that neuroscience frameworks are relevant to psychiatry? I wonder if Neuroskeptic has ever debated a patient’s plan of care with someone who doesn’t value neuroscience. It’s an awakening experience.
Neuroskeptic may be unaware of the National Neuroscience Curriculum Initiative, which was funded by the U.S. National Institutes of Health with the explicit goal of helping psychiatry trainees appreciate, understand, and implement a neuroscience framework in their clinical care.
And how could Neuroskeptic appreciate very serious resistance within psychiatry to the use of data science in patient care, a controversy that I discussed in “The Rise of Evidence-Based Psychiatry”?
Perhaps I may be of help. Below is a brief reading list for Neuroskeptic (or anyone) who does not have clinical experience and wishes to learn more:
I recommend they read commentaries by John Torous and Justin Baker, Harvard clinical psychiatrists published in JAMA Psychiatry, who promote the data-driven methods in psychiatry as a way to “unify” the field and improve patient care.
And the series of articles I mentioned in my piece, including David Ross’s educational review in JAMA Psychiatry, “An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder.” (One might wonder why such a series would be necessary if neuroscience was already incorporated into clinical practice.)
And the article by a Chair of Psychiatry, Dr. Sophia Vinogradov, in Nature Human Behavior who further attempts to persuade her colleagues to consider and implement the vast amount of knowledge we have about neurocircuits, neuroplasticity, and computational neuroscience in the way we evaluate and treat patients.
And the book “Shrink: the untold story of Psychiatry” by Jeffrey Leiberman, Columbia University’s Chair of Psychiatry and previous President of the American Psychiatric Association. In this highly-enjoyable memoir-style narrative, he outlines the history of this “Fake War”, and how long and hard clinical neuroscientists like Leiberman fought to bring about more data-driven approaches to the field.
Finally, if Neuroskeptic is interested in first-hand clinical experience, perhaps I can help organize for them come to New Haven and spend a day with us. Learning about clinical applications of neuroscience (say, at our Clinical Neuroscience Research Unit) would be a valuable experience to anyone who would like to understand and comment on the controversy, not simply as a skeptic but as someone in the trenches.
Editor's note: this post has been updated by the author, starting with the paragraph that begins "Well, that's true for many medicines" and ending with the paragraph that begins "Data-driven frameworks..."