Psychiatry and Neurology

To the Editor: The proposal in the editorial by Drs. Yudofsky and Hales gives me pause. What is the difference between this proposal and the ones made by others (1, 2)? If the answer is that they continue to include the psychodynamic, interpersonal, and other psychosocial perspectives, do they propose a continuation of psychotherapy training in residency training programs? If not, how are these perspectives to be transmitted? What about retraining for current physicians?

The point about two medical specialties treating disorders of the central nervous system is inaccurate. There are currently four such specialties, the other two being neurosurgery and physical medicine and rehabilitation. Just as the last two distinguish themselves by their treatment modalities, not by their disease entities, so psychiatry and neurology distinguish themselves by their differing treatment targets: the former addressing difficulties in affect, cognition, perception, and behavior and the latter targeting difficulties in movement, sensation, and equilibrium.

Have Drs. Yudofsky and Hales asked neurologists if they wish to attend to problems with affect, cognition, and behavior? Do they or other psychiatrists wish to attend to problems of the senses or extremities or the peripheral nervous system that are remote from their customary clinical problems?

As a child psychiatrist, I can state that the clinical problems we treat are less well defined as neuropsychiatric illnesses, so the argument for merging pediatric neurology and psychiatry is less cogent (3). For example, the hallmarks for defining depression in adults (changes in the hypothalamic-pituitary-adrenal axis, monoamine depletion, altered sleep architecture, increased limbic blood flow, modified periventricular structure, response to pharmacological agents) are equivocal in children, despite the descriptive criteria for the illness being the same.

Finally, even if neurology and psychiatry are merged into a single medical specialty, there is still reason to consider some boundaries. In obstetrics and gynecology, a patient who is in the postpartum may not be in the same hospital unit as a woman with metastatic cervical cancer. Similarly, a patient who is beginning to walk after a stroke, even though he or she may have mood symptoms, may not be best served on a unit with an agitated patient who has schizophrenia and mild motor symptoms. The arguments made by Drs. Yudofsky and Hales are valid, but these issues need to be taken into account.