EMPIRICAL REPORT

Neuropsychiatry and Neuroscience Education of PsychiatryTrainees: Attitudes and Barriers

Sheldon Benjamin & Michael J. Travis &

Joseph J. Cooper & Chandlee C. Dickey &

Claudia L. Reardon

Received: 22 June 2013 /Accepted: 4 November 2013 /Published online: 19 March 2014# Academic Psychiatry 2014

AbstractObjective The American Association of Directors of Psychi-atric Residency Training (AADPRT) Task Force on Neuro-psychiatry and Neuroscience Education of Psychiatry Resi-dents was established in 2011 with the charge to seek infor-mation about what the field of psychiatry considers the coretopics in neuropsychiatry and neuroscience to which psychi-atry residents should be exposed; whether there are any “com-petencies” in this area on which the field agrees; whetherpsychiatry departments have the internal capacity to teachthese topics if they are desirable; and what the reception wouldbe for “portable curricula” in neuroscience.Methods The task force reviewed the literature and developeda survey instrument to be administered nationwide to allpsychiatry residency program directors. The AADPRT Exec-utive Committee assisted with the survey review, and theirfeedback was incorporated into the final instrument.Results In 2011–2012, 226 adult and child and adolescentpsychiatry residency program directors responded to the sur-vey, representing over half of all US adult and child psychiatrytraining directors. About three quarters indicated that faculty

resources were available in their departments but 39 % felt thelack of neuropsychiatry faculty and 36 % felt the absence ofneuroscience faculty to be significant barriers. Respectively,64 and 60 % felt that neuropsychiatry and psychiatric neuro-science knowledge were very important or critically importantto the provision of excellent care. Ninety-two percent wereinterested in access to portable neuroscience curricula.Conclusions There is widespread agreement among trainingdirectors on the importance of neuropsychiatry and neurosci-ence knowledge to general psychiatrists but barriers to train-ing exist, including some programs that lack faculty resourcesand a dearth of portable curricula in these areas.

Keywords Psychiatric residency education . Curriculumdevelopment . Neuropsychiatry . NextAccreditation System .

Milestones

For at least 50 years, leading psychiatrists have called forpsychiatry to embrace the inclusion of additional training inneurology, neuropsychiatry, and neuroscience as part of psy-chiatry training [1–14]. Whereas the majority of psychiatryprograms offer seminars in neurology for psychiatrists [15]and neuropsychiatry training objectives for psychiatrists havebeen promulgated [16], the number of programs offeringneuropsychiatry and psychiatric neuroscience education perse is not known. The Accreditation Council for GraduateMedical Education (ACGME) and the American Board ofPsychiatry and Neurology (ABPN) specify that psychiatryresidency must include at least 2 months of neurology train-ing, defined as “supervised clinical experience in the diagno-sis and treatment of patients with neurological disorders/conditions” [17]. As part of the ACGME’s Next AccreditationSystem [18], all medical specialties will measure progresstoward competency by the achievement of training mile-stones. The inclusion of milestones in clinical neuroscience

S. Benjamin (*)University of Massachusetts Medical School, Worcester, MA, USAe-mail: sheldon.benjamin@umassmed.edu

M. J. TravisUniversity of Pittsburgh School of Medicine, Pittsburgh, PA, USA

J. J. CooperUniversity of Chicago, Chicago, IL, USA

C. C. DickeyV.A. Boston Healthcare System, Brockton, MA, USA

C. L. ReardonUniversity of Wisconsin School of Medicine and Public Health,Madison, WI, USA

Acad Psychiatry (2014) 38:135–140DOI 10.1007/s40596-014-0051-9

means that, for the first time, the content of neurology, neu-ropsychiatry, and neuroscience training of psychiatry residentswill be specified [19]. We conducted the American Associa-tion of Directors of Psychiatric Residency Training(AADPRT) Neuropsychiatry and Neuroscience Education ofPsychiatry Residents Survey to determine the views of adultand child and adolescent psychiatry residency directors on theimportance of neuropsychiatry and neuroscience education ofgeneral psychiatrists and the barriers that may exist to widerimplementation of related educational content.

Methods

All 486 US general adult psychiatry and child and adolescentpsychiatry residency directors and associate residency direc-tors were sent invitations to an anonymous online survey.Nonresponders were sent three follow-up invitations. Forpurposes of this survey, we defined neuroscience as the studyof the nervous system and behavior using cellular and molec-ular biology, animal models, neuroanatomy, neuroimaging,genetics, neuropsychology (cognitive neuroscience), and ba-sic pharmacology (not clinical pharmacology) andneuropsychiatry as the clinical study of brain–behavior rela-tionships as revealed through the psychiatric manifestations ofneurological disorders and the neurobiology of psychiatricdisorders.We based the survey content on a review of relevantliterature and vetted it with the AADPRT Executive Commit-tee. The survey instrument included inquiry as to availabledepartment resources (neuropsychiatry residency or fellow-ship programs, neuroscience doctoral and postdoctoral pro-grams, faculty identified as neuropsychiatrists or psychiatricneuroscience researchers), respondent attitudes (number ofyears until neuroscience advances will change treatment, im-portance of neuropsychiatric and neuroscience knowledge toresidents entering psychiatry training in 2012, differentiationof neuropsychiatry from general psychiatry), and importanceto psychiatry trainees of familiarity with research findingslinked to the NIMH Research Domain Criteria (RDoC) [20]

and competency in neuropsychiatric clinical skills. Respon-dents were queried as to the amount of didactic time and typeof teaching currently dedicated to these areas and to the degreethey felt that availability of resources in their departmentsposed barriers to enhancing neuropsychiatry and neurosciencetraining. Respondents were then asked about their interest inthe development of portable neuroscience curricula. We car-ried out between-group comparisons using independent sam-ples t tests. Some of the questions in the survey intentionallyoverlapped with a survey by Fung et al. [21] to facilitatecomparison with responses by general psychiatry practi-tioners, department chairs, and residents.

Results

Two hundred twenty-six people responded to the survey,representing over 58 and 55 % of adult and child and adoles-cent psychiatry programs, respectively. Respondent character-istics are listed in Table 1. Sixty-two percent of the respon-dents were at university-based programs, and 38 % represent-ed a variety of public and private sector programs.

Resources

Seventy-four percent of the respondents had one or morefaculty members who identified themselves as neuropsychia-trists, and 81 % had one or more psychiatric neuroscienceresearchers. Sixty-four percent were affiliated with institutionsoffering doctoral or postdoctoral work in psychiatric neuro-science, 22 % were part of institutions offering neuropsychi-atry or behavioral neurology fellowships, and 7 % said theirinstitutions offered psychiatry/neurology “double board”programs.

Attitudes

Thirty-two percent of respondents felt that neuroscience ad-vances would lead to significant new treatments or the

Table 1 Characteristics of survey respondents (N=226 unique respondents including 32 respondents identifying as both adult and child psychiatryeducators; 47% response rate)

Adult psychiatry (N=169) Child and adolescent psychiatry (N=89)

Training directors Associate directors Chair/vice chair/division head

Training directors Associate directors Chair/vice chair/division head

106 (58 % of programs) 43 20 67 (55 % of programs) 14 8

>20 years sinceresidency: 45

> 20 year sinceresidency: 8

> 20 year sinceresidency: 14

>20 years sinceresidency: 25

>20 years sinceresidency: 1

>20 years sinceresidency: 5

0–5 years in position: 72 ≥6 years in position: 80 0–5 years in position: 38 ≥6 years in position: 44

136 Acad Psychiatry (2014) 38:135–140

personalized application of existing therapies in 5 years, 50 %in 10 years, 14% in 20 years, and 4% in greater than 20 years.Asked to consider residents beginning training in 2012, 64 %considered neuropsychiatry knowledge and 60 % consideredknowledge of psychiatric neuroscience findings to be eithervery important or critically important to the provision ofexcellent psychiatric care (4 or 5 on a five-point scale). Itshould be noted that only 19 % of the respondents felt thatneuropsychiatry was clearly differentiated from general psy-chiatry from their perspective, with twice asmany respondentsunable to see the difference and three times as many with noopinion, despite having been provided with the definitionsgiven in the “Methods” section above.

Respondents were asked to rate the familiarity with thetopics in the National Institute of Mental Health (NIMH)RDoC that should be expected upon graduation of apsychiatry resident beginning training in 2012 (Table 2).They were also asked about the competence that shouldbe expected for clinical neuropsychiatry skills by the timeof graduation for a resident entering training in 2012(Table 3).

Despite no difference in years since residency graduation,child and adolescent psychiatrists felt that familiarity with thefollowing areas was significantly more important for residentsthan did general adult psychiatrists: genetics and genomics,t(145)=−3.4, p=0.001; epigenetics, t(140)=3.13, p=0.002;attention/cognition, t(159)=−3.39, p=0.001; emotion regula-tion, t(143)=−2.26, p=0.025; neurobiology of attachment,t(146)=−3.43, p=0.001; and developmental neurobiology,t(171)=−4.42, p<0.001.

Academic environment appeared to have the greatesteffect on attitudes. Institutions that offer or are affiliatedwith an institution that offers PhD or postdoctoral work inpsychiatric neuroscience saw a shorter lag time needed foradvances in neuroscience to lead to the discovery of signif-icant new treatments or to the personalized application ofexisting therapies (t(168)=−2.59, p=0.01) and saw generalpsychiatry as being clearly delineated from neuropsychiatry(t(151)=2.21, p=0.03). Regarding the RDoC and clinicaltopics, institutions offering psychiatric neuroscience weremore likely to see as important the knowledge of animalmodels (t(143)=−2.27, p=0.025) and neural circuits(t(139)=2.06, p=0.04). Likewise, they rated the followingitems as more important: knowing when to order and how tointerpret clinical reports of structural neuroimaging (t(133)=2.41, p=0.017); knowing when to order and how to interpretclinical reports of electrophysiological testing (t(154)=3.02,p=0.003); and being able to explain to patients the currentunderstanding of the neurobiological basis of the treatmentthey are/will be receiving (t(141)=2.06, p=0.04). Addition-ally, they rated knowledge of the differential diagnosis andtreatment of sleep disorders as being significantly moreimportant (t(144)=2.37, p=0.021).

Current Curriculum

Respondents were asked how many didactic hours per train-ing year are spent in neuropsychiatry training and neurosci-ence training currently. Of the respondents, 97 and 98 %,respectively, offer neuropsychiatry and/or neuroscience train-ing in the PGY-4 year, as compared with 87 and 89 % in thePGY-2 and PGY-3 years. Table 4 shows the distribution ofrelevant didactics by year and number of hours offered.Only 20 % of the respondents teach these subjects instandalone seminars. Most courses are integrated with otherofferings.

RDoC subject area Average familiarityexpected

Basic pharmacology—the interactionof endogenous neurotransmitters/receptorsand second messengers

4.63

Emotion regulation—the neural systemssubserving emotion processing and integration

4.56

Attention/cognition—the neural systemssubserving attention/cognitive processingand integration

4.49

Reward systems—frontal–striatal–midbrain neuralcircuitry—relevance to addictive, compulsive,and repetitive behaviors

4.48

Neuroimaging/neuroanatomy—neuroimagingmethods/technologies and specific knowledgeof neuroanatomical regions

4.43

Neural circuits (macro- and microcircuits)—keyneural circuitry implicated in cortical processing

4.42

Fear/extinction—the amygdala and itsconnections—relevance to anxiety disorders,processing of trauma

4.40

Neurobiology of attachment—the biologicalbasis for social connectivity and how it isaffected during critical phases in development

4.37

Developmental neurobiology—critical phasesin brain development and effects on behavior

4.32

Pain perception—the neural basis of acute,chronic, and emotional pain

4.18

Perceptual systems—neural processingfrom sensation to cognition

4.14

Genetics and genomics—changes to the genomethat confer altered disease risk

4.10

Epigenetics—micro- and macroenvironmentalchanges that affect gene expression

4.02

Basic research-driven drug development—pathophysiologically based drug development

3.86

Cellular and molecular biology—cellular/molecular structure and function in healthand disease

3.67

Animal models—specific rodent and nonhumanprimate models of human disease

3.23

1 = No familiarity needed; 2 = little familiarity needed; 3 = no opinion;4 = familiarity desirable; 5 = familiarity essential

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Table 2 Familiarity with NIMH RDoC topics desired by time of gradu-ation for a resident beginning training in 2012, in order of decreasingaverage importance

Barriers

The majority of programs did not feel that departmental re-sources posed significant barriers to training in neuropsychi-atry and neuroscience. However, 39 and 36 % of the respon-dents, respectively, felt that lack of neuropsychiatry and neu-roscience faculty constituted a significant or severe barrier(Table 5).

We split the “barrier” respondents into two groups for eachpossible barrier. The first group scored 3 or below (no barriergroup), and the second scored 4 or 5 (significant barrier group).

Those who thought that lack of neuroscience faculty was asignificant barrier were significantly less likely to agree thatthere is a separation between general psychiatry and neuropsy-chiatry (t(147)=2.41, p=0.017). No similar group differencewas found in those who perceived lack of neuropsychiatryfaculty to be a significant barrier. Respondents with no faculty

identifying as neuropsychiatrists or neuroscience researcherssaw lack of faculty as a significantly greater barrier to provid-ing neuroscience training (t(108)=−9.3, p<0.001 and t(91)=−5.93, p<0.001, respectively).

The group who felt that lack of interest on the part offaculty was a significant barrier had graduated from residencysignificantly fewer years before (t(111)=−2.03, p=0.026).They also thought that epigenetics knowledge was less im-portant (t(111)=−2.03, p=0.045) and were more likely to rateknowledge of basic pharmacology and how to interpret theresults of cerebrospinal fluid (CSF) analysis as important(t(147)=2.05, p=0.04 and t(107)=2.48, p=0.015, respective-ly). Those who saw a lack of either neuropsychiatry andneuroscience curricula as a barrier had graduated from

Table 4 Current clinicalneuropsychiatry or neu-roscience curriculumhours offered in variousPGY-1 years (catego-rized by percentages ofrespondents offeringnone, 1–9 h, or at least10 h per year)

None 1–9 h ≥10 h

Clinical neuropsychiatry

PGY-1 16 54 16

PGY-2 13 55 24

PGY-3 13 50 24

PGY-4 3 62 23

PGY-5 39 37 18

PGY-6 86 10 3

Neuroscience

PGY-1 13 57 16

PGY-2 11 56 23

PGY-3 11 46 26

PGY-4 2 57 23

PGY-5 39 42 10

PGY-6 88 8 2

Table 3 Desirable competence in neuropsychiatric clinical skills by thetime of graduation for a resident beginning training in 2012, in order ofdecreasing competence requirement

Patient evaluation: knowing when to order a neurologyconsult and how to construct a neurology consult question

4.82

Patient management: differential diagnosis and treatmentof drug-induced movement disorders

4.79

Patient evaluation: performing a bedside cognitive examincluding the assessment of attention, memory, language,visual–spatial, and executive functions beyond the MMSE

4.75

Patient management: differential diagnosis and treatmentof dementia

4.74

Patient evaluation: knowing when to order neuropsychologicaltesting, how to construct a neuropsychology consult question,and how to interpret and integrate the recommendationsof neuropsychological testing into a patient’s treatment plan

4.69

Patient education: being able to explain to patients the currentunderstanding of the neurobiological basis of axis I and IIpsychiatric disorders

4.67

Patient education: being able to explain to patients the currentunderstanding of the neurobiological basis of the treatmentthey are/will be receiving

4.65

Patient management: differential diagnosis and treatmentof sleep disorders

4.57

Patient evaluation: performing and interpreting a basicneurologic exam

4.44

Patient evaluation: knowing when to order and how to interpretclinical reports of structural neuroimaging (CT and MRI)(including interpreting the report for the patient)

4.43

Patient management: differential diagnosis and treatmentof Tourette spectrum disorders

4.40

Patient evaluation: knowing how to utilize the resultsof functional neuroimaging studies (PET, SPECT, fMRI)

4.13

Patient evaluation: knowing when to order and how to interpretclinical reports of electrophysiological testing (EEG, EMG,evoked potentials, polysomnography). This includes interpretingthe report for the patient

4.03

Patient evaluation: knowing when to order and how to interpretthe results of CSF(cerebrospinal fluid) analysis

3.86

1 = No competence needed; 2 = little competence needed; 3 = competencesomewhat helpful; 4 = competence very helpful; 5 = competence essential

Table 5 The degree to which departmental resources are perceived asbarriers to offering increased training in neuropsychiatry and neurosci-ence, in order of decreasing severity as a barrier

Departmental resource Averagescore

Significant orsevere barrier (%)

Lack of neuropsychiatry faculty 3.00 39

Lack of neuroscience faculty 2.90 36

Lack of available neuroscience curriculafor psychiatry trainees

2.71 26

Lack of available neuropsychiatry curriculafor psychiatry trainees

2.71 27

Lack of interest or time of faculty to teachthis material to residents

2.68 27

Lack of time within the didactic curriculum 2.44 19

Lack of interest of psychiatry residentsin learning this material

2.22 13

1 = No barrier at all; 2 = mild barrier; 3 = moderate barrier; 4 = significantbarrier; 5 = severe barrier

138 Acad Psychiatry (2014) 38:135–140

residency significantly more years earlier. There were nosignificant differences for any of the other barriers.

Portable Curricula

Ninety-two percent of respondents were either interested orextremely interested in having access to portable neurosciencecurricula. When asked if they had ever used other portablecurricula, however, 47 % had never used them, and only 10 %used portable curricula at least monthly.

Discussion

With over half of all general adult psychiatry and child andadolescent psychiatry training programs responding to thissurvey, the results are felt to be likely representative of pro-grams across the USA.

There was 60 % or higher agreement with the importanceof neuropsychiatry and neuroscience education for psychiatryresidents currently in training. The most frequently perceivedbarriers to increasing neuropsychiatric and neuroscience edu-cation were lack of appropriate faculty and lack of availablecurricula, much more so than lack of interest on the part offaculty or trainees. Although a number of curriculum ideashave been promulgated in this area [22], their adoption is notyet widespread. There was a large amount of interest in thedevelopment of portable curricula despite little experience intheir use.

Additionally, there was widespread agreement that neuro-psychiatric clinical skills, including performing cognitive andneurologic exams and utilizing structural imaging and neuro-psychological testing, are essential for general psychiatrists.There was less consensus on the need for familiarity in utiliz-ing functional imaging, electrophysiology, or CSF analyses.Of the neuroscience RDoC subject areas, there was wide-spread agreement on the importance of neural systems andcognitive topics. Rated least important were the topics ofanimal models, cellular and molecular biology, and basicresearch-driven drug development.

The academic environment of psychiatry departments ap-peared to influence the opinions of survey respondents. Train-ing directors in departments with active psychiatric neurosci-ence groups were more inclined to see neuroscience advancesas having an impact on the practice of psychiatry sooner andwere more likely to see neuropsychiatry as differentiated fromgeneral psychiatry. These training directors also were morelikely to identify as important psychiatrists being able to orderand use the reports of structural imaging and neurophysiologictesting and to explain to their patients the neurobiologicalhypotheses relevant to their treatment. These very competen-cies were among those listed in the clinical neurosciencesubcompetency in the new psychiatry milestones [19].

Because 64 % of respondents were affiliated with institutionsoffering advanced psychiatric neuroscience training and 81 %were in departments with psychiatric neuroscience re-searchers, this finding suggests robust agreement with at leastsome components of these newly adopted milestones. Ofinterest, the recently released AADPRT Milestone Surveyresults indicated that the “Medical Knowledge—Clinical Neu-roscience” milestones were one of four that generated mostconcern among respondents, in this case about having theresources to carry out the necessary education [23], therebyillustrating the timeliness of this survey and of its implications.

There is widespread agreement among training directors inboth adult and child and adolescent psychiatry that neuropsy-chiatric and neuroscience knowledge are becoming importantaspects of the education of general psychiatrists. The avail-ability of faculty and curricula in these areas constitutes abarrier to training at some programs. A strong interest inportable curricula in neuropsychiatry and neuroscience existsamong psychiatry training directors. Taken together with theconcerns expressed about the “Medical Knowledge—ClinicalNeuroscience” milestone, this suggests a relatively urgentneed to create such curricula.

Implications for Educators

• Knowledge of neuropsychiatry and psychiatric neuroscience isconsidered very important or critical to the provision of excellentpsychiatric care by the majority of residency training directors.

• A 2-month intern rotation in neurology alone will not be adequateto fulfill the neuropsychiatry and neuroscience knowledge needs ofpsychiatry trainees.

• Most programs reserve neuropsychiatry and neuroscience didactictraining for the PGY-4 year, presumably in preparation for boardexaminations. Neuropsychiatric and neuroscience education willhave to occur throughout psychiatry training if neurobiologicalthinking is to truly be integrated into psychiatric practice.

• There is a large amount of interest in the development of portablecurricula in neuroscience, made more prominent by the inclusion ofa clinical neuroscience subcompetency in the psychiatry milestones.

Implications for Academic Leaders

• Psychiatry departments should cultivate or consider recruitingfaculty with interest in neuropsychiatry and psychiatricneuroscience.

• Neuropsychiatry and clinical neuroscience educators should beincluded in a department’s core teaching faculty if neurobiologicalthinking is to be expected of all general psychiatry graduates.

• Psychiatry departments may wish to consider building educationalcollaborations with neurology and graduate neurosciencedepartments.

• Neuropsychiatric clinical skills, including performing cognitive andneurologic exams and utilizing structural imaging andneuropsychological testing, are considered essential for generalpsychiatrists by the majority of training directors.

Acad Psychiatry (2014) 38:135–140 139

Disclosure Dr. Benjamin is a partner in Brain Educators, LLC, apublisher of neuropsychiatric educational materials. The other authorshave nothing to disclose.

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