 |
 |
|
|
By Richard Karel
Top psychiatric leaders from academia and the public sector met at APA's central office in Washington, D.C., last month to wrestle with the future of clinical research in psychiatry.
The meeting was the culmination of three days in Washington by a group of leaders known as "the academic consortium." In the last 15 years, the lobbying efforts of the consortium have resulted in a fourfold increase in research funding, according to APA Medical Director Steven M. Mirin, M.D., who opened the session at APA headquarters. But despite federal largesse, the "conduct of research requires enormous resources that cannot be supplied solely through research grants," he noted. Even with generous, multisource research funding, it is important for both researchers and clinicians to ponder how best to "facilitate the flow of ideas."
In particular, said Mirin, it is important that leaders in the field, including those attending the meeting, mentor medical students interested in research. But National Institute of Mental Health (NIMH) Director Steven Hyman, M.D. noted that many clinicians express frustration at having too little time to mentor residents.
It is very difficult to get talented young medical students to go into psychiatric research, said Eric Nestler, M.D., Ph.D., of the Yale University School of Medicine. Many instead choose a career in neuroscience. "There is a perception, in part accurate, of a crisis in clinical psychiatry," he said.
Compared with other medical specialties, psychiatry has not progressed significantly in routine diagnostic methods, Nestler said. In cardiovascular medicine, for example, diagnosis has progressed from reliance on the patient interview and stethoscope to use of the electrocardiogram, ultrasound, arteriography, nuclear magnetic resonance imaging, tissue biopsy, and genetic analysis. Psychiatry's primary tool remains the patient interview, and despite the development of brain-imaging technologies and other technical research, there has been little translation of this research into routine diagnostic applications, he observed.
Psychiatry has relied "too much on phenotype and not enough on genotype," added Ronnie Swift, M.D., of New York Medical College. Future progress, Nestler concluded, will rely on the development of better animal models and an integrated understanding of how genes impact behavior.
It is difficult to attract medical students into psychiatric research careers, agreed Michael Flaum, M.D., of the University of Iowa Hospitals and Clinics. "Medical students make decisions early in their careers," he noted. Yet they receive little exposure to researchers at the time they are making decisions about their future.
One possible approach is to provide modest summer grants of about $1,000 to $2,000 for first-year medical students to enable them to participate in a summer research program, said Flaum. This approach has had some success at the University of Iowa and might work elsewhere, he suggested. Students must also have role models, and if researchers are in positions of leadership within academic departments of psychiatry, this can have a positive influence. Finally, it is necessary for the university to provide an adequate infrastructure for research, something that is increasingly problematic, he said.
Mirin noted that APA is "now engaged" in talks with four medical school deans who are psychiatrists to help them revise the medical student curriculum to provide greater opportunities for research. The goal is "to free up time" for residents to explore research. "We should not view training as revenue generation; we should view it as education," he said.
APA must "renew and revitalize its commitment to research," said NIMH director Hyman. The two priorities for clinical research now and in the future must be incorporating neuroscience into research and developing intervention research. The ultimate measure of success for the research community is "what we can do for patients," he remarked.
But John Greden, M.D., of the University of Michigan Medical Center expressed skepticism about APA's capacity to lead the way for more research. "APA is still a guild in its orientation, and it's not going to lead this fight," he asserted.
Medical school is primarily "vocational training," asserted Donald Klein, M.D., of Columbia University. He cited a medical school student survey showing that 85 percent of medical students said they would have gone into business if unable to enter medical school. Very few budding physicians are intrinsically interested in scientific research, he contended.
Success as a clinical researcher can be predicted by an early start, a good mentor, and the receipt of a postdoctoral fellowship, according to Charles Reynolds III, M.D., of the University of Pittsburgh's Western Psychiatric Institute and Clinic. An early start implies getting started at latest in medical school if not as an undergraduate, said Reynolds. "Starting early may really be a key to future success."
Ideally, it should be possible to develop a means by which a new researcher can walk "a seamless pathway" from a postdoctoral fellowship to the first research grant, said Reynolds. It may be possible to shorten the typical postdoctoral career from three years to two years to facilitate the transition into real-world research, Reynolds said. "We need to be real people to our students," he added. "We need to invite them home and let them see that we have a life outside of clinical research."
But Reynolds stressed that the NIH strategy of providing research support for residents and postdoctoral fellows was "just too late" to galvanize people into pursuing research careers. NIMH, in particular, should look at the shifting demographics of medicine, especially regarding the increase in the numbers of women pursuing medical careers, said Reynolds. NIMH should also identify and facilitate access to a nationwide network of mentors. Further, the review and funding cycle should be accelerated so that there is less time between a student's completing a postdoctoral fellowship and receiving an initial externally funded research grant, and the stipend for such grants should be increased.
NIMH is already seriously considering the last two suggestions, said NIMH grant administrator Henry Khachaturian, Ph.D. The agency is also seriously considering raising the caps on some of its grant awards in the near future, he added. NIMH would like to support "more interdisciplinary basic training research programs," he commented.
APA is interested in exploring opportunities to promote research careers for women, said Mirin, and is working with the American Association of Medical Colleges to see how APA could contribute.
"This is really a key issue for us," he commented. "APA does not want to be an organization that totally represents 55-year-old white men."
Another issue for junior scientists taking part in large, multicenter studies is that they are often only one of many researchers on a given project and hence never receive adequate recognition, according to Marcelle Morrison-Bogorad, Ph.D., of the National Institute on Aging. It is important to find a way to credit junior researchers who never receive recognition as the lead author on a multiresearcher study.
Junior scientists play a critical role in research and pursue a research career out of a love of science, observed Mirin. These scientists could earn more as clinicians, and without adequate recognition and support, some of these talented people will be lost to the scientific community.
Academicians should receive more paid time to pursue research, and promotional criteria in the academic community should be broadened to credit scientists who play a meaningful role in research but are rarely or never principal investigators, Mirin suggested.
Participants agreed that it is important that the field not become overly dependent upon NIH for research funding. Other sources, including the National Alliance for Research in Schizophrenia and Depression and drug companies, also play a critical role.
The problem with drug companies, however, is that "they are not really concerned with how well their drugs are used," observed Robert Liberman, M.D., of the University of California at Los Angeles School of Medicine. Although drug companies are good at persuading physicians to prescribe the drugs they manufacture, it is clear that psychiatric drugs are often used incorrectly, he said. The issue is how knowledge is transferred from premarketing studies to the clinic.
Given the favorable climate in Congress, there is an opportunity for NIMH to "reshape the research agenda," and APA will offer support in any way possible, said Mirin. In Congress, legislators want to know how technology is "filtering down" to advance treatment and improve the quality of care their constituents receive, Liberman noted. Legislators take for granted that research creates new technologies and are little swayed to support or increase research funding on the basis of technology creation alone.