Today's psychiatric residents have chosen a specialty that is profoundly different from the psychiatry of only a decade ago. The Human Genome Project and burgeoning genetic technologies will permit us finally to discover genes that produce vulnerability to mental disorders. A panoply of non-invasive imaging technologies affords us the opportunity to see the living human brain at work. Basic neuroscience is progressing at an accelerating rate and, indeed, is one of the most exciting frontiers in all of science. With psychiatric perspectives contributing, in turn, to the further development of the aforementioned fields, the discipline is unequivocally a full participant in the general medical research renaissance. On the clinical front, advances in diagnosis, epidemiology, treatment/diagnosis-matching, psychopharmacology, and other areas have led to numerous innovations and insights.
A jarring counterpoint to this auspicious picture is the persistent "endangered species" status of the clinician—researcher in psychiatry. Although not unique to the discipline (witness the recent National Academy of Sciences report, "Addressing the Nation's Changing Needs for Biomedical and Behavioral Scientists," that documents a decline in the number of M.D.s conducting research [R219711]) the shortage is keenly felt in psychiatry both because of the pace of scientific progress and the lack of an evenly and widely distributed research tradition within the profession.
Motivated by the needs of persons with mental disorders as well as the self-interest of the mental health field, the National Institute of Mental Health attaches high priority to training and career-development initiatives that will increase the number of physicians trained to conduct clinical research. Like many worthwhile goals, this one involves formidable challenges. An obvious one is the already full curriculum of psychiatry residents. An oft-held view is that the residency requirements in psychiatry, as compared with other disciplines, are relatively burdensome. Any educator with more than a few years in academic psychiatry can name areas that should be included as part of psychiatric residency training, but the curriculum is already full. Compounding this perceived problem, science has, in fact, grown more and more complex and more and more distant from the skills gleaned in a clinical residency.
Another challenge clearly has been the advent of managed care, which has had a less-than-salutary impact on the choice of a research career. It is considerably more difficult now for psychiatrists, in their early years after residency, to support their salaries by seeing patients while reserving adequate time to learn their chosen research discipline; anticipating such financial pressures post-residency, it is understandable that residents and educators alike might question the requisite investment of time, energy, and resources to begin a career in clinical research. Diminished opportunities to generate income are put in stark relief by increasing debt burdens carried by medical school graduates that make additional research training years very difficult for the majority of psychiatry's early post-residency graduates.
These and other challenges notwithstanding, the National Institute of Mental Health (NIMH) is committed to ensuring that training and career development support meets the needs of the future scientific research workforce spanning the range of sciences from molecular neurobiology to behavioral and social sciences to clinical services and prevention research. The following section describes several career development opportunities that have been introduced for the express purpose of clinical research training. First, however, let us suggest other considerations that buttress the argument for an increased focus on research exposure during psychiatric residency.
One compelling reason, of course, is the lasting benefit of a scientific mindset. In addition to extensive new knowledge accumulated regarding diagnosis, treatment, and pathophysiology, recent years have called upon psychiatric educators and practitioners to "unlearn" beliefs taken, in previous generations, as gospel. Many of these have turned out, on the basis of scientific evaluation, not to be correct. The processes by which one adapts new paradigms and discards those that do not stand scientific scrutiny are clearly research processes. In order for medical students and residents to "stay current" and enhance their abilities, they require education in the way scientific research is conducted and evaluated. Although great emphasis is placed on reading the scientific literature during training, in preparation for board exams, and as part of continuing medical education, ensuring that one is an "informed consumer" of scientific information is a much broader issue. In order to interpret the results of a new therapy, for instance, residents need to consider the degree to which extraneous factors were controlled, the use of blind raters, placebo controls, randomization, initial similarity of groups, and reliable and valid assessments, as well as appropriate statistical analysis and reporting.
In years past, the search for the underlying causes and pathophysiology of major psychiatric disorders has been difficult and marked by a lack of adequate replications of findings in areas such as genetic linkage, biological markers, treatment outcome predictors, and so forth. The coming decade promises additional reports and reevaluations of these and other subjects. Evaluating the strengths and limitations of such findings will be essential if we are to demonstrate that our training and practice are what is needed to help people with mental disorders. The enormous advances of genomics, proteomics, and pharmacology will have a profound influence on psychiatric practice in the next decade. Research literacy on the part of all psychiatrists will make clear to patients and—importantly—policymakers that our ability to diagnose and treat disorders of brain and behavior is at least equal to that of other branches of medicine.
Finally, a core component of contemporary research training is exposure to the principles of human-subject protections and research integrity. Familiarity with these topics is necessary if the field (researchers and clinicians alike) is to avoid repeating past mistakes. Informed consent, risk—benefit considerations, voluntary participation, decision-making capacity, and additional safeguards for participants in clinical research are vital issues for clinicians and researchers.
To foster opportunities for clinically trained professionals, NIMH offers a wide variety of research training and career development programs that provide stipend and salary support for various periods during the training and developmental stages leading to a research career. The Institute provides research trainees with opportunities to obtain 3—5 years of intense clinical research training. Such training needs to occur in the proper setting, which often may not be within the trainee's home psychiatry department. Psychiatrists who would plan to undertake genetic studies should involve themselves with the very best genetics research groups, regardless of whether the focus of their training experience, at least initially, is on mental disorders. The same is true of trainees who would dedicate their research careers to clinical trials. A career that uses the tools of functional imaging to study mental disorders requires additional training in such areas as neuroanatomy and cognitive neuroscience as well as immersion in the complex issues of analyzing data that emanate, for example, from an fMRI experiment. The genetics of mental disorders, no less than the study of biostatistics and research design issues relevant to clinical trials, are highly complex professional disciplines, requiring intensive study and excellent mentorship. Those who under-train or fail to gain adequate depth and experience will have an increasingly difficult time maintaining funding and productivity in the world of modern science.
Given these demands, NIMH has recommitted itself in recent years to the support of early research careers. Funding mechanisms include the traditional Mentored Clinical Scientist Development Award (K08) and the Mentored Patient-Oriented Research Career Development Award (K23), introduced in 1998. The K08 provides specialized study for individuals with a health-professional doctoral degree committed to a career in laboratory- or field-based research. The K23 is designed to provide support to young investigators who want to devote substantial parts of their careers to patient-oriented clinical research. For the purposes of the K23 award, patient-oriented research is defined as research conducted with human subjects (or on material of human origin, such as tissues, specimens, and cognitive phenomena). Examples of patient-oriented research include 1) mechanisms of human disease; 2) therapeutic interventions; 3) clinical trials; and 4) the development of new technologies. This focus notwithstanding, the Institute anticipates that some K23 recipients will become involved in translational research. Both the K08 and K23 mechanisms provide support for 3—5 years of supervised study and research experience.
The K23 is complemented by the Mid-Career Investigator Award in Patient-Oriented Research (K24), which will provide support to outstanding clinical scientists within 15 years of their specialty training. The grant will underwrite a period of intensive research to enhance needed skills and support an expressed commitment on the part of awardees to mentor others in patient-oriented research.
Also, the Clinical Research Curriculum Award (K30) is a new institutional grant meant to foster multidisciplinary didactic training in settings where significant clinical training already is underway. All NIH institutes are contributing to this initiative, which is administered by the Heart, Lung, and Blood Institute. The mechanism supports the institution per se and clinical research mentors; not any disease- or Institute-specific training interests. Complementing the K30, moreover, is another recently introduced mechanism, the R25, designed to exploit the strengths of a larger training environment by very specifically targeting certain opportunities—for example, fostering collaborations between molecular neurobiologists and psychiatrists. An example of one such program is the "Clinical Neuroscience Mental Health Research Training" program at Yale University Medical School. Open to medical students and residents, as well as to graduate students and postdoctoral fellows, this 1-year program has two components: 1) a psychiatry-oriented didactic curriculum that integrates basic and clinical neuroscience with clinical psychiatry, and 2) a 12-month structured, mentored clinical neuroscience research training experience.
Research training clearly represents a difficult choice at the end of residency, when many feel that it is time to capitalize on their long educational investment. Nonetheless, NIMH is seeking innovative ways to work with department chairmen and training directors to find ways to incorporate exposure to research experiences in the early years of career development. Model curricula are being developed to help residents learn basic research skills, not just to interest more residents in research, but also to enable all future psychiatrists—clinicians as well as researchers—to understand and evaluate the research literature and apply more evidence- and research-based methods in clinical practice.
The research tools that we have in our hands as we enter the new century confer enormous power to do good and to develop an extraordinarily gratifying career. Without clinically-trained investigators who are absolutely committed to the area of mental illness, all of our patients and, indeed, the whole field will suffer.