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Education and Training in Psychopharmacology

Drs. Blanco, Lujan, and Nunes are with the Department of Psychiatry at Columbia University, New York, New York. Address correspondence to Dr. Blanco, Department of Psychiatry, Columbia University. 1051 Riverside Dr., Box 69, NY, NY 10032; cb255{at}columbia.edu (E-mail). Copyright © 2005 Academic Psychiatry.

INTRODUCTION

TOP INTRODUCTION REFERENCES

 
Over the last 40 years, psychopharmacology has moved from a peripheral tool in the armamentarium of clinical psychiatrists to the most commonly used intervention in the treatment of psychiatric disorders, and recent analyses of treatment trends suggest that increases in the use of psychopharmacological interventions are likely to continue in the future (5, 6). One important factor influencing the rise of psychopharmacological treatment is the extensive amount of resources devoted to research on pharmacological treatments for psychiatric disorders. In contrast to this effort, very little has been done to examine how to best teach this growing body of knowledge to the training and practicing clinician. For this reason, we commend the initiative of Academic Psychiatry to devote a special issue to the teaching of psychopharmacology. The articles collected in this monograph survey a vast array of topics. In this commentary, we discuss two of the topics featured in this issue: 1) what should be taught, and 2) how should it be taught?.

Although we believe that the specific contents of psychopharmacological curricula will evolve over time, as new medications or new uses for existing medications are established, it is likely that three forces will shape these curricula: advances in neuroscience, market forces, and patient preferences.

The history of psychopharmacology indicates that, initially, treatments were discovered through the combination of the serendipity and skillful observation of astute clinicians (7), and pharmacological interventions were used at times to dissect clinical syndromes or hypothesize about their pathophysiology (8–11). Even today, it is not uncommon to seek to extend the use of a medication for new indications based on analogy rather than pathophysiology, as the growing use of anticonvulsants for the treatment of mood disorders clearly illustrates (12). To date, the practice (and learning) of pharmacological treatment has relied more on the empirical findings of clinical trials and case series and on the experience or experimentation of the individual clinician (or supervisor in the case of trainees) than on a true understanding of the biological bases of mental illness.

Although art and a certain degree of originality and creativity will always constitute part of psychopharmacological practice, we believe that neuroscience will play an increasingly important role in prescription decisions. In the last two decades, we have witnessed an unprecedented progress in our understanding of the central nervous system (CNS). That understanding is now translating into a more refined ability to design drugs directed toward specific receptors. Increasingly, medications will be used to target specific neurotransmitter systems or, more precisely, specific neurotransmitter systems in particular brain areas. These developments in neuroscience and psychopharmacology will require an increasing emphasis on the neurobiology of mental illness as a foundation for learning (and teaching) clinical psychopharmacology. Excellent textbooks already exist (13–15) and more will probably become available in the near future. Thus, evidence-based practice will not be limited to the evidence provided by the clinical sciences but also by preclinical findings.

A second aspect that will become progressively important in the teaching of psychopharmacology is the importance of the market forces in influencing psychiatric education. Several of the papers in this issue touch on this issue and present diverse perspectives. The most obvious market force is represented by pharmaceutical companies, but it is certainly not the only one. Because the certificate of the American Board of Psychiatry and Neurology (ABPN) is widely considered to be an important indicator of psychiatrists’ quality and has important market value, psychiatrists will continue to attempt to obtain or renew this certificate. Consequently, the decisions of the ABPN regarding what level of competency is expected of examinees will also be highly influential in determining the contents of the curricula on psychopharmacology.

A third market force will be the level of psychopharmacological competency of other professionals. Increasingly, other health professionals are performing procedures in all areas of medicine that were reserved for physicians in the past (16). Furthermore, there is a growing interest in training primary care physicians (PCPs) to provide psychopharmacological treatment, given the amount of psychiatric care provided outside the mental health system. A challenge for psychiatry will be to determine when treatment is best provided by psychiatrists and when collaborative models with PCPs or other health professionals are preferred. If the collaborative model is adopted (1), psychiatrists might need to learn how to monitor and supervise the provision of psychopharmacological treatment by other professionals, a skill that, presently, may not be systematically taught in most training programs. Another implication of the collaborative model will be that the cases seen by the psychiatrists will be those that cannot be easily treated. This will require that psychiatrists convincingly show a deeper knowledge of psychopharmacology than any other health professionals. Germane to the discussion is the fact that psychiatrists will need to show that the increase in quality of care is valuable enough to persuade a fourth market force—the payer of the treatment (e.g., individual, insurance company or government)—to incur this additional cost.

The third force that, in our opinion, will shape the teaching of psychopharmacology is patient preferences. Two articles in this issue (2,3) address this topic from the psychological point of view and address the need to investigate the meaning of the medication for the patient. Recent work in health services research (17–19) is also starting to emphasize the need to treat the patient as a true partner in medical decisions. This implies taking into account not only evidence-based information when deciding whether medication(s) should be used or which medication(s) to use, but also patients’ beliefs and expectations about their disorders and their treatment. Learning how to elicit those concerns from the patient and how to negotiate a treatment plan that is mutually acceptable to the patient and the clinician will become increasingly important. Most seasoned and successful clinicians learn this skill in one way or another during their training or practicing years. We suggest that in the future, a more systematic approach to learning these techniques will be necessary in order to provide high quality patient- and outcome-oriented treatments.

In addition to the suggested lines of change in the content of psychopharmacology teaching, teaching methods may also present some opportunities for improvement (4). Repeatedly, studies have shown that psychiatric clinical practice often departs from evidence-based treatment (5, 6, 12, 20, 21), suggesting that better methods are needed to help diffuse (i.e., teach) the existing knowledge. This gap between research and practice prompted the landmark report of the Institute of Medicine (22), which concludes that concerted efforts are needed to promote the dissemination of new evidence-based treatment methods into routine clinical practice.

Although there is little empirical literature available, particularly in psychiatry, on how to close the gap between knowledge and practice, the problem of disseminating new diagnostic and treatment techniques into practice has been a focus of considerable study in general medicine, and findings from this literature on Continuing Medical Education (CME) may inform the design of training methods for training in psychopharmacology. Reviews of this literature conclude that traditional methods of disseminating information, such as journal articles, printed materials, and lectures, are relatively ineffective at influencing clinicians’ practice or adoption of new techniques (23–25). Methods involving didactic work followed by intensive supervision and feedback on cases are more successful in influencing physician behavior, although they tend to be time consuming.

Independent lines of evidence suggest that several factors are needed to facilitate the learning and proficient use of new skills (i.e., behavior) that are fairly robust over time and contexts. First, practice sessions that are distributed over time produce greater and longer lasting skill acquisition than practice sessions of a long duration conducted over a shorter time period (26, 27). The positive effect of distributed practice has been demonstrated across a wide range of behaviors and supports the use of training models that employ several learning sessions as opposed to mass teaching (e.g., lectures or seminars).

Second, providing immediate performance feedback is an important component in training programs that are directed at shaping behaviors to a particular performance level (28). Third, skill development may be best facilitated in learning sessions that differentially reinforce targeted behavioral responses (29) from a larger set of behavioral responses. Differential reinforcement procedures can be particularly effective for developing proficiency in skills as well as reducing the frequency of alternative or competing behaviors that are inconsistent with skills being learned.

Overall, we believe these findings to suggest that the teaching of psychopharmacology will need to prioritize methods that emphasize the practice of skills over passive models of learning. To the extent patients in the residents’ caseloads closely match the materials taught during the lectures and the residents receive appropriate supervision, trainees will be able to incorporate the materials learned in those lectures. It will be important, though, that supervision is not limited to ensuring that the resident is prescribing the "right" medication, but also that the rationale (i.e., clinical and neurobiological foundations and patient preferences) be consistent with the principles learned in the classroom. It is customary to review process notes or audiotaped sessions in psychotherapy. Using these or similar methods may improve the process of medication prescribing. Technology currently offers opportunity for variations on such techniques, for example, using live supervision either in person or through teleconferencing. The use of live supervision may facilitate the provision of immediate feedback to the trainee, increasing the chances of successful learning.

Although learning through the supervision of one’s caseload is an essential part of training, it is important to point out that it is unlikely that most residents will encounter enough variety among patients during their residency necessary to practice all the skills that they should master at the end of their training. Case conferences have traditionally served the role of presenting broad topics of discussion to ensure that prototypical patients or situations are discussed. Again, new technology may allow the development of simulated cases that could be used to teach residents about specific situations and provide remedial training to those who need it or advanced training to those who have a particular interest in psychopharmacology.

A second domain in which the teaching of psychopharmacology may become more fruitful is in the area of postresidency training or continuous education. The continuous growth of knowledge in neurobiology and psychopharmacology will require frequent updates on the part of practicing clinicians. Currently, most psychiatrists rely on traditional CME methods to update their knowledge, but the available data reviewed above suggest that those methods have only modest effects (25). A challenge for medical education will be to offer attractive methods that convey recent data and also allow for the practicing of newly acquired information. Turning again to the analogy of psychotherapy, it is not unusual for recent graduates to continue in supervision for several additional years or join peer-supervision groups. Similar strategies or the adaptation of some of the techniques (e.g., simulated cases) that may improve teaching during residency might also benefit the ongoing training of practicing psychiatrists.

In summary, psychopharmacology has experienced enormous growth during the last 40 years. In contrast, the teaching of psychopharmacology has substantially lagged in its development, presenting important opportunities for improvement, and the collection of articles presented in this special issue constitutes an important effort to begin to remedy this situation.

ACKNOWLEDGMENTS

 
This article was supported in part by grants DA-00482 (Dr. Blanco) and DA-000288 (Dr. Nunes) and a Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression (Dr. Blanco).

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