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Psychiatry supremos

Three specialists are using imaging to advance scientific research in this area

Illustration of green brain filled with cogs In the British Journal of Psychiatry in 2007, Prof Guy Goodwin from Oxford University argued that psychiatry had abandoned the medical model. The cause of the problem, said Goodwin, was that in the 1960s the problems of patients with schizophrenia – psychiatry's defining disorder – were reformulated as 'social', a model that Goodwin described as a minority, left-wing, 'show biz' cause. This was a formative time for our generally late-middle-aged policy makers and hence 'social care' is still in vogue now.

According to Goodwin, the current dominance of this view was neither measured, nor moderate. He described it as an essentially totalitarian spirit with its own language where no one must be said to have an 'illness', 'comply' with treatment or be a 'patient'.

One of the consequences has been that resources were invested in the wrong areas, and many doctors have felt marginalised by managers with regards to resource allocation.

Attrition rate
Many doctors that go into psychiatry are unhappy and end up leaving it. 20–30 per cent of those who express an early choice for the speciality, are not working in it 10 years after graduation. Department of Health figures from 2005 show that 7.7 per cent of consultant posts in psychiatry were vacant, compared with a vacancy rate for consultant posts in all specialities of 3.3 per cent.

In a survey of doctors who had left psychiatry, published in 2006, psychiatry was seen to be understaffed, under-resourced, excessively bureaucratic, stressful, and beset with heavy workloads and high public expectations. A full 42 per cent agreed with the statement that "diagnosis and treatment were not sufficiently evidence-based".

Highly regarded
According to Dr Phil Corlett, however, psychiatry is in great shape. UK academic psychiatry is highly regarded around the world and British neuropsychopharmacology, a highly promising multidisciplinary approach involving pharmacology and the study of brain function through research methods such as functional magnetic resonance imaging (fMRI), is "second to none". In Advances in Brain Imaging: An Overview of What the Primary Psychiatrist Needs to Know, Mark S. George and Ralph H.Johnson state that neuropsychopharmacology has allowed psychiatry to "rediscover" the brain. "We now fully recognise the obvious fact that normal and abnormal behaviour is mediated through neuronal function," the authors claim.

The rising stars featured here all conduct research using imaging. Hopefully, such work will not only lead to advances in the management of psychiatric illnesses, but will also dispel the view that "diagnosis and treatment are not sufficiently evidence-based".

Dr Phil Corlett, Cambridge University and visiting fellow, Department of Psychiatry, Yale Medical School
It is not often that you come across someone as enthusiastic about his subject and as happy with life as Dr Phil Corlett, and it is easy to see why he is so pleased. He is currently on a one-year visiting fellowship at Yale Medical School in the US; he has developed an exciting new research technique, of which he is clearly very proud and his academic reputation is rising. He is also building up a body of publications in reputable journals and last year, with colleagues Dr Garry Honey and Prof Paul Fletcher from his Alma Mater, Cambridge University, he won the British Association for Psychopharmacology/Organon 2008 Journal Prize. This is awarded to the authors of the best paper published in the Journal of Psychopharmacology during the preceding year.

In addition to the visiting fellowship, being funded by Cambridge University, Dr Corlett has been given a research grant by the highly influential National Alliance for Research on Schizophrenia and Depression in the US, and is thus in the happy position of "being able to pay for my own experiments".

Dr Corlett's main area of research is schizophrenia. A major symptom of this is, of course, the formation of delusional beliefs. He has developed a technique for inducing psychosis in healthy people by giving them controlled infusions of the drug, ketamine. They then, temporarily, have experiences like those of schizophrenia, which Dr Corlett says they describe as "a bit like being on The Truman Show". He is trying to understand these delusions in terms of genes, psychological processes and changes in brain function and says it feels like it has been possible to "get a handle" on these symptoms for the first time.

By using functional MRI, Dr Corlett hopes it will be possible to identify young people who are just starting to have perceptual changes and show the same pattern of brain responses, as well as making it possible to identify those at risk of psychosis earlier by examining these patterns of brain responses. The technique is already being used in drug development to test novel therapeutic approaches by trying to reverse the effects of ketamine.

Dr Corlett atributes the fact that he is getting noticed to enthusiasm and dogged determination and a big measure of luck in the people he has worked with, both in Cambridge and now at Yale Medical School.

Dr Cousins, MRC clinical research training fellow in Psychiatry at Newcastle
Dr David Cousins is not yet on the national radar as an opinion leader but, according to colleagues, achieving this is only a matter of time. So far, he has only a few publications and major presentations to his name, and more of these are needed for wider recognition, however, he is now starting to put out data. He has submitted three reviews for publication and there will be many more papers as his PhD and current research come to an end.

Dr Cousins maintains that if your work stands up to peer review, it will get recognised, but he is increasingly aware that active steps to raise your profile pay dividends. Such recognition can aid funding applications and this is particularly important because the work he is doing in imaging is both expensive and competitive. His current research is working towards developing models of mania, integrating various approaches to better understand the cerebral effects of neurotransmitters and drug treatment.

Dr Cousins has developed a non-invasive means of measuring brain lithium distribution, and his work on lithium and brain structure is likely to be contentious. His projects have MRC funding, which he describes as the first step towards independence, as doctors are judged on the outcomes of research rather than day-to-day activities.

Like another of our profiled doctors, his attitude to the pharma industry has changed considerably over time. Previously, he maintained that collaboration was "selling your soul", but now he recognises that many goals of academic medicine, like the development of new treatment modalities, cannot be fulfilled without this partnership. At a time when this relationship is increasingly under scrutiny, it is encouraging that the next generation of opinion leaders recognises its importance. However, Dr Cousins stresses the need to be clear and open in dealings with industry about what he will and will not do. For example, in sponsored talks, he does not review guidelines or compare one drug to another.

Dr Andrew McIntosh, senior lecturer in Psychiatry, University of Edinburgh
Hearing Dr Andrew McIntosh, senior lecturer in Psychiatry in Edinburgh, talk about his research gives an idea of the excitement and innovation that is bringing bright young researchers into psychiatry. As early as his time at medical school, Dr McIntosh felt that psychiatry was the field with the most unknowns and the one in which he could make a significant contribution.

He is widely talked about as a future international opinion leader based on his research into bipolar disorder. "Persistence", and building up a critical mass of papers is what gets you noticed, Dr McIntosh says.

He has only recently developed a degree of independence with his own research funding and finds it very satisfying to plan his own experiments and be able to study exactly what interests him. There are still some big unanswered questions, such as how can we tell if a treatment is effective before it is used in trials, how can we predict whether people will become unwell before the onset of diagnosable illness, and how can we reliably measure and then prevent disease progression in those with established illness?

Dr McIntosh's research involves the use of increasingly sophisticated brain imaging to look at how genes alter brain structure. Little is known about the biological basis of bipolar disorder, although it is understood to run in families. He is studying genetic factors and both brain structure and function in people at high risk of developing the condition before they become unwell, which has not been done before. The current drugs are effective, but nobody really understands why and he argues that a better understanding of the aetiology could help pharma companies develop drugs on a more rational basis.

His attitude to the pharma industry is encouraging. Until recently, his involvement with the industry was strictly limited to clinical trials, however now he speaks positively about the industry providing funding for innovative, high-risk research and believes collaboration is essential.

The Author
Neil Kendle is managing director of Kendle Healthcare
To comment on this article, email pm@pmlive.com

8th May 2009

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