Drs. Yudofsky and Hales Reply

To the Editor: We thank Drs. Ross and Cooper for their replies to our editorial and understand full well that the issues they raise would be shared by many other of our thoughtful and concerned colleagues in psychiatry and neurology.

Dr. Ross’s assertion that “physicians who treat patients with brain disorders are typically interested only in treating a subset of patients with these disorders using a subset of the available treatment options” and Dr. Cooper’s questions, “Have Drs. Yudofsky and Hales asked neurologists if they wish to attend to problems with affect, cognition, and behavior? Do they or other psychiatrists wish to attend to problems of the senses or extremities or the peripheral nervous system that are remote from their customary clinical problems?” highlight precisely why we believe the fields of psychiatry and neurology should move more closely together under the conceptual scaffolding of neuropsychiatry.

Let us consider the example of a neurologist’s treatment of a 17-year-old boy with grand mal seizures. Without an intensive emphasis in his or her residency education on the psychosocial aspects of care, the neurology practitioner might regard the localization of the underlying lesion in the patient’s brain and prescribing the appropriate anticonvulsant as adequate treatment. However, what about the young man’s complex emotional and behavioral sequelae to having had a grand mal seizure—with incontinence—in front of his entire 11th-grade class, and how will he respond to no longer being able to drive a car like the rest of his peers? Our experience from having spent significant parts of our careers in hospitals that specialize in the care of patients with neurological and neurosurgical disorders is that such a patient would most likely be discharged without full consideration of these issues or without a referral to a psychiatrist—often with dire consequences for the recovery of the patient. In our editorial, we referenced the unfortunate history and attendant damage to our patients and to the field of psychiatry when the neurobiological aspects of causality and treatment of people with mental illness have been neglected by psychiatrists.

Perhaps the following comparison will help Drs. Ross and Cooper understand better the point that we endeavored to make in our editorial. It has been suggested by others, using hauntingly similar arguments to those posited by Drs. Ross and Cooper, that psychopharmacology and psychotherapy should become separate subspecialties of psychiatry approved by the American Board of Psychiatry and Neurology. We are sure that Drs. Ross and Cooper would agree with us that this is a dangerous idea and that these therapeutic (and somewhat theoretical) realms have been and should remain fundamental to the education and clinical repertoire of every psychiatrist. Similarly, in the mid-19th century, psychiatry and neurology were much more closely aligned (1). We maintain the firm conviction, as delineated in our editorial, that the subsequent separation of neurology and psychiatry into discrete specialties has tenuous conceptual validity and deleterious consequences for the patients served by both fields.