A Neuroscientific-Medical Perspective

Recent research emphasizes our need for better understanding of the interface between the specialties of psychiatry and medicine. Psychiatrists need to monitor emerging work that highlights the need for both a neuroscientific and medical perspective in the management of complex disorders. Our patients will benefit when a collaborative approach to complex conditions improves diagnosis, treatment, and outcomes.

In this Special Report we look at the evolving understanding of the role of inflammatory function in behavioral and psychiatric disorders. Inflammatory cytokines such as interleukin-6 and tumor necrosis factor rise during flare-ups of rheumatoid arthritis. These inflammatory factors appear to have adverse effects on the brain and increase perception of pain, increase symptoms of depression, and impair sleep. Although the pain in rheumatoid arthritis directly increases risk of depression, direct brain effects of inflammatory markers may also be involved. Patients with a history of major depression may be at highest risk for depression associated with rheumatoid arthritis.

Although the treatment focus in rheumatoid arthritis is to reduce inflammatory function, therapy for hepatitis C is focused on antiviral activity through stimulating immune function. Use of interferon and ribavirin in hepatitis C may stimulate inflammatory function and produce some of the same adverse CNS effects as rheumatoid arthritis flare-ups. Fortunately, SSRI therapy can effectively prevent or treat interferon-induced depression. Active treatment of patients with hepatitis C often requires collaborative care between psychiatrists and hepatologists to provide optimal treatment tolerance and outcome.

Increased inflammatory response has been linked directly to depression. This inflammatory response may modulate elevated risk for cardiovascular disease found in patients with major depression. Depression has other physical consequences including increased platelet activity, increased activity of the hypothalamic-pituitary-adrenal axis, dysregulation of cardiac autonomic tone, and impairment of arterial function. These findings underscore the importance of early diagnosis and treatment of depression for physical as well as mental health.

Patients with unexplained physical symptoms and somatoform disorders may be the most challenging. These patients often present at the clinical care interface of psychiatry and medicine (ie, in psychiatric consultation service populations and emergency departments). A key recent finding in somatoform disorders is the promise of cognitive behavioral therapy (CBT) to address and control unexplained physical symptoms. There is a need to expand the number of expert CBT therapists with training in the treatment of somatoform disorders. Controlled clinical trials support CBT as part of routine treatment for somatoform disorders.

The growing interface between psychiatry and medicine will challenge the specialties to improve collaborative care. Too often, psychiatrists have been seen as uninterested or unavailable to help patients with complicated medical illnesses who have significant psychiatric problems. On the other hand, primary care physicians have limited time and limited financial incentive to address mental health issues. Payment systems often do not support collaborative care but seek to isolate the 2 specialties. This approach has produced fragmented care and barriers to developing multidisciplinary teams that are needed to manage complex cases.

Routine psychiatric assessment needs to be part of the assessment for many patients seen in the medical setting. Better access to psychiatric consultation and liaison services will be needed from psychiatrists. A collaborative care system will become more important as our understanding of the interface between psychiatry and medicine evolves.

In This Special Report:
Behavioral Comorbidities in Rheumatoid Arthritis, by Michael R. Irwin, MD, Mary Davis, PhD, and Alex Zautra, PhD
Recognizing and Treating IFN-α–Induced Neuropsychiatric Symptoms, by Charles L. Raison, MD
Depression and Cardiovascular Disease, by Julie Schulman, MD and Peter A. Shapiro, MD
Unexplained Physical Symptoms, by Humberto Marin, MD and Javier I. Escobar, MD
Collaborating With Our Medical Colleagues, by Roger G. Kathol, MD and Sarah Rivelli, MD