Vascular Psychiatry: A New Specialty?

Vascular surgeons, internists, and neurologists all exist-but why aren’t there any vascular psychiatrists? There certainly is a need.

[[{"type":"media","view_mode":"media_crop","fid":"25918","attributes":{"alt":"vascular dementia","class":"media-image","id":"media_crop_2314432812163","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2442","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"","typeof":"foaf:Image"}}]]Cardiovascular syndromes yield the highest morbidity and mortality of all diseases.¹ In daily practice, psychiatrists commonly encounter vascular syndromes, such as vascular depression,² vascular cognitive impairment,³ and depression in heart disease.⁴ Surgeons, internists, and neurologists can obtain subspecialty training in vascular disorders, but at this time, psychiatrists who are interested in this area are encouraged to pursue either psychosomatic medicine or geriatric psychiatry fellowships. Many psychiatrists who publish in vascular psychiatry are in one of those subspecialties. Therefore, vascular psychiatry at this time could be considered a sub-subspecialty.

Imagine a psychiatrist who is hubbed in a cardiovascular center clinic with cardiologists and vascular surgeons and who provides consultation on psychopharmacology or preoperative assessment. Or a psychiatrist who rounds in the cardiac ICU to evaluate depression, delirium, and dementia. Or a psychiatrist who rounds with the stroke team to evaluate cognitive impairment and provide psychotropic recommendations. These examples serve as innovative ways to collaborate and integrate care. Comorbidity of psychiatric syndromes, such as depression, and vascular diseases has already been firmly established. This has led to joint consensus guidelines from the American Heart Association, American Stroke Association, American Psychiatric Association, American Academy of Neurology, and the Alzheimer’s Association.^3,4 There is no other area of medicine that has this high degree of collaboration.

Last year, the Royal College of Psychiatrists held a conference titled “Vascular psychiatry: the interface between vascular disease and mental disorders, and its clinical relevance.”⁵ Certainly, a similar conference could be held in the US. The specialty most closely related to vascular psychiatry at this time is probably vascular neurology,⁶ and it is already part of the American Board of Psychiatry and Neurology. On their Web site, it states that vascular neurology is a “subspecialty that involves the evaluation, prevention, treatment, and recovery from vascular diseases of the nervous system.”⁶ Just substitute “the mind” for “the nervous system,” and vascular psychiatry would be defined.

If a training fellowship for vascular psychiatry were to begin, I imagine that it would definitely have to be interdisciplinary. A central educational goal of a true “collaborative” fellowship would be to work with psychiatrists, cardiologists, neurologists, and surgeons. The fellow would be expected to go to didactics and rounds for all of these specialties and provide consultation on anything related to vascular psychiatry. Research would be cross-disciplinary, and grants could help to establish centers of excellence for vascular psychiatry, just like for geriatric psychiatry or depression. Interestingly, if a Society for Vascular Psychiatry were to be established, the initials would be “SVP,” which also stands for “systemic venous pressure.”

Disclosures:

Dr Hsu is the Alzheimer’s Disease Research Fellow in the departments of psychiatry and neurology at Massachusetts General Hospital and Brigham and Women’s Hospital, Boston. An Instructor of Psychiatry through Harvard Medical School, he is a staff geriatric psychiatrist and internist. Dr Hsu evaluates subjects in clinical trials for Eli Lilly and Eisai.

References:

1. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-e245.
2. Taylor WD, Aizenstein HJ, Alexopoulos GS. The vascular depression hypothesis: mechanisms linking vascular disease with depression. Mol Psychiatry. 2013;18:963-974.
3. Gorelick PB, Scuteri A, Black SE, et al; American Heart Association Stroke Council, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:2672-2713.
4. Lichtman JH, Bigger JT Jr, Blumenthal JA, et al; American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, American Heart Association Council on Clinical Cardiology, American Heart Association Council on Epidemiology and Prevention, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment. Circulation. 2008;118:1768-1775.
5. Royal College of Psychiatrists. Vascular psychiatry: the interface between vascular disease and mental disorders, and its clinical relevance. http://www.rcpsych.ac.uk/traininpsychiatry/conferencestraining/conferences/oldagewinter13presentation.aspx. Accessed July 18, 2014.
6. American Board of Psychiatry and Neurology. Vascular neurology. http://www.abpn.com/sub_vn.html. Accessed July 18, 2014.