I would say that neuropsychiatry and biological psychiatry are different, though the two terms are often conflated. The field has definitely become mindless (i.e. more biologically oriented) over the past 30-40 years which is not a good thing, though at one point many American psychiatrists were brainless (i.e. did not consider the brain at all) which was not good either. The field is definitely not moving in a more neuropsychiatric direction however. Only a
few hundred psychiatrists identify as neuropsychiatrists, and there are about 40 000 psychiatrists in the US. These numbers are only
diminishing as these people die off. Most psychiatrists know very little about brain behavior correlates, neuropsychiatric disorders, neuropsychology, or cognitive neuroscience. Despite a push in the ACGME milestones to emphasize neuroscience training more, outside of the major academic medical centers most residencies don't have the resources to do this, and even some of the larger programs have neglected this or don't have the resources to improve their training in this area. and for those programs that do have faculty with clinical neuroscience faculty, the often don't have expertise in neuropsychiatry.
Psychiatrists don't treat MS or Parkinson's disease. You may certainly treat patients who incidentally have these diseases, or whose neuropsychiatric symptoms are related to these diseases, however this would not usually be done in private practice. These patients are best treated in academic medical centers or within a multispecialty or neurology group practice with a psychiatrist co-located or integrated. These are fairly atypical in private practice settings but I've definitely seen it happening and in fact a friend of mine was offered a job in a neurology clinic at multispecialty clinic. It's not that it's not possible to have your own solo private practice for this, just that it would be difficulty, would not be the ideal setup (ideally you would want close collaboration with neurology, neuropsychology, neuroradiology) for example, is only going to become more difficult in the future, and you may find it hard to get the super interesting patients who tend to end up being referred to large academic centers. the only people I know who have successful private neuropsychiatry practices are all very senior people, who have faculty appointments, did/do research, and in several cases have published books in popular press or have other media presence etc.
You can of course treat dementia patients, but solo private practice is not a good setting, and would not be financially viable. If dealing with 65+ patients these would (almost) all be medicare patients and it will be a nightmare to deal with in a solo pp setting (assuming medicare is still here once youre in practice) especially with all this MACRA crap. I suppose if someone was business minded enough they could run a neuropsychology center and hire lots of neuropsychologists, but I think it would be more common for a neuropsychology practice to hire a psychiatrist than the other way around, and often neuropsychologists just have their own practices.
BTW "gerstmans" (sic) is not something a neuropsychiatrist "manages". It is an interested neurobehavioral syndrome which you see in stroke patients or things like primary cortical atrophy, but there's no medical management and it's not really a psychiatric syndrome either. It is fun to pick up though and do bedside testing
🙂
It is not necessary to have fellowship training to be a neuropsychiatrist. It is not necessary to have geriatric psychiatry training to be a geriatric psychiatrist. It is always better to go into a specialty happy with a broad range of different kinds of problems as inevitably, the more narrow your interests, the harder it will be to find a job that meets your specifications. Certainly if you are interested in psychotic disorders you may find working in inpatient, PES/CPEP/EPS/PER/CSU or whatever we're calling it settings, in jails, state hospitals or on ACT teams. Though community psychiatry is about as far as you can get from neuropsychiatry, and they typical neuropsychiatry would not be able to cope in such a setting.
You might like geriatric psychiatry. Inpatient geropsychiatry units are often clamoring for psychiatrists to work there. You will get to work with high acuity (and less acute) patients with fascinating (and often devastating/tragic) presentations and illness. Younger patients with dementias and neurodegenerative diseases often get admitted to these units. Most people would rather gouge their eyes out than work on one of these units, but if you have good nursing staff and access to neuropsychology, neuroradiology, therapeutic/recreational services, and a geriatrician it can be a pretty neat job. You would be managing the behavioral and psychological symptoms of dementia including lots of agitation, psychosis, sexual behaviors, and other acts of physical violence and aggression. You will likely see patients with very late onset "schizophrenia" (which can first present at any age), late paraphrenia, new onset bipolar disorder, Lewy Body Dementia, Parkinson's Dementia, Vascular Dementia, Alzheimer's, TBI and so on. There are less acute/voluntary units that may be less fun.
You might like consultation-liaison psychiatry where the psychiatrist is a consultant to medical and surgical units, and increasingly in outpatient primary care and specialty clinics. It is increasingly possible for the C-L psychiatrist to focus on consulting on neurology and neurosurgical patients.
When it comes to dementias, I think neurologists are in general better at diagnosis, and psychiatrists are better at management, which primarily means managing psychological symptoms, breaking bad news, providing compassionate family based care, preparing for end of life, and dealing with medicolegal aspects including capacity, wills and probate, elder abuse and so on. If you are more excited about sticking needles in patients to get their CSF, and running up huge costs by order whole body PET scans, and sending off for AMPA-R or GAD-65 antibodies, or RT-QuIC assays then neurology may be a better fit. If on the other hand you enjoy the idea of providing comprehensive care to patients with neuropsychiatric symptoms, with an emphasis on psychosocial, ethical, and medicolegal aspects of care then psychiatry is a better fit.
With the increasing use of biologics in MS, I think it would be hard to treat without a neurology residency
even without biologicals I think it would be totally irresponsible for a psychiatrist to diagnose and treat MS, especially in solo private practice. Lawsuit waiting to happen!
