Psychiatric education across the world


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Psychiatric Training and education across the world

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Psychiatric education across the world

  1. 1. World PsychiatricAssociation
  2. 2. World PsychiatricAssociation 1
  3. 3. WHO Library Cataloguing-in-Publication Data Atlas : psychiatric education and training across the world 2005. 1.Psychiatry – education 2.Education, Medical – statistics 3.Academic medical centers – statistics 4.Atlases I.World Health Organization II.World Psychiatric Association. ISBN 92 4 156307 9 (NLM classification: WM 19) © World Health Organization 2005 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; email: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or con- cerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approxi- mate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of pro- prietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being dis- tributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in Designed by Tushita Graphic Vision Sarl, CH-1226 Thonex For further details on this project or to submit updated information, please contact: Dr S. Saxena Department of Mental Health and Substance Abuse World Health Organization Avenue Appia 20, CH-1211, Geneva 27, Switzerland Fax: +41 22 791 4160, email: mhatlas@who.int2
  4. 4. REFERENCE CONTENTSContentsAcknowledgements ....................................................................................... 4Foreword ....................................................................................................... 5Preface .......................................................................................................... 6Introduction................................................................................................... 7Method ......................................................................................................... 8Summary of results ........................................................................................ 9Presence of psychiatric training programmes ................................................. 10Training programmes and infrastructure ........................................................ 12Training curricula and teaching methods ........................................................ 16Evaluation of training..................................................................................... 21Super-specialization and bilateral arrangement .............................................. 23Licensing and roles of national institutions .................................................... 25Case study ..................................................................................................... 27AppendicesPsychiatric education and training across the world ....................................... 28WPA’s activities in psychiatric education and training ..................................... 30Case study: A comparison in psychiatric training ............................................ 31Atlas respondents/key contacts and training institutes/bodies ....................... 35Contributors of additional Information........................................................... 40 3
  5. 5. ACKNOWLEDGEMENTS Acknowledgements A tlas: Psychiatric Education and Training Across the World is the result of a joint collaborative effort between the World Health Organization (WHO) and the countries where there were no WPA Member Societies. The Presidents, Secretaries, and other officers of WPA Member Societies responded to the questionnaire, which became World Psychiatric Association (WPA). The Project was the basis of this report. Other members of the WPA who supervised and coordinated by Dr Shekhar Saxena, WHO, provided constructive and valuable support, were the Geneva. Technical support was provided by Dr Pallab K. WPA Educational Liaisons Network and the staff of the Maulik and in the initial phase by Dr Pratap Sharan. Dr WPA Education Coordination Centre. Mr Eduardo Ausejo Benedetto Saraceno provided the vision and guidance to Yzaguirre helped with the statistical analysis. this project. Ms Rosemary Westermeyer provided adminis- Contributions from all individuals who responded to the trative support and assisted with production. questionnaire and provided written comments on specific Key collaborators from WHO Regional Offices include: Dr topics have been valuable in the production of this volume. Thérèse Agossou, Regional Office for Africa; Dr José Miguel Their names are provided in the appendices. Caldas de Almeida, Regional Office for the Americas; Dr The contribution of each of these team members and part- Vijay Chandra, Regional Office for South-East Asia; Dr Mat- ners, along with the input of many other unnamed people, thijs Muijen, Regional Office for Europe; Dr R.S. Murthy has been vital to the success of this project. and Dr A. Mohit, Regional Office for the Eastern Mediter- ranean; and Dr Xiangdong Wang, Regional Office for the The publication of this volume has been assisted by Ms Western Pacific. Tushita Bosonet (graphic design) and Mr Christophe Grangier (map). At WPA, the principal collaborator was Professor Roger Montenegro, WPA Secretary for Education. Support was received from the WPA Zone Representatives, especially in reaching National Societies or leading professionals in4
  6. 6. FOREWORDForewordP sychiatrists play an important role in the delivery of mental health services. However, global informa-tion about the quality of training of psychiatrists is largely income countries. Atlas Psychiatric Training provides further information to assist in planning by countries to reduce this shortfall.unavailable. Do countries train adequate numbers of psy-chiatrists for their mental health needs? How satisfactory is The World Psychiatric Association is an international asso-the training in view of the changing roles of a psychiatrist? ciation of psychiatric societies. Its objectives include toDoes the training take into account enormously different “increase knowledge and skills necessary for work in theenvironments in which psychiatrists work across the world? field of mental health and in the care for the mentally ill”These and other similar questions need urgent answers. and “to promote the development of the highest qualityAtlas: Psychiatric Education and Training across the World standards in psychiatric teaching as well as observance ofis an initial attempt in this direction. such standards”. The WPA Secretary for Education and the Education Coordination Center strive to fulfil these objec-This member of the Atlas family is a joint publication of the tives. Atlas Psychiatric Training provides critical informationWorld Health Organization (WHO) and the World Psychi- for national psychiatric societies to take their work forwardatric Association (WPA) and is a testimony to the active in this important area.collaboration between these two organizations. The Atlasalso clearly responds to the mandates and visions of the two At the global level, the Atlas provides an overview of theorganizations. situation and also documents the existing regional varia- tions. At the country level, it provides some useful informa-The overall strategic direction of the World Health Organi- tion along with references to sources within countries thatzation, Department of Mental Health and Substance Abuse, can provide more to reduce the burden associated with mental, neurologi-cal and substance use disorders and to promote mental We hope that this Atlas is successful in drawing the atten-health worldwide. WHO recognizes that close attention to tion of health and medical education departments of coun-training of appropriate human resources is crucial to achiev- tries to the enormous need for developing plans to establishing these objectives. Mental Health Atlas-2005 has clearly or reform psychiatric training in their countries. WHO, asdemonstrated the severe shortfall of mental health profes- well as Member Societies of the World Psychiatric Associa-sionals, including psychiatrists especially in low and middle tion are ready to assist them in this important task.Benedetto Saraceno Ahmed OkashaDirector, Department of Mental Health Presidentand Substance Abuse World Psychiatric AssociationWorld Health Organization 5
  7. 7. PREFACE Preface W e are pleased to present Atlas: Psychiatric Education and Training Across the World. The results of Atlas Psychiatric Training reveal a general defi- ciency and a marked variability in training across the world. Many medium sized countries have either no training facili- Project Atlas of the World Health Organization has the ties or the facilities cater to a very small number of trainees primary objective of collecting, compiling and disseminat- every year. The content of training and the quality also vary ing information on mental health resources on a worldwide considerably. Standards either do not exist or cannot be scale. Psychiatrists are essential and important human followed strictly due to a variety of constraints. Inadequate resources to provide mental health care as well as to assist attention is given to making the trainees develop knowl- development of policy and services for mental health within edge and skills in activities that they are likely to undertake the country. The present Atlas provides information on psy- in actual practice during their professional career. Teaching chiatric education and training from across the world. Like methods, evaluation, licensing and continuing education all other publications in the Atlas series, the information has showed considerable scope for improvement within many been collected using a questionnaire sent to key informants responding countries. within countries. Since the project has been undertaken jointly by the World Health Organization (WHO) and the Though the present Atlas was not able to achieve a high World Psychiatric Association (WPA) through its Educa- coverage of countries, the findings nevertheless provide a tion Coordination Center, the extensive network of these good indication of the areas needing the greatest and the two organizations were available to support the project. most urgent attention. We hope that the Atlas will facilitate Key informants were largely the office bearers of WPA action to make psychiatric education and training more Components (WPA Member Societies and Members of the widely available and respond to the critical needs of mental WPA Educational Liaison Network), but additional informa- health systems within countries. tion was collected from WHO Collaborating Centres and Regional Offices. Shekhar Saxena Roger Montenegro Coordinator, Mental Health: Evidence and Research Secretary for Education World Health Organization World Psychiatric Association6
  8. 8. INTRODUCTIONIntroductionC ountries are under increasing pressure to expand and reform their mental health services and systems. Thiswas anticipated in the World Health Report 2001 (World – 35.2%). Overall, the chances of getting treated for any type of disorder was more in developed countries than in less developed countries.Health Organization 2001a). Recent research findings havefurther confirmed the high prevalence of mental disorders The role of psychiatrists in reducing the burden of mental(WHO World Mental Health Survey Consortium 2004) and disorders is quite apparent. Psychiatrists have to play multi-the large burden associated with them (The World Health ple roles if this treatment gap is to be corrected – as cliniciansReport 2004). The World Mental Health Survey, in the and mental health experts within multidisciplinary teams,analyses of data from 15 countries found that the 12 month as teachers imparting knowledge and skills to studentsprevalence of mental disorders varied between 4.3% in and other staff, as researchers to increase the repertoire ofShanghai, China to 26.4% in the United States of America. knowledge on mental health, as public health specialists inMilder disorders were more prevalent than severer ones. The developing the infrastructure for mental health services andprevalence of moderate and severe disorders was 0.5-9.4% as advocates to increase awareness and needs around mentaland 0.4-7.7%, respectively, compared to 1.8-9.7% for mild health issues. These multiple roles require comprehensive ini-disorders. World Health Organization (2004) also estimates tial as well as continuing training of psychiatrists.that the burden of neurospychiatric conditions in Disability Psychiatric training has undergone major development overAdjusted Life Years is 13% of the total burden of all health the past decades and scientific developments in the field ofconditions and this is likely to increase. molecular biology, neurobiology, genetics, cognitive neuro-Expansion and reform of mental health services and systems sciences, neuroimaging, psycho-pharmacology, psychiatricrequire human and financial resources. Information on mental epidemiology and many other related fields have contrib-health resources of the world was almost absent prior to the uted to the increasing growth of psychiatry as a medicalpublication of the findings of the WHO Project Atlas (World discipline (Rubin and Zorumski, 2003). However, very little isHealth Organization 2001 b, c). Recent data show that the known about the availability and quality of psychiatric train-median distribution of psychiatrists per 100 000 population ing imparted to medical students in different countries. Asin the world is 1.2 (SD 6.07) with a variance of 0.04/100 000 with information on mental health resources, basic informa-population in Africa to 9.8/100 000 population in Europe tion on psychiatric training is especially deficient from low(World Health Organization 2005). Resources are especially and middle income countries.scarce in low and middle income countries (Saxena and The World Health Organization (WHO) along with theMaulik 2003). Researchers have also identified a huge gap in World Psychiatric Association (WPA) embarked on an ini-the need for psychiatric care (Kohn et al 2004). The median tiative to gather basic information on psychiatric trainingtreatment gap, as evident from of review of 37 studies across programmes in all countries of the world, with the aim ofregions of the world, was estimated to be 32.2% for schizo- generating a knowledge base and using the information tophrenia and other non-affective psychotic disorders, 56.3% develop or improve psychiatric training facilities in countries.for major depression, 50.2% for bipolar disorder, 78.1% for The Atlas: Psychiatric Education and Training Across thealcohol abuse and dependence, etc. The WHO World Men- World reflects that effort. The project was launched in 2004tal Health Survey Consortium (2004) found that treatment after consultations between WPA and WHO. This publica-was received by 0.8% to 15.3% of those affected with a tion presents the first set of data collected in this project.mental disorder, the proportion of treatment was higher for It is envisaged that this data will require strengthening andsevere cases (14.6% – 64.5%) compared to mild cases (0.5% updating periodically.ReferencesKohn R, Saxena S, Levav I, Saraceno B (2004). The treatment gap in World Health Organization (2001a). The World Health Report 2001: mental health care. Bulletin of the World Health Organization 82(11): Mental Health: New Understanding, New Hope. World Health 858 – 866. Organization. Geneva.Rubin E.H., Zorumsk, C.F. (2003). Psychiatric education in an era of World Health Organization (2001b). Atlas: Mental Health Resources in rapidly occurring scientific advances. Academic Medicine, 78(4), 351- the World 2001. Geneva: World Health Organization. 354. World Health Organization (2001c). Atlas: Country Profiles on MentalSaxena S., Maulik P.K. (2003). Mental health services in low-and- mid- Health Resources 2001. World Health Organization. Geneva. dle income countries – an overview. Current Opinion of Psychiatry. World Health Organization (2004). The World Health Report 2004: 16(4): 437-442. Changing History. World Health Organization. Geneva.The WHO World Mental Health Survey Consortium (2004). Preva- World Health Organization (2005). Mental Health Atlas 2005. World lence, severity, and unmet need for treatment of mental disorders in Health Organization. Geneva. the World Health Organization World Mental Health Survey. JAMA dence/atlas/index.htm 291(21): 2581-1590. 7
  9. 9. METHOD Method T his study was undertaken jointly by the World Health Organization (WHO) and the World Psychiatric Association (WPA). At WPA, the work was carried under rated. While the quantitative data were analyzed by WHO Regions, World Bank country level income groups and population in countries, the qualitative data were collated the direction of the Secretary for Education. At WHO, in a logical manner and used to highlight certain issues. The the work was coordinated by the team of Mental Health: population figures were based on the values of the World Evidence and Research under the Department of Mental Health Report 2005 and the income group of the countries Health and Substance Abuse. The format was that of a was based on the figures obtained from the World Bank cross-sectional assessment in the form of a questionnaire website – based survey. classgroups.htm (as accessed on 16th February 2005). The income groups according to Gross National Income per Initially, WPA and WHO, identified the need for such a capita are – low income (<$825), lower middle income project and defined the areas for assessment. Mental health ($826 – $3255), higher middle income ($3256 – $10 065) professionals within WHO, carried out an initial search to and high income (>$10 065). Statistical analysis involved identify the different themes that required probing through simple frequency distribution and measures of central ten- the questionnaire. Once the themes were identified the dency. Experts within Member Societies were also requested next stage involved developing the questionnaire which to provide additional information on selected themes which was done at WHO by a team of mental health profession- were used to enrich the qualitative data. als. Though no psychometric assessments were done, the questions were framed so that they reflected the different The major limitation of the study was the low response areas of need for assessment. The questionnaire was then rates from the countries. Information on presence or sent to the WPA for further modification. After implement- absence of training is available from 179 countries and ing the modifications, WPA Education Coordination Centre information on aspects of psychiatric training is available (WPA ECC) sent the questionnaires to the National Member from only 74 countries and WHO Territories. The reasons Societies. It was sent to 143 National Societies from 121 for this could be many – absence of a training programme; countries. To reinforce the importance of this project, all inability to provide aggregated information when the coun- WPA Components were informed of the actions to be taken try is large with a lot of diversity in the quality of individual through the WPA Electronic Bulletin and the WPA website. programmes; absence of any functioning psychiatric organi- The WPA Zone Representatives and members of the Educa- zation in the country; absence of any known key person tional Liaisons Network were specially asked for collabora- with the ability to respond to the questionnaire. Even when tion regarding those countries in which there were no WPA they did respond the completion rate was poor. In view Member Societies. of these limitations, the analyses presented could not be generalized to reflect WHO Regional differences. Even dif- The Member Societies were requested to complete the ferences shown under World Bank income criteria should questionnaire and return it to the WPA ECC along with any be judged keeping the above limitations in perspective. The other supportive documents. Reminders were sent several other limitation was that some of the questions required times. Eventually completed questionnaires were received qualitative grading and so were liable to certain degrees of from 73 countries and one WHO territory. Another attempt inaccuracy. Some of the other limitations pertaining to spe- was made to contact countries that had not responded cific sections are dealt with under the respective sections. through WPA Member Societies as well as WHO contacts within the Regions and countries. Information was gathered The final analysis are presented in this volume under themes about presence or absence of psychiatric training in their and supported by tables and graphical representation as country. charts and maps. An electronic database was generated and the data were entered at the ECC and later analysed by the ECC and WHO. Both quantitative and qualitative data were incorpo-8
  10. 10. SUMMARY OF RESULTSSummary of ResultsT his project attempted to gather basic information about psychiatric training programmes in the worldthrough the use of a questionnaire. The questionnaire was tal disorders and diagnostic and therapeutic skills – were imparted in most centres in more than 60% of countries. However, teaching and managerial skills were taught bysent out to 121 countries and responses were received fewer centres in some countries only. About half of thefrom 73 countries and one WHO territory. This represented countries preferred using case vignettes, case conferencesonly 38% of the 192 countries of the world. Hence, WHO and seminars as the most commonly used teaching tech-and WPA used other sources to gather more information niques. Self-directed learning was a less prevalent techniqueabout the presence or absence of a psychiatric training pro- and was most commonly used in one fourth of countries.gramme. Eventually, it was found that 122 (68.2%) coun-tries had a psychiatric training programme. This varied from Evaluation of training was done either by oral or written47.4% countries in Africa Region to 94.1% countries in methods during some point of time during the training.European Region. When analyzed according to World Bank Ongoing or end of training evaluation of knowledge byincome group psychiatric training facilities were present oral methods was the more preferred modes of evaluationin 54.5% of low income countries compared to 77.1% of in 39 and 46 countries, respectively. Teaching and researchhigh income countries. Information on aspects of psychiatric skills were evaluated during some point of training in abouttraining was however available from 74 countries and WHO 55% and 70% of countries, respectively. The commonestTerritories. assessment methods for examinations as recommended by national bodies were clinical examination (73.0%) fol-About half of the countries reported having an accredited lowed by essay type answers (66.2%), patient interviewsdiploma or a Master’s degree in psychiatry. Super-specializa- (66.2%), multiple choice questions (63.5%) and disserta-tion in specific areas of psychiatry or a doctoral programme tion (55.4%). Thirty-three countries used a combination ofin psychiatry was reported by fewer countries. While 16 internal and external examiners to evaluate the trainees.countries reported that they had facilities to train more than45 students in a diploma course, 10 countries reported hav- Information about super-specialization courses was reporteding facilities to train the same number of students in a Mas- by fewer countries. Child psychiatry courses were the mostter’s degree. While more than 10 teachers for psychiatry commonly reported super-specialization in psychiatry fol-were reported by 32 countries, less than 15 countries had lowed by addiction psychiatry and forensic psychiatry.more than 10 teachers in the area of clinical psychology, About half of the countries reported having no bilateralpsychiatric social work and psychiatric nursing. Each country arrangement with another country for postgraduate train-sets specific criterion for training programmes depending ing. Migration of trained psychiatrists to high income coun-on the regulations laid down by its institutions or bod- tries was an issue for many low income countries.ies. Forty-five countries (60.8%) reported the criterion of While 40 countries reported that they had permanentminimum number of teaching beds with an average of 136 licensing facilities, 19 countries reported licensing facilitiesbeds. The average outpatient attendance was a criterion for limited duration only. Different bodies were identifiedin 33 (44.6%) countries. Presence of rehabilitation facili- by the countries as having a role in psychiatric trainingties and support of anaesthetists was a pre-requisite in less and accreditation of the qualification. The most commonthan 40% of countries. Presence of open wards, residential were the different Ministries of the Government, Medi-facilities, facilities for day-care were reported by 77-87% of cal/Psychiatric Councils, National Psychiatric institutionscountries. Only a third of the low income countries reported and the Psychiatric Societies. Besides being involved inthat they had open wards in most centres in their respective setting guidelines for training and accreditation, thesecountries. institutions or bodies were also involved in setting a curricu-The training methods also varied across countries. A written lum, maintaining the quality of infrastructure, conductingcurriculum was present in 63 countries. While a rotation in examinations and arranging seminars for continued medicalmedicine and neurology was a prerequisite in most centres education.across a third of the countries, training in psychotherapy, The results of Atlas: Psychiatric Education and Trainingnational mental health activities and promoting independ- Across the World suggest that attention is needed on theence in trainees were encouraged in most centres in only quantitative and qualitative aspects of psychiatric training,19-27% of countries. Training in psychotherapy, training in especially within low and middle income countries. Inter-multidisciplinary teams and participation in national mental national technical assistance and guidelines in combinationhealth activities was reported by two-third of low income with strong professional leadership within the countries arecountries compared to almost four-fifth of high income necessary to improve the situation.countries. Knowledge about – psychopathology and men- 9
  11. 11. 1 PRESENCE OF PSYCHIATRIC TRAINING PROGRAMMES Presence of psychiatric training programmes Salient Findings Information about the presence of psychiatric training countries and 77.1% of high income countries. Seventy- programmes in a country was obtained from all possible three countries (38% of WHO countries) and one WHO sources. Out of the 192 Member States of WHO, psychi- territory (China, Hong Kong, SAR) had responded to the atric training was present in 122 countries (63.5%), absent assessment. Completed questionnaires were received from in 57 countries (29.7%) and information was unavailable 4/46 countries in Africa, 17/35 in Americas, 6/11 in South about 12 countries (See appendix 1 for the list of countries). East Asia, 31/51 in Europe, 7/22 in Eastern Mediterranean Countries with a training programme accounted for a total and 9/28 (including Hong Kong, SAR) in Western Pacific. population of 6039.8 million which is 96% of the world’s When analysed according to income group of countries, population. Psychiatric training programmes among the responses were received from 16/66 low income countries, different WHO Regions varied between 47.4% in Africa 23/54 lower middle income countries, 17/37 higher middle Region to 94.1% in European Region. Similarly, it was income countries and 18/36 high income countries and ter- present in 54.5% of low income countries, 68.5% of lower ritories (including Hong Kong, SAR). middle income countries, 59.5% of higher middle income 1.1 Psychatric education and training across the world s Ye on ati orm inf No WHO 05.121 f eo nc y in se s ts The designations employed and the presentation of material on the above Pre pilep ialis ld maps do not imply the expression of any opinion whatsoever on the part of r 10.1 e spec wo the Wold Health Organization concerning the legal status of any country, e 55 th 1 territory, city or area or of its authorities, or concering the delimitation of its N= frontiers or boundaries. Dashed lines represent approximate border lines for which there may not yet be full agreement.10
  12. 12. PRESENCE OF PSYCHIATRIC TRAINING PROGRAMMES 1 Limitations ImplicationsPresence of a training facility neither provides sufficient Expansion of psychiatric training is needed in all but theinformation regarding the quality of training provided nor smallest low income countries. Psychiatric training is bestthe uniformity of training across the country. carried out within the country so that the training can be most appropriate for the needs of the mental health sys- tem within the country. Regional collaboration on training ng would be beneficial to all countries especially those with ini s c tra trie inadequate resources and training facilities. This would also tri oun hia nt c ) benefit the smallest low income countries (eg., some of the yc ps ere (% island countries in the Western Pacific Region that have a of diff ons 94.1% ce n i en s i eg 72.7% small population and limited resources) which would find it res ilitie O R P c extremely difficult to develop their own training facilities. a WH 9 f f 67.7%1.2 o 17 N= 47.7% 66.7% 48.1% 68.2% ric HO iat h W sych ac y p ) n e d b (% i e as ion er ies Af ric lat cov acilit ric as pu n f 98.5% me Po egio ing ia R ain 9 83.4% A As 1.3 tr 99.8% st e 17 Ea rop N= 99.9% uth Eu ea n 91% So an err ic it cif 99.5% ed Pa d nM ern orl s ter est W 97.2% Ea W ric iat as y ch es Af ric ps amm f as al ric oc rogr up o f l p ro A me As ia e o te g st e nc dua me Ea rop e ist tgra inco 54.5% 34.8% uth Eu ea n So Ex os ss err an ic1.4 p cro tries it Pa cif a oun ed d c w Lo 66 nM ern orl = 10.7% s ter est W N Ea W 59.5% 37.8% 68.5% 25.9% le idd 37 2.7% le r m N= idd 54 5.6% g he r m N= Hi we Lo 77.1% 17.1% s Ye gh 5.8% on Hi =35 ati rm N info No 11
  13. 13. 2 TRAINING PROGRAMMES AND INFRASTRUCTURE Training programmes and infrastructure Salient Findings Thirty-one countries reported having at least one accredited time frame for the Master’s programme. Super-specializa- postgraduate diploma course and 35 countries reported the tion required 1-2 years in 18 out of the 35 countries report- presence of at least one accredited Master’s programme. ing on it. PhD training was generally completed in 3-4 Twenty-three countries reported having at least one accred- years in 22 countries that reported its presence. ited super-specialization course in areas like child psychiatry, addiction psychiatric, geriatric psychiatry, and 22 countries Diplomas were the most common postgraduation training had at least one doctoral course. While super-specializa- offered to students, with 16 countries reporting more than tion was not reported by any of the Eastern Mediterranean 45 students each per year. Master’s programmes were also countries, more than half of the countries from Europe had offered in large numbers, with 10 countries reporting that super-specialization within the country. Only two out of they trained more than 45 students each per year. Fourteen the seven countries reporting from Eastern Mediterranean countries reported having at least 15 students in their Mas- Region and three out of the nine countries reporting from ter’s programme. Super-specialization training was provided the Western Pacific Region had a Master’s course. to 1-15 students per year in 17 countries and PhD was offered to 1-15 students per year in 21 countries. Facilities The minimum duration of training varied to a great degree to train more than 15 students in super-specialities and doc- among countries. While 22 countries out of 74 reported 3-4 torate degrees were reported by nine and four countries, years training for diplomas, 28 countries reported the same respectively. f no ni tio g try og nin hia rec trai psyc for ate in s Ye 28.4% 44.6% ria adu es ite r m ti on Cr ostg ram ma p rog 25.7% or 2.1 p =74 13.5% inf nt No tie ce 27% N tpa dan u n of e o tte er ds 60.8% erag a mb g be Av Nu hin c tea 23% 23% 29.7% 39.2% 13.5% 55.4% l 27% 39.2% ica g 54% of logestin rt ts ho t po etis 31.1% yc for s p Ps ies nt 31.1% Su esth for c ilit atie an a ies ion 33.8% Fa us p ilit ilitat c Fa hab ero ng re da 21.6% 68.9% 25.7% 43.2% 26.9% 46.2% 23% ies 9.5% 27% l ilit ica g fac log stin 31.1% rar y og y ysio te Lib l ica g diol 26.9% ph Ra u ro em tin 50% Ne io ch tes B 27% 56.8% 25.7% 41.9% ics eth ees 16.2% or to mitt y f cs ss c ilit tisti 32.4% ce com Fa osta Ac bi12
  14. 14. TRAINING PROGRAMMES AND INFRASTRUCTURE 2 te ua ith rad ry w tg nt s y os an M r p cou r aid fo he on es t so m ati 18.9% 24.3% ntr g in ilitie for ce n fac in of ini 13.5% 21.6% No i on ic tra ining tia l p ort iatr tra en ies sid acilit 23% Pro sych ified s 16.2% Re f 33.8%2.2 p pec ard s =74 nw 48.7% N e Op 14.9% 27% 20.3% 35.1% 8.1% 21.6% 21.6% ids 23% 27% l a ng 23% for s 60.8% is ua achi ies nt -V te for 39.2% ilit atie ac c p 10.8% dio for ies ion F si Au or ilit ilitat 17.6% s f re 23% c Fa hab en cil itie y ca for Fa da 27% re 17.6% 28.4% 20.3% 25.7% 23% 29.7% or y f es 21.6% e lik d ilit aine ac e) s ses bme 23% r f of tr 32.4% r a ute e mo rnal 20.3% tab s/pu 31% mp us or u da u Co e ( jo 27% to dic fiv atric o i c ess x me n t ch Ac nde tio psy i scrip b SuThe number of recognized postgraduate teachers varied radiological and neurophysiological testing was a prerequi-according to the discipline. While more than 10 teach- site in 43-50% of countries.ers for psychiatry were reported by 32 countries; clinicalpsychologists, psychiatric social work and psychiatric nurs- Specified training facilities like the presence of open wards,ing teachers were fewer in numbers. Out of the countries residential facilities and facilities for day-care were reportedresponding, more than 10 teachers in clinical psychology, by 77-87% of countries. Audio-visual aids, computingpsychiatric social work and psychiatric nursing were report- facilities and access to electronic databases and subscrip-ed by 15, nine and eight countries, respectively. tion to five or more psychiatric journals were reported to be present in 77-85% of countries. Rehabilitation facilities andThe minimum criteria for training could be broadly divided facilities for forensic patients though present in many coun-into two groups – those related to psychiatry directly like tries, was available in a few centres in most of the countries.number of teaching beds, facilities for rehabilitation and While quantifying the number of centres within a countrypsychological testing; and general infrastructure like bio- having the above facilities, low income countries reportedchemical testing, radiology, support of anaesthetists, library that only a third of them had open wards in most centres.facilities, biostatistics, access to ethics committee. Forty- The remaining facilities were present in most centres in lessfive countries (60.8%) reported the criterion of minimum than 10% of countries. This contrasts with the report fromnumber of teaching beds with an average of 136 beds. higher middle income and high income countries, whichThe average outpatient attendance was a criterion in 33 reported having all the training facilities in most centres in(44.6%) countries. Presence of facilities for rehabilitation 40-65% of countries. But even for them, rehabilitation andand anaesthetists support was a prerequisite in less than forensic psychiatry facilities were present in fewer centres.40% of countries. Presence of psychological, biochemical, 13
  15. 15. 2 TRAINING PROGRAMMES AND INFRASTRUCTURE T The quality of psychiatric training varies to a large extent across countries. Even within countries there are areas of training which are particularly weak. Turkey has good training opportunities in five years and the curriculum is established by the Swedish National Board of Health with cooperation from professionals in the Swedish Medical Association and the Swedish Board of Psychiatry. The curricu- biological psychiatry, psychopharmacology and psychiatric nosology. lum is set to be revised in 2006. On the other hand, training opportunities in psychotherapy, com- The M.Med Psychiatry course in Tanzania consists of six semesters munity psychiatry, forensic psychiatry and cultural and administrative and includes basic sciences courses and theoretical and skill mod- issues are relatively less. Bolivia has modules on epistemology, sta- ules specific to the discipline of psychiatry and mental health. Basic tistics, community care, epidemiology and methodology of scientific science courses include physiology and clinical pharmacology, bio- research as a part of their psychiatric training. Psychiatric training in chemistry, microbiology/immunology, epidemiology and biostatistics. Syria started seven years ago. The trainees are based in two mental Apart from clinical psychiatry, medical, sociological, anthropological asylums and the curriculum is under-developed. There are no facilities and psychological disciplines are part of the course. A structured for psychotherapy, social work and quality research. The quality of supervised dissertation is an essential part of the curriculum. training is poorly monitored and there are no licensing laws. In con- trast, postgraduate psychiatric training in Australia and New Zealand In Tunisia, the curriculum lasts four years during which residents are is essentially an apprenticeship model, with great emphasis placed encouraged to spend a six-month training period in child psychiatry on a particular set of clinical rotations and careful clinical supervision. and in neurology. Many residents are offered a one-year training The college maintains an accreditation process and oversight of all of period abroad, mainly in France to increase their knowledge in an those clinical placements and the documented supervision. In addi- area not available in Tunisia e.g. cognitive behavioural therapy or tion, there are formal, more academic programmes which vary a lot neuroimaging. Psychiatric training in China lasts for three years. A from place to place, but usually occupy one or two half days per aca- doctoral programme on the other hand extends for 5-6 years. There demic year, for three to five years. Those courses cover the standard is no specific programme devoted solely to psychiatry in Kuwait. knowledge base relevant to clinical psychiatry e.g. relevant pre-clinical However, the Kuwait Institute for Medical Specialization (KIMS) disciplines, biological psychiatry, psychological and social sciences, runs a specialist programme, for which the native Kuwaiti doctors psychotherapy, ethics. Psychiatric training in Sweden is for a period of involved do rotation in the psychiatric hospital. Limitations Though WPA has defined criteria for diploma, Masters and Teachers related to psychiatric nursing and psychiatric social super-specialization programmes, it is possible that many work are often not directly associated with the training of countries have different definitions. Thus there is a variance psychiatrists. Thus, it is possible that many countries did not in the data, both in number of programmes and time frame. have sufficient information to report on them. Again the For example, the United Kingdom and Australia/New Zea- definitions of these two disciplines vary across countries. land have different nomenclatures for postgraduate training to the one specified in the question. Since no quantitative criteria were provided to define ‘few’, ‘many’ and ‘most’, the responses were purely qualitative in The time frame could also vary depending on how the nature and subject to variance and random measurement respondents had calculated the beginning of the course, e.g. error. Again the definition of some of the training facilities the training period for Master’s degree within the super-spe- may have been ambiguous, especially those related to reha- cialization period, may or may not have been included. bilitation and forensic psychiatry. Implications Despite the availability of the WPA curriculum for training of rehabilitation facilities were fewer in all countries across the psychiatrists, there is a large amount of variance in both the world. It is surprising to find that less than 40% of countries nomenclature and period of training. This leads to a huge dis- have rehabilitation facilities and anaesthetist support as a parity in the quality of training across countries and even with- pre-requisite, given that psychiatric conditions are chronic in in countries. Though, it is desired that each country should nature and require long-term management and rehabilita- cater to its own needs and the training programme should tion. Anaesthetist support is generally considered essential for incorporate those needs, there should be some common administering electroconvulsive therapies. Low income coun- standard which all training programmes should adhere to. tries need to increase their training resources in definite even though small steps to reach the standards generally prevalent The basic training requirements should be standardized and a in higher income countries. broad guideline should be followed. Forensic psychiatry and14
  16. 16. TRAINING PROGRAMMES AND INFRASTRUCTURE 22.3 Proportion of centres for postgraduate psychiatric training in the country with specified training facilities or aids across income group of countriesFacilities Low Lower middle Higher middle High N=16 % N=23 % N=17 % N=18 %Open wardsfew 5 31.3 9 39.1 2 11.8 0 0.0many 1 6.1 2 8.7 5 29.4 4 22.2most 5 31.3 12 52.2 9 52.9 10 55.6unrated 5 31.3 0 0.0 1 5.9 4 22.2Residential facilitiesfew 6 37.4 7 30.4 3 17.6 2 11.2many 4 25.0 4 17.4 3 17.6 6 33.3most 1 6.3 9 39.1 9 53.0 6 33.3unrated 5 31.3 3 13.0 2 11.8 4 22.2Facilities for day carefew 6 37.5 8 34.8 3 17.6 3 16.7many 3 18.8 3 13.0 5 29.4 6 33.3most 1 6.2 7 30.4 7 41.2 5 27.8unrated 6 37.5 5 21.7 2 11.8 4 22.2Facilities for rehabilitationfew 7 43.8 12 52.2 6 35.2 4 22.2many 2 12.5 4 17.4 2 11.8 5 27.8most 1 6.2 3 13.0 7 41.2 5 27.8unrated 6 37.5 4 17.4 2 11.8 4 22.2Facilities for forensic patientsfew 6 37.5 18 78.3 10 58.8 11 61.1many 2 12.5 2 8.7 2 11.8 2 11.1most 0 0.0 1 4.3 4 23.5 1 5.6unrated 8 50.0 2 8.7 1 5.9 4 22.2Audio – Visual aids for teachingfew 6 37.5 9 39.1 2 11.8 3 16.7many 3 18.8 7 30.4 3 17.6 4 22.2most 1 6.2 7 30.4 11 64.7 7 38.9unrated 6 37.5 0 0.0 1 5.9 4 22.2Subscription to five (or more) psychiatric journalsfew 6 37.5 12 52.2 3 17.6 1 5.6many 1 6.3 6 26.1 2 11.8 6 33.3most 1 6.2 2 8.7 10 58.8 7 38.9unrated 8 50.0 3 13.0 2 11.8 4 22.2Access to databases like index medicus/pubmedfew 5 31.3 9 39.1 2 11.8 3 16.7many 2 12.5 7 30.4 4 23.5 4 22.2most 2 12.5 4 17.4 10 58.8 7 38.9unrated 7 43.7 3 13.0 1 5.9 4 22.2Computer facility for use of traineesfew 7 43.8 10 43.5 2 11.8 2 11.1many 3 18.8 3 13.0 5 29.4 5 27.8most 1 6.2 7 30.4 9 52.9 7 38.9unrated 5 31.2 3 13.0 1 5.9 4 22.2 15
  17. 17. 3 TRAINING CURRICULA AND TEACHING METHODS Training curricula and teaching methods Salient Findings The structure of training for a diploma as well as a Masters Among the training skills imparted to trainees – knowledge degree varied across countries. A written curriculum was about psychopathology, diagnostic interview and clinical present in 63 countries. Rotation in medicine, neurology skills, knowledge of mental disorders and diagnostic and and multidisciplinary team work was a prerequisite in most therapeutic skills – were present in most centres in more centres across one third of the countries. Training in psy- than 60% of countries. About a third of the countries chotherapy, national mental health activities and promoting reported that most centres provided training in psychother- independence in trainees were encouraged in most centres apy, genetics and basic neuroscience, psychology, research in 19-27% of countries. One third of the countries had methodology including biostatistics and ethics and public scope for continued medical education and kept records of health psychiatry. Teaching and managerial skills were dissertation in most of their centres. Out of those respond- taught by a few centres in one third of countries. ing to the questionnaire, about 70-80% of countries across the Americas and the European Region, had facilities for While case vignettes, case conferences and seminars were medical and neurology rotation, psychotherapy training and the most commonly used teaching techniques in 50-60% participation in national mental health activities. Training in of countries, discussion on ethics and self-directed learning psychotherapy, training in multidisciplinary teams and par- was commonly used in about one fourth of the countries. ticipation in national mental health activities was reported by two thirds of low income countries compared to almost four fifths of high income countries. te ua th r ad y wi ss y stg tr cro an po coun ts a M or en on s f he ati tre in t ngem rm en g nfo f c nin arra ns No i io n o trai ing egio 20.3% 25.7% n ort tric rai R op chia ed t WHO Pr sy ifi 25.7% 25.7% 3.1 p pec rent 14.9% 24.3% ts s iffe en y 16.2% d 74 em rolog N= nts e 13.5% ir qu neu 37.8% me in re ula 10.8% u ire edic 35.1% ion in rric eq m tat cu 50% n r in Ro 16.2% en tio ritt Ro ta 21.6% W 39.2% 27% 25.7% 20.3% 24.3% al 23% 36.5% on s ti- s n ati ivitie 23% ul 25.7% in act ith s n m rum 21.6% on th g w am 23% n g i l fo ip ati heal py nin y te ini nta rtic tal era sion 13.5% ai ar Tr in 32.4% Tra tme Pa men oth ervi 27% ipl pa r ch up y s isc de Ps ltid 29.7% 27% mu 24.3% 20.3% 29.7% 32.5% of 24.3% 17.6% rd ns 14.9% of d co atio rd 14.9% Re ert ng co raine dis s 28.4% oti ees 18.9% Re s t 40.5% al t om train ate on 27% r s p in 18.9% du ssi men fe p e e ra pro velo 31.1% mm nc stg gra ende po ing de tin u Pro dep Con in16
  18. 18. TRAINING CURRICULA AND TEACHING METHODS 33.2 Proportion of centres for postgraduate psychiatric training in the country with specified training arrangements across different income group of countriesTraining Low Lower middle Higher middle Higharrangements N=16 % N=23 % N=17 % N=18 %Written curriculafew 5 31.2 7 30.4 4 23.5 2 11.1many 4 25.0 1 4.3 1 5.9 2 11.1most 3 18.8 13 56.6 10 58.8 11 61.1unrated 4 25.0 2 8.7 2 11.8 3 16.7Rotation requirements in medicinefew 6 37.5 8 34.8 2 11.8 3 16.7many 3 18.8 3 13.0 2 11.8 2 11.1most 2 12.5 9 39.2 8 47.0 7 38.9unrated 5 31.2 3 13.0 5 29.4 6 33.3Rotation requirements in neurologyfew 4 25.0 7 30.4 3 17.6 5 27.8many 5 31.2 3 13.0 3 17.6 1 5.6most 3 18.8 11 47.9 8 47.1 6 33.3unrated 4 25.0 2 8.7 3 17.7 6 33.3Psychotherapy supervisionfew 8 50.0 12 52.2 1 5.9 6 33.3many 1 6.3 3 13.0 5 29.4 1 5.6most 1 6.3 3 13.0 9 52.9 7 38.9unrated 6 37.4 5 21.8 2 11.8 4 22.2Training with multidisciplinary teamsfew 8 50.0 7 30.4 1 5.9 2 11.1many 1 6.2 9 39.2 4 23.5 3 16.7most 1 6.2 3 13.0 10 58.8 10 55.5unrated 6 37.6 4 17.4 2 11.8 3 16.7Training in multi-departmental forumsfew 6 37.5 8 34.8 3 17.6 2 11.1many 3 18.7 6 26.1 5 29.4 5 27.8most 1 6.3 2 8.7 7 41.2 6 33.3unrated 6 37.5 7 30.4 2 11.8 5 27.8Participation in national mental health activitiesfew 7 43.8 11 47.8 4 23.5 7 38.9many 2 12.5 7 30.5 4 23.5 4 22.2most 2 12.5 3 13.0 7 41.2 4 22.2unrated 5 31.2 2 8.7 2 11.8 3 16.7Continuing professional developmentfew 4 25.0 7 30.4 2 11.8 0 0.0many 6 37.5 7 30.4 3 17.6 4 22.2most 0 0.0 4 17.4 10 58.8 9 50.0unrated 6 37.5 5 21.8 2 11.8 5 27.8Programmes promoting independence in traineesfew 6 37.5 10 43.5 4 23.5 4 22.2many 3 18.7 2 8.7 4 23.5 5 27.8most 1 6.3 2 8.7 6 35.3 5 27.8unrated 6 37.5 9 39.1 3 17.7 4 22.2Record of postgraduates trainedfew 4 25.0 7 30.4 1 5.9 3 16.7many 6 37.5 2 8.7 2 11.8 1 5.6most 2 12.5 9 39.2 11 64.7 8 44.4unrated 4 25.0 5 21.7 3 17.6 6 33.3Record of dissertationsfew 5 31.3 8 34.8 3 17.6 4 22.2many 3 18.8 6 26.1 1 5.9 1 5.6most 2 12.5 5 21.7 10 58.8 4 22.2unrated 6 37.5 4 17.4 3 17.7 9 50.0 17