Psychiatric Training and education across the world

1. World Psychiatric
Association

3. World Psychiatric
Association
1

4. 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
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For further details on this project or to submit updated information, please contact:
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Fax: +41 22 791 4160, email: mhatlas@who.int
2

5. REFERENCE CONTENTS
Contents
Acknowledgements ....................................................................................... 4
Foreword ....................................................................................................... 5
Preface .......................................................................................................... 6
Introduction................................................................................................... 7
Method ......................................................................................................... 8
Summary of results ........................................................................................ 9
Presence of psychiatric training programmes ................................................. 10
Training programmes and infrastructure ........................................................ 12
Training curricula and teaching methods ........................................................ 16
Evaluation of training..................................................................................... 21
Super-specialization and bilateral arrangement .............................................. 23
Licensing and roles of national institutions .................................................... 25
Case study ..................................................................................................... 27
Appendices
Psychiatric education and training across the world ....................................... 28
WPA’s activities in psychiatric education and training ..................................... 30
Case study: A comparison in psychiatric training ............................................ 31
Atlas respondents/key contacts and training institutes/bodies ....................... 35
Contributors of additional Information........................................................... 40
3

6. 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 in
4

7. FOREWORD
Foreword
P 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 to
Does the training take into account enormously different “increase knowledge and skills necessary for work in the
environments 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 quality
Atlas: Psychiatric Education and Training across the World standards in psychiatric teaching as well as observance of
is 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 information
World Health Organization (WHO) and the World Psychi- for national psychiatric societies to take their work forward
atric Association (WPA) and is a testimony to the active in this important area.
collaboration between these two organizations. The Atlas
also clearly responds to the mandates and visions of the two At the global level, the Atlas provides an overview of the
organizations. 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 that
zation, Department of Mental Health and Substance Abuse, can provide more information.
is 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 establish
ing these objectives. Mental Health Atlas-2005 has clearly or reform psychiatric training in their countries. WHO, as
demonstrated 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 Okasha
Director, Department of Mental Health President
and Substance Abuse World Psychiatric Association
World Health Organization
5

8. 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 Association
6

9. INTRODUCTION
Introduction
C ountries are under increasing pressure to expand and
reform their mental health services and systems. This
was 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 have
further 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 clinicians
Report 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 students
prevalence of mental disorders varied between 4.3% in and other staff, as researchers to increase the repertoire of
Shanghai, China to 26.4% in the United States of America. knowledge on mental health, as public health specialists in
Milder disorders were more prevalent than severer ones. The developing the infrastructure for mental health services and
prevalence of moderate and severe disorders was 0.5-9.4% as advocates to increase awareness and needs around mental
and 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 over
Adjusted Life Years is 13% of the total burden of all health the past decades and scientific developments in the field of
conditions 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, psychiatric
require 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 medical
publication of the findings of the WHO Project Atlas (World discipline (Rubin and Zorumski, 2003). However, very little is
Health 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. As
in 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 the
Maulik 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 training
treatment gap, as evident from of review of 37 studies across programmes in all countries of the world, with the aim of
regions of the world, was estimated to be 32.2% for schizo- generating a knowledge base and using the information to
phrenia 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 the
alcohol abuse and dependence, etc. The WHO World Men- World reflects that effort. The project was launched in 2004
tal 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 and
severe cases (14.6% – 64.5%) compared to mild cases (0.5% updating periodically.
References
Kohn 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 Mental
Saxena 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. www.who.int/mental_health/evi-
the World Health Organization World Mental Health Survey. JAMA dence/atlas/index.htm
291(21): 2581-1590.
7

10. 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 – http://www.worldbank.org/data/countryclass/
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

11. SUMMARY OF RESULTS
Summary of Results
T his project attempted to gather basic information
about psychiatric training programmes in the world
through 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 by
sent out to 121 countries and responses were received fewer centres in some countries only. About half of the
from 73 countries and one WHO territory. This represented countries preferred using case vignettes, case conferences
only 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 technique
about 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 written
47.4% 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 by
income group psychiatric training facilities were present oral methods was the more preferred modes of evaluation
in 54.5% of low income countries compared to 77.1% of in 39 and 46 countries, respectively. Teaching and research
high income countries. Information on aspects of psychiatric skills were evaluated during some point of training in about
training was however available from 74 countries and WHO 55% and 70% of countries, respectively. The commonest
Territories. 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 interviews
diploma 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 of
in 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 than
45 students in a diploma course, 10 countries reported hav- Information about super-specialization courses was reported
ing facilities to train the same number of students in a Mas- by fewer countries. Child psychiatry courses were the most
ter’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 bilateral
psychiatric 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 permanent
minimum number of teaching beds with an average of 136 licensing facilities, 19 countries reported licensing facilities
beds. The average outpatient attendance was a criterion for limited duration only. Different bodies were identified
in 33 (44.6%) countries. Presence of rehabilitation facili- by the countries as having a role in psychiatric training
ties and support of anaesthetists was a pre-requisite in less and accreditation of the qualification. The most common
than 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 institutions
countries. Only a third of the low income countries reported and the Psychiatric Societies. Besides being involved in
that they had open wards in most centres in their respective setting guidelines for training and accreditation, these
countries. 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, conducting
curriculum was present in 63 countries. While a rotation in examinations and arranging seminars for continued medical
medicine 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 Training
national mental health activities and promoting independ- Across the World suggest that attention is needed on the
ence 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 combination
health activities was reported by two-third of low income with strong professional leadership within the countries are
countries compared to almost four-fifth of high income necessary to improve the situation.
countries. Knowledge about – psychopathology and men-
9

12. 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

13. PRESENCE OF PSYCHIATRIC TRAINING PROGRAMMES 1
Limitations Implications
Presence of a training facility neither provides sufficient Expansion of psychiatric training is needed in all but the
information regarding the quality of training provided nor smallest low income countries. Psychiatric training is best
the 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
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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
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e
ist tgra inco
54.5% 34.8% uth Eu
ea
n
So
Ex os ss err
an ic
1.4 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

14. 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
bi
12

15. 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
Su
The 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; clinical
psychologists, 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 reported
responding, more than 10 teachers in clinical psychology, by 77-87% of countries. Audio-visual aids, computing
psychiatric 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 and
The 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 country
psychological testing; and general infrastructure like bio- having the above facilities, low income countries reported
chemical 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 less
five countries (60.8%) reported the criterion of minimum than 10% of countries. This contrasts with the report from
number of teaching beds with an average of 136 beds. higher middle income and high income countries, which
The 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 and
and anaesthetists support was a prerequisite in less than forensic psychiatry facilities were present in fewer centres.
40% of countries. Presence of psychological, biochemical,
13

16. 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, Master's 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 and
14

17. TRAINING PROGRAMMES AND INFRASTRUCTURE 2
2.3 Proportion of centres for postgraduate psychiatric training in the country with specified training facilities or aids
across income group of countries
Facilities Low Lower middle Higher middle High
N=16 % N=23 % N=17 % N=18 %
Open wards
few 5 31.3 9 39.1 2 11.8 0 0.0
many 1 6.1 2 8.7 5 29.4 4 22.2
most 5 31.3 12 52.2 9 52.9 10 55.6
unrated 5 31.3 0 0.0 1 5.9 4 22.2
Residential facilities
few 6 37.4 7 30.4 3 17.6 2 11.2
many 4 25.0 4 17.4 3 17.6 6 33.3
most 1 6.3 9 39.1 9 53.0 6 33.3
unrated 5 31.3 3 13.0 2 11.8 4 22.2
Facilities for day care
few 6 37.5 8 34.8 3 17.6 3 16.7
many 3 18.8 3 13.0 5 29.4 6 33.3
most 1 6.2 7 30.4 7 41.2 5 27.8
unrated 6 37.5 5 21.7 2 11.8 4 22.2
Facilities for rehabilitation
few 7 43.8 12 52.2 6 35.2 4 22.2
many 2 12.5 4 17.4 2 11.8 5 27.8
most 1 6.2 3 13.0 7 41.2 5 27.8
unrated 6 37.5 4 17.4 2 11.8 4 22.2
Facilities for forensic patients
few 6 37.5 18 78.3 10 58.8 11 61.1
many 2 12.5 2 8.7 2 11.8 2 11.1
most 0 0.0 1 4.3 4 23.5 1 5.6
unrated 8 50.0 2 8.7 1 5.9 4 22.2
Audio – Visual aids for teaching
few 6 37.5 9 39.1 2 11.8 3 16.7
many 3 18.8 7 30.4 3 17.6 4 22.2
most 1 6.2 7 30.4 11 64.7 7 38.9
unrated 6 37.5 0 0.0 1 5.9 4 22.2
Subscription to five (or more) psychiatric journals
few 6 37.5 12 52.2 3 17.6 1 5.6
many 1 6.3 6 26.1 2 11.8 6 33.3
most 1 6.2 2 8.7 10 58.8 7 38.9
unrated 8 50.0 3 13.0 2 11.8 4 22.2
Access to databases like index medicus/pubmed
few 5 31.3 9 39.1 2 11.8 3 16.7
many 2 12.5 7 30.4 4 23.5 4 22.2
most 2 12.5 4 17.4 10 58.8 7 38.9
unrated 7 43.7 3 13.0 1 5.9 4 22.2
Computer facility for use of trainees
few 7 43.8 10 43.5 2 11.8 2 11.1
many 3 18.8 3 13.0 5 29.4 5 27.8
most 1 6.2 7 30.4 9 52.9 7 38.9
unrated 5 31.2 3 13.0 1 5.9 4 22.2
15

18. 3 TRAINING CURRICULA AND TEACHING METHODS
Training curricula and teaching methods
Salient Findings
The structure of training for a diploma as well as a Master's 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 in
16

19. TRAINING CURRICULA AND TEACHING METHODS 3
3.2 Proportion of centres for postgraduate psychiatric training in the country with specified training arrangements
across different income group of countries
Training Low Lower middle Higher middle High
arrangements N=16 % N=23 % N=17 % N=18 %
Written curricula
few 5 31.2 7 30.4 4 23.5 2 11.1
many 4 25.0 1 4.3 1 5.9 2 11.1
most 3 18.8 13 56.6 10 58.8 11 61.1
unrated 4 25.0 2 8.7 2 11.8 3 16.7
Rotation requirements in medicine
few 6 37.5 8 34.8 2 11.8 3 16.7
many 3 18.8 3 13.0 2 11.8 2 11.1
most 2 12.5 9 39.2 8 47.0 7 38.9
unrated 5 31.2 3 13.0 5 29.4 6 33.3
Rotation requirements in neurology
few 4 25.0 7 30.4 3 17.6 5 27.8
many 5 31.2 3 13.0 3 17.6 1 5.6
most 3 18.8 11 47.9 8 47.1 6 33.3
unrated 4 25.0 2 8.7 3 17.7 6 33.3
Psychotherapy supervision
few 8 50.0 12 52.2 1 5.9 6 33.3
many 1 6.3 3 13.0 5 29.4 1 5.6
most 1 6.3 3 13.0 9 52.9 7 38.9
unrated 6 37.4 5 21.8 2 11.8 4 22.2
Training with multidisciplinary teams
few 8 50.0 7 30.4 1 5.9 2 11.1
many 1 6.2 9 39.2 4 23.5 3 16.7
most 1 6.2 3 13.0 10 58.8 10 55.5
unrated 6 37.6 4 17.4 2 11.8 3 16.7
Training in multi-departmental forums
few 6 37.5 8 34.8 3 17.6 2 11.1
many 3 18.7 6 26.1 5 29.4 5 27.8
most 1 6.3 2 8.7 7 41.2 6 33.3
unrated 6 37.5 7 30.4 2 11.8 5 27.8
Participation in national mental health activities
few 7 43.8 11 47.8 4 23.5 7 38.9
many 2 12.5 7 30.5 4 23.5 4 22.2
most 2 12.5 3 13.0 7 41.2 4 22.2
unrated 5 31.2 2 8.7 2 11.8 3 16.7
Continuing professional development
few 4 25.0 7 30.4 2 11.8 0 0.0
many 6 37.5 7 30.4 3 17.6 4 22.2
most 0 0.0 4 17.4 10 58.8 9 50.0
unrated 6 37.5 5 21.8 2 11.8 5 27.8
Programmes promoting independence in trainees
few 6 37.5 10 43.5 4 23.5 4 22.2
many 3 18.7 2 8.7 4 23.5 5 27.8
most 1 6.3 2 8.7 6 35.3 5 27.8
unrated 6 37.5 9 39.1 3 17.7 4 22.2
Record of postgraduates trained
few 4 25.0 7 30.4 1 5.9 3 16.7
many 6 37.5 2 8.7 2 11.8 1 5.6
most 2 12.5 9 39.2 11 64.7 8 44.4
unrated 4 25.0 5 21.7 3 17.6 6 33.3
Record of dissertations
few 5 31.3 8 34.8 3 17.6 4 22.2
many 3 18.8 6 26.1 1 5.9 1 5.6
most 2 12.5 5 21.7 10 58.8 4 22.2
unrated 6 37.5 4 17.4 3 17.7 9 50.0
17