The aim of this review was to determine current training programmes in General Adult Psychiatry and Child and Adolescent Psychiatry across Europe and to assess if and how transition as a topic is incorporated in the training curricula of these disciplines. A systematic review was conducted and provided 45 documents.
Current GAP and CAP training in Europe: the issue of harmonization
A key objective of the European Economic Community is to allow the free movement of professionals (Treaty of Rome, 1957). Hence, one of the major challenges concerning psychiatry in Europe has been the harmonization of training and certification requirements. Various professional organizations have been working for 20 years on recommendations to harmonize an optimal quality of national psychiatry training programs in Europe [62, 63].
According to data collected through our review, this harmonization has reached a significant level on several aspects of both GAP and CAP trainings: national programs, program length (in the average range of 4–6 years for about 3/4 of countries), mandatory GAP training in CAP and mandatory CAP training in GAP. For GAP training in particular, quality control of the training programs implementation is reported in most countries. For CAP, supervision in general is widely accessible in the vast majority of countries.
However, harmonization is still to be achieved on several other aspects. Most importantly, in both CAP and GAP trainings, differences between the stated national programmes and the lived experience of trainees are reported, suggesting substantial variations at a local level [20, 29, 63]. For both, there is still no final board exam in 1/3 of countries and no mandatory training in psychotherapy in 1/3 or even more for CAP. As regards data available for GAP more specifically, crucial aspects of the compulsory common trunk of knowledge and skills defined by UEMS [13] like old age psychiatry or liaison and consultation psychiatry are still not mandatory (respectively, in 31 and 41% of countries)Footnote 1,Footnote 2. In terms of examination and assessment methods, there is still no consequence in case of failed assessment in 28% of countries. Concerning assessment methods in particular, a most interesting evolution is taking place but is still restricted to a few countries like UK [64] or the Netherlands [42]: a shift from a system based only on participation of the trainee towards a “competence-based training” model where trainees are much more responsible and skills are central. Finally, very scarce data about CME show that few countries keep a register or set minimum standards [65] and that there are important variations in modalities [35, 36, 47]. For CAP, available data show harmonization is not yet realised regarding the access to an independent educational supervision.
As a major manifestation of this harmonization still to be achieved, we delineated 3 coexisting models of training and practice of GAP and CAP in Europe (Fig. 2). In the first model, psychiatry is a general speciality, with possible subspecialties that are not mandatory. Trainees are provided with a generalist education and receive a general diploma of “psychiatrists”. This model was identified only in 5/33 countries (15%)Footnote 3, among which Spain was included since the separation of GAP and CAP has not been implemented in the training programmes yet [33]. In the second model, psychiatry is divided into totally independent specialties (e.g. CAP, AP, forensic, addictions, old age, etc). Trainees are provided with a separate specialized training from the start after medical studies, with completely different programs. This model is common and prevalent in 18/33 countries (55%)Footnote 4. Finally, 5/33 countries (15%)Footnote 5 countries used a third model, where trainees were provided with a common specialist psychiatry core program followed by further specialization – this often led to longer total training periods. Five remaining countries (15%)Footnote 6 could not be classified, due to unclear or contradictory data.
Transition as a topic in training of CAP and GAP in Europe
This review identified only two countries where this topic appeared in the curricula. In Ireland and the UK, transition has recently become a mandatory topic, but it is only covered briefly in the training documentation (in the UK, however, an elective course provides also more detailed training). Furthermore, transition is only addressed in CAP training, with no mention of it in GAP training. Likewise, training in transition has been newly identified by the UEMS as part of the goals that should be acquired by trainees, but this is limited to CAP in the interim [66, 67]. It is important to note that both Ireland and the UK fall into the third model, which involves long periods in training and possibly allows for varied topics to be covered, including transition as a topic.
Outside Europe, authors from Australia, Canada and the United States (US) have identified difficulties in access to care and coordinated services for youth with mental health conditions [68,69,70,71]. Training in transitional care has also been identified as a strategy to aid continuity of care and support for different domains of functioning in young people with mental health conditions. Cross-training about transition in mental health where adult and child case managers are trained together has been documented in 19 out of 50 states in the US [72] and a systems of care guidelines for transition-aged youth has been provided [73].
Within the MILESTONE-project training material about transition in mental health conditions will be delivered. These training modules are intended for health care professionals, stake-holders and for the general public and will be made available on the project website: www.milestone-transitionstudy.eu. In France, a specific training module has recently been added in the revised mandatory national curriculum of trainees in psychiatry https://sides.uness.fr/.
Facilitators and/or barriers to transition in training - avenues
Relationships between GAP and CAP are a crucial issue in the transition process, both in terms of the experience that professionals have of the other discipline and in terms of common knowledge allowing a better dialogue and collaboration. Data collected in this review are reassuring from this point of view: 83% (26/31) of CAP training programs required a compulsory period of training in GAP and 96% (27/28) of GAP training programs required a compulsory period of training in CAP (Tables 6 and 7). However, the real length of exposure to the other discipline and content of training is variable and should be specifically explored in further studies.
Crucial structural differences in training models should be taken into account, as they probably have an impact on the relationships between both specialities. Thus, the monospeciality type of training (model 2) may significantly reduce the training in CAP for those who choose GAP specialty, and vice versa. Separate training pathways with no common basis, and often with no training provided in the other speciality (e.g. Germany), may contribute to a fragmented understanding of, and less experience in developmental psychopathology. While adolescence is a crucial period in the emergence of psychopathology and onset of disorders, trainees undergoing GAP training in this model may end up with a lack of knowledge and understanding of developmental psychopathology. The generalist type of training (model 1) and the common core program with further mandatory specialization (model 3) appear to better guarantee a more balanced experience in both specialities during the whole postgraduate training. These two models may also guarantee a better cooperation between child and adult psychiatrists when young service users face transition. The generalist training should, nevertheless, be long enough to allow a real core training in which CAP occupies a significant part of the curriculum. In its publications, the MILESTONE group have started examining the influence of the different training models on the transition outcome of young people in the MILESTONE study, combining European mapping data of child and adolescent mental health services with data on training models [74].
How can training programs ensure improved quality of transition?
First, in order to improve the quality of care in transition, both CAP and AP training programs should definitely start including transition as a mandatory subject. This is the direction currently followed by professional organizations: the two corresponding sections of UEMS have recently been involved in discussions regarding transition and a joint working group has been set up to look at transition from child to adult services [66, 74]. Fegert et al. (2017) mention “transition psychiatry” as a topic to be established both in training and continuous medical education, to compensate for a missing expertise [67, 75].
Second, the content of training must be reviewed. A structured and evidence-based training to transition, related to skills, should be provided as a priority. The TRACK study [1] suggested four major criteria for an optimal transition in mental health care, which could act as a starting point for training in transition: 1) ‘Continuity of care’, 2) ‘Period of parallel care (relational continuity)’, i.e. a period of joint working where the service user is involved with both CAMHS and AMHS; 3) ‘Transition planning meetings’ (cross-boundary and team continuity)’, i.e. at least one meeting discussing the transition from CAMHS to AMHS, involving the service user and/or carer and key professionals, prior to the handover of care from CAMHS to AMHS; 4) ‘Optimal information transfer (information continuity)’, i.e. referral letter, summary of CAMHS contact, any or all CAMHS notes and a contemporary risk assessment.
Beyond the transition as a topic in itself, developing other specific related topics is also crucial: 1) promoting a life span concept of the patient, like in the USA where training about child and adult development is available during the core training [36]; 2) extending this developmental approach particularly in GAP training [8, 76, 77], giving trainees mandatory experience across ages [64]. This is particularly needed for neurodevelopmental disorders like Attention-Deficit Hyperactivity Disorder [78] or Autism Spectrum Disorder, which are now well known to go on far beyond childhood and adolescence. 3) The specific needs and issues of adolescents and young adults should also be emphasized, as has already been done for the elderly in many countries (without necessarily making it a specialty in itself). The care for young people should be more comprehensive, or far-reaching, and take into account potential school problems, autonomy, support and involvement of parents, professional involvement, all of which necessitate collaboration between professionals and developing partnerships. For many years now, somatic medicine has emphasised this necessary focus on adolescents and their specific needs [7, 9, 77, 79]. A position paper about transitional care in adolescents with chronic conditions published by the Society of Adolescent Medicine has identified environmental support, decision-making and consent, family support and professional sensitivity to psychosocial issues as key factors for a successful transition [80]. Therefore, training in transition care should not only be a symptoms-based approach but a comprehensive developmental approach. Health providers in both paediatric and adult settings should be trained in shared case management. Contents of training should include the development of decision-making skills in adolescents during the transition process as well as family support because some parents will need the help of health providers to adjust to the changing needs of their children. In a study about parent perspectives, family members of young people with mental health conditions requested service providers to consider them as resources and potential collaborators in supporting young people in transition to live successful lives in the community [81].
Third, what is the best timing and manner for delivering training on transition and other relevant topics? A minimum mandatory content regarding transition should be included in training (in theoretical courses or in case studies). CME could be another opportunity for training in transition, provided that relevant modules are available. Developing a CME training programme in transition is one of the objectives of the MILESTONE Project. Joint training events between CAMHS and AMHS professionals could also be an avenue, particularly because they have been shown to improve working relationships and create opportunities for collaborative work [82,83,84].
Limitations
As regards the critical analysis of papers selected in our systematic review, several aspects should be taken into account when considering the results. Half of the references were expert papers, narrative reviews and other documents of the grey literature. Therefore, our review suffers from limitations usually related to the very nature of these documents (e.g. non-representative samples of studies, lack of quality appraisal, and multiple citation bias). The formal quality appraisal of the quantitative studies yielded low scores in sampling and data analysis as well as in ethics/bias assessment. Transferability/generalizability was questionable due to the type of data collection. Indeed, trainees were the only source of information in a majority of the studies (17/22, 77%). This participant selection may have impacted the quality of the reported information because trainees may not be aware of every aspects of the official curricula and may rely on limited experience within their own training centres. Our review also suffers from database and language biases because certain national journals may have been underrepresented in the databases we used and because of exclusion of a limited amount of studies in other languages that English or Spanish.
Some data were not available for all countries, making comparisons difficult when exploring the harmonization process. In addition, the number of references on CAP and GAP training varied widely between countries, from one to more than six references per discipline and country. Most countries (68% for CAP and 86% for GAP) had between two to five references per discipline (Additional file 2: Table S3, Additional file 3: Table S4, Additional file 4: Table S5 and Additional file 5: Table S6). More specifically, scarce (information obtained for < 5/19 items) or no data was available for 9/351 countries regarding GAP, and for 6/352 countries regarding CAP. Some essential issues were poorly covered: minimum length of training in psychotherapy, research, exact content of theoretical education, time dedicated to the different disciplines, continuing medical education.
Contradictory data were found in 5/19 items for GAP training and 10/19 items for CAP training (e.g. duration of GAP training in France was six years according to Kuzman [28] and four years according to Mayer [47]). This was particularly significant (with more than 10% of contradictory data) for program length (GAP and CAP training), assessment, and mandatory psychotherapy (GAP training), separate GAP and CAP training, paediatric experience, and psychotherapy training (CAP training) (Additional file 2: Table S3, Additional file 3: Table S4, Additional file 4: Table S5 and Additional file 5: Table S6). Lack of precise definitions of terms used in questionnaires may have contributed to this, leading to unclear or imprecise questions and/or answers (e.g. what is meant by the word “speciality”, or “separate training”). Another limitation is that the degree of implementation of national programs was not measurable, as this aspect were not systematically analysed at both national and local levels.
Finally, this review focusses on psychiatry but it must be kept in mind that other mental health disciplines are also involved in transition (i.e. psychologists, behavioural therapists and psychotherapists, psychiatric nurses, paediatricians). The training of professionals in these disciplines should be explored in relation with transition as well.
Strengths
Our systematic review of literature aimed at minimizing bias and reducing subjectivity by usage of inclusion/exclusion criteria and of a formal quality appraisal. Interpretation bias was also limited by the different background of the researchers. Among the twenty-three questionnaire-based surveys (abstracts and full text altogether) seventeen reported response rates (Tables 3, 4 and 5), most of which can be considered good: between 60 and 80% in 6/16 (37%) surveys and equal or more than 80% in 7/16 (44%).
