Teaching and training in old age psychiatry: a general survey of the World Psychiatric Association member societies

Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association

INTRODUCTION

Present knowledge about depression in the elderly is still scarce and often controversial, despite its high frequency and impact. This article reports the results and most relevant conclusions of a Delphi-based consensus on geriatric depression promoted by the Spanish Psychogeriatric Association.

METHODS

A 78-item questionnaire was developed by 7 highly specialized geriatric psychiatrists and was evaluated using the Modified Delphi technique in two rounds answered by 35 psychiatrists with an extensive expertise in geriatric depression. The topics and number of questions (in brackets) covered were: concepts, clinical aspects, and risk factors (12); screening and diagnosis (7); psychotic depression (17); depression and dementia (5); antidepressant drug treatment (18); non-pharmacological biological treatments (5); psychotherapeutic treatments (4); comorbidity and preventive aspects (6); professional training needed (4). In addition, the expert panel's opinion on the antidepressants of choice in 21 common comorbid conditions and on different strategies to approach treatment-resistant cases in terms of both efficacy and safety was assessed.

RESULTS

After the two rounds of the Delphi process, consensus was reached for 59 (75.6%) of the 78 items. Detailed recommendations are included in the text. Considering pharmacological treatments, agomelatine was the most widely mentioned drug to be recommended in terms of safety in comorbid conditions. Desvenlafaxine, sertraline, and vortioxetine, were the most frequently recommended antidepressants in comorbid conditions in general. Combining parameters of efficacy and safety, experts recommended the following steps to address cases of treatment resistance: 1. Escalation to the maximum tolerated dose; 2. Change of antidepressant; 3. Combination with another antidepressant; 4. Potentiation with an antipsychotic or with lamotrigine; 5. Potentiation with lithium; 6. Potentiation with dopamine agonists or methylphenidate.

DISCUSSION AND CONCLUSIONS

Consensus was reached for a high number of items as well as for the management of depression in the context of comorbid conditions and in resistant cases. In the current absence of sufficient evidence-based information, our results can be used to inform medical doctors about clinical recommendations that might reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders.

Geriatric Psychiatry Teaching in Canadian Medical Schools: a Cross-Sectional Study

OBJECTIVE

With a growing geriatric population and limited geriatric psychiatrists in Canada, it is crucial to provide sufficient training in geriatric psychiatry during medical school. The authors examined how geriatric psychiatry education is delivered in Canadian medical schools during clerkship. Factors that could be associated with increased geriatric psychiatry teaching in medical schools were examined. The authors were also interested in comparing Canadian to US findings.

METHODS

A cross-sectional survey was distributed to the psychiatry medical education representatives attending the Canadian Organization of Undergraduate Psychiatry Educators (COUPE) semi-annual meeting in September 2017.

RESULTS

All 17 (100%) medical schools completed the survey. Fifteen of the 17 schools (88%) have geriatric psychiatry-specific learning objectives. Five schools (29%) offer a clinical component in geriatric psychiatry. One school has an award for clerks (6%), and no awards exist for faculty. The number of lecture hours in geriatric psychiatry is moderately correlated with the presence of a geriatric component to psychiatry clerkship (Spearman's rho = 0.67, p = 0.003) and the length of the geriatric portion of clerkship (Spearman's rho = 0.64, p value = 0.006). Lecture hours are also moderately correlated with the presence of a geriatric fellowship (Spearman's rho = 0.68, p value = 0.003).

CONCLUSIONS

Geriatric psychiatry clerkship education is inconsistent in Canada. There is virtually no recognition of excellence in teaching or undergraduate performance in this area in clerkship. Geriatric psychiatry may receive more frequent attention in Canadian medical schools than in US medical schools.

International Perspectives on Old Age Psychiatry Training

Psychiatry of old age is a psychiatric subspecialty that has been developed in many countries since the 1950s as an attempt to improve the care of older adults with mental health disorders. Psychiatry of old age specialist training programs were subsequently established to develop a medical workforce that has the required competencies to work in this subspecialty. This article describes the psychiatry of old age specialist training programs in Australia, New Zealand, the United Kingdom, and Mexico. These training programs have varying durations, ranging from 1 to 3 years. Although it may not be a mandatory requirement to complete a psychiatry of old age clinical rotation, psychiatry of old age experience and competencies are expected during general psychiatry training. There is generally a lack of opportunity to learn about other clinical specialties relevant to older adults, such as geriatric medicine and neurology. Finally, much work is needed to better coordinate psychiatry of old age specialist training positions, workforce development, and service delivery to ensure there is a sufficient supply of psychiatry of old age specialists to meet the mental health needs of older adults in different countries in the coming years.

Psychiatry and geriatric psychiatry in Romania

Romania is now in a period of transition from communism to democracy. Geographically, Romania, like other Eastern European countries, is on the border between the Western world and the Middle East and Asia; until December 1989 it was behind the ‘Iron Curtain’.

Practice eligible route for certification in geriatric psychiatry: why some Canadian psychiatrists are disinterested in writing the RCPSC subspeciality examination?

Geriatric psychiatry was officially recognized as a subspecialty by the Royal College of Physicians and Surgeons of Canada (RCPSC) in 2009, with the first RCPSC exam written in 2013 (Andrew and Shea, 2010). The unique mental health needs of Canadians' seniors requires geriatric psychiatrists trained to address them (Herrmann, 2004), but current rates of recruitment in informal fellowship programs have been inadequate (Bragg et al., 2012). One hope of subspeciality recognition was to increase recruitment in Canada, but there have been some challenges in accrediting psychiatrists already caring for older adults. Many currently practicing geriatric psychiatrists have elected to take the Royal College examination, with >120 graduates in the first year, 2013, but others have been more ambivalent. In this letter, we perform a preliminary exploration of the prevalence and correlates of disinterest in completing the RCPSC geriatric psychiatry examination.

A survey of geriatric psychiatry training across Europe

BACKGROUND

Training, practice, and continuing professional development in old age psychiatry varies across Europe. The aims of this study were to survey current practice and develop recommendations to begin a debate on harmonization.

METHODS

A survey was sent out to 38 European countries via email. The survey was sent to members of the European Association of Geriatric Psychiatry (EAGP) Board, members of the World Psychiatric Association, and key old age psychiatrists or other psychiatrists with a special interest in the area for countries where old age psychiatry was not formally a specialty.

RESULTS

Through a process of networking, we identified a key individual from each country in Europe to participate in this study, and 30 out of 38 (79%) representatives responded. Training programs and duration varied between countries. Eleven countries reported that they had geriatric psychiatry training programs and most of these required geriatric psychiatry trainees to complete mandatory training for two years within old age psychiatry. Representatives from ten countries reported having specific Continuing Professional Development (CPD) for old age psychiatrists at consultant level.

CONCLUSION

There is a clear indication that the recognition of geriatric psychiatry as a specialist discipline in Europe is on the rise. The training procedures and processes in place vary considerably between and sometimes within countries. There are several options for harmonizing old age psychiatry training across Europe with advantages to each. However, support is required from national old age psychiatry bodies across Europe and an agreement needs to be reached on a training strategy that encompasses supervision, development, and appraisal of the knowledge and skills sets of old age psychiatrists.

The baby boomers are nearly here - but do we have sufficient workforce in old age psychiatry?

In 2011, the baby boomer generation officially commences its residency in the 65 years and over age group (U.S. Census Bureau, 2006). The much anticipated rapid growth in the population aged 65 years and over between 2011 and 2030 will challenge health care systems worldwide. Mental health services for older people will need to prepare for a near doubling of possible demand based upon estimates of the increase in prevalence of mental disorders in late life in this period in the developed world, with the increase likely to be greater in low and middle income countries (Bartels, 2003; Alzheimer's Disease International, 2009). The pressures that this will place upon the old age psychiatry workforce has contributed to the impetus for the Faculties of Psychiatry of Old Age of the Royal College of Psychiatrists and the Royal Australian and New Zealand College of Psychiatrists to prepare a ‘Joint Statement on Specialist Old Age Psychiatry Workforce and Training’ (see Appendix).

Geriatric psychiatry education in Canada: the pathway to subspecialty recognition

BACKGROUND

This paper outlines the evolution of the training of Canadian physicians and other professionals in the mental health care needs of older adults over the past 2 decades, which has culminated in long-awaited subspecialty recognition by the Royal College of Physicians and Surgeons of Canada (RCPSC). Despite the fact that Canada has more than 4000 psychiatrists officially recognized by RCPSC, and a national body of more than 200 members who practice primarily in geriatric psychiatry, the status of geriatric psychiatry as a subspecialty of psychiatry in Canada remained "unofficial" until 2009.

METHODS

Early along the pathway toward subspecialization, Canadian educational efforts focused on enhancing the capacity of primary care physicians and other mental health professionals to meet the mental health needs of older adults. Over the past decade, and with the encouragement of RCPSC, Canadian psychiatric educators have carefully and collaboratively defined the competencies necessary for general psychiatrists to practice across the life span, thereby influencing the psychiatry training programs to include dedicated time in geriatric psychiatry, and a more consistently defined training experience.

RESULTS

With these two important building blocks in place, Canadian psychiatry was truly ready to move ahead with subspecialization. Three new psychiatric subspecialties - geriatric, child and adolescent, and forensic - were approved at the RCPSC in September 2009.

CONCLUSIONS

The developments of the past 20 years have paved the way for a subspecialty geriatric psychiatry curriculum that will be well-aligned with a new general psychiatry curriculum, and ready to complement the existing mental health work force with subspecialized skills aimed at caring for the most complex elderly patients.

The emergence of the novel H1N1 virus: implications for global mental health

The emergence of the novel swine-origin influenza A (H1N1) virus in humans has aroused great concern among medical professionals about the possible evolution of a full-blown influenza pandemic, one on the scale of the “Spanish” influenza pandemic of 1918–19 (Belshe, 2009). It has been speculated that the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill more than 100 million people worldwide, including a large number of economically active young people (Taubenberger and Morens, 2006). Health administrations worldwide have stepped up reporting and surveillance of the deaths and illnesses associated with H1N1, and most countries have national strategies to fight the outbreak, though skeptics doubt how such plans could be operationalized, especially in developing countries (Coker, 2009). As of 6 July 2009, the cumulative total of H1N1 cases exceeds 90,000 in over 100 countries, with over 400 deaths directly related to the infection (World Health Organization, 2009a). Optimists might believe this pandemic is not going to match the scale of the historical 1918 pandemic given the relatively low fatality rate observed thus far. However, the World Health Organization has cautioned that we have just entered Phase 6 of the pandemic – i.e. we are in the early days of the 2009 flu pandemic (Chan, 2009). The course of the pandemic is thus unpredictable at this stage but it is evident that international multilateral plans and agreements have enabled much greater coordination of communication and action than ever before. The guidance behind these multilateral international actions, rooted in the World Health Organization's International Health Regulations (IHR) 2005, only came into being five years ago in response to the threat of emerging infectious diseases and particularly by the events related to the emergence of Severe Acute Respiratory Syndrome (SARS) (Katz, 2009). The morbidity and mortality directly resulting from this novel influenza A H1N1 outbreak are in the center of the world media's spotlight, but the potential impact of the pandemic on global mental health has not yet received the attention it deserves.

Diagnosis of dementia in primary care: a representative survey of family physicians and neuropsychiatrists in Germany

AIM

To measure the diagnostic competence of family physicians (FP) and neuropsychiatrists (NP) for moderate dementia.

METHODS

Written case vignettes describing moderate dementia either of Alzheimer type or vascular type were randomized to a representative sample of 122 FP and 68 NP, corresponding to response rates of 71.8 and 67.3%, respectively. They served as the basis for a structured face-to-face interview.

RESULTS

NP and FP did not differ with regard to their diagnostic considerations, however, concerning diagnostic workup. Vascular dementia was much better recognized than dementia of Alzheimer type. Neuropsychological tests and brain imaging would be done by 14.8 and 32.8% of the FP in the case of vascular dementia. In Alzheimer dementia they would apply these methods in 24.6 and 19.7%, respectively. The corresponding numbers for NP were about 60% in both cases for testing and more than 80% for brain imaging.

CONCLUSIONS

There is still a wide gap between guidelines and practice in primary care. The apparent overdiagnosis of vascular dementia may be one reason for the low drug treatment rates.

Postgraduate training for young psychiatrists--experience of the Berlin Summer School

BACKGROUND

Growing professional exchange between Eastern and Western European countries increases the possibilities for international postgraduate training courses and by that satisfying the need for rapid and facilitation of travel and migration in the enlarged European Union increase achieving high standards. The purpose of this study was to evaluate a summer school program that trained young Eastern European psychiatrists and to assess the impact of the program on their professional development and future activities.

METHOD

We evaluated the training effect of the first 3 years of the Berlin Summer School with respect to (1) the participants' satisfaction with the topics, quality and originality of the presentations, and (2) long-term effects and implications for their professional career. All participants (N=43) filled out anonymously the evaluation form at the end of each summer school. An evaluation of long-term effects was carried out 2 years later with a questionnaire that was sent via e-mail to all former participants.

RESULTS

Participants were most satisfied with practical topics such as "how to prepare a paper", "how to evaluate a paper", or "how to participate in a congress." The appreciation of the presented topics and the appreciation of courses increased in each consecutive summer school. All summer school participants reported that the course had some influence on their future career, and one fifth of the participants felt that their professional development was influenced "a lot".

CONCLUSIONS

Although limited to 1 week of intensive training, a summer school program can have a longer lasting positive influence on the professional development of the participants. Participants felt that particularly the training of practical skills improved their research performance. Former participants founded an independent multicentric and multinational research group and supported national courses that were organized similar to the Berlin Summer School.