Training in old age psychiatry

Old age psychiatry is still a young subspecialty. Although there have been a number of published curricula and training guidelines since 1979 (Blumenthal et al., 1979; Marin et al., 1988; Thorpe et al., 1993), formal criteria for old age psychiatry training were only adopted in the United Kingdom in 1989 (Joint Committee in Higher Psychiatric Training, 1989), the United States in 1993 (American Board of Psychiatry and Neurology, 1992), Canada in 1994 (Le Clair and Sadavoy, 1998), and in Australia and New Zealand in 1999 (Draper and Snowdon, 1999). In this issue, the developmental process continues with the publication of the first European consensus core curriculum on skill-based objectives that define the subspecialty of old age psychiatry. Developed jointly by the European Association of Geriatric Psychiatry, the World Health Organization, and the World Psychiatric Association (WPA) Section of Psychiatry of Old Age, the curriculum is intended to stimulate and facilitate the training of old age psychiatrists in Europe (Gustafson et al., 2003). The current state of development in Europe is revealed in a WPA survey of teaching and training in old age psychiatry that also appears in this issue. It reports that old age psychiatry is a subspecialty in only 18% of European region countries that responded (Camus et al., 2003), even though Europe is one of the main regions of the world that recognises old age psychiatry. Clearly there is much room for improvement, both in Europe and in other regions, as only 27% of responding countries worldwide recognized old age psychiatry as a subspecialty. How important is it to have a curriculum and formal training guidelines for training in old age psychiatry? I would suggest that it is essential. Although many current old age psychiatrists around the world have received adequate informal training, it is not possible to assure licensing authorities, our medical peers, the general public and others that we have particular expertise unless we can demonstrate that we have received adequate training. And this means that there has to be a curriculum that outlines the attitudes, knowledge and skills that are fundamental to old age psychiatry and training guidelines that describe how this training should be delivered by training programs. The European skill-based objectives cover both the curriculum and training guidelines. One important feature of the objectives is that they are designed to be relevant to a broad range of specialists, as old age psychiatrists, general psychiatrists, neuropsychiatrists, neurologists and other physicians provide specialist mental health services to older people in various European countries. In addition, service delivery systems also vary considerably across Europe. This inclusive approach will foster uniformity of standards between countries and training programs and will bring together disciplines across Europe. It is also a model that can be more widely applied in other parts of the world. This does mean that some sections of the curriculum, e.g. on history taking and mental state examination, are pitched at a more basic level than might be expected but this is required when non-psychiatrists are being trained. It also means that the recommended minimum duration of training of one-year whole time equivalent is certainly less than the two years training required in countries that have established old age psychiatry subspecialty programs. Again this is understandable, as it is likely to be the maximum duration that is currently feasible in some countries. So, what are the core skills required in practicing old age psychiatry? Unfortunately, the absence of a list of training goals in the European curriculum means that the core skills are not clearly specified. However, I would suggest that they involve the competent ability to assess, diagnose, treat, and manage psychiatric problems in old age in a comprehensive manner and in partnership with older people and their carers. This should occur in a range of clinical settings that include general and psychiatric hospitals, ambulatory clinics, domiciles, and long term residential care. To successfully achieve this also implies the acquisition of skills of consultation, collaboration and liaison with other professionals, e.g. general