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Editorial                                                                                                                                                     Open Access

## The Swedish Patient

Sven Bölte

There is a ghost in the house of academic child and adolescent  psychiatry  in  Sweden  that  harbors  an inconvenient truth that has been ignored for far too long: there is currently a dramatic  shortage  of domestic child and adolescent psychiatrists who are qualified for university professorships, and there is a serious risk for the extinction of several chairs in this field.  About  450  child  and  adolescent  psychiatrists are registered in Sweden;  150  of these are in Stockholm  County  alone,  which  represents  one  of the highest-if not the highest-density of practitioners  of  this  profession  in  the  world.  Child and Adolescent Psychiatry Stockholm has 900 employees and serves an area with a population of 2.2 million, which makes it one of the largest single child and adolescent psychiatry organizations worldwide. Nevertheless, among all child and adolescent  psychiatrists  in  Sweden,  the  proportion with PhDs  is low, and  the number  of  senior researchers with track  records  that  make  them eligible  for  professorships  and  that  demonstrate international competitiveness is humble.

In  Sweden,  there  are  six  university  child  and adolescent psychiatry departments: Lund, Gothenburg,  Linköping,  Stockholm,  Uppsala,  and Umeå. In Uppsala and Umeå, the chairs have been formally vacant for several years, having only been kept alive by the former and now retired chairs taking continuous responsibility. Fortunately, in Uppsala, it seems  that  a  valuable  new  recruit  is  within  reach. Lund,  Gothenburg,  and  Linköping  are  facing  the emeritus statuses of their chairs in the not too distant future. In Stockholm,  the traditional child  and adolescent psychiatry chair has not been continued, and it is likely to be terminated completely after the current senior  professor's final  retirement.  Instead, two new professors have been recruited for the area of child and adolescent psychiatric science, particularly to address neurodevelopmental disorders as well as obsessive-compulsive disorders and related conditions.  However,  these  individuals  are  clinical psychologists rather than child and adolescent psychiatrists. It may be considered a positive move that  academia  and  child  and  adolescent  psychiatry have  opened  themselves  up  to  psychologists  and acknowledged their pivotal role in clinical child and adolescent psychiatry and that the field is prioritizing scientific excellence, irrespective of profession. Still, one of the major reasons that child and adolescent psychiatrists  were  not  recruited  for  these  positions was simply the lack of availability. For example, for the professorship on neurodevelopmental disorders, Karolinska Institutet and  Child  and  Adolescent Psychiatry  Stockholm  had  searched  Sweden  for eligible  candidates  who  were  child  and  adolescent psychiatrists for several years, without success. It is also worth noting that the two psychologists recruited for the chairs came from abroad. Although it  is  vital  for  Swedish  psychiatry  to  diversify  by incorporating international perspectives, the inability to employ domestic experts raises additional questions about the availability of sufficiently academically qualified senior researchers in this field in Sweden as a whole.

What are the reasons for this problematic situation, and what can be done to improve it? Most of my academic and clinical colleagues in Sweden agree that the negative developments in this area began during the 1980s as a result of the politics associated with the decisions made in many counties to separate the academics and clinical practice of child and adolescent  psychiatry  as  much  as  possible.  This generated  gaps  between  research,  education,  and practice, and it made it hard for clinicians to combine their  clinical  and  scientific  work.  It  diminished  the inclusion of research and education as natural parts of an active clinician's working life, and it excluded the use of any clinical resources for research, development, and education. Consequently, academic skills were no longer considered necessary or beneficial to standard child and adolescent services.  In  many  of  today's  child  and  adolescent psychiatry departments, even the leaders lack scientific  qualification.  For  child  and  adolescent psychiatrists who may wish to start scientific careers, a  particular  challenge  related  to  the  dissociation  of academia from practice is compensation. Salaries for physicians are high as compared with other professions  in  clinical  psychiatry;  such  salaries  are very unusual for junior researchers or simply impossible for universities to afford. Most physicians, for understandable reasons, do not feel that  they  can  tolerate  large  salary  cuts  to  conduct science.  In  addition,  for  some  areas  of  psychiatric research,  medical  expertise  is  not  mandatory,  so employing  young  gifted researchers from  other professions can be equally meaningful. As compared with the examinations that must be passed in the field of  psychology,  an  explicit  scientific  education  in medicine  is  limited,  which  is  another  disadvantage for  physicians  who  may  want  to  begin  performing research.

Are  there  other  explanations  for  the  shortage  of highly merited academic senior child and adolescent psychiatrists? I am afraid that there are at least two additional  aspects  of  significance.  First,  research  is still not valued highly enough in the field of clinical child  and  adolescent  psychiatry  in  Sweden,  and evidence-based clinical practice is a goal that is far from  being  achieved.  There  are  still  many  antiscientific practices and traditions that are tolerated by health care authorities and influential in many clinical organizations. There is also a widespread, subliminally  shared  belief  that  research  does  not really  contribute  to  clinical  practice  and  thus  that practice can do well without science. Guidelines for the diagnosis and treatment of mental disorders do not exist, are not evidence based, or are not sufficiently followed. Regrettably, these circumstances-which  contribute  to  academic  child  and adolescent psychiatry being threatened with extinction-are not taken very seriously or are not even recognized by many. Second, despite the bad odds described previously, academic child and adolescent  psychiatry  frankly  must  blame  itself  for not having made a better effort to bring up the next generation of senior child and adolescent psychiatrists to lead the profession in this country's universities.

Although the situation appears to be critical, there are  also  some  positive  developments  to  report.  In 2004, the Swedish Association for Child and Adolescent Psychiatry started a child and adolescent psychiatry academy with the objective of connecting all  academic  child  and  adolescent  psychiatry  chairs and senior researchers to coordinate and strengthen the  field  and  to  develop  an  adequate  academic curriculum.  The  Child  and  Adolescent  Psychiatry Research Center in Stockholm 1  (Karolinska Institutet & Stockholm County Council) was also established to unite three strong clinical research centers (Center of  Neurodevelopmental  Disorders  at  Karolinska Institutet [KIND] 2 , Child and Adolescent Psychiatry Stockholm (BUP) Obsessive Compulsive Disorders and related disorders [BUP OCD], and BUP Center for Psychiatry Research [BUP-CPF] at one location, thereby  integrating  clinical  services,  education,  and research and development. I am keeping my fingers crossed for more such developments, and I sincerely promise to increase my own engagement with these issues so that the Swedish patient can recover.

1 www.bup.se/sv/Om-BUP/Forskning/Barn--ochungdomspsykiatriskt--forskningscentrum/

The Scandinavian Journal of Child and Adolescent Psychiatry  and  Psychology assists  in  addressing  these matters by offering timely and high-quality reviews to child and adolescent psychiatrists at all stages of their careers and by providing open access to its findings to the scientific community at large.

Sven Bölte, Editor in Chief, Scandinavian Journal of Child and Adolescent Psychiatry and Psychology, Karolinska Institutet & Stockholm County Council