PSYCHOPHARMACOLOGY EDUCATION IN PSYCHIATRY* PAUL E. GARFINKEL, PAUL CAMERON, EDWARD KINGSTONE,
Psychiatric education in the last 25 years has had to address two important issues: the marked growth of information relevant to the psychiatrist's practice and the "struggle for eclecticism" (6). Recently, the Association for Academic Psychiatry's Career Teacher Group (14) specified that the psychiatrist should be able to do the following: I. Use the somatic therapies including ECT and psychopharmacological agents. 2. Know how to practice the various psychotherapies. Training in individual therapy is essential; training in group therapy, family therapy and behaviour modification is desirable. 3. Know the concepts and practices of community psychiatry, including consultative techniques and aspects of preventive psychiatry. 4. Have the tools and motivation for continuing his own education after training. Those aims are not dissimilar to Lewis's "all purpose psychiatrist" (15). Hill (II) described it thus: "there is a certain basic knowledge which we require for all psychiatrists which we can test and there are certain basic clinical skills which we again can test". A danger, however, is that the training program may produce a "generation
M.D.I M.D.2 M.D.3
of psychiatrists skilled at practising Reader's Digest psychiatry ... nibbling at many branches of psychiatry instead of studying them" (4). A recent study evaluating the practice characteristics of University of Toronto graduates found that many relied on a variety of theoretical orientations and therapies in dealing with patients; for example, 85% practised individual psychotherapy and 70% prescribed psychotropic drugs frequently (19). In an effort to determine the perception of background knowledge for the use of psychotropic drugs, one aspect of'psychiatric education, psychopharmacology, was studied. Method Questionnaires were sent to all residents in the University of Toronto program in January 1978. This questionnaire assessed the satisfaction and concerns of residents with their education over the previous six months and over their entire residency. Specifically, questions enquired about the frequency of supervision in psychopharmacology and the individual's satisfaction with this supervision in various settings. Only those residents in the adult program were reviewed; 69 residents (70%) completed and returned questionnaires. Of these, 18 were in their first year, 15 in their second year, 16 in their third year and 20 in their fourth year of training.
The results of this questionnaire are demonstrated in Tables I-VI. Several key issues emerged: I. Residents rated their overall training in psychopharmacology as: poor 18% fair 23% good 40% excellent 12% not applicable 7%
'Manuscript received November 1978; revised February 1979. 'Coordinator. Research Course and Associate Professor, Department of Psychiatry, University of Toronto; Psychiatrist in Charge, Psychosomatic Medicine Unit, Clarke Institute of Psychiatry, Toronto, Ontario. 'Associate Professor and Director, Postgraduate Education, Department of Psychiatry, University of Toronto; Staff Psychiatrist, Sunnybrook Medical Centre, Toronto. 'Professor of Psychiatry and Vice-Provost, Health Sciences, University of Toronto. Can, J. Psychiatry Vol. 24 (1979)
2. Most residents received frequent supervision of medication use in patients with major psychiatric disorders (for example, schizophrenia, mania, depression). The supervised use of psychotropic drugs for psychophysiologic reactions appeared to be infrequent in most but not all settings (Table I). 3. Residents were supervised on adequate numbers of patients with most psychotropic drugs. Few had extensive experience with MAOI (Table II).
TABLE I FREQUENCY OF PHARMACOTHERAPY SUPERVISION FOR PATIENTS WITH DIFFERENT DIAGNOSES (% OF RESIDENTS SUPERVISED IN THE TREATMENT OF 3 OR MORE PATIENTS/6 MONTHS)
Range for Various Hospitals
Schizophrenia Mania Depression Organic Brain Syndrome Personality Disorder Neurosis Psychophysiologic Disorder
86% 81% 83% 45% 71% 59%
72-100% 42-90% 42-100% 28-62% 28-87% 28-87%
4. There was little variation in perceived quality of supervision of individual families of drugs (Table III). 5. Within a hospital, there may be marked discrepancy in satisfaction with supervision in different settings (Table IV). Of significance, over onehalf the respondents felt pharmacology supervision to be unsatisfactory in emergency settings. 6. In ranking methods of learning, an apprenticeship and textbooks were clearly favoured (Table V).
TABLE II FREQUENCY OF PHARMACOTHERAPY SUPERVISION FOR PATIENTS WITH TYPES OF MEDICATION (% OF RESIDENTS SUPERVISED IN THE USE OF A CLASS OF DRUG 3 OR MORE TIMES/6 MONTHS)
Range for Various Hospitals
Neuroleptics Tricyclic antidepressants Monoamine oxidase inhibitors Minor tranquilizers Lithium Carbonate
7% 62% 72%
0-28% 28-100% 56-100%
TABLE III QUALITY OF SUPERVISION OF EACH CLASS OF DRUGS
Neuroleptics Tricyclic antidepressants Monoamine oxidase inhibitors Minor tranquilizers Lithium Carbonate
7% 7% 74% 12% 12%
29% 28% 29% 26%
64% 65% 13% 59% 62%
10% 54% 30% 32%
52% 14% 18% 28%
37% 32% 52% 40%
TABLE IV QUALITY OF SUPERVISION WITHIN HOSPITALS
Emergency Consultation Service Inpatient Outpatient
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TABLE V RELATIVE RANKING OF METHODS OF LEARNING(ALL TRAINING TO DATE)
Mean Ranking Apprenticeship Textbooks Journals Study Groups Lectures Other Residents
1.66 2.60 3.89 4.00 4.49 4.90
-This question was answered on a ranking basis (1-6) by each resident; the lower the score the greater importance assigned.
7. A review of specific topics (Table VI) showed several to be of major concern: a) basic pharmacology absorption, distribution, metabolism excretion mechanisms of action drug interactions b) integration of pharmacology with the psychology ofdrug use - compliance- placebo effect c) A significant weakness is the inability of residents to have confidence in critically evaluating the literature. This is a problem not only for psychopharmacology, but psychiatry in general; Greden (10) has shown 49% of residents felt psychiatrists to be extremely susceptible to fads in considering new treatments.
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Discussion This study has demonstrated significant resident dissatisfaction with current psychopharmacology training. Almost onehalf reported their training to be poor or only fair. Several methodologic issues may have contributed to these findings. First, not all residents responded and those not responding may have been more satisfied. Second, some residents may be less critical than others; for example, settings which specialize in psychotherapy supervision may attract residents interested only in psychotherapies and therefore, rate pharmacology training uncritically. This is unlikely to ha ve been a significant factor since residents responded to the final questions (about all their training) in a similar fashion regardless of their current hospital placement. Third, the question pertaining to coverage of specific topics may be biased by the number of previous years of training. However, responses of second, third and fourth year residents were quite similar. Fourth, this questionnaire examined perceived attitudes, not actual performance.
In spite of these difficulties, it is justifiable to conclude that there is significant concern with the current program. These deficiencies may derive from several sources and will be described under five headings: Conceptualization of Psychiatric Disorder; The Resident; Staff; Methods of Teaching; and Research.
TABLE VI COVERAGE OF SPECIFIC TOPICS (ALL TRAINING TO DATE)
Topic Patient compliance Placebo effect Critical evaluation of advances Indications for medication Indications for specified drugs' Contraindications Side effects Drug interactions Mechanisms of action Absorption, distribution, metabolism, excretion
40% 35% 23% 66% 68% 64% 68% 23% 35% 22%
77% 34% 32% 36% 32%
77% 65% 78%
Conceptualization of Psychiatric Disorder Psychiatrists may be reductionistic in their understanding of psychiatric illness; some may view patients entirely from either a psychosocial or biological perspective. This dichotomous model of classifying illness, best exemplified by the endogenousreactive view of affective illness, has contributed to a tendency to split psychosocial from biologic treatments and to elect to use one, or the other, for depressed patients. Early on, Lewis (16) but more recently, Kendell (13) and Akiskal and McKinney (1) have suggested that depressive illnesses cannot be subclassified on clinical features and that in fact the depressive syndrome may be best regarded as a final common pathway, that is not entirely biological nor psychosocial in origin. This view gives rise to the use of a combination of treatments chosen on an individual basis. Such a rationale has recently received experimental support. Weisman and Klerman (23) have reported a series of studies which confirm the value of weekly maintenance psychotherapy together with tricyclic antidepressants in recovering depressive patients. While maintenance pharmacotherapy prevents relapse, psychotherapy in addition improves overall adjustment, work performance, and interpersonal relationships. Similar results have been observed in schizophrenia and psychophysiological disorders. While May (18) and others have shown the neuroleptic drugs to be the single most important aspect of treatment for schizophrenia, psychosocial therapies provide added gains as suggested by Wing (24) and Fairweather (8). In the field of psychophysiological disorder, Lipowski (17) has argued for "individually tailored therapeutic intervention". "There is no room in the psychosomatic approach for preconceived notions that sufferers from a given somatic disorder, or those having a particular personality disorder, demand a standard therapeutic strategy". In each of these areas, the a voidance of a dichotomous view to psychobiological factors as playing an exclusive role in the genesis or perpetuation of the disorder, leads to an integrated approach to therapy
and better patient care. This underscores the need for an integrated approach to teaching residents about psychopharmacology and its interactions with other therapies. The Resident There are several reasons why psychiatric residents may perceive difficulties with pharmacotherapies i) Glick and Epstein (9) note some residents may enter training with an unusually strong psychologic bias. They may regard mental illness to result wholly from experiential childhood factors and reject understanding the theories and techniques of biological intervention. If such an extreme orientation is not noticed by staff early, or is fostered, these residents may never master or appreciate the value of psychopharmacology. Special emphasis and case selection for such residents would be indicated (7). ii) Emotional illness in the resident may interfere with his learning and interpersonal relationships (9). Psychothera py or a personal analysis or an invitation to withdraw from training should be recommended for these residents. iii) Some physicians may enter psychiatry to escape from medicine and the medical role. Screening of applicants and periodic review of trainees is necessary. Some residents may be encouraged to change specialities if unable to work through these difficulties satisfactorily. iv) Hunter (12) found that a cause of medical school failure was the students' lack of awareness of what was expected of them. This may also apply to training in psychiatry. A definition and general aware': ness ofstandards necessary for the application of pharmacotherapy would help alleviate this problem as would close resident involvement with the Director of Postgraduate Education. Regular feedback of a resident's strengths and weaknesses is crucial. The Staff i) The resident may encounter difficulty in identifying with the role model of the
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psychiatric supervisor. Staff are often very busy with multiple jobs: outpatient psychotherapy, administration, consultations, research, and so on. The supervisor should encourage identification with the teacher as a role model who can integrate a variety of approaches (9). Interviewing patients with the resident, frequent meetings about patients and discussions about the supervisor's difficult patients would prove beneficial. ii) Staff show variable initial levels of knowledge in pharmacotherapy and more important have highly variable motivations for "keeping up" with new advances in the field. The development of a specialized university department to deal with education in clinical psychopharmacology would prove useful for: (a) providing staff with critical summaries of important literature; (b) identifying individuals with specific expertise in psychopharmacology; (c) providing consultations on difficult problems; (d) facilitating clinical research. This department might be part of a clinical unit specializing in psychopharmacology. iii) At present psychopharmacology is being taught by most staff, regardless of their qualifications. Each hospital should have a designated psychiatrist with special expertise in psychopharmacology to act as liaison person for pharmacologic issues (22). This may be gradually developed at each hospital by selective hiring of staff with such specific expertise. iv) Residents who later become supervisors often have little experience as teachers when they complete their training. Selected senior residents should be provided with teaching opportunities under critical supervision that would prepare them for teaching careers. Similarly, those with identifiable characteristics of good teachers (21) should be selected for the heaviest teaching load. Methods of Teaching i) The apprenticeship/ supervisory model is the cornerstone of clinical pharmacotherapy education as it is in all clinical medicine. The residents in this study overwhelmingly emphasized its impor-
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tance and yet were not satisfied with their training. Increased emphasis on supervisors' knowledge in psychopharmacology is necessary and may be achieved as described in points i-iv under staff. ii) While residents currently rely heavily on textbooks, an increased emphasis should be placed on selected journal articles. The following would help achieve this: a) A regularly updated list of important current and historical references should be supplied to all residents. b) A tutorial small group course in learning to evaluate the psychiatric literature should become mandatory for all residents in their senior years. iii) Lectures may continue to playa role in training. However, these may be augmented through self-instructional aids (manuals or audio cassettes) given to residents prior to lectures. Bogner et al. (2) have shown that audio cassettes were superior to lectures in terms of cognitive knowledge and were also favoured by medical students. Some topics may require extra emphasis, for example, in this study they were highly varied and ranged from the psychology of medication use to basic pharmacology. iv) Examinations emphasizing core issues in psychopharmacology should be given after the first and second year. Research Research in a department is closely linked to education and clinical practice. Brook (3) has shown that only 7% of trainees working in non-teaching hospitals and 25% in teaching hospitals were engaged in research. In Canada the figures are probably no better. Yet, there is great value in some experience in clinical research. Popper (20) has suggested that creativity can be divided into two phases - getting ideas and then deciding which ones are worthwhile and which are worthless. It may be that the ability to generate ideas is innate but the development of a critical faculty can be cultivated through education. The development of a critical enquiring approach to all psychiatry, knowledge
of the limitations of current drug and psychosocial therapies, understanding of various methodologies and statistical techniques would serve many psychiatrists well in their later clinical practices. A major role for a clinical psychopharmacology unit would be to encourage senior residents to participate in supervised programs. Standards A question in assessing the quality of a program lies in determining its major tasks. These may be preparing practitioners, preparing researchers or combinations ofthese. Clark (5) recently surveyed deans of graduate schools to determine characteristics of high quality programs. Of interest, those Ph.D. programs that ranked highly through peer opinion surveys rated the preparation of scholars! researchers as the primary objective of their programs (that is, a research degree); for residency training preparing practitioners must be the major purpose. If preparation of competent psychiatrists is the primary purpose of the program, the next step must be agreement on goals. This can be a difficult process, particularly in a professional school where there may be considerable conflict between professional and scientific interests. There are some who feel that residency is a type of vocational school whose purpose is to train people for jobs. Others believe one must educate scholars (4). The best programs must be committed to excellence and the spirit of enquiry. We must aspire to such excellence if psychiatrists trained in our programs are to serve as consultants to their medical colleagues. Standards of excellence must be defined and known to all staff and residents. For psychopharmacology such a set of standards would include the following: Standardsfor the Application of Pharmacotherapies in Psychiatry: 1. Expertise in general psychiatry relating to interview technique, mental status, formulation and natural history of disorders. 2. Knowledge of the relative efficacies of
various therapeutic modalities for different psychiatric disorders. Application of this knowledge to determine when psychotropic drugs are indicated and when the risks of medication outweigh their benefits. 3. Competence in the use of one or more drugs from each of: Neuroleptics Tricyclic and related antidepressants Monoamine oxidase inhibitors Minor tranquilizers and hypnotics LiCO] Antiparkinsonian agents Psychostimulants This should include ability to choose appropriate individual agents from each family of drugs. 4. Knowledge of the basic pharmacology of these medications as it pertains to clinical practice: absorption; distribution; metabolism; excretion; duration of action (and frequency of administration); mechanisms of action; sites of action; potency. 5. Expertise with titration of doses of each drug in various types of patients, including use of psychotropic drugs in emergency settings, differences between acute and maintenance doses, knowledge of toxic! therapeutic ratios for each drug used. 6. Ability to administer medication through several routes (oral, 1M, IV) as indicated; to be able to use depot phenothiazines and to conduct Na Amytal interviews. 7. Familiarity with plasma levels of medication and how they affect dosage. 8. Knowledge of absolute and relative contraindications for each drug. 9. Determination of time period for patients to remain on medications. 10. To recognize and properly deal with unwanted effects; to assess clinical and laboratory indices for early untoward effects at appropriate intervals, to be familiar with standard techniques for prevention of side effects (for example drug holidays for tardive dyskinesia, and so forth).
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11. To be aware of possible psychotropic side effects of medications used in medical practice. 12. To be familiar with interactions between medications. 13. To be familiar with the psychology of drug use in recognizing factors involved in the placebo effect and patient compliance. 14. To know how to prevent drug dependency and to be able to treat drug withdrawal. 15. To be able to convey his knowledge as a consultant to his medical colleagues. 16. To have the tools and motivation to continue his education regarding medications and their application. Summary
This study has documented resident dissatisfaction with education in psychopharmacology in one large university and has proposed several solutions. These include: • increased awareness of standards of knowledge necessary for a consultant. • the establishment of a central educative office of clinical psychopharmacology to encourage dissemination of selected literature and to facilitate residents' research under supervision. • recognition that not all staff should be considered capable to provide psychopharmacology supervision and that each hospital should have a designated psychiatrist with special expertise in psychopharmacology. • developing study groups for the purpose of teaching critical evaluation of the literature. • increasing encouragement for residents' participating in clinical research. • awareness of residents' difficulties in learning (emotional illness, rejection of biological therapies, and knowing what is expected or not suited to psychiatry) and appropriate actions to alter these. • increased use of audio aids, self-teaching manuals and journals to augment lectures and texts. • increased emphasis on training selected senior residents in how to teach.
Acknowledgement The authors wish to acknowledge the assistance of Ms. D. Ratansi.
References I. Akiskal, H.S., McKinney, W.T. Jr.: Overview of recent research in depression. Arch Gen Psychiatry, 32: 285-305, 1975. 2. Bogner, P., Sajid, A. W., Ford, D.L.: Effectiveness of audiobased instruction in medical pharmacology. J Med Educ, 50: 677682, 1975. 3. Brook, P.: Psychiatrists in Training: The Report ofthe Royal Medico Psychological Association's Manpower and Education Project. Br J Psychiatry, (Spec. Publication no. 5), 1973. 4. Clare, A.W.: Training of psychiatrists. Lancet, 2: 753-756, 1972. 5. Clark, M.J., Hartnett, R.T., Baird, L.L.: Assessing Dimensions of Quality in Doctoral Education: A Technical Report of a National Study in Three Fields (Educational Testing Service Project Report No. 76-27), Educational Testing Service, Princeton, N.J., 1976. 6. Ebaugh, F.G.: The evolution of psychiatric education. Am J Psychiatry, 126: 135-139, 1969. 7. Ekstein, R., Wallerstein, R.: The Teaching and Learning of Psychotherapy 2nd ed. New York: International Universities Press, 1972. 8. Fairweather, G.W., Sanders, D.H., Maynard, E., Cressler,D.L., Bleck,D.S.: Community Life for the Mentally ll/: An Alternative to Institutional Care. Chicago: Aldine Publishing, 1969. 9. Glick, 1.D., Epstein, L.J.: Increasing learning during the psychiatric residency. Compr Psychiatry, 18: 545-550, 1977. 10. Greden, J.F., Casariego, J.1.: Controversies in psychiatric education: A survey of residents' attitudes. Am J Psychiatry, 132: 270-274, 1975. II. Hill, D.: The Training of Psychiatrists. London: R.M.P.A. Special Publication, 1970. 12. Hunter, R.C.: Some factors affecting undergraduate academic achievement. Can Med Assoc J, 92: 732-736, 1965. 13. Kendell, R.E.: The classification of depression. Br J Psychiatry, 129: 1528, 1976. 14. Langee, H., Glick, I.D., Hoffman, B., Silver, L.B., Morrison, A.P.: Requirements of a residency training program
circa 1972. Am J Psychiatry, 130: 11511152, 1973. 15. Lewis, A.: The education of psychiatrists. Lancet, 2: 79-83, 1947. 16. Lewis, A.: States of depression: their clinical and aetiological differentiation. Br Aled~ 2: 875,1938. 17. Lipowski, Z.J.: Physical illness, the patient and his environment. In Reiser, M. (editor): American Handbook of Psychiatry, Vol. IV. New York: Basic Books, 1975. 18. May, P.: Treatment of Schizophrenia: A Comparative Study of Five Treatment Methods. New York: Science House, 1968. 19. Persad, E., Garfinkel, P.E.: Practisingpsychiatrists' views of the certification examination in psychiatry. Can J Psychiatry, 24(4): 303-307. 1979. 20. Popper, K.R.: Science: Conjectures and Refutations (3rd ed.). London: Routledge, Kegan, Paul, 1969. 21. Stritter, F.T., Hain, J.D., Grimes, D.A.: Clinical teaching reexamined. J AIed Educ, 50: 876-882, 1975. 22. Taylor, M.A.: Training in psychiatry: Time for a change. Bioi Psychiatry, 10: 483-484, 1975. 23. Weisman, M.M., Klerrnan, G.L., Paykel, E.S., Prusoff, B., Hanson, 8.: Treatment effects on the social adjustment of depressed patients. Arch Gen Psychiatry, 30: 771-778, 1974. 24. Wing, 1.K., Brown, G.W.: Institutionalism and Schizophrenia. New York: Cambridge, 1970.
Cette etude fait etat de l'insatisfaction que les residents d'une grande universite ressentent al'egard de l'enseignement de la psychopharmacologie et propose plusieurs
solutions pour y remediere, Elles comprennent: I. Une plus grande conscience des niveaux de connaissance necessaire a un consultant. 2. La mise en place d'un bureau central d'enseignement de la psychopharmacologie clinique afin d'encourager la circulation de la litterature choisie et de faciliter pour les residents la recherche sous supervision. 3. La reconnaissance que tous les membres d'un departement ne sont pas aptes a exercer une supervision en psychopharmacologie et que chaque hopital devrait designer un psychiatre possedant une expertise particuliere en psychopharmacologie. 4. Le developpement de groupes d'etude afin d'enseigner comment faire une evaluation critique de la litterature. 5. L'incitation des residents ala participation a la recherche clinique. 6. La prise de conscience des difficultes d'apprentissage des residents (i.e. la maladie mentale, le rejet des therapies biologiques, la connaissance de ce qui est attendu de la psychiatrie et de ce qui ne lui convient pas) et la prise de mesures appropriees pour y remedier. 7. L'utilisation plus frequente des techniques audio-visuelles, des livres pour une formation autodidactique et des journaux pour augmenter ainsi le nombre de lectures et de textes. 8. L'accentuation de la formation pour l'enseignement des residents les plus avances.