(Editor's note: In this section, noted psychiatric educators respond to questions frequently asked about their area of expertise.)
Substance abuse is a worldwide problem that is the United States' largest public health issue. Eighteen percent of the U.S. population experiences a substance use disorder at some point over the course of their lifetime, and the annual cost of addictive disorders to U.S. society is measured in the hundreds of billions of dollars (
+1). Above and beyond the dollar costs is the price paid in human suffering that results from the wide range of physical and psychological damage to patients, families, and others that is caused by addictive disorders.
The long road toward official recognition for the subspecialty area of addiction psychiatry was a controversial one (
+2,
+3). A major milestone for the field was achieved in 1997, when the 5-year review by the American Boards of Medical Specialties (ABMS) was successfully completed. The ABMS review acknowledged that the requirement of 25 accredited addiction psychiatry residency programs by the 1998 5-year deadline had been met.
Regardless of past controversy, residency programs in addiction psychiatry are up and running in many of the premier academic centers in the country. In these programs, residents prepare to follow a variety of career paths. Careers will include the clinical practice of addiction psychiatry in both the public and private sectors, as well as participation in the ongoing clinical research that is identifying effective treatment approaches for the addictive disorders.
Q: What are addiction psychiatry residencies?
A: In 1993 the American Board of Psychiatry and Neurology (ABPN) created a new category of "Added Qualifications in Addiction Psychiatry" to certify psychiatrists with expertise in this subspecialty area. Addiction psychiatry residencies are 1-year training programs that focus primarily on the clinical care of patients. Accredited residencies teach physicians not only the diagnosis and treatment of a wide range of substance use disorders, but also how to treat dually diagnosed individuals with complicated coexisting psychiatric disorders. As of January 1998, 24 addiction psychiatry residency programs have been approved for training by the Psychiatry Residency Review Committee (PRRC) (see
+Table 1). The PRRC reviews programs by using the training requirements of the Accreditation Council for Graduate Medical Education (ACGME). The Graduate Medical Education Directory specifies these ACGME training requirements and is published annually (
+4).
Q: If I wish to become board-certified in addiction psychiatry, whom do I contact?
A: The ABPN is one of the 24 boards of ABMS and is responsible for issuing certificates in addiction psychiatry to board-certified psychiatrists who fulfill the specified requirements. The requirements for certification are available from the ABPN office and are published in the
Information for Applicants Booklet for the Subspecialties of Geriatric Psychiatry, Clinical Neurophysiology, Addiction Psychiatry and Forensic Psychiatry (
+5). In addition, the ABPN operates a FAXBACK Automated Fax Document Service. This system is a simple-to-operate, automated fax-response system requiring a Touch-Tone phone. Available 24 hours a day and 7 days a week, you can use the system to retrieve up to three documents and have them sent to your fax machine in a matter of minutes. One of the selections is a complete list of documents currently available via FAXBACK. To have the complete list of documents currently available faxed to you, call (847) 374—4229, press 1, then press 2, then press the # key, and finally enter your fax number, starting with the area code (do
not press 1 before the area code). To have specific documents faxed to you, call (847) 374—4229, press 1, enter the number of each document, press the # key, and finally enter your fax number, starting with the area code (do
not press 1 before the area code).
Q: Can individuals sit for the ABPN Addiction Psychiatry Exam without completing an additional 1 year of training beyond the general psychiatry residency?
A: Under the ABMS regulations, individuals may sit for board certification examinations for the first 5 years through a practice track. After that, all candidates must complete a residency in addiction psychiatry at the postgraduate year (PGY)-5 level or above. Since the first examination was given in 1993, the 1998 examination will be the last examination for which the practice track will be acceptable; however, the deadline for applications has already passed (October 1, 1997). For all future applicants, the ABPN will require that applicants provide documentation of successful completion of a 1-year residency training in addiction psychiatry prior to being allowed to sit for the ABPN board-certification examination.
Q: Why are trainees in addiction psychiatry called residents instead of fellows?
A: Addiction psychiatry trainees who are in an ACGME-approved program are officially known as residents. In fact, "resident" is the correct term for trainees in any of the five categories of ACGME-approved psychiatry training programs (i.e., addiction, child and adolescent, forensic, general, geriatric). The term "fellow" continues to be used informally for these PGY-5 residents, albeit incorrectly, in a manner similar to the use of the term "intern" when referring to a PGY-1 resident. Non-ACGME approved psychiatry training programs (e.g., administrative, consultation-liaison, psychopharmacology, research) generally use the term "fellow" for trainees who are above the PGY-4 level.
Q: Is there a National Uniform Entry Process similar to the one established for child and adolescent psychiatry?
A: Currently, there is neither a matching program nor a national uniform entry program for addiction psychiatry. Furthermore, there is little specific guidance related to an individual program's application deadlines, selection processes, or acceptance policies beyond the general guidelines provided by the ACGME.
Q: How do applicants transfer from a general psychiatry training program into an addiction psychiatry program?
A: By definition, all trainees in addiction psychiatry residency programs must have successfully completed an ACGME-approved general psychiatry program before starting training as an addiction psychiatry resident. This means, by definition, the addiction psychiatry resident is in at least a PGY-5 position of training.
Q: What about "Double Credit"?
A: No part of the PGY-1 through PGY-4 general psychiatry experience can be applied toward training as an addiction psychiatry resident. For example, fourth-year elective time spent in addiction psychiatry clinical service cannot be applied toward the PGY-5 year of addiction psychiatry residency training.
Q: How can a small addiction psychiatry division meet all of the ACGME requirements?
A: Meeting the ACGME requirements requires a great deal of commitment on the part of the addiction psychiatry residency training director. Many activities must be conducted within a department of psychiatry to gain and maintain an approved addiction psychiatry program. Foremost is that the initial application must have the support of the psychiatry department's chairman and the general psychiatry residency training director. The ACGME requires that addiction psychiatry residencies must operate as a collaboration with an ACGME-approved general psychiatry residency program. Beyond the initial application, the work of administration, clinical supervision, didactic teaching, and financing can be accomplished only through an ongoing collaborative effort.
Q: What information resources are available to help addiction psychiatry training directors?
A: Several national organizations offer information and assistance. Information related to board certification in addiction psychiatry can be obtained from the American Board of Psychiatry and Neurology (ABPN) at 500 Lake Cook Road, Suite 335, Deerfield, IL 60015, Tel: (847) 945—7900, FAXBACK System: (847) 374—4229, Website: http://www.abpn.com/.
Information about the process of program application can be obtained from the ACGME's Residency Review Committee for Psychiatry, Larry D. Sulton, Ph.D., Executive Director, at 515 North State Street, Suite 2000, Chicago, IL 60610—4322, Tel: (312) 464—5404, E-mail: lds@acgme.org, Website: http://www.acgme.org/.
The American Academy of Addiction Psychiatry (AAAP) is another organization that has been particularly active in assisting departments of psychiatry in developing residency programs in addiction psychiatry. The AAAP can be contacted at 7301 Mission Road, Suite 252, Prairie Village, KS 66208, Tel: (913) 262—6161. E-mail: addicpsych@aol.com. Website: http://members.aol.com/addicpsych/private/homepage.htm.
The American Association of Directors of Psychiatric Residency Training (AADPRT) recently adapted its organizational policies to be more inclusive of the training directors of the subspecialty psychiatry residency programs, including addiction psychiatry. The AADPRT Executive Secretary can be contacted at the University of Connecticut Health Center, Department of Psychiatry, 10 Talcott Notch Road, East Wing, Farmington, CT 06030—6410, Tel: (860) 679—6766. E-mail: aadprt@psychiatry.uchc.edu. Website: http://www.aadprt.org/
Dr. Pichot is Director, Addiction Psychiatry Residency Program, University of Texas (UT) Health Science Center at San Antonio, UT/Veterans Affairs Medical Center (116A), 7400 Merton Minter Blvd., San Antonio, TX 78284. E-mail: pichot@swbell.net. Dr. Harris and Dr. Jones are both residents in the Addiction Psychiatry Residency Program, University of Texas Health Science Center at San Antonio.