The American Board of Psychiatry and Neurology (ABPN) recognized the subspecialty of addiction psychiatry in 1993, when it offered the initial board certification examination (¹). Between 1993 and 1995, board-certified psychiatrists with clinical experience in addictions were eligible to sit for the subspecialty examination. After 1995, only ABPN certified psychiatrists who had also completed 1 year advanced training in an accredited addiction psychiatry fifth postgraduate year (PGY-5) residency were eligible to sit for the subspecialty examination. Between 1995 and 2005, the ABPN granted initial certification in addiction psychiatry to 1,118 psychiatrists. In the last few years, the number of certificates issued annually has averaged about 20, and many previously certified addiction psychiatrists elected not to seek recertification. Each year between 15% and 20% of available PGY-5 addiction psychiatric residency positions are unfilled. As of November 2006, there were 39 active accredited residencies with a total of 72 available positions. Only 59 of these positions were filled, and seven previously active programs have either closed or changed to inactive status (¹). Currently the number of newly certified addiction psychiatrists is not adequate to replace the number of subspecialists who retire each year.

Psychiatric residency training is the pivotal time for residents to determine whether to pursue additional subspecialty training. Despite the increased need for addiction psychiatrists in both community and academic settings, there has been a gradual decline in the number of psychiatrists seeking subspecialty training. In 2002, an earlier survey found 44 active accredited addiction psychiatry programs (²). In that survey almost two-thirds of training graduates were employed in addiction clinical settings, and the majority of graduates were satisfied with their income and compensation. Other reports have cited wide variations in the amount and quality of addiction training (³) and attitudes among general psychiatric residents toward the field (⁴, ⁵); this may be another factor influencing the likelihood of psychiatric residents enrolling in addiction subspecialty programs.

Based on these reports and the declining recruitment into addiction psychiatry, APA Council on Addiction Psychiatry and its Corresponding Committee on Training and Education in Addiction Psychiatry conducted a survey of all current APA Members-in-Training in PGY-2—4 to determine their current attitudes and interest in addiction psychiatry as a specialty and to elicit their recommendations for improving recruitment into the subspecialty.

Between April and June, 2006, an electronic survey questionnaire regarding the residents’ attitudes and interest toward addiction psychiatry was e-mailed to 2,511 PGY-2—4 APA Members-in-Training. The questionnaire (Table 1 ) consisted of 14 attitude/interest questions rated on a 5-point Likert-scale (1=strongly agree, 5=strongly disagree). The questionnaire also contained an open-ended question: "If you were planning a strategy, what would be the most effective way to make fellowship training in addiction psychiatry more attractive to residents?" Responses were empirically grouped in three categories to better convey the central themes contained in the comments.

A total of 276 general psychiatric residents responded to the questionnaire (10.6% of the surveyed sample). We aggregated "strongly agree" with "agree" for each item; the resulting percentages are listed in Table 1 . The majority of respondents expressed positive attitudes toward addiction psychiatrists and the addiction psychiatry field. Addiction psychiatrists were seen as making a difference in their patients’ lives . They were also seen as being respected by other members of the medical community, although fewer than half the respondents felt addiction psychiatrists were respected by the public. Treatment of addictions was perceived as based on empirical evidence and a career in addiction psychiatry was thought of as intellectually satisfying. It is important to note that less than 15% of respondents disagreed with the statements in any of these questions (n=41), indicating relatively few negative attitudes on these issues.

In contrast, respondents had less favorable attitudes toward the actual practice of addiction psychiatry and the patient population served. The majority felt jobs in addiction psychiatry were readily available, but few felt addiction psychiatrists were well paid. While 45% felt a career in addiction psychiatry would provide them with job satisfaction (n=124), 29.7% did not (n=82). Additionally, 45.6% felt that addiction psychiatrists experience "burn out" more than other psychiatrists (n=126); only 5.4% disagreed with that statement (n=15). In total, 44.5% expressed an interest in the subspecialty (n=123), while 37% disagreed with that statement (n=102). The most negative finding was the response to the statement "addiction psychiatrists work with a patient population that I would like to work with," 31.6% of the respondents were in the strongly agree/agree category versus 56% in the strongly disagree/disagree category (n=155).

Only 118 of the respondents (42.8%) answered the open-ended question, offering comments about addiction training and recruitment. This represented 4.7% of the original sample of 2,511 residents. The responses were empirically grouped into three major categories: employment security and compensation, inadequate PGY-1—4 training in addiction, and fellowship training issues. The most common responses related to the need for improved awareness of job opportunities, salaries and benefits (33.1% of respondents, n=39) followed by the need for both early introduction of psychiatric residents to addiction psychiatry (13.5%, n=16) and a broader exposure to addiction psychiatry in the general psychiatry curriculum (12.7%, n=15), including outpatient, rehabilitation and other treatments, as well as detoxification and inpatient rotations. Eleven percent suggested incorporating the addiction psychiatry fellowship into general psychiatry training to reduce the need for extended training. There was support for improved addiction training in the general residency (8.5%, n=10) and for a focus on countertransference issues that arise in the treatment of substance abusers (4.2%, n=5). Regarding ways in which the addiction psychiatry fellowships might be made more desirable, suggestions made by more than one respondent included: provide assurance that the extra training is financially worth it (3.4%, n=4); link the fellowship to clinical research (3.4%, n=4); emphasize the positives of addiction psychiatry (2.5%, n=3); provide perks such as travel to meetings (1.7%, n=2); provide mentorship (1.7%); highlight evidence-based treatment (1.7%); and put more emphasis on psychosocial treatments (1.7%) (Table 2 ).

The very positive attitudes toward addiction psychiatry suggest that the subspecialty is seen as a well accepted and needed part of psychiatry. There were few respondents who expressed negative attitudes in this area. This high percentage of approval (almost 90%) may be due to a self-selection bias, as it would be anticipated that those residents who are not interested in addiction psychiatry may not have answered the survey. We speculate that respondents were primarily residents who are either interested or very interested in addiction. If this assumption is true, then these 276 general psychiatric residents would be an important group that ought to be targeted for strategies to improve recruitment into the addiction subspecialty. In future surveys, respondents should be given the option to self-identify, to permit follow-up contact. While the low response rate of 10.6% can be regarded as too low to consider this data representative, in reality, noncompensated surveys typically draw a 10%—20% response rate (⁶, ⁷). Modest prepaid monetary incentives have been reported to have a strong impact on the response rate to mail surveys (⁶). Another possible contributor to the low response is the use of an e-mail survey; today’s high volume of e-mail spam forces many people to automatically delete unsolicited e-mails.

Many residents saw the practice of addiction psychiatry as problematic both from the perspective of economic compensation as well as clinician "burn out." This added to the "negative attitude" regarding addicted patients. These specific problems can be a target for corrective action. One of these problems may be real in many instances (economic issues) but the other is usually a perceived notion (burn out and negative attitudes). These problems should be addressed if increased recruitment to the field is to be achieved. These particular points are further supported by the answers to the open-ended question. Earlier findings suggest that graduates of addiction psychiatry fellowships do not find these factors to be problematic since almost two-thirds were practicing primarily in addiction psychiatry and found their compensation satisfactory (²). One possible intervention or strategy is to make this type of information broadly available to PGY-2—4 residents as they contemplate career paths.

The other two major issues identified related to improving the timing and content of addiction training in the general residency and the structure of fellowship training. The need to better integrate the teaching of addiction psychiatry into the general psychiatric residency and to schedule addiction rotations early in training is an important message for psychiatry program directors. It is important that residents function primarily as psychiatrists on any addiction rotation. Rotations that rely primarily on general medical skills do not satisfy this training requirement. To address concerns about burn out and "undesirable patients," residents need to be exposed to appropriate role models and to see how the long-term treatment of addiction patients can be effective and can be integrated into a general psychiatry practice (⁸, ⁹). One possible area for emphasis, especially for programs which include addiction psychiatry fellowships, would be to more fully integrate these fellowships into the general residency to provide peer role modeling and mentoring (¹⁰). In addition, general psychiatric residents need to be exposed to the practice of addiction psychiatry in a variety of settings (e.g., independent practice, community clinics) in addition to the public inpatient settings that are more commonly used. Exposure to the full range of patients treated by addiction psychiatrists will help to address the negative attitudes regarding burn out and undesirable patient populations (⁸, ⁹). The relatively low response rate, especially to the open-ended question, suggests that these results be taken with caution. However, the findings taken as a whole provide important directions for future inquiries and for efforts at improving the recruitment of psychiatric residents into addiction psychiatry.

This survey provides preliminary, descriptive data regarding psychiatric residents’ attitudes regarding addiction psychiatry as a career. It is encouraging that there is a pool of general residents (276 residents) who have positive attitudes toward the field. General psychiatry programs need to develop creative models that integrate addiction training into general psychiatry training and ensure that residents are exposed to patients and mentors who reflect the more positive aspects of this subspecialty. In future surveys, residents interested in addiction psychiatry should be identified to try to meet their perceived needs and to provide feedback to improve recruitment to the subspecialty. Surveys with compensation (⁶) and tracking are needed to increase the response rate, to identify models for integrating addiction psychiatry into general psychiatric residency training, to explore the impact of exposing residents to a variety of clinical settings, the relative impact of early (PGY-1) versus late (PGY-3 or 4) exposure to clinical rotations, and the importance of peer role modeling and mentoring.

Dr. Renner is employed full-time by the Department of Veterans Affairs and has a faculty appointment at Boston University and a staff appointment at Boston University Medical Center. He teaches addiction psychiatry in all of these settings. At the time of submission, Drs. Karam-Hage, Levinson, Craig, and Ms. Eld disclosed no competing interests.