The field of psychiatry has adopted a renewed emphasis on applying a public health approach to mental health care. A fundamental principle in public health is to focus on the prevention of illnesses and the promotion of well-being. Psychiatry has long stressed the importance of prevention and mental health promotion with every significant stride that is made in research and policy arenas, particularly in the areas of national and international policy, but also in everyday psychiatric practice (1). The recent passage of the Patient Protection and Affordable Care Act has the potential to attract even greater attention to issues of prevention and mental health promotion in psychiatry and throughout medicine. However, even with an increased understanding of the importance of these interventions, few psychiatrists are properly equipped with a foundation of knowledge in the prevention of mental illnesses and the promotion of mental health (2). Currently, the timing is ideal for reframing the importance of wellness and prevention in residency training programs, preparing psychiatrists with the necessary skills to practice prevention- and health promotion-minded psychiatry. The Group for the Advancement of Psychiatry (GAP) Prevention Committee recommends expanded training in the prevention of mental illnesses and the promotion of mental health in psychiatry residency training through three specific interventions: 1) creating a patient care-based preventive psychiatry rotation; 2) adding didactic curricula that address specific topics in mental illness prevention and mental health promotion; and 3) providing specialized training in systems-based practice aspects of mental health promotion and mental illness prevention.
Psychiatrists can effectively highlight prevention of mental disorders and promotion of mental wellness by serving as advocates, technical advisors, program directors, researchers, and preventive care providers in various settings (3). Residency training is an ideal starting point to move forward in the dissemination of prevention and mental health promotion principles.
The Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for graduate medical education in psychiatry set the training standards by which all U.S. psychiatrists become proficient practitioners. The Council clearly defines the specialty of psychiatry as “a medical specialty focused on the prevention, diagnosis, and treatment of mental, addictive, and emotional disorders” (4). As the Prevention Committee of GAP, we are indeed pleased and encouraged to see that the specialty is defined first and foremost by an emphasis on prevention. However, we believe that even more specific, well-defined competencies will increase the relevant knowledge and experience base for all psychiatrists.
Among the six ACGME competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) prevention is mentioned in two competency areas. There is a focus on prevention when describing components of medical knowledge within the didactic curriculum, and an expectation that residents “advocate for the promotion of mental health and the prevention of disease” from a systems-based practice perspective (4). We believe that additional competency domains would benefit from more clearly defined prevention- and promotion-related training goals. In particular, we will outline our position on the expansion of training (and the expansion of actual program requirements) with regard to three competency domains: patient care, medical knowledge, and systems-based practice.
First, in terms of the Patient Care competency domain, in addition to having “supervised experience in the evaluation and treatment of patients,” as required by the ACGME, residents would greatly benefit from a supervised experience in the promotion of mental health and the prevention of mental and behavioral disorders. The World Health Organization defines “health” as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” An enhanced focus on health and well-being—consistent with recent conceptualizations of recovery—is entirely warranted, given the near-complete dominance of the disease/disorder perspective in current training. Resident physicians need practical experience in communicating health promotion activities, as physicians are seen as experts in promoting healthy lifestyles and behaviors, in addition to evaluating and treating disease. Various clinical activities that include the assessment of risk and protective factors and the consideration of various preventive interventions represent a much needed experience for residents. These clinical activities would emphasize promotion of mental health not only in communities and among individuals, but also promotion of mental health among psychiatric residents themselves. In expanding the focus of prevention and mental health promotion in patient care, these additional responsibilities would focus on improving skills in interacting with individual patients, adding prevention and mental health promotion to the patient-evaluation process, and communicating promotion and prevention effectively to the patient.
The ACGME recognizes critical areas in which residents should have specific competence; for example, “using pharmacological regimens,” “understanding the indications and uses of electroconvulsive therapy,” and “recognizing and appropriately responding to family violence" (4). We believe that there are also critical areas of competence in the domain of prevention, including: 1) suicide prevention, comprising the assessment of risk and protective factors, and the application of risk-reduction methods and protective factor augmentation; and 2) relapse-prevention for mental and addictive disorders, which must include the treatment of comorbidities, utilization of appropriate maintenance therapies, and enhancement of family and social support systems.
Such clinical experiences should focus on specific populations that would benefit from preventive interventions; for example, children of patients with a major mental illness and/or a substance use disorder represent a high-risk population that would benefit from targeted risk factor reduction and protective factor enhancement. Expanding the child psychiatry clinical experience to include outreach to these groups would improve the training experience of general psychiatry residents.
One approach that would improve residents’ competence in areas related to prevention of mental illnesses would be a required clinical experience that focuses on issues of prevention in psychiatry. Much like clinical experiences in Geriatric Psychiatry, Forensic Psychiatry, and Community Psychiatry, a clinical experience in Preventive Psychiatry would help to emphasize the importance of prevention and mental health promotion. We conceptualize a Preventive Psychiatry clinical experience as a 1-month, full-time, organized experience focused on psychiatry from a public-health perspective. This experience should include analyzing risk and protective factors for mental and behavioral disorders at a population level, including individuals without a diagnosable mental illness, as well as family-based interventions. The focus would be prevention of mental and behavioral disorders and promotion of mental health, including surveillance, needs assessment, epidemiology, risk and protective factors, prevention-relevant policy, and environmental interventions. Various settings may be relevant for such experiences, including schools and universities; faith communities; detention facilities; and local, state, or federal agencies.
With regard to the Medical Knowledge competency domain, although prevention is already mentioned in the didactic curriculum portion, this current curriculum of residency training is dominated by diagnosis and treatment, and we believe that much greater emphasis needs to be placed on educating residents on the principles of prevention and mental health promotion. The didactic curriculum should include topics in primary, secondary, and tertiary prevention; universal, selected, and indicated preventive interventions; risk and protective factor identification; mental health epidemiology, including incidence and prevalence; the use of screening instruments; and the application of evidence-based preventive modalities. Key literature that addresses public-health issues of prevention and mental health promotion should be added to residency training program reading lists, including (but not limited to) The Surgeon General’s Report on Mental Health and Mental Health Services: A Public Health Perspective, 3rd Edition (5, 6). Equipping residents with the available knowledge base regarding prevention and mental health promotion ensures a strong foundation from which to apply prevention and mental health promotion in clinical practice and systems-based practice settings.
Third, in terms of the Systems-Based Practice competency domain, the ACGME requirements recognize the importance of prevention and mental health promotion in advocacy, as evidenced by the statement, “…know how to advocate for the promotion of mental health and the prevention of disease” (4). We concur with this, but believe that more specific details regarding advocacy are needed to help guide program directors on appropriate experiences in prevention and mental health promotion. Such approaches should explicitly include legislative and policy advocacy through collaborating with medical and psychiatric associations, private and public healthcare organizations, community agencies, and other mental health professionals. Residents could be expected to serve as liaisons and advocates to the policy community for various public health issues that affect overall mental health. Also, residents could be required to analyze and evaluate the impact of local, national, and global trends and interdependencies on mental health related problems and systems, and translate policy into organizational plans, structures, and programs. Systems-based practice could also focus on specific models of prevention in key established systems, such as educational settings. Integration of universal, selective, and indicated primary preventive interventions with stepped clinical care models would be a useful educational tool. Early intervention programs and Head Start settings are ideal locations to experience advocacy for prevention and mental health promotion in psychiatry. Specifically, residents could interact with stakeholders and decision makers to have an impact on public policy.
The ACGME guidelines provide a wide range of flexibility in the implementation of requirements. Broadening the scope of training that residents receive would require in-depth analysis of, and potentially revisions to, current ACGME guidelines. However, by emphasizing the importance of prevention and mental health promotion in psychiatry, the Council could set important educational priorities for the entire field of psychiatry. Prioritizing prevention and mental health promotion from the perspective of ACGME guidelines ensures that residency program directors emphasize prevention and mental health promotion in training programs. Other efforts within our field, such as voluntary, rather than mandated, prevention curricula; elective experiences; grand rounds presentations; and greater partnerships with schools of public health, represent opportunities to enhance prevention-related competencies aside from the specific ACGME guidelines. We believe that these enhancements are essential for ensuring that U.S. psychiatrists of the future are knowledgeable about the increasing importance of prevention and mental health promotion in psychiatric practice.