Mental health problems are common in older adults. Nearly 20% of adults 65 years old and older have psychiatric disorders. The most common mental disorders in older adults are anxiety, severe cognitive impairment, and mood disorders (1). As many as 45% of persons ages 85 years and older are estimated to have significant cognitive impairment (2). The rate of suicide among older adults is higher than any other age group (1, 3).
A 1999 consensus statement (4) on the upcoming crisis in geriatrics mental health care stated that the number of geriatric psychiatrists available to treat elderly mentally ill persons in the United States was inadequate, and this is still accurate in 2008 (5, 6). General psychiatrists will continue to provide the majority of physician specialty mental health services to older adults (7). General psychiatry programs must ensure that residents attain basic competency in geriatric assessment and treatment (8).
The Residency Review Committee requirements for general psychiatry training in place in 2006, at the time of this research, required 1 month of supervised clinical management of geriatric patients with a variety of psychiatric disorders, including familiarity with long-term care in a variety of settings (9). The current program requirements, in effect July 2007, contain a similar requirement, but provide more detailed guidance to program directors (10).
This article reports the results of a national survey conducted during 2006 of general psychiatric residency program directors. The purpose of this study is to describe the current characteristics of geriatrics training within general psychiatry training programs. These results may be of value as a snapshot of geriatrics training activity in 2006, and future studies can document change in training activity from this baseline. The results also allow psychiatry program directors to compare their geriatrics training curriculum with a large sample of other programs.
During the fall of 2006, we conducted a cross-sectional survey of all 181 program directors of psychiatric residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). This survey is part of the Association of Directors of Geriatric Academic Programs’ (ADGAP) longitudinal Status of Geriatrics Workforce Study, which began in July 2000. The Office of Geriatric Medicine and the Institute for the Study of Health at the University of Cincinnati conducted the study. The University of Cincinnati Institutional Review Board–Social and Behavioral Sciences approved this project. The survey was endorsed by the American Association for Geriatric Psychiatry (AAGP).
In October 2006, the survey was mailed and also made available online to each of the 181 psychiatric residency programs directors.
Experts in psychiatry, geriatrics, and survey methods developed the survey tool using similar surveys from internal medicine and family medicine residency programs as a guide (11, 12). The 22-question survey asked program directors about eight general areas of their residency programs, including general program information (e.g., number of residents and types of fellowship programs); required geriatrics experiences, including the number of clinical days and sites of required geriatric experiences; whether elective geriatrics experiences were offered; faculty resources (e.g., number of faculty with a certificate in geriatric psychiatry); anticipated changes in their geriatrics curriculum time over the next 3 years; and an open-ended question about the best aspects of their programs. The program directors were also asked to rate barriers to implementing their geriatrics curricula and the importance of 10 clinical curricular areas.
The survey was endorsed by the AAGP, and a cover letter acknowledging this endorsement was mailed with the survey in October 2006. The survey was also made available online and housed on a secure server to prevent unauthorized access. Psychiatry program directors were requested to complete and return the mailed survey or to complete the online survey. Reminder e-mails were sent to nonresponders 12 and 21 days after the initial mailing. A second copy of the survey was mailed to nonresponders at 29 days, and reminder e-mails were sent 4, 13, and 28 days later. Postcards were sent 18 days after the second mailing.
The ACGME gathers information regarding the number of residents in each program, the number of physician educators, and whether the program is government affiliated (7). These data were used to compare responders to nonresponders.
A Mann-Whitney U test was used to compare the medians of continuous variables, chi-square test was used to check for association between categorical variables, and Spearman’s rank correlation coefficient was used to analyze relationships between continuous variables. Two-tailed p values less than 0.05 were considered significant.
A total of 97 of 181 surveys were returned completed, for a response rate of 54%. Twenty-two percent of the responders (n=21) completed the paper survey, while 78% (n=76) completed the survey online. Responders and nonresponders did not differ significantly by program size (median of 23 residents in nonresponding programs compared with 25 in responding programs [U=7,547, n1=97, n2=84, p=0.8]), nor by number of physician educators (median of 20 physician educators in nonresponders and responders [U=7,518, n1=84, n2=97, p=0.7]). Responders and nonresponders also did not differ significantly regarding Northeast, Midwest, South, and West regions (χ2=1.2, df=3, p=0.75) or whether the program was government affiliated (χ2=0.3, df=1, p=0.6).
Characteristics of the Responding Programs
There was a mean of 27.8 residents (median=24) in the responding programs, with a range from 0–70 (SD=12.47). Thirty-four programs (35%) offered a geriatric psychiatry fellowship, and 14 of these reported that they had unfilled geriatric psychiatry fellowship positions in the past 5 years. Overall, psychiatric residency programs reported a mean of 1.5 residents (SD=2.1, median=1, range=0–10) entering either their own or another program’s geriatric psychiatry fellowship program from 2004 to 2006.
Geriatric Psychiatry Curriculum
Among the 97 responding psychiatry programs, four did not require a clinical experience in geriatrics. Of those programs requiring clinical geriatrics training specifically structured to teach geriatric care principles, the mean half days of clinical training during the 4-year program was 54.9 (median=47, range=0–180, SD=36.1). Eight programs (9%) required 15 half days or fewer of clinical instruction; seven programs (8%) required 16 to 30 half days, 29 programs (31%) required 31 to 45 half days, 23 programs (25%) required 46 to 60 half days, and 23 programs (25%) required more than 60 half days of clinical training.
The mean number of hours of lecture and seminar time dedicated to geriatrics during the 4 years of residency training was 22 (median=12, range=0–260, SD=37.06). Fifty programs (51.5%) required 0–12 hours of didactic instruction in geriatrics; 25 programs (26%) required 13–24 hours; seven programs (7%) required 25–36 hours; and 10 programs (10%) required more than 36 hours.
Most of the responding training programs utilized more than one setting to teach geriatric psychiatry. The clinical sites utilized for training and the percent of programs utilizing these sites included inpatient geriatric psychiatry acute care units (62%), ambulatory care experiences precepted by one or more geriatric psychiatrists (52%), and outpatient geriatric psychiatry assessment centers (45%) (Table 1). A small number of programs required home and hospice care experiences. Twenty-five programs (26%) utilized just one clinical site for training, 20 programs (21%) required two, 43 programs (44%) required three to six, and three programs (3%) required seven to 10 different sites. Of the 25 programs that utilized just one clinical site, 22 listed it as an inpatient geriatric psychiatry acute care service.
Seventy-nine programs (82%) offered an elective in geriatrics. From 2004 to 2006 an average of one to two residents per program participated in the elective in geriatrics. Twelve of these electives were a longitudinal opportunity for selected residents to work 2, 3, or 4 years with older patients.
Residency program directors were asked to rank 10 curriculum topics on their importance for training psychiatrists. They ranked emergency and addiction psychiatry as the highest priorities. Geriatric psychiatry ranked third (Figure 1).
In 2006, the mean number of physician faculty dedicated to teaching geriatrics in psychiatric residency programs was 2.8 full-time equivalents (range=0–20, SD=3.21) per training program. The mean number of individual physician faculty certified in geriatric psychiatry was 3.2 (range=0–18, SD=2.59) per program. In 10 programs (10%), no faculty were certified in geriatric psychiatry. Of the 306 faculty certified in geriatric psychiatry, 46% were certified through the practice pathway; the remaining 54% received their certification after completing a geriatric psychiatry fellowship.
There was no significant correlation between the number of faculty certified in geriatrics (Spearman’s ρ=0.13, p=0.23, n=90) and the number of half days required in geriatrics. However, there was a significant correlation between the total number of physician full-time equivalents (including both certified and uncertified physician faculty) and the number of half days of required geriatrics training (Spearman’s ρ=0.28, p=0.01, n=90). There was no significant correlation between the number of faculty certified in geriatrics (Spearman’s ρ=0.09, p=0.4, n=92) or the total physician full-time equivalents (Spearman’s ρ=0.17, p=0.1, n=92) and the number of didactic hours dedicated to geriatrics.
Most programs (85%) used a multidisciplinary approach (a team of physicians and other nonphysician health care workers, such as a social worker, psychologist, and/or pharmacist) in their training programs. About half (46%) used nonphysician geriatric specialists, such as nurses or social workers, to teach residents when a physician was not available.
Geriatric Psychiatry Fellowship Programs
There was no correlation between the number of residents entering a geriatric psychiatry fellowship program and the hours required in lecture and seminar (Spearman’s ρ=0.06, p=0.6, n=91), the half days of clinical experience (Spearman’s ρ=0.08, p=0.5, n=88), or the number of physician full-time equivalents dedicated to geriatrics (Spearman’s ρ=0.17, p=0.1, n=95). The number of residents entering a geriatric psychiatry fellowship differed between schools whose residency programs offered an elective in geriatrics (median=1) and those whose did not (median=0 [U=524, n1=77, n2=17, p<0.01]).
There was significant evidence that residency programs associated with a geriatric fellowship program were more likely (97% compared with 74%) to offer an elective geriatric experience (χ2=8.06, p=0.01); had more full-time equivalent psychiatry physicians (mean=3.5, median=2.5 compared with mean=1.4, median=1.0, respectively [U=2,228.5, n1=34, n2=62, p<0.01]); and had more certified faculty (mean=4.5, median=4.0 compared with mean=2.4, median=2.0, respectively [U=2,158, n1=34, n2=62, p<0.01]) than programs that did not.
When asked to project whether their geriatrics curriculum time would change over the next 3 years (2006–2009), 3% of the program directors anticipated a substantial increase in their dedicated geriatrics curriculum; 45% anticipated a modest increase; 51% anticipated no change; and 1% anticipated a decrease in curriculum time.
Residency directors rated conflicting time demands with other curricula as the most significant barrier to implementing geriatric psychiatry curricula.
This survey documents that progress has been made over the past decade in the training of general psychiatric residents to care for the elderly. In this study, 96% of the responding programs required geriatrics training, and 82% offered an elective in geriatrics. In 1989, only 36% of psychiatric residency training programs required a geriatric rotation, and only 21% offered a geriatric elective (13). Required nursing home rotations were found in only 28% of the programs (13). By 1993, half of a representative sample of the then 140 U.S. accredited programs provided a substantial geriatric experience, defined by a required inpatient, outpatient, or elective experience in which at least 50% of residents participated (14).
However, the amount of time and the characteristics of dedicated geriatrics clinical training varied widely among the responding general psychiatric residency programs. Less than one-third of the programs required residents to see patients in nursing homes, and very few required experiences in home care, assisted living, or hospice care. One-fifth of the programs required only an inpatient geriatrics experience. Given the high prevalence of psychiatric disorders in long-term care settings (15), it is a concern that these settings are not utilized more often for clinical training.
The number of trained faculty available to teach geriatric psychiatry also varied considerably among the responding programs. Exposure to enthusiastic and expert faculty role models engaged in the care of older adults may contribute to the attitudes and future practice patterns of general psychiatrists (16).
However, dedicated faculty available to teach geriatric psychiatry compared favorably with findings from recent, similar surveys of family medicine and internal medicine programs (11, 12). Psychiatric residency programs had a higher median number of physician faculty full-time equivalents per resident (0.08) and median number of certified faculty per resident (0.1) than did internal medicine (0.05 full-time equivalents and 0.08 faculty per resident) or family medicine (0.03 full-time equivalents and 0.05 faculty per resident) residency programs. Ten percent of psychiatric residency programs reported that they had no faculty certified in geriatrics, compared with 6% in internal medicine and 32% in family medicine.
General psychiatry program directors must balance many competing curriculum priorities. Although the program directors rated geriatrics training as a high priority, the majority did not anticipate significant expansion of their geriatrics curriculum. Utilizing the results of this study, individual program directors can compare the characteristics of their existing geriatrics curriculum with a large sample of other programs and determine if this important area is receiving adequate attention.
The potential biases of survey research results must be noted. In this study, surveying all U.S. psychiatric residencies eliminated selection bias, although responder bias remains a possibility. Nonresponders may have been less invested in their geriatrics programs and could have reported weaker geriatric curriculum experiences that would have diluted these results. However, because we found no differences between responders and nonresponders on basic program characteristics, and because considerable curriculum variation existed among responders, the results appear generalizable to psychiatric residency training.
Comparable data are not available for other important general psychiatry training priorities, limiting the ability to place our findings into overall context. However, it is encouraging that the responding program directors ranked training in geriatric psychiatry as a high priority.
Inevitably, the demand for psychiatric services by the growing older population will increase. Is the psychiatric profession ready to meet this demand? Approximately 1,000 psychiatrists complete residency programs each year (17). Residents in some of these programs spend very little time in specific, required geriatric psychiatry clinical experiences and have limited exposure to well-trained geriatric psychiatrists. Most of these residents will not receive further, formal geriatrics training after completing their residency programs. Therefore, some psychiatrists who will take care of older patients in the future may be ill prepared to do so. Although other health care workers provide mental health care to older adults, it remains imperative that all general psychiatrists be trained to provide optimal mental health services to older adults.
This study was funded by grants to the Association of Directors of Geriatric Academic Programs by the Donald W. Reynolds and the John A. Hartford Foundations.
At the time of submission, the authors declared no competing interests.