Divorce is a ubiquitous phenomenon with potentially devastating consequences. The United States divorced population reached 22.8 million in 2006, a fivefold increase since 1970. In 2006, nearly one million U.S. marriages were dissolved, leaving 9.8% of the adult population divorced (1). Children and extended family, not counted in these statistics, are also affected.

As far back as 1967, Holmes and Rahe (2) rated divorce as the second most stressful life-changing event on their Social Adjustment Rating Scale and published their work recognizing the onset of physical illness with life-event stressors. The evidence base in the literature establishes divorce as a significant risk factor for adverse mental and physical sequelae. Psychiatric disorders following divorce include depression (3), substance abuse (4), and posttraumatic stress disorder (5). Mortality through suicide and/or homicide is an ultimate and potentially preventable consequence that often occurs during separation (6).

Increased medical morbidity and mortality associated with divorce is also documented. Ikeda et al. (7) reported that divorce in men is associated with a higher risk of mortality from cardiovascular disease. Lorenz et al. (8) found significantly higher levels of illness in women in the decade following divorce, even after controlling for age, remarriage, education, income, and previous health. Most recently, Bodley-Tickell et al. (9) reported a doubling of sexually transmitted diseases in the population 45 years or older in England from 1996 to 2003. The increased divorce rate was postulated as a contributing factor.

The literature also describes the medical and psychological consequences on extended family. Children show a higher incidence of mental and medical health problems, such as asthma and atopic eczema, related to parental conflict and divorce (10). Furthermore, the health of grandparents has been reportedly affected by divorce when it results in isolation from their grandchildren (11).

This article seeks to assess the level of psychiatric residency education that currently addresses divorce and to make curriculum recommendations on the basis of these findings.

We conducted a literature search using the MEDLINE, PsycINFO, and Academic Psychiatry databases for all manuscripts that address medical education related to divorce through 2008 using divorce with the terms training, curriculum, education, psychiatry, psychiatric training, psychiatry residency, and psychiatric curriculum.

Additionally, a search was conducted for training information on divorce on the Accreditation Council for Graduate Medical Education (ACGME) web page (www.acgme.org), along with its psychiatric residency review committee web page (http://www.acgme.org/acWebsite/navPages/nav_400.asp) and accredited psychiatry program links page (http://www.acgme.org/adspublic).

On the MEDLINE database, 4,889 manuscripts were listed when searching for divorce. Most addressed sequelae of divorce, with a smaller number addressing prevention or treatment. No papers were identified when divorce was searched with psychiatric curriculum or psychiatry residency.

The Academic Psychiatry literature search identified 26 manuscripts associated with divorce, four of which were related to training. The Group for the Advancement of Psychiatry Committee on the Family published two articles addressing the need to train residents to work with families in meeting the residency review committee core competencies. Its 2006 article (12) cited divorce once under the eighth training priority, special issues, and its 2008 article (13) listed divorce once in a case example of a couple coming to discuss divorce. Two other articles emphasized the importance that trainees be knowledgeable of the effect of divorce on parents and children. Josephson (14) cited divorce as the first environmental stressor/social family factor that residents should address in developing a case formulation. New York University proposed the course “Divorce in America” for a new undergraduate minor in child and adolescent mental health (15).

Finally, two articles were found in journals other than Academic Psychiatry that discussed specific courses on divorce for nonresidency training. Purdue University described a graduate course in response to legislation aimed at decreasing the divorce rate (16). Melnyk and Alpert-Gillis (17) described a similar emphasis in training nurse practitioners.

The search of the ACGME website resulted in one reference to divorce in an anecdotal report that divorce rates of residents decreased with night floats. Divorce is not specifically mentioned in the general or child and adolescent psychiatry programs’ residency review committee requirements. A further search of the 182 accredited psychiatry program links, though not comprehensive, revealed no reference to divorce in available curriculum, grand rounds, or educational materials posted.

A Prospective Curriculum

Given the prevalence of divorce and the lack of documentation of available training material to address it, an initial prospectus curriculum was developed on the basis of the author’s professional experience (see Appendix 1). This curriculum would begin teaching residents to recognize the differential effect of divorce, assess its variables, and use this information in risk management of the patient. The proposed content outline can first be incorporated into existing didactics and later expanded.

The psychiatric profession must train the next generation of clinicians to fully recognize the impact of divorce, given that the U.S. divorced population currently exceeds 22 million people, impacting one in every 10 adult patients. It does not appear that psychiatric education is adequately recognizing nor addressing this need. To continue to under-evaluate the impact of such a devastating, disruptive, and pervasive life event will adversely affect the health of our nation.

At the time of submission, Dr. Godleski reported no competing interests.