Results

The previously outlined search strategy identified a total of 41,222 articles. After removing 9,994 duplicates, the titles and abstracts of 31,281 studies were screened, and 30,676 were excluded because of irrelevance. Six hundred and five potentially relevant full-text articles were sought for retrieval, among which three were unable to be retrieved. Six hundred and two articles underwent further screening, and 554 were excluded for the following reasons: inappropriate outcomes (n = 126), inappropriate study design (n = 364), or inappropriate participant population (n = 64). Forty-eight articles fulfilled all requirements and were included in this systematic review (Figure 1). Table 1 summarizes the key findings of each included study.

Table 1. Psychotherapy training interest and opportunities literature summary

Abbreviations: CAP, child and adolescent psychiatry; CBT, cognitive behavioral therapy; DBT, dialectical behavior therapy; ECP, early career psychiatrist; EMDR, eye movement desensitization reprocessing; ESCAP, European Society for Child and Adolescent Psychiatry; MDD: major depressive disorder; PT, psychotherapy training; RR, response rate; UEMS, Union Européenne de Médecins Spécialistes-European Union of Medical Specialists.

Among the included studies published between January 1, 2000, and August 1, 2024, 47 reported quantitative results, 3 incorporated qualitative components following the survey [Reference Revet, Raynaud, Marcelli, Falissard, Catheline and Benvegnu40, Reference Katz and Kaplan46, Reference Foulkes59], and 1 had primarily qualitative methodology [Reference Van Effenterre, Azoulay, Briffault and Champion33]. According to the quality assessment of the 47 included studies using Q-SSP, 38 (80.9%) articles demonstrated acceptable quality, while 9 (19.1%) articles had questionable quality (Table 2). Considering a 60% threshold resulting in better consensus between experts [Reference Protogerou and Hagger18], 40 (85.1%) were identified as having acceptable quality. One study with qualitative methodology showed reasonable quality according to the Evaluation Tool for Qualitative Studies. World maps created with mapchart.net demonstrate the results of the quality assessment of each included study (Figure 2).

Table 2. Quality assessment of included studies with Q-SSP

Abbreviations: A, acceptable quality; Q, questionable quality; Q-SSP, quality assessment checklist for surveys in psychology.

Figure 2. Quality assessment of included studies – World Map Charts.

Three-quarters of the studies reported data across the European region (n = 24, 50%) and the region of the Americas (n = 12, 25%). The remaining ones were collected from the Western Pacific region (n = 6, 12.5%), the South-East Asian region (n = 4, 8.3%), the Eastern Mediterranean region (n = 1, 2%), and the African region (n = 1, 2%). All studies evaluated psychiatry trainees’ and/or ECPs’ experiences with psychotherapy training by applying surveys, questionnaires, or semi-structured interviews. The majority of the studies used different, unvalidated questionnaires, mostly developed by the authors. Five (10.4%) studies applied uniform questionnaires titled the World Psychotherapy Survey as part of broader international research [Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13, Reference Adiukwu, Adedapo, Ojeahere, Musami, Mahmood and Saidu Kakangi20, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54, Reference Rai, Karki and Pinto Da Costa57]. The number of respondents for each article varied from 12 to 869. Reported response rates were highly variable, ranging from 2.9 to 100%. A few studies mentioned attrition rates of 5% [Reference Schmidt and Foli-Andersen36], 4.9% [Reference Grover, Sahoo, Srinivas, Tripathi and Avasthi56], and 4.6% [Reference Petersen, Fava, Alpert, Vorono, Sanders and Mischoulon45]. A total of 7,196 participants were represented across studies, of whom 3,780 and 1,456 were indicated as psychiatric trainees and ECPs, respectively. Seven studies were conducted with only senior trainees or specialist registrars, pointing to an advanced level of training or trainees in their last year of training [Reference McCrindle, Wildgoose and Tillett22, Reference Pretorius and Goldbeck26, Reference Fàbrega Ribera and Ilzarbe38, Reference Khurshid, Bennett, Vicari, Lee and Broquet43, Reference Khawaja, Pollock and Westermeyer47, Reference Foulkes59, Reference Lee, Bahn, Lee, Lee, Lee and Park60]. In five studies, representatives of trainee or ECP associations were surveyed regarding the system in their countries of training [Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference Oakley and Malik30–Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39]. Child and adolescent psychiatry (CAP) trainees and/or ECPs were included in four studies focusing on psychotherapy training in CAP. Among those, 728 ECPs and 61 representatives of trainee associations were surveyed [Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39, Reference Revet, Raynaud, Marcelli, Falissard, Catheline and Benvegnu40, Reference Hongsanguansri, Charatcharungkiat, Alfonso and Olarte64]. One study reported the views of CAP trainees and ECPs as part of the whole group [Reference Kaya, Tasdelen, Ayık and da Costa41]. In the following sections of the article, the term ECP refers to both psychiatry trainees and ECPs, if not otherwise indicated.

Thirty-one of the included studies reported data regarding ECPs’ interest in psychotherapy training. Overall, 57–80% (minimum–maximum) of the participants were interested in psychotherapy training [Reference Van Effenterre, Azoulay, Champion and Briffault14, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference Kuzman, Jovanović, Vidović, Margetić, Mayer and Zelić28, Reference Ertekin, Ergun and Sungur35, Reference Schmidt and Foli-Andersen36], and 75.8–99% mentioned the importance of such training in becoming fully competent psychiatrists [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference O’Mahony and Corvin23, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42, Reference Hadjipavlou and Ogrodniczuk44, Reference Radu, Harris, Bonnell and Bursey51, Reference Kishore, Shaji and Praveenlal55, Reference Foulkes59, Reference Charernboon and Phanasathit62, Reference Jacobson, Sketcher and Sergejew63, Reference Morrissette, Fleisher, Anang and Harrington52]. ECPs demonstrated a favorable/positive attitude toward psychotherapy training [Reference Schmidt and Foli-Andersen36, Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata and Haak48], and 76–94% were willing to practice or advance it further [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42, Reference Hadjipavlou and Ogrodniczuk44, Reference Katz and Kaplan46, Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata and Haak48, Reference Radu, Harris, Bonnell and Bursey51, Reference Ng, Teshima, Tan, Steinberg, Zhu and Giacobbe53, Reference Charernboon and Phanasathit62]. Moreover, 67–92% of the participants tended to consider being a psychotherapist as an integral and valuable part of their identities as psychiatrists [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Hadjipavlou and Ogrodniczuk44, Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata and Haak48, Reference Radu, Harris, Bonnell and Bursey51]. A considerable proportion of trainees wished for greater exposure to psychotherapy training (54%) and desired to develop a special interest (65%) [Reference Podlejska-Eyers and Stern24, Reference Pretorius and Goldbeck26]. Psychotherapy interest was identified as one of the main factors in choosing to specialize in psychiatry [Reference Revet, Raynaud, Marcelli, Falissard, Catheline and Benvegnu40, Reference Hadjipavlou and Ogrodniczuk44]. ECPs supported that psychotherapy training should be included in psychiatry training (88–97.7%) and it should be an obligatory part of the curriculum (57.2–87.2%) [Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34, Reference Schmidt and Foli-Andersen36, Reference Levi Shachar, Mendlovic, Hertzberg, Baruch and Lurie37, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Lanouette, Calabrese, Sciolla, Bitner, Mustata and Haak48, Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54]. Among numerous psychotherapy modalities, CBT (62.5–100%), psychodynamic psychotherapy (26.3–71.4%), family/systemic therapy (42.5–71.4%), supportive psychotherapy (65.5%), and interpersonal psychotherapy (34.8–44%) were favored to be included in the curriculum to a variable extent [Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42, Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54, Reference Jacobson, Sketcher and Sergejew63]. Studies investigating the awareness of ECPs of psychotherapy training guidelines revealed that 51–84% had notice of competence requirements [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Carley and Mitchison25, Reference Schmidt and Foli-Andersen36, Reference Khurshid, Bennett, Vicari, Lee and Broquet43]. In all, 33–48.8% reported being accredited or meeting the relevant requirements during the evaluation [Reference Pretorius and Goldbeck26, Reference Kaya, Tasdelen, Ayık and da Costa41]. Participants’ self-perceived psychotherapy competence rates were 47–65% [Reference Katz and Kaplan46, Reference Morrissette, Fleisher, Anang and Harrington52, Reference Ng, Teshima, Tan, Steinberg, Zhu and Giacobbe53].

Van Effenterre et al. found that psychiatry trainees viewed psychotherapy as central to their psychiatric identity and saw it as ranging from a strong therapeutic alliance to formal interventions. The psychotherapeutic orientation was diverse, with various modalities enriching psychiatry practice. Trainees expressed a desire for advanced theoretical and practical knowledge to maintain effective psychotherapy skills [Reference Van Effenterre, Azoulay, Briffault and Champion33].

Psychotherapy training rates and opportunities in psychiatry training varied widely across countries, regions, institutions, and even within the same institution. Half of the studies were from Europe, where most countries considered psychotherapy training essential, although its inclusion in programs varied. It was mandatory in Denmark, Germany, Ireland, the Netherlands, Norway, Switzerland, and the United Kingdom [Reference O’Mahony and Corvin23, Reference Pretorius and Goldbeck26, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27], while it was optional in Belgium, France, and Portugal [Reference Fiorillo, Luciano, Giacco, Del Vecchio, Baldass and De Vriendt31, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34]. Austria, Israel, Spain, and Turkey recommended it as a core competence and included it in the training to some extent [Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference Levi Shachar, Mendlovic, Hertzberg, Baruch and Lurie37, Reference Kaya, Tasdelen, Ayık and da Costa41]. The most accessible psychotherapy training modalities were CBT and psychodynamic psychotherapy, followed by family/systemic, supportive, and interpersonal psychotherapy [Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference McNeill and Ingram29, Reference Oakley and Malik30, Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Fàbrega Ribera and Ilzarbe38, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42]. In studies reporting data from Europe, CBT training was available for 18–95% of the participants [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27–Reference Oakley and Malik30, Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34, Reference Ertekin, Ergun and Sungur35, Reference Fàbrega Ribera and Ilzarbe38, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42]. Psychodynamic psychotherapy training rates were 8–91% [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Margariti, Kontaxakis, Madianos, Feretopoulos, Kollias and Paplos21, Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Carley and Mitchison25, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference Kuzman, Jovanović, Vidović, Margetić, Mayer and Zelić28, Reference Oakley and Malik30–Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34, Reference Fàbrega Ribera and Ilzarbe38, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39, Reference Kaya, Tasdelen, Ayık and da Costa41], whereas 8.7–81.8% of the samples reported receiving training in systemic/family therapy [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Carley and Mitchison25, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference Kuzman, Jovanović, Vidović, Margetić, Mayer and Zelić28, Reference Oakley and Malik30–Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Pinto da Costa, Guerra, Malta, Moura, Carvalho and Mendonça34, Reference Fàbrega Ribera and Ilzarbe38, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39, Reference Kaya, Tasdelen, Ayık and da Costa41]. Other modalities like interpersonal psychotherapy, supportive psychotherapy, group therapy, cognitive-analytical therapy, integrative/eclectic therapy, sex therapy, psychodrama, dialectical behavior therapy, and third-generation psychotherapies were offered to a more limited extent in European programs.

A quarter of the studies included were from the region of Americas. In Canada and the United States, psychotherapy training was a required competency [Reference Zisook, Mcquaid, Sciolla, Lanouette, Calabrese and Dunn49, Reference Morrissette, Fleisher, Anang and Harrington52]. Ng et al. [Reference Ng, Teshima, Tan, Steinberg, Zhu and Giacobbe53] reported that 83% of Canadian trainees received adequate CBT exposure, followed by 39% with interpersonal psychotherapy. In Brazil, psychotherapy training was mandatory in the core curriculum for psychiatry, with 78.6% of participants confirming its inclusion. The most accessible modalities were CBT, psychodynamic, and interpersonal psychotherapy [Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54].

Six studies from the Western Pacific Region provided data on psychotherapy training in Australia, New Zealand, the Republic of Korea, Singapore, and Thailand. In Australia and New Zealand, psychotherapy training varied by region and institution [Reference Foulkes59, Reference Jacobson, Sketcher and Sergejew63], with psychodynamic psychotherapy, supportive psychotherapy, and CBT being the most accessible modalities [Reference Foulkes59]. In the Republic of Korea, psychotherapy was a requirement for certification, with 67.4% of the respondent trainees practicing insight-oriented psychodynamic psychotherapy, 28.5% supportive psychotherapy, and 4.2% psychoanalysis [Reference Lee, Bahn, Lee, Lee, Lee and Park60]. Singapore had high trainee interest but lacked standardized competency assessments [Reference Tor, Ng and Kua61]. In Thailand, psychotherapy training availability varied by institution, exacerbating challenges like heavy workloads, lack of confidence, and inadequate training [Reference Charernboon and Phanasathit62]. Notably, Satir’s systemic therapy and Buddhist therapy were among the unique modalities practiced. The most common therapies were supportive psychotherapy (82.9%), CBT (39%), behavioral therapy (35.4%), and Satir’s systemic psychotherapy (32.9%).

Four studies from the South-East Asian region (three from India and one from Nepal) were included. In India, the National Medical Commission highlighted psychotherapy training as essential, but 64.3–73.8% of ECPs reported receiving it [Reference Kishore, Shaji and Praveenlal55, Reference Kumar, Somani, Chandran, Kishor, Isaac and Visweswariah58]. The most common modalities included behavior therapy (90.3%), supportive psychotherapy (87.6%), CBT (86.5%), and motivational interviewing (85.7%) [Reference Grover, Sahoo, Srinivas, Tripathi and Avasthi56]. In Nepal, postgraduate psychiatry training lacked a uniform curriculum, and 67.6% of ECPs reported receiving mandatory psychotherapy training [Reference Rai, Karki and Pinto Da Costa57]. The most accessible modalities were CBT, interpersonal psychotherapy, and family therapy.

There was one study for each region that included the African and Eastern Mediterranean regions. Psychotherapy training was an integral rotation in psychiatry training in Iran [Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13]. In contrast, in Nigeria, it was not considered one of the mandatory rotations, with limited structured programs to incorporate psychotherapy into psychiatry training [Reference Adiukwu, Adedapo, Ojeahere, Musami, Mahmood and Saidu Kakangi20].

Four studies focused on psychotherapy training during CAP training programs. Revet et al. [Reference Revet, Raynaud, Marcelli, Falissard, Catheline and Benvegnu40] mentioned that 52.8% of CAP trainees chose the specialization due to their interest in psychotherapy. Simmons et al. [Reference Simmons, Barrett, Wilkinson and Pacherova32] reported that 19 of 28 European countries, namely Croatia, Czechia, Denmark, Estonia, Finland, Germany, Hungary, Ireland, Israel, the Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Sweden, Switzerland, Turkey, and the United Kingdom, included mandatory psychotherapy training in CAP, with 82% offering both theoretical and practical experience. In Romania, there was no psychotherapy experience available at the time of that study. The most available modalities were CBT (78%), psychodynamic psychotherapy (67%), and systemic therapy (64%) [Reference Simmons, Barrett, Wilkinson and Pacherova32]. The CAP-STATE study showed that 90% of countries taught theoretical psychotherapy topics, with 12 countries requiring practical training in individual psychotherapy with children. Systemic therapy training was provided by almost all countries (n = 27) [Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39]. In Thailand, psychotherapy training varied across institutions, with Satir’s transformational systemic therapy (76.3%), CBT (72.9%), and supportive psychotherapy (72.9%) being the most common modalities [Reference Hongsanguansri, Charatcharungkiat, Alfonso and Olarte64].

In studies reporting on psychotherapy training, theoretical training rates ranged from 41.6 to 97.6%, while practical training took place for 35.3–96% of participants [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13, Reference Adiukwu, Adedapo, Ojeahere, Musami, Mahmood and Saidu Kakangi20, Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Carley and Mitchison25, Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27, Reference McNeill and Ingram29, Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Yazici, Turker Mercandagi, Ogur, Kurt Tunagur and Yazici42, Reference Ng, Teshima, Tan, Steinberg, Zhu and Giacobbe53, Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54, Reference Rai, Karki and Pinto Da Costa57, Reference Kumar, Somani, Chandran, Kishor, Isaac and Visweswariah58]. Psychotherapy training outside the psychiatry training institute occurred for 24.3–52% of trainees [Reference Gargot, Dondé, Arnaoutoglou, Klotins, Marinova and Silva12, Reference Eissazade, Shalbafan, Eftekhar Ardebili and Pinto da Costa13, Reference McCrindle, Wildgoose and Tillett22, Reference Podlejska-Eyers and Stern24, Reference Carley and Mitchison25, Reference Kuzman, Jovanović, Vidović, Margetić, Mayer and Zelić28, Reference Simmons, Barrett, Wilkinson and Pacherova32, Reference Levi Shachar, Mendlovic, Hertzberg, Baruch and Lurie37, Reference Barrett, Jacobs, Klasen, Herguner, Agnafors and Banjac39, Reference Kaya, Tasdelen, Ayık and da Costa41, Reference Belinati Loureiro, Ratzke, Nogueira Dutra, Mesadri Gewehr, Cantilino and Pinto Da Costa54, Reference Rai, Karki and Pinto Da Costa57, Reference Kumar, Somani, Chandran, Kishor, Isaac and Visweswariah58]. Van Effenterre et al. [Reference Van Effenterre, Azoulay, Champion and Briffault14] stated that 95% of the psychiatry trainees preferred a two-phase training model, combining general theoretical training with in-depth training in a preferred modality, although current models were incompatible. Numerous training techniques, such as case formulations, reading materials, videos, logbooks, and workshops, were reported [Reference Fiorillo, Luciano, Giacco, Del Vecchio, Baldass and De Vriendt31, Reference Khurshid, Bennett, Vicari, Lee and Broquet43]. Kovach et al. [Reference Kovach, Dubin and Combs50] noted that trainees ranked supervision highest among teaching modalities, followed by psychotherapy practice, didactic instruction, readings, and personal psychotherapy.

Funding for psychotherapy training was also a key issue. In Nigeria, 56.5% of ECPs self-funded their training [Reference Adiukwu, Adedapo, Ojeahere, Musami, Mahmood and Saidu Kakangi20]. In Europe, Lotz-Rambaldi et al. [Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27] reported that 48% of centers covered all (27%) or part (22%) of the costs, while 46% of training was publicly funded. Where not fully publicly funded, trainees often paid between 2,500 and 10,000 Euros, with some centers charging over 10,000 Euros (in Austria, Switzerland, and Germany) [Reference Lotz-Rambaldi, Schäfer, ten Doesschate and Hohagen27].

Interest in, accessibility to, and training modalities of psychotherapy training were compared between HICs and LMICs using results from 34 studies (Table 3). Others were excluded due to the lack of comparable country data and the fact that they were regional. Our results showed that, despite small discrepancies between countries, there were no significant differences in terms of interest in psychotherapy between HICs and LMICs.

Table 3. Psychotherapy training in high-income versus low- and middle-income countries

Abbreviation: CBT, cognitive behavioral therapy.

^a Includes interest in psychotherapy in terms of mentioning the importance of the topic, demonstrating a favorable/positive attitude, willingness to practice, or advance further.