Are we training psychiatrists to develop skills in intellectual disability psychiatry? Current European context and future directions

The majority of people with intellectual disabilities (ID) and psychiatric disorders access mainstream mental health services across Europe. However, only 56% of countries provide postgraduate psychiatric training in ID according to a survey across 42 European countries. We explore the challenges of ID training and make recommendations for education and health policymakers.

(uemspsychiatry.org), and the automatic mutual recognition of qualification in EU, the practice differs vastly [10].
Each person, regardless of the country they live in, has the right to health, to have the best care possible, and to have it delivered by skilled professionals.

A European Survey of Postgraduate Psychiatry Training Across 42 Countries
The European Federation of Psychiatric Trainees (EFPT, www.efpt.eu), an umbrella organization for trainee associations, conducted the most comprehensive study so far of postgraduate psychiatric training and provision of ID training across Europe.
In this cross-sectional study, the online questionnaire was sent to the representatives of national psychiatric trainee associations, or trainees with comparable functions and with access to accurate and comprehensive data on national practices in countries without such associations. Topics covered included the general structure and length of psychiatric postgraduate training and specific questions about the availability and provision of ID training.
Out of the 42 countries surveyed in 2014, 41 (98% response rate) answered the questions on the availability of ID training (see Table 1). Twenty-three (56%) of the countries provided postgraduate psychiatric training on ID and 18 (44%) did not, of which, one did not have a training scheme of their own. Where training was provided, it took several formats such as lectures, clinical rotations, and case discussions (Table 1). In many countries, ID training was linked to child and adolescent psychiatry training. In two countries, Ireland and the United Kingdom, ID is recognized as a subspecialty with ID training lasting 3 years. This subspecialty training takes place after 3 years of core training in psychiatry (total specialty training of 6 years). In other countries, the length of ID training varied from 6 months, offered as a clinical rotation, to merely hours in those countries offering lectures only. Psychiatry training programs varied considerably in length, from 7 years in Ireland to 1 year in Belarus. In Belarus, despite having the shortest training program, a mandatory 2-week clinical rotation in "behavioral and emotional disorders with onset usually occurring in childhood and adolescence" is provided.
The design of this study, where the respondents have the responsibility of being national representatives, ensured an extremely high response rate (98%) and assures us of the accuracy of the data. Furthermore, the information provided reflects the actual experiences of trainees about the provision of training. In countries where training is not nationally standardized there may be bigger variation within different regions of the same country that could not be captured, although these respondents would be the best placed to have such intelligence. The authors are not aware of significant changes to psychiatric training programs since the time of data collection.
To our knowledge, this is the most recent and comprehensive study on this topic. The only other survey done so far that covered postgraduate psychiatry ID training was done in 2004 and was much smaller [8]. It showed that 14 out of the 22 (64%) countries surveyed offered structured theoretical training in their national training scheme and 5 (23%) offered mandatory practical training, although it did not specify which countries, so we cannot draw a comparison. That study recommended intellectual disabilities, leadership and management, informatics and telemedicine should be introduced in the training curricula, but we have not seen much progress in over 10 years.

Challenges
The biggest question is whether we need specialists in ID psychiatry.
In many countries, less time available for training and constraints of service provision during training limit the exposure to ID. Limited exposure to people with ID and their problems contributes to increase the stigma these people already face. Previous exposure, either in personal or working life, has shown to influence choice of ID subspecialty training. Different modalities of training operate in Europe with a debate about the need for a subspecialty in IDversus theneed forallpsychiatrists to haveIDtraining. Theformer has been criticized alongside other subspecialties as it can lead to fragmentation of care. The latter, despite great efforts, has yet to be implemented within and between countries.
The cost of ignorance on the subject matter due to lack of training can be far-reaching. Firstly, diagnosing mental disorders in people with ID can be challenging for many reasons. There is the risk of under-diagnosing or mis-diagnosing mental disorders in people with ID. The presence of multiple physical, neurodevelopmental, and psychiatric co-morbidities can change the way mental illnesses present in people with ID. Diagnostic overshadowing is very commonly reported. Lower intellectual functioning along with communication difficulties can affect how psychiatric symptoms are manifested. Failing to identify and treat early can have an adverse outcome in health leading to premature death and social disintegration. Secondly, lack of skills to identify the real issues and lack of knowledge or availability of specialist multidisciplinary centers lead to unwarranted and off-label prescription of medication, for example, antipsychotics with the deleterious consequences associated with those, or to over-use of physical restraint. Thirdly, the lack of skilled adult psychiatrists leads on many occasions to child and adolescent psychiatrists being approached by parents of people with ID already in their 20s because they are desperate and have no-one to turn to with sufficient expertise.

Recommendations for education and health policymakers
• Given the above, the authors believe ID psychiatry should be a mandatory part of training curricula and exams (assessment drives learning) in all European countries. • Weacknowledgethedifferent challengesfacedbydifferentcountries, related to economic power, organization of services, organization of training, provision of social care, and general societal expectations. Nonetheless, we suggest that through harmonized training-between and within countries-we can promote harmonized care despite all the existing contextual differences [10]. • Professional exchange programs, like those provided by EFPT and EPA offer a means to complement the training curricula where opportunities are not available locally. • Importantly, even after the completion of postgraduate training, the provision of quality Continuous Medical Education (CME) on the topic, especially through new technologies, can increase the reach of ID training, overcoming location and economic barriers. • We recommend that ID training should not be limited to CAP training, but should work on facilitating the transition between CAP, when the disorders are normally identified, adult psychiatry, as well as old age psychiatry-as the life-expectancy of people with ID continues to increase. Ireland Yes Learning outcomes for psychiatry of intellectual disability must be attained. In practice it will not be possible to achieve outcomes in all specialties with a clinical attachment; therefore, doing an attachment in intellectual disability is not mandatory for BST. Where this is not provided by clinical attachment the learning outcomes must be addressed through other methods (e.g., a combination of courses, workshops, seminars, specialist clinic attendance, e-learning, etc. European Psychiatry 3 • Last but not least, it is important to remember that improvements in the field will come from good cooperation with other professionals and including people with ID, their families, and carers as stakeholders.
National and international policy is an important lever for directing and effecting change. Without improvements in postgraduate psychiatric training in ID, psychiatric care for people with ID will not fundamentally improve. Looking at the survey results, not much has happened in the past decade. For the benefit of people with ID, we need to come together to make a more active push for curriculum reform across Europe. Data Availability Statement. The data that support the findings of this study are available from the corresponding author, M.C.D., upon reasonable request.
Ethical Statement. There was no direct patient involvement in this study. Yes This is taught as part of the compulsory MRCPsych exam preparation course and is tested in the exam. Additionally, some trainees may complete an ID placement (6 months) during core training. There is also the possibility of completing the 3-year higher specialty training program in ID.