The prevalence of psychiatric disorders among persons with mental retardation is as much as four to five times higher than among persons who do not have mental retardation (1,2,3). Because at least 1 percent of the population is estimated to have mental retardation (3,4,5), these patients are frequently encountered in psychiatric practice.
Despite the high prevalence of persons with mental retardation who require psychiatric care (1,4,6), general psychiatry residents are rarely formally trained to treat this patient population. A recent study found that less than half of the Canadian psychiatric training programs provided mandatory clinical experience in the field of mental retardation (7). Another Canadian study reported that 59 percent of senior psychiatry residents thought that more training on developmental disabilities was needed in their residency programs (8). Although Canadian and Australian educators have begun to examine this issue (4,7,8,9), there is a lack of data that examines U.S. psychiatry residents' perceptions of developmental disabilities training.
At the Zucker Hillside Hospital in New York, general psychiatry residents undergo a one-month specialized training program on a 20-bed inpatient unit for patients with mental retardation who have co-occurring psychiatric disorders. On this unit, patients are treated by using multimodal approaches, which are provided by nursing staff, attending psychiatrists, a psychologist, several mental health workers, psychiatric rehabilitation therapists, social workers, and an internist. Diverse treatment modalities are used, ranging from group therapy, activity groups, and community meetings to behavioral management and psychopharmacology. The unit has been adapted to the needs of patients who are psychiatrically ill and developmentally disabled, including improved visibility from the nursing station and the addition of heavy furniture. Psychiatry residents in their second year participate in daily multidisciplinary rounds in this unit and carry a caseload of six patients. The unit chief and another experienced psychiatrist supervise the residents. Specific readings to supplement clinical cases constitute the didactic component of the specialized training program. During their rotation, psychiatry residents are exposed to many of the specific techniques of working with patients with mental illness and mental retardation, such as the use of nonverbal strategies and how to manage patients' agitation. The goal of our study was to ascertain how residents who had received specialized training in working with persons with developmental disabilities viewed their educational experience.
A 41-item anonymous questionnaire was developed for residents who had finished their rotation in the inpatient unit for patients with mental retardation and co-occurring psychiatric disorders. The survey was pretested with five psychiatry residents and was reworded on the basis of their feedback. The questionnaire was divided into four sections: the resident's demographic data and assessment of the utility of the rotation in relation to his or her overall psychiatric training; a survey of educational experiences; questions about how the rotation influenced the treatment of specific symptoms; and open-ended questions to assess how the training influenced the resident's evaluation of mentally retarded patients. Respondents rated answers on a 5-point Likert scale: 1, strong agreement; 2, agreement; 3, neither agreement nor disagreement; 4, disagreement; and 5, strong disagreement.
This study was approved by the North Shore-Long Island Jewish Health System's institutional review board. The questionnaire was mailed in February 2002 to all 58 current and former psychiatry residents who had completed this training between the classes of 1999 and 2004. A cover letter that was approved by the institutional review board requested that residents identified by a code known only to a third party complete and return the anonymous questionnaire. Two reminder letters were sent to nonresponders at one-month intervals following the initial letter.
A total of 43 of the 58 questionnaires (74 percent) were returned after the third mailing. A total of 22 respondents (51 percent) were currently in the residency program; the remaining 21 respondents (49 percent) had completed their residency. No significant differences were found between responders and nonresponders in gender or whether they were a current or former resident from a U.S. or foreign medical school. Likewise, responders did not differ from nonresponders in whether they had completed their residency.
A total of 42 respondents (98 percent) strongly agreed or agreed that training in the field of mental retardation during their psychiatric residency was valuable (mean±SD Likert score of 1.45±.5). A total of 18 respondents (42 percent) strongly agreed that this specialized training should be required during psychiatry residency training, 18 respondents (42 percent) agreed, six respondents (14 percent) neither agreed nor disagreed, and one respondent (2 percent) disagreed.
Respondents generally disagreed (mean Likert score of 3.88±.96) with the statement that "residencies that do not offer training in mental retardation provide sufficient general training to care for these patients." The majority of former residents (13 of 22 former residents, or 59 percent) and current residents (12 of 21 current residents, or 57 percent) either strongly agreed or agreed that this experience prepared them to work with persons with mental illness and mental retardation; only one respondent strongly disagreed.
When queried about various components of the training unit, 39 respondents (91 percent) reported that the multidisciplinary team approach was useful (mean Likert score of 1.5±.63). Notably, 35 respondents (81 percent) were neither fearful nor concerned for their physical safety while they were working on the inpatient unit.
The specific educational components queried were in the categories of general pharmacological, behavioral, and safety techniques as well as lessons learned on working in team approaches and techniques to help residents work with families. With respect to the utility of specific educational components, respondents rated pharmacological techniques (mean Likert score of 1.63±.72), behavioral techniques (mean Likert score of 2.02±.89), and safety techniques (mean Likert score of 2.02±.94) as being most useful. A total of 33 respondents (77 percent) reported that this training influenced their treatment approach to patients with mental retardation, six respondents (14 percent) abstained from answering the question, and four respondents (9 percent) disagreed. Most respondents reported that clinical supervision (mean Likert score of 1.64±.79) and didactic information (mean Likert score of 1.67±.89) received from an experienced psychiatrist were rated as the most helpful. The majority (40 respondents, or 93 percent) rated the training as important or necessary in helping them modify their interview techniques for nonverbal patients. The timing of the training was judged to be the most appropriate when it was given in the second year of residency; the mean recommended length of the program was 5.6±1.7 weeks.
Only a third of the respondents (16 respondents, or 37 percent) would have liked additional specialized training. Although four respondents (9 percent) indicated an interest in careers treating patients with mental retardation, seven respondents (16 percent) were opposed to creating a distinct subspecialty that they could focus on when they entered their fellowship training.
Responses did not differ significantly between current and former residents, except with respect to the treatment of symptom clusters. Compared with current residents, more of the former residents reported treating symptoms of aggression toward self (t=2.31, df=40, p=.03), aggression toward others (t=3.12, df=41, p=.003), and behavioral disturbances (t=2.33, df=40, p=.02) more frequently than trainees.
Responses to the open-ended questions supported the conclusion that the training program had been useful in preparing residents to treat the population of patients with mental illness and mental retardation. According to three respondents (7 percent), the lack of an outpatient component was a weakness of the program.
Editor's note: This paper is part of a series of papers by, about, and for residents, currently edited by Joshua L. Roffman, M.D. Prospective authors—current residents, fellows, and faculty members—should contact Dr. Roffman at the Wang Ambulatory Care Center 812, Massachusetts General Hospital, 15 Parkman Street, Boston, Massachusetts 02114, firstname.lastname@example.org.
Nearly all (98 percent) of the 43 psychiatry residents in our survey rated specific training in the area of mental retardation as important. Eighty-four percent of the respondents agreed or strongly agreed that specialized training in this field should be required during psychiatry residency. This desire for training parallels the findings of a recent Australian study (10), which reported that up to 76 percent of psychiatrists were interested in further training in how to treat psychiatric patients with developmental disabilities.
Fifty-nine percent of the respondents who had completed their residency felt that this training prepared them to work with persons with mental illness and mental retardation, which further supports the idea that this educational program was perceived as positive. Thus it seems as though specialized training attracts physicians to this field and prepares psychiatric residents to work with patients with mental retardation.
The perceptions of current and former residents did not differ significantly, except in the greater frequency with which former residents treated patients with symptoms of aggression toward self and toward others and behavioral disturbances. The greater frequency may reflect the practice patterns of individuals who have completed their residency and have more clinical experience.
Although most general psychiatry residents (81 percent) did not fear for their safety while they worked on the specialized unit, 19 percent of the respondents did express some safety concerns. We did not ask whether this concern for personal safety was alleviated by participating in this specialized training program.
Residents found this specialized training program useful, which was also reflected by the fact that only 30 percent (13 respondents) would have liked additional training. This result differs from the findings of one of the Canadian surveys, in which 59 percent of the residents who underwent specialized training in the field of mental retardation recommended additional training (8). In contrast to our study, the Canadian survey examined residents who were taking a national preparatory exam and had participated in several different types of training; the Canadian survey likely reflected various levels of individual satisfaction because of the varied training locations represented in the many training programs sampled. Additionally, the Canadian study focused on both undergraduate and postgraduate training, which makes it difficult to compare with our study.
In terms of educational structure, general psychiatry residents in our survey reported that direct supervision and didactic sessions with a psychiatrist who is experienced in the field of mental retardation were the most useful elements of training. Most residents that we surveyed also found the training to be particularly helpful for working with nonverbal patients and that training in both psychopharmacologic and nonpsychopharmacologic approaches was useful. Overall, our findings highlight the importance of specialized training in mental retardation, which could further educate future generations of psychiatrists in this area.
These results are subject to several limitations. The training program that we studied consisted of a single-site inpatient psychiatric unit. This specialized program is unique in that there are few inpatient units dedicated to treating patients who are psychiatrically ill with mental retardation, which might make it difficult to compare with other programs. Respondents noted that one weakness of the program was the lack of outpatient exposure. In view of a progressive trend toward least restrictive levels of care, it would be important to include outpatient training. Although we did not observe obvious demographic differences between respondents and nonrespondents, we cannot exclude the possibility that respondents may have been more or less satisfied with their overall training experience than nonrespondents. Finally, our sample size was modest, because our program is still relatively new.
In summary, this survey of the perceptions of general psychiatry residents of a specialized program that trains residents to work with patients with mental illness and mental retardation indicates that overall residents were very satisfied with their training and that they perceived it as useful. On completion of this specialized training, general psychiatry residents felt better prepared to work with patients with mental illness and mental retardation. Additional studies of general psychiatry residents' experiences in specialized training at other U.S. residency programs are needed.
Dr. Reinblatt, Dr. Castellanos, and Dr. Coffey are affiliated with the division of child and adolescent psychiatry at New York University School of Medicine, 550 First Avenue, NBV-21 South 6, New York, New York 10016 (e-mail, email@example.com). Dr. Rifkin is with the department of psychiatry at the Zucker Hillside Hospital in Glen Oaks, New York.