Sub-specialties in psychiatry: towards parity in mental health training and services.

Neuropsychiatric disorders account for 5 of the 10 most disabling medical disorders worldwide, 1 and for a particularly large component of the burden of disease in South Africa. 2 Unfortunately, as elsewhere, training and services in psychiatry have lagged behind those of other major disciplines, and much additional work is needed to achieve parity. We focus in particular on the status of psychiatric sub-specialties in South Africa, considering the pros and cons of their recognition in a developing country. South Africa has long recognised the existence of various specialties and sub-specialties in medicine. Internal medicine and surgery were among the first recognised specialties, but we also have a long history of formal recognition for a broad range of sub-specialties. Paediatrics and obstetrics and gynaecology have also had a range of their sub-specialties recognised. Psychiatry was a relative latecomer to the specialties, and until recently offered a certificate in only one sub-specialty – child and adolescent psychiatry. The reasons for the past neglect of psychiatry in undergraduate and postgraduate training are debatable. Possible contributors include conceptual and methodological weaknesses in psychiatry and stigmatisation of mental illness. But in the past several decades psychiatry has become increasingly scientific in its approach, and the efficacy and cost-efficiency of its treatments have become increasingly valued, given recognition of the burden of mental illness. 3,4 Consistent with the re-medicalisation of psychiatry, and the advances in its diagnoses and treatment, psychiatry has become recognised as one of the 'big five' undergraduate and postgraduate clinical disciplines throughout the world. Where the need for parity of psychiatry with other medical disciplines is recognised by policy-makers, clinicians, and consumer advocates, on the basis of the burden of psychiatric disorders and the rights of those with these conditions to accessible treatment, then resources for psychiatric services and research are more likely to match those provided to other medical or surgical disciplines. In such settings, a range of psychiatric sub-specialties have been formally recognised (e.g. child and adolescent psychiatry, old age psychiatry, forensic psychiatry, addiction psychiatry, consultation-liaison psychiatry, neuropsychiatry, public or community psychiatry). Some sub-specialties may be open to various disciplines including psychiatry (e.g. intellectual disability, pain medicine, sleep medicine). While parity for psychiatry is more often achieved in high-income countries, several of these sub-specialties are now recognised in various low-and middle-income countries. There are important advantages of formally recognising the psychiatric sub-specialties. At a scientific level, this acknowledges significant growth …