In mental health care, transition refers to the pathway of a young person from a child and adolescent mental health service (CAMHS) to an adult mental health service (AMHS). This health services transition occurs at a particularly vulnerable developmental stage, when young people are also simultaneously going through social, family and academic life transitions (1, 2). Discontinuity of care may therefore have harmful consequences for those with ongoing mental health needs in various life domains (3). Unfortunately, only a minority experience good transitional care (4, 5), mostly because of a limited co-ordination between services and the lack of effective evidence-based interventions in transitional care (6, 7). Health services and policy makers from countries around the world are increasingly recognizing the importance of improving transitions from CAMHS to AMHS and developing effective interventions and models of care that are youth-informed and oriented (6, 8, 9). The European Union of Medical Specialists-Child and Adolescent Psychiatry (UEMS-CAP) is currently working on European guidelines for Transitional care (see www.uemscap.eu/working-group).

An optimal transition involves a coordinated, purposeful, planned and patient-centered process, ideally involving a period of parallel care/joint work between services, to ensure a smooth transition (5, 10, 11). Previous qualitative research showed that young people transitioning between services perceive the consistency of clinicians and periods of parallel care as being among key factors enabling effective CAMHS to AMHS transition (12, 13). This highlights the importance of having clinicians in both services trained in navigating the various aspects of transitional care.

Training of mental health professionals on transition-related topics could therefore facilitate the process at the clinical level and improve clinical practice. Among existing studies on psychiatry training across Europe (14–22), only one focused on transitional care and revealed that, according to trainees, practical and theoretical training on this topic occurred, respectively, in only 27.8 and 16.7% of European countries (21). A systematic review of psychiatrist's training in Europe highlighted that a training specifically dedicated to transition was included only in the United Kingdom (UK) and in Ireland (23). The existing literature points toward gaps in teaching about the process and planning of transition, calling for proper training in “transition psychiatry” in the postgraduate curriculum (24).

Improving knowledge about clinical presentations of mental disorders in adolescence and specific communication skills are other possible areas of training. Some mental health professionals may not feel comfortable or lack the expertise and interviewing techniques needed to work with young people and their families (25–28). Only 17% of Adult Psychiatry (AP) trainees and 35% of General Psychiatry trainees have lectures on adolescent psychopathology, vs. 61% of Child and Adolescent Psychiatry (CAP) trainees (21).

Furthermore, the transition literature shows clinical and conceptual differences between child and adult mental health service models that may lead to mutual misperceptions (4, 29) and may impede the coordination and collaborative working between services that is needed. Training content and training models may account for the cultural divide existing between CAMHS and AMHS, characterized by different beliefs and attitudes, a lack of understanding of different service structures and different working practices related to communication and information transfer (27). In Europe, trainees in AP and CAP follow a separate specialized training from the start of postgraduate studies in 55% countries (21), but there are no studies on the impact of training models on transitional care.

One of the aims of the “MILESTONE project,” a EU-funded research programme exploring the transition of young people from CAMHS to AMHS in eight countries (www.milestone-transitionstudy.eu/) (30), is to study the training of professionals in transitional care. This survey has been designed in the context of the MILESTONE project to describe the current status of transition and related issues in AP and CAP postgraduate training in Europe. It also examines the respective content of AP and CAP postgraduate training, with a particular focus on the amount of theoretical and practical cross training between both specialties (e.g., training in CAP in the AP or General Psychiatry curriculum, and vice-versa).

Data collection was carried out between 2015 and 2018. This research did not require ethical approval as no personal data were collected.

We received completed questionnaires for 21/39 countries (54%) (Figure 1). Since the psychiatry postgraduate training in Luxembourg replicated the French model, it was excluded from the analysis. Among respondents, 50% were representatives of national psychiatry associations while 50% were from universities or research institutions engaged in training.

Eight countries indicated plans to revise their training syllabus. By study completion, updated information was available from four of them, while the change was awaiting approval in one country and had not yet occurred in another one. The remaining two countries did not provide additional information.

Three models of training in CAP and AP training were identified. In the first model, trainees are provided with a general education in psychiatry including a training in both AP and CAP, with optional subspecialities (3/20 countries, 15%, hereafter referred to as generalist countries). In the second model, trainees follow a joint psychiatry core programme, followed by mandatory further specialization (7/20 countries, 35%). In the third model, CAP and AP are considered as independent specialities and trainees are provided with separate training from the start, with different programmes (10/20 countries, 50%). Countries with model 2 or 3 are referred to as countries with specialization route. Figure 1 depicts these three models.

Training of psychiatrists is identified as a determining factor in improving transitional planning and care, both from the perspectives of trainees and youth experiencing transition between services (12, 13, 21, 23). A more informed training and education in transition in both AP and CAP curriculum is likely to facilitate transition and to have long term-effects in terms of mental health prevention. About half of all lifetime cases of mental illness start by the age of 14, rendering prevention and early treatment among adolescents all the more necessary, and emphasizing the importance for CAP specialists to be informed about general psychiatry (37). Around one-fourth of patients in AP aged 18–25 had previously received care at CAP (38), while around one-third of late teenagers/young adults at CAP need care from AP in adulthood (39). This stresses the importance of a smooth transition instead of rigid boundaries between disciplines, since mental disorders in adolescence predict mental health problems in adulthood (40). Parents of children treated in CAP are more likely to have mental health problems themselves, while children of patients treated in AP will be more prone to mental health difficulties. Providing a safe environment to children, for example in developing parental skills, plays a crucial role in preventing mental health conditions among youth and should be emphasized in all training routes. Early detection of emergent mental disorders is another topic that highlights the importance for specialists in both CAP and AP to develop knowledge in core competencies of each specialty.

This article provides the results of a survey describing the current status of training in transitional care in both AP and CAP postgraduate training across Europe. We also report data on the respective content of AP and CAP postgraduate training, with a particular focus on the amount of theoretical and practical cross-training between both specialties.

This study suggests that specific training in transitional needs and management of patients in transitional care is still scarce across all training models. This may contribute to the well-recognized “transition gap” and should be addressed while designing best models of care and guidelines for transition. This situation calls for increased awareness of training gaps within psychiatry programmes and a need to enhance collaborative work and mutual understanding between CAP and AP services. A better postgraduate training on transition may thus proceed from programmes designed in joint faculty working groups and may take place through modules attended jointly by AP and CAP trainees. The role of those responsible for training programs at a local, national and international level to address the issue of transition and cross training between AP and CAP should also be considered. Finally, there is a need for further research on how best to develop specific training to transitional care that encompasses theoretical and practical knowledge which also includes strengthening collaborative teamwork, communication, information transfer and family involvement. Some further research should also be conducted on how this training would have an impact on the success of transitions experienced by young people. Apart from better clinicians, bridging the gap between services involves a change in research cooperation, transition planning, organization of care, mutual understanding about each other's workplaces, and bringing together different care cultures and different perspectives such as family-oriented care in CAP and individual-oriented care in AP.

The data that support the findings of this study are available on request to the authors at f-russet@chu-montpellier.fr.

The survey is part of the MILESTONE project, for which an ethics approval was granted by the Ethics Committee Comité de protection des personnes Sud Méditerranée I. No further ethical approval was required for this specific survey, as no personal data were collected.

Swaran Singh, Helena Tuomainen, Jason Madan, Jane Warwick, Cathy Street, Dieter Wolke, Moli Paul, Priya Tah, Rebecca Appleton, Alastair Canaway, James Griffin, Philip Wells, Rose-Marie Lomax (University of Warwick, UK), Giovanni de Girolamo, Giulia Signorini (Saint John of God Clinical Research Center, Italy), Paramala Santosh, Natalie Heaney, Mathilde Mastroianni, Laura Adams, Sagar-Ouriaghli I, Kate Lievesley, Jatinder Singh, Federico Fiori (Kings College London, UK), Diane Purper-Ouakil, Frédérick Russet, Virginie Maurice, Véronique Humbertclaude (Hôpital Saint Eloi, France), Athanasios Maras, Larissa van Bodegom, Mathilde Overbeek (Yulius Academie, the Netherlands), Ulrike Schulze, Melanie Saam, Ulrike Breuninger, Anne Sartor, Elena Tanase, Vehbi Sakar (University of Ulm, Germany), Sabine Tremmery, Gaëlle Hendrickx, Veronique De Roeck (KU Leuven, Belgium), Fiona McNicholas, Aleksandra Gronostaj, Ingrid Holme, Lesley O Hara (University College Dublin, Ireland), Tomislav Franić, Nikolina Davidović (University Hospital Split, Croatia), Frank Verhulst, Gwen Dieleman, Suzanne Gerritsen (Erasmus MC, The Netherlands), Kate Lievesley (HealthTracker, UK), Amanda Tuffrey, Anna Wilson, Charlotte Gatherer, Leanne Walker (Young project advisors, University of Warwick, UK), Andrea Wohner (concentris research management GmbH, Germany).

FR and VH were in charge of the study design, conducted the data search and analysis, and wrote the first draft of the manuscript. DP-O and ST were in charge of Work Package lead, study design, and writing. ND, GD, KD-Ć, TF, SG, GG, GH, HK, FM, AM, SP, MP, AS, US, CS, HT, DW, and SS provided substantial contribution to the final manuscript. All authors read and approved the final manuscript.

The MILESTONE project received funding from the European Union's Seventh Framework Programme for research, technological development, and demonstration under Grant Agreement No. 602442. The European Commission (FP7 programme) had no involvement in the writing of the manuscript or in the decision to submit the manuscript for publication. SS was supported by the National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands.

The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This Health Policy reflects only the author's views and the EU is not liable for any use that might be made of the information contained therein.

SP is employed by HealthTracker Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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