Our results revealed that an interest in CAP significantly correlated with experience in the field (r = 0.437, p < 0.0001, Spearman rank correlation). A distinct difference was found on a nine-point scale between self-evaluated CAP interest (5.34 ± 2.5) and self-evaluated CAP experience (3.05 ± 1.9). The considerably low scores on CAP knowledge (3.43 ± 1.9) and confidence about the ability to diagnose and treat appropriately (3.13 ± 1.9) could be explained by insufficient CAP experience in the early stages of the respondents' training. The score quantifying the probability of CAP as a subspecialty choice was 4.15 ± 2.5. These results suggest that limiting early-career psychiatrists' exposure to CAP could dissuade them from this subspecialty, even though the subjects thought that CAP, as a psychiatric subspecialty, could be somewhat satisfying and would have a relatively bright future.
Of the 182 subjects, 105 (57.7 percent) answered that they liked children, scoring seven or higher on this question, and the mean was 6.35 ± 2.3. It would seem reasonable to assume that those who like children would be likely to choose an occupation related to children. Interest in CAP significantly correlated with the indicated degree of liking children (r = 0.448, p < 0.0001, Spearman). However, the correlation between the extent to which a respondent self-evaluated being fond of children and the self-evaluated possibility of choosing CAP as a career was somewhat weaker (r = 0.370, p < 0.0001, Spearman).
In the clinical practice of CAP in Japan, subjects with developmental disorders account for a considerably high percentage among those seeking health care [20, 21]. Recent epidemiological studies on PDD demonstrate a steep increase of its prevalence in Japan (1.81 percent) . It has been reported that many children and adolescents with developmental disorders have normal or borderline intelligence quotients [22, 23]. This fact seems to be one reason that detection of developmental disorders by non-CAP professionals is delayed. The average score for the survey question about the level of difficulty in diagnosing PDD was 6.60 ± 2.1. This high score could suggest that many clinicians are concerned about the uncertainty of their PDD diagnoses as distinct from schizophrenia. The mean score on interest in schizophrenia and mood disorders in children and adolescents was 6.01 ± 2.2, measuring slightly higher than that of interest in PDD. Gaining experience in the child and adolescent psychiatric disorder cases that also commonly present among adults might attract psychiatrists to CAP and could be a factor that facilitates their entrance into CAP.
As we mentioned earlier, the subjects with developmental disorders represent a notably high proportion of new referrals to the CAP clinics. In our study, the mean scoring of interest in PDD was 5.39 ± 2.4; one quarter of the respondents answered that their interest was research-oriented. These results are consistent with the current exploratory research trends in pathophysiology and genetics [24–27]. The increased social awareness of PDD originated in 2000 when a act of violence by an adolescent with suspected PDD was widely reported by the mass media. In May 2000, a 17-year-old high-school student hijacked a bus and killed a passenger with a knife. According to the report in the newspaper, he was later diagnosed as having PDD. Similarly brutal acts by adolescents with possible PDD occurred following this and since then, the number of scientific papers on PDD has been increasing. For these reasons, PDD is a disorder that has recently attracted the most intense interest in biological psychiatry in Japan. Thus, further development of PDD studies might attract early-career psychiatrists and lead them to CAP.
Considering the results of the present study, we would like to emphasize the necessity of exposing early-career psychiatrists to more CAP cases to ensure adequate and effective recruitment into CAP. For this purpose, we recommend that all psychiatric training programs require 1) Didactics in development and psychiatric disorders in children and adolescents; 2) Provide, for example, at least two months of intensive training during residency with children and adolescents under the supervision of a psychiatrist who has been certified as an expert in child and adolescent psychiatry by the JSCAP; 3) Short-term training courses on specific topics to improve the psychiatric trainees' clinical skills to diagnose and treat child and adolescent cases. To materialize these proposals, we should think of dividing the country into several regions and provide accessible resources to all residents by establishing at least one core institute in each region. The voice of young psychiatrists should be respected to begin the discussion about a concrete action plan, and as the first step for this movement, the foundation of a section for young psychiatrists within the academic society for CAP would be helpful in order to facilitate communication with early-career psychiatrists.
We must recognize some limitations within this study. Because of a design flaw in the online questionnaire system, we were unable to calculate a precise response rate. The number of subjects surveyed was too small to draw a definitive conclusion. Considering the data provided by JMHLW which reported that the number of psychiatrists was 12,474 in 2006 (4.48 percent of all medical doctors), we estimated the number of early-career psychiatrists in Japan to be 5,063. Thus, the subjects of this study account for only 3.6 percent of all early-career psychiatrists. However, the invitation letter to this survey was sent to all 80 medical schools in Japan and the respondents were distributed throughout the country. Thus, our sample could provide a certain level of representativeness. The intention of each item on the questionnaire could be interpreted slightly differently among the respondents. Most of the respondents worked at university or general hospitals, which suggests a sampling bias. Further, survey answers were subjective assessments by the respondents, and respondents' clinical experience and diagnostic/treatment skills were not objectively evaluated by the mentors.