Response

The recent cross-sectional study by Kelleher et al exploring the number of professorships and interventional trials in child and adolescent psychiatry (CAP) is an eye-opening summary of current academic CAP in the UK and Ireland. The authors highlight the scarcity of CAP professorships and the relatively low levels of research in the field, and call for a major effort from all stakeholders targeting research as a material and long-term solution to the current crisis. This includes new higher education research infrastructure and sustained funding: ‘…long-term solutions to a youth mental health crisis will not simply emerge from expanding existing clinical services but, rather, from research’. ^{Reference Kelleher, Poziemska, Kieseppa, Thapar, Dubicka and Lockhart1}

We agree with this principle: in the long term, an expansion in academic CAP is absolutely necessary. Research strengthens clinical services by generating evidence for effective interventions and informing evidence-based practice. A strong research culture fosters innovation, improves efficiency and contributes to better patient outcomes. However, for research to be effective in helping to solve the rapidly developing disparity between demands on the service and its capabilities, there is first the need for clinical provision to vastly develop and increase. Attracting a broader range of talent may not only then support the development of CAP academia, but also enable effective implementation of subsequent change. Unfortunately, this is simply not being seen at present.

As the authors discuss, we are in the midst of a deepening mental health crisis for children and adolescents. Between 2017 and 2023 we saw an increase in the overall rate of young people with probable mental health conditions, from 12.5 to 20.3%, a substantial uptick on service demand. ² The latest census from the Royal College of Psychiatrists highlights the fact that 19% of CAP consultant posts are currently vacant, which rises to 34.8% when locum posts are taken into account. Similar trends are seen across psychiatry, but CAP has by far the highest proportion of vacancies of any specialty. ³ With suboptimal clinical service provision and a reinvigorated call for academics, the risk is to stretch further an already stretched professional population.

There have been some attempts to directly address trainee capacity over the past few years, but these have been limited. For example, the CAP run-through training programme was piloted in 2018 and became an established training programme in 2023. However, for the 2025 Round 1 intake, only 6 posts have been advertised across the UK. This is a year-over-year decrease in the number of places available, with most deaneries across the country not offering even one post. Not only does this preclude most candidates from accessing streamlined CAP training, but it erodes confidence in the sustainability and advancement of the programme itself.

Kelleher et al have drawn comparisons with neurology to demonstrate the dearth of CAP professorships and interventional trials at present. The total number of academic leaders (professors) was directly compared, because neurology is a specialty with an equivalent number of General Medical Council-registered post-training specialists. ^{Reference Kelleher, Poziemska, Kieseppa, Thapar, Dubicka and Lockhart1} However, if we take this comparison further and examine data for recruitment and training for these same specialties, ² different trajectories emerge. In the number of posts available, we see a sustained increase in training capacity for neurology alone. From 2021 to 2024, neurology higher training places increased by 37%, yet psychiatry higher training (all specialties) increased by only 3% and fell in the intermediary years. Although psychiatry subspecialty breakdown is no longer disclosed, prior to this CAP posts followed the same trends as overall training numbers. Nationally, fill rates for higher training demonstrate a 15% higher percentage for neurology; since 2020 neurology has had an average fill rate of 93% compared with only 78% for CAP. ⁴ Thus, neurology is seeing a rapid and sustained increase in total trainee numbers leading to long-term growth of the profession, but CAP is not. One must contemplate how the field of psychiatry can be expected to produce more world-leading academics and facilitate higher levels of research when the human resource with that potential is already operating beyond a sustainable capacity.

Academia is vital for the propagation of excellence in clinical practice, and across psychiatry there is a growing sentiment that this requires concerted effort of the entire field, not the few. A recent editorial in BJPsych by Critchley et al discussed the absolute necessity for harmony between academia and clinical practice. Of note, in discussing how to inspire the next generation, Critchley et al highlighted that fundamental barriers to progression still exist, including job availability, job stability and overwhelming clinical pressures. ^{Reference Critchley, Tracy, Malhi, Alexander, Baldwin and Cavanagh5} Currently, we are seeing that the overall numbers of academic psychiatrists are falling. ⁶ The relationship between academia and clinical practice must be understood to be reciprocal and not unidirectional. Indeed, world-class research will help facilitate world-class clinical practice, but at present we do not appear able to facilitate sufficient clinical practice to even sustain the reportedly low levels of research.

‘Urgent action is needed to address the lack of professorships in child and adolescent psychiatry.’ ^{Reference Kelleher, Poziemska, Kieseppa, Thapar, Dubicka and Lockhart1} This is undeniable. We simply ask whether, alongside the call to arms from stakeholders including government, academia and research-funding bodies, there should also be more onus on optimising those factors more within our control, those specifically addressing recruitment and retention. Children and young people are the next generation, but rates of mental disorder are higher than they have ever been. ² A well-trained and resourced CAP clinical service is needed to address these needs (also in schools), ^{Reference Soneson, O’Leary and Fazel7} and to support academic research and innovation. The future health of the psychiatric workforce is everyone’s business too.