Specialisation School in Psychiatry at the University of Pavia: what have we learned from 50 years of final dissertations? 50 years of theses in Psychiatry

Academic psychiatry and the organisation of Italian schools of specialisation in psychiatry have progressively changed over the years. The present paper aims to analyse the trends in number and topics of final dissertations chosen by trainees in psychiatry at the University of Pavia, Italy. We examined the full-texts of 479 final theses discussed by trainees in psychiatry over a period of 50 years - from 1972 to 2023. Our analysis showed that the number of trainees widely varied over the years, with a significant decrease since the end of the 90s. There was a clear prevalence of dissertations on social psychiatry, clinical psychiatry, and psychopathology. Other topics, such as psychotherapy and psychopharmacology have been rarely chosen by trainees. Overall, our findings reflect the importance of integrating different disciplines - from neuroscience to psychotherapy - in the schools of specialisation in psychiatry and the need for an adequate planning of psychiatrists to provide high-quality care to the increasing number of people suffering from mental disorders.

INTRODUCTION

Postgraduate medical specialisation schools in Italy have undergone a complex evolution, as a result of a long legislative process that has sought to respond to the needs of the healthcare system and the growing demand for physicians with specialised skills. Their development is closely linked to the country’s political, cultural, social, and public health transformations, as well as the need to conform to European standards. The history of medical schools, with their postgraduate complement, can be divided into several stages, starting from the earliest forms of advanced education to the current modern systems.

Before the Unification of Italy (1861), medical training was organised in a fragmented way in the various Italian city-states. Historic universities, such as those in Bologna, Naples, and Padua, were the main centres of medical training, but there was no real specialisation. Physicians used to acquire advanced skills through apprenticeships in hospitals or prolonged practical experience, rather than through formal courses of study.

Subsequently, the country tried to centralise and standardise education in different fields, including medical education. However, until the early 20th century, specialisation was still not regulated by specific legislation and medical education was limited to a basic university course. The need for specialised physicians became increasingly evident as medical science progressed, but the first reforms came only in the 20th century ¹.

The first significant regulation of medical specialisation in Italy dates back to the last years of the fascist regime for the practice of certain medical branches such as surgery, gynaecology, and obstetrics. However, due to the war and the economic and political difficulties of the period, the actual implementation of these regulations was slow and heterogeneous. After World War II, with the reconstruction of the country and the reorganisation of the healthcare system, a more structured system of medical specialty schools began to take shape.

The evolution of psychiatric thought and practice, in the second half of the 20th century, received its most significant connotation from three pivotal events. First, in 1951, psychotropic drugs appeared on the therapeutic horizon, leading to an important change in the treatment of people with mental disorders ². Second, the psychoanalytic theory spread as a cultural phenomenon ³. Third, there was an increased sensitivity in the community context to the problems related to mental disorders, with the push toward social and community psychiatry. These events caused an awakening of mutual attention between Psychiatry and the Universities. In the early 1950s, with the direct involvement of the Italian Society of Psychiatry and also thanks to the influence of Prof A. Ferraro – an Italian professor at the New York State Psychiatric Institute of Columbia University who emigrated to the United States before the First World War – important changes occurred, leading to the development of psychiatry disjointed from neurology, to be implemented with autonomous teaching and research sites ⁴.

In 1933, some isolated professorships of psychiatry were unified with the more numerous professorships in neurology, under the group “Clinic of Nervous and Mental Diseases”. From 1933 to 1958 there was no official professorship specific for the discipline of psychiatry, but only a “tenure”. In 1958, thanks to the efforts of Prof G.C. Riquier, director of the Clinic of Nervous and Mental Diseases of the University and the Provincial Administration of Milan, the first Italian Chair of Psychiatry was created. However, the situation was ambiguous: psychiatry appeared as optional and complementary teaching alongside the compulsory teaching of the clinic of nervous and mental diseases. The Chair was housed the following year in a pavilion outside the psychiatric hospital “Paolo Pini”, characterised by large relational spaces, with facilitation of communication between patients and between physicians and patients. The combination of psychoanalytic theories with the pioneering research in the biological field characterised the emergence of scientific and clinical psychiatry outside the asylum that would later be felt in the 1968 Congress. In the same period (1962), the first competition for Chairs of psychiatry only took place, affiliated with the provincial administrations, but outside psychiatric hospitals ⁴. In 1965, during the first Congress of Neuropsychopharmacology, it was established to officially divide the School of Specialisation in “Clinic of Nervous and Mental Diseases” into Neurology and Psychiatry, thus giving birth to the first Schools of Psychiatry in Italy ⁴.

A turning point for medical education in Italy was the 1978 Health Reform, with the establishment of the National Health Service (Servizio Sanitario Nazionale, SSN) ⁵. This reform emphasised the need to train specialised physicians to ensure quality health services throughout the country. The demand for specialist physicians increased dramatically, and graduate schools began to be more tightly regulated. SSN stipulated that certain roles and positions in public hospitals should be filled only by medical specialists, thus increasing the pressure for a formal, accredited system of graduate schools.

In parallel with the creation of the SSN, the “Orsini/Basaglia Law”, officially known as Law 180, was enacted in Italy in 1978 and marked a groundbreaking reform in the country’s mental health care system. Named after the influential psychiatrist Franco Basaglia and the politician Bruno Orsini, this law effectively stopped new admissions to psychiatric hospitals and encouraged the deinstitutionalization of patients. Basaglia advocated for more humane treatment of individuals with mental illness, challenging the widespread use of asylums, which often isolated and marginalised patients. Law 180 promoted community-based care, shifting the focus to outpatient services, social reintegration, and voluntary treatment. It prohibited the construction of new mental hospitals and set the framework for existing institutions to be gradually phased out ⁶. This radical shift not only transformed psychiatric care in Italy but also inspired similar reforms worldwide, emphasising the rights and dignity of people with mental health conditions. This inevitably influenced the organisation of the schools of specialisation in Psychiatry across Italy. During this period, graduate schools began to be overseen not only by the Ministry of Education but also by the Ministry of Health to ensure that training met the practical needs of the healthcare system.

After the formal institution of the Schools, several changes have occurred in their organisation over the years. In 1990, Law 341 reformed medical specialty schools, seeking to standardise their duration and operation. This law sanctioned the introduction of “specialisation diplomas” as an essential requirement to work within the national health system ⁷. This has represented an important step toward harmonising the Italian educational system with European standards. Recognition of specialisations at the international level became essential to allow Italian physicians to work abroad and to improve the quality of training offered in Italy ⁸. This period also saw the beginning of greater regulation in terms of access to specialisation schools, with the introduction of national competitions and stricter criteria for admission. In the 2000s, pressure to improve the residency school system continued to grow. As a consequence, Italy transposed European directives on specialist medical training, harmonising the duration of courses with European standards (4 to 6 years depending on the specialisation) ⁹. One of the most important reforms of the 21st century was Law 240 of 2010 (Gelmini Reform), which introduced new rules for accreditation of specialisation schools and quality assessment criteria. The law imposed stricter controls on the quality of the training offered by the schools and made the selection process of medical residents more transparent ¹⁰. Since 2014, with Decree-Law 104, the system of access to specialisation schools has been reformed with the introduction of a single national competition. In addition, the decree established the requirement of a minimum number of years of training for each specialisation, making the path more standardised and in line with European standards ¹¹.

In recent years, the system of medical specialty schools in Italy has continued to evolve, to further improve the quality of training and meet the growing needs of the national health care system. Of note, new rules have been introduced to address the gap between psychiatric and psychotherapeutic education, ensuring that psychiatry residents receive comprehensive training in psychotherapy as part of their medical specialisation ^12,13. Prior to this reform, many psychiatrists had to seek additional certifications in psychotherapy outside their standard training. The new law mandates that specialisation schools in psychiatry include formal psychotherapy training, allowing psychiatrists to practise psychotherapy without needing separate qualifications. This reform aims to improve the holistic care of mental health patients, enabling psychiatrists to provide both pharmacological and therapeutic interventions, and fostering a more integrated approach to mental health care in Italy. It reflects a broader trend toward multidisciplinary treatment in psychiatric practice, aligning Italy with other European countries that emphasise the role of psychotherapy in psychiatric care ^12,13.

Given the integration of the specialisation programs within the educational systems, the final dissertation represents the last step in the training of a resident. The specialisation thesis represents not only an academic exercise but also an important educational experience. Through research, residents develop scientific, critical, and clinical skills that will be crucial in their future careers. In addition, the topic chosen for the thesis may reflect the area of interest the resident intends to pursue in his or her clinical work or future research. Unlike degree theses, which often reflect the academic interests of the tutor, postgraduate theses topics are regularly chosen by trainees based on their personal interests and inclinations, aiming at demonstrating their competence to conduct a quasi-independent in-depth research or dissertation. However, more than in other medical branches, training in psychiatry is complex and multifaceted, requiring a deep understanding of both the biological and psychological aspects of mental health. Psychiatry residents must master a broad range of disciplines, including neurobiology, psychopharmacology, psychotherapy, and social and cultural factors influencing mental health. Besides the ability to diagnose and treat a wide variety of mental disorders, trainees must also develop strong communication skills to build therapeutic relationships with patients, who often have deeply personal and challenging issues. Additionally, psychiatry requires continuous adaptation to evolving treatments, including advancements in neuroscience, psychiatric medications, and psychotherapeutic techniques. The complexity of psychiatric training is further heightened by the need to navigate ethical dilemmas, particularly around issues like patient autonomy, involuntary treatment, and confidentiality. Psychiatric final dissertation can thus include numerous areas of research, which may vary depending on the trainee’s specific interest and their department’s areas of expertise. The present study has been conducted to give an overview of the variations in number and main topics of final dissertations since the establishment of the specialisation school in Psychiatry at the University of Pavia.

METHODS

The Specialisation School in Psychiatry at the University of Pavia

The University of Pavia, one of Italy’s oldest universities, boasts a prestigious medical school with a rich history dating back to its founding in 1361. Over the centuries, it has played a significant role in shaping medical education and research in Europe, producing numerous notable scholars and physicians. The medical school became renowned for its focus on innovation and rigorous training ¹⁴. Within this legacy, the School of Specialisation in Psychiatry holds particular importance. Founded in 1969 ¹⁵, it has been instrumental in advancing psychiatric education and clinical practice in Italy. The program integrates theoretical knowledge with clinical training, providing future psychiatrists with a comprehensive understanding of mental health, diagnostics, and therapeutic approaches. It also emphasises research, contributing to the development of modern psychiatric treatment methodologies and fostering collaboration with other international psychiatric institutions ¹⁶. Over the course of its 50-year history, four Professors of Psychiatry have taken turns in leading the School: Dario De Martis (DDM; 1969-1983), Fausto Petrella (FP; 1984-2006), Edgardo Caverzasi (EC; 2007-2016), Pierluigi Politi (PP; 2017-2024). Since October 2024, Prof. Natascia Brondino is in charge of the Direction of the School.

Currently, the School hosts about 40 trainees and operates in strict cooperation with the Department of Mental Health and Addictions of the Azienda Socio-Sanitaria Territoriale (ASST) of Pavia. Thanks to this collaboration, trainees are requested to rotate into different healthcare facilities, such as residential facilities (CRA, CRM, CPA), outpatient services (CPS), and inpatient structures (SPDC). On a voluntary basis, residents may add one or more internships in the units of addictions, toxicology, child psychiatry, neurology, and forensic psychiatry ¹⁷.

Data collection and classification

We have collected the full texts of the dissertations of medical doctors who have completed the specialisation school in Psychiatry at the University of Pavia from the foundation up to 2023. For dissertations that were not available at the local library, we contacted the discussants in person in order to obtain the full texts. We created a pre-pilot database, extracting the following relevant information: author; year of graduation; title; grade.

Dissertation topics were independently evaluated and classified into 9 macro-categories. The infrequent, discordant cases were discussed, until reaching a consensus among the co-authors. The macro-categories identified were:

1. Clinical psychiatry: clinical presentations of mental disorders including clinical vignettes and/or case series;
2. Psychopathology: clinical presentations of mental disorders without the inclusion of clinical cases or clinical data collected from patients;
3. Psychological medicine: psychological or psychiatric issues in people with medical conditions, including the presentation of clinical cases;
4. Social psychiatry: various aspects of social psychiatry, including activities, organisation, and legislation of mental health services;
5. Forensic psychiatry: theses encompassing the interface between law and psychiatry;
6. History of psychiatry: dissertations with an historical perspective;
7. Psychopharmacology: study of the efficacy and tolerability of psychotropic drugs;
8. Psychotherapy and other non-pharmacological therapies: psychotherapeutic methods, techniques, description of interventions, clinical case reports on psychotherapy;
9. Neuroscience: neuroimaging and biomarkers.

RESULTS

Characteristics of the dissertations

We examined a total of 479 theses in psychiatry. As illustrated in Figure 1, over the 50 years of the school, there has been a continuous variation in the number of graduates, due to the continuous changes in the number of admissions. The number of theses per year varies from 0 (2010, 2013 - corresponding to the increase in the duration of the course of study from 4 to 5 years) to 26 (1987).

The overall quality of the specialisation theses was judged as average good. Most of them have a good methodological structure and a lively presentation of clinical material. Of note, only a part of the theses had an experimental design, while many of them were based on case reports or case series.

Trends in dissertation topics over time

Considering the totality of the theses discussed in the period between 1972 and 2023, the majority of the works fall into three main categories: social psychiatry (38.4%), clinical psychiatry (29.4%), and psychopathology (16.3%). A smaller proportion of theses have been defended on medical psychology (8.6%), psychotherapy and other non-pharmacological therapies (2.1%), neuroscience (1.5%), forensic psychiatry (0.8%), and history of psychiatry (0.4%). The overall distribution of topics is presented in Figure 2.

Over 50 years, the proportional distribution of the topic has been quite consistent, as represented in Figure 3, with an increase of interest towards psychopharmacology. Of note, in the last five years examined, only four topics have been chosen by trainees (social psychiatry, clinical psychiatry, psychopathology, and psychopharmacology).

The main research interests of the Directors of the School were as follows:

1. DDM: social psychiatry, clinical psychiatry, psychotherapy and psychoanalysis.
2. FP: psychopathology, psychotherapy and psychoanalysis, medicine and the art(s).
3. EC: psychotherapy, psychoanalysis and group analysis.
4. PP: psychiatric epidemiology, psychological medicine, clinical psychiatry.

The distribution of the dissertation topics during the years of the four Directors of the School of Specialisation in Psychiatry of the University of Pavia is presented in Figure 4. Under the direction of DDM, the majority of the dissertations were classified under the category of social psychiatry (39%), followed by clinical psychiatry (34%), and psychopathology (18%). Under the direction of FP, 35% of the dissertations were focused on social psychiatry, 32% on clinical psychiatry, and 15% on psychopathology. During the direction of EC, almost half (45%) of the theses were focused on social psychiatry, while a minority were categorized under clinical psychiatry (16%), psychopathology (15%), and psychological medicine (15%). The trainees who graduated under the supervision of PP were more interested in social psychiatry (52%), clinical psychiatry (12%), psychopathology (12%), and psychological medicine (5%).

DISCUSSION

The School of Specialisation in Psychiatry of the University of Pavia dates back to 1969, as an evolution of the Clinic of Nervous and Mental Diseases^15,16,17. The present study aimed to analyse the trend and topics of the final theses discussed by trainees in Psychiatry over the last 50 years.

First, we observed a wide variation in the number of trainees who discussed their final theses over the last 50 years at the University of Pavia. Specifically, it is possible to notice a substantial reduction in the number of psychiatrists that have completed the school of specialisation over the last 30 years, compared with the previous period. This reflects the shortage of specialised doctors currently working in mental health services in Italy. Indeed, contractions and expansions in the number of places available have occurred for complex socio-political-economic reasons. In our opinion, the majority of these changes have been decided on the basis of compelling situations, without conscious planning of the needs of the Italian National Health System.

Second, our detailed analyses revealed that, since the foundation of the School, postgraduate theses had a solid focus on the topics of social psychiatry and clinical psychiatry. This is in line with the main research interests of the four Professors of Psychiatry who have alternated in the Direction of the School up to 2024. Despite the appearance of issues related to particular periods - for example, deinstitutionalisation between the 1970s and 1980s, or the impact of the Coronavirus pandemic in the three-year period 2020/2022 - the approach to mental health issues has often remained within the two areas mentioned. Psychopathology (i.e., discussion of psychiatry-related issues without a detailed presentation of clinical cases or clinical data) was a third major area of interest. Since 1980, theses in medical psychology have been also regularly discussed. Other areas were less explored. For example, theses on psychotherapeutic topics represent only a small minority of the dissertations. This finding is somehow surprising, considering that the direction of the Pavia School - at least until now - has always been psychodynamic. Occasionally, during these fifty years, a few theses in psychopharmacology, forensic psychiatry, and neuroscience in general were realised.

Trainees have always been actively involved in the activities of local mental health services, rather than university hospitals. Therefore, their consistent interest in the organisational and legislative aspects (i.e., social psychiatry) is not surprising. In addition, the study of clinical and psychopathological issues can be easily done through cross-sectional methodologies not requiring follow-ups. Contrariwise, the collection of data regarding the efficacy and tolerability of treatments (both psychological and pharmacological) requires a longer duration for patients’ observation and data collection. However, it is important to note that the number of theses in psychopharmacology has grown over the last five years, probably thanks to the introduction of novel psychotropic drugs in the clinical practice as well as the implementation of psychopharmacological trials within the clinical services of the Department of Mental Health and Addiction. Contrariwise, we did not notice significant changes in the number of theses focused on psychotherapy. As anticipated in the Introduction of the present manuscript, Schools of Specialisation are now required to provide significant training in psychotherapy during the four years in order to habilitate young psychiatrists to the profession of psychotherapists. The acquisition of fundamental psychotherapeutic techniques with adequate supervision may help trainees in taking care of patients through psychological/psychotherapeutic support during the study course, thus improving their knowledge and interest in psychotherapy also for the purpose of the final dissertation.

As for neuroscience, the scarce interest might be related to the lack of economic resources and staff; in fact, both neuroimaging and the study of biomarkers require specialised facilities as well as collaboration with trained personnel. It could be hypothesised that only people actually interested in pursuing an academic career or who decided to spend a period as visiting researchers abroad for their final experimental thesis had the opportunity to work more specifically on a neuroscientific level. As for forensic psychiatry, it is important to underline that only in recent years the trainees have had the opportunity to attend a specific traineeship. It is also worth mentioning that the trainees in psychiatry, at least in Pavia, change their tutors at least once a year. The tutors assigned may partially influence the choice of a certain topic based on their personal interests and expertise.

To the best of our knowledge, this is the first study to give an overview of the dissertation topics of a School of Specialisation in Psychiatry. Nevertheless, it is important to underline some limitations. First, since the sample of the theses has been collected in one School of Specialisation only, the results cannot be generalised to other Schools, which may have different orientations (e.g., pharmacological). In the future, it would be interesting to compare the dissertation topics of more Schools of Specialisation with different orientations in order to analyse similarities and differences. Additionally, we did not focus on sub-categories within the macro-categories, and we did not investigate the specific study designs (e.g., case studies, cross-sectional, experimental, meta-analysis).

CONCLUSIONS

In conclusion, our findings revealed that the number of specialists in psychiatry has drastically decreased over the last thirty years, eventually leading to a shortage of human resources in mental health services. Additionally, the topics chosen by psychiatric trainees for their final dissertations have been primarily oriented to social psychiatry, clinical psychiatry, and psychopathology, likely due to the convenience of data collection and case analysis. In general, however, adequate planning of the number of specialists in psychiatry integrated with more comprehensive training on less explored aspects of mental disorders may improve the quality of psychiatric services and provide adequate care to the increasing number of people suffering from mental disorders ¹⁸.

Acknowledgements

We would like to thank all the psychiatrists who have provided their theses for the analyses included in the present paper.

Funding

None to declare.

Conflicts of interest statement

All authors declare that they have no conflicts of interest.

Authors’ contributions

PP and LF-P conceptualised the study, performed data collection, analysed and interpreted the data, and wrote the manuscript.

Ethical consideration

The present study does not include human subjects and therefore no Ethical Committee approval was needed.

Figures and tables

FIGURE 1. Number of final dissertations per year.

FIGURE 2. Distribution of topics of the dissertations in psychiatry.

FIGURE 3. Proportional distribution of the topics over 50 years.

FIGURE 4. Proportional distribution of the topics according to the Director of the School.