Closing the 10/90 divide in global mental health research

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In this issue of Acta Psychiatrica Scandinavica, Kornadsen and Munk-Jorgensen (1) report the findings of a survey of the proportion of submissions to this journal from low- and middle-income countries (LMIC) compared with submissions from high-income countries (HIC), over two consecutive observation periods (2002–03 and 2004–05). They compare the proportion sent for external review, the proportion finally accepted for publication, and the impact of accepted publications assessed through estimating number of downloads and citations. Their survey reports that <20% of submissions originate from countries which are the home of over 80% of the global population. The acceptance rates of these articles are low – <10% are finally accepted, and although there has been a reassuring increase in the acceptance rate over the two consecutive biennial periods, the acceptance rate is significantly lower than for articles from HIC. Despite appearing iniquitous, these rates are actually higher than that reported by other high-impact general psychiatric journals (2, 3). At least part of this gap may be accounted for by the higher proportion of articles from LMIC which are not sent for external review. Finally, amongst those papers which were accepted, there is no difference in download or citation statistics, providing some indication that the quality of articles from LMIC and HIC, post-acceptance, is equivalent. These findings suggest that one reason for the lower acceptance rates is because of lower quality of the research manuscript.

The principal take-home messages are of low submission and low acceptance rates of research from LMIC. These findings replicate reports of surveys of several high-impact journals and of the ISI database (2–4) and confirm that the 10/90 gap in global health research (5) is likely to be at least as significant, if not more so, in the field of global mental health. Elsewhere, authors including myself have argued about the different possible reasons for these findings and journals, including this one, have issued a Joint Statement along with the WHO to promote mental health research from LMIC (6); after all, such research is needed not only to further mental health policy and programs in LMIC, but also to add scientific validity to psychiatric research which remains severely biased through its reliance on observations and interventions with a tiny fraction of the world's population who largely share similar social and economic environments.

How does one close the 10/90 divide in global mental health research? Perhaps the single most important strategy is strengthening research capacity – both individual and institutional – in LMIC to carry out priority research. There are tremendous opportunities ahead for building capacity, building on the growing investments in public health research capacity in many LMIC. We will clearly need a range of choices for building capacity, and we must focus on both mental health and public health professionals to generate high quality research. Indeed, of these two groups, focusing only on the former is likely to be an unsustainable and ineffective strategy, not least due to the severe shortage of mental health professionals in LMIC and the overwhelming clinical service commitments for these professionals. I believe the most effective strategy to scale up priority research is by integrating mental health in general public health research training programs. To achieve this, the mental health community in LMIC must actively engage with the public health community to ensure that mental health is adequately represented in the curricula for master's programs in public health. Similar integration has been achieved in some programs in India and the ambitious new Public Health Foundation of India's curriculum will explicitly acknowledge mental health as a core health outcome.

Who should be responsible for building capacity? Clearly, a sound basis for sustainable capacity building must be a partnership between institutions with capacity and weaker institutions. Leading institutions in both HIC and LMIC must acknowledge capacity building in less-fortunate institutions as an academic responsibility in a globalizing world. The Fogarty International Clinical, Operational and Health Services Research and Training Awards Program and the International Clinical Epidemiology Network (INCLEN) are exemplary examples of collaborative research capacity building initiatives, funded mainly by charities and governments, which are supporting mental health and substance abuse research in LMIC. The strengths of these schemes are that the bulk of capacity development takes place in the LMIC and there is an explicit aim to build institutional capacity to ensure trained researchers have a promising research environment to implement their skills. In contrast, many schemes relying on training in HIC – such as the Manchester Scheme for Training Overseas Psychiatrists in the UK – have had less success in building capacity in LMIC. Many of the trained researchers simply do not return home! Shorter training programs, targeted at mental health professionals, may also be suited for LMIC countries for they are likely to more feasible for full-time clinicians and less likely to fuel a brain drain; the Harvard Medical School-University of Melbourne 4-week International Mental Health Fellowship Program, Australia, established in 2001, has been able to develop and sustain a network of leaders for policy and services research and development in mental health in the Asia-Pacific region. The 1-week Short Course in International Mental Health Research Methods run by the Institute of Psychiatry (UK) and the London School of Hygiene & Tropical Medicine is another example of such a short course which has had over 50 participants in its first 2 years.

It is often argued that more funds should be available for research; however, without capacity to utilize these effectively, these funds will be of little use. Funds are needed, but a significant share must be to build capacity; in research projects, capacity building must represent a specific budget head, for example to pay for LMIC researchers to complete higher degrees. This is an ethical imperative to ensure sustainable growth in LMIC research. It remains disappointing that most international research agencies – with some notable exceptions such as the US National Institutes of Health and the UK-based Wellcome Trust – do not support international mental health research in spite of the evidence of the burden of mental disorders (7) and their relevance to global development (8). Ironically, while many LMIC are themselves expressing the need for more mental health research, the ‘global agenda’ is being set for them by experts with little appreciation of, and considerable misgivings about, mental health as a priority in LMIC. Here too, academics and those with influence in HIC must play a leading advocacy role: building mental health capacity among leaders in global health, most of whom are from, or based in, HIC is a major step toward strengthening mental health research resources in LMIC.

There is a need for a renewed commitment by Governments and academic institutions – in both HIC and LMIC – to invest in research capacity, and research careers, in LMIC. Research is not a popular career option for mental health professionals in LMIC; many researchers are often unhappy and seek ways of leaving the country contributing to the ‘brain drain’ from LMIC. Simply providing training or collaboration will not stop this drain; on the contrary, if structural or systemic changes are not enabled in LMIC to make research careers attractive and sustainable, providing training may only serve to increase the brain drain (9). In many LMIC academic medicine is, in essence, a full-time clinical position with additional teaching and administrative responsibilities. Research is often not valued in terms of promotion nor in terms of relief from other responsibilities. Universities must reform to permit greater freedom for researchers, and create specific career tracks for clinical researchers; without such an allowance, the ‘push’ factors which are important reasons for the brain drain of some of the brightest LMIC talent to HIC will not be stemmed (10). Evidence of the impact of government and university support to stemming the brain drain and strengthening mental health research is evident from countries like Brazil (11, 12) which now enjoys a dynamic mental health research infrastructure, including one of only a handful of indexed national psychiatric journals from an LMIC. However, HIC must also acknowledge their debt to LMIC – particularly countries like the UK, US, Canada and Australia who have been host to the largest number of health practitioners from LMIC – in another article, colleagues and I have described some initiatives form the UK to strengthen capacity in LMIC, although most of these are largely the endeavors of individuals and charities motivated to reduce global inequity in mental health (13). Finally, the WHO could play a key role in networking researchers and research institutions and facilitating the provision of international training materials. The WHO has had extensive experience in capacity building in research in tropical diseases including training fellowship grants and provision of ‘small’ grants for research in developing countries (9). Such models can be extended to mental health research capacity building.

Ultimately, building research capacity in mental health in LMIC cannot be done in isolation from acknowledging that this is only a part of the larger gap in health research capacity in LMIC. The global mental health community will need both to make its case at the level of international and HIC-based donors and governments, and to support colleagues and institutions in LMIC, to ensure that mental health research attains its rightful place on the global health agenda. Building research capacity lies at the heart of an evidence-based response to address the enormous unmet needs of people with mental disorders in LMIC; but we also need this evidence to strengthen the scientific basis of the clinical mental health disciplines themselves. It is only by researching in diverse societies and cultures are we likely to throw up new answers to some of the most vexing questions in contemporary psychiatry. The ultimate beneficiaries of such capacity building would therefore be the entire global community for the networks of skilled researchers across the world could work together to identify the causes of mental disorders and ways to improve the quality of lives of persons affected by mental disorders.

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