Head, Department of Psychiatry, Faculty of Medicine, University of Kelaniya, Sri Lanka
The call for scaling up of mental health services in South Asia where more than a fifth of humanity live has never been stronger (Isaac, 2011). Providing mental health for all, is a lofty ideal. The reality though may be in bridging the treatment gap for common mental disorders and major mental and neuro-psychiatric disorders that impose a huge burden on society (Thirunavukarasu and A Shyam Sundar, 2011).
From a research standpoint, bridging the treatment gap is also integrally linked to bridging the evidence gap. Research is essential to generate the evidence that can be applied to practice. Most studies are done in high-income countries, and the finding are not directly relevant to our populations that have vastly different ethnographic, demographic and socio-cultural variables.
Thus there is a growing requirement for a cadre of researchers to monitor trends, to assess the health burden and develop novel cost-effective, sustainable and equitable models of care in the region.
Shortfall in Research
The global mapping study conducted by the WHO and Global Forum for Health Research (2007) found that capacity for mental health research in the majority of low and middle income countries (LMIC) is minimal. A quarter of LMIC countries have no mental health researchers at all, and a further quarter of LMIC have five or fewer researchers in total.
Research output from LMIC has suffered as a result: an analysis of research output between 1992 and 2001 indicates that many low-income countries published almost no research papers at all and that fewer than 4% of all health-related publications involve mental health (Saxena et al., 2006). These facts and figures may also be influenced by the paucity of research in psychiatry from LMIC in high impact indexed journals (Patel and Kim, 2007, Patel and Sumathipala, 2001). The enormous inequalities in global health research are shown by this under-representation of publications and authors from developing countries in high impact medical journals (Sumathipala et al., 2004). When the research is published in LMIC based journals, the 5/95 gap in the indexation of journals from LMIC prevents wider dissemination and access to research and opinion form these regions (Mari et al., 2010).
Priorities and Resources
The 10/90 report on health research (2000) argues that less than 10% of the world’s research resources are earmarked for 90% of the health problems (Global Forum for Health Research, 2000). Funding for research in LMIC is poor. The research agenda is low within the government health sector where competing service needs take priority (Razzouk et al., 2010). Studies are donor-driven and cater to the needs of external donor agencies thus rarely addressing national needs. Most studies (80%) in low and middle income countries are on epidemiology, social, psychological and clinical aspects (Sharan et al., 2009). Up to 87% of all trials of mental health interventions are carried out in high income countries, only 1% in low income countries.
Thus little of the published mental health research is directly pertinent to infrastructural and societal contexts of individual communities, precluding the development of mental health policies based on robust evidence and local priorities. Much needed system research which look at service delivery are often abandoned due to lack of funding. Conflicting political interests prevent even the ones that are conducted from being published if they have the potential to implicate the government in providing shoddy service.
Global surveys of mental health researchers indicate that major perceived challenges facing researchers are lack of funding, shortage of trained staff, difficulties in provision of training owing to poor instrumental infrastructure, constraints on researchers’ time owing to service delivery and teaching commitments, the absence of a strong research ‘culture’ in many countries and weak peer networks and collaboration (Academy of Medical Sciences, 2008). The mental health research mapping group found that important criteria for prioritizing research were burden of disease, social justice and availability of funds (Sharan et al., 2009).
Concrete steps will have to be taken to address these concerns. A culture of research should be encouraged and fostered as it has definite rewards (Alem and Kebede, 2003). Adequate training should be imparted to trainees in psychiatry, not just in critical appraisal of existing evidence, but on research methodology, scientific writing and how to get their work published. Avenues to publish research, even if below international expectations, have to be facilitated. Here, we may have to learn important lessons from cricket – a favorite sport among the majority of South Asians. World class cricket players are not discovered from elite schools with leather ball and bat wielding playgrounds but from the backstreets and alleys of soft-ball schoolboy teams, which are the nurseries in which the greats are first introduced to this popular game.
Often the factor impending publication of research in high impact journals is the lack of validated psychometric instruments acceptable to the international community (de Silva and Hanwella, 2010). Psychometric instruments cannot be validated in global research terms in the South Asian region in haste, as we are addressing hundreds of dialects and different literacy levels. Psycholinguistic equivalence is indeed difficult to achieve and so called validated instruments cannot be used across the board in a vastly different socio-cultural milieu. This factor should encourage innovative approaches to using psychometric measurements that would nevertheless be valid and reliable.
Collaboration is possibly the way forward. Partnerships between the academics and the clinicians; the public and the private sector; intra and inter regional experts will have to be forged. Training programmes and partnerships between journals, institutions or researchers to high income countries can provide important support and guidance. This will also discourage ‘parachute’ research, which often only focuses on the external researchers’ agenda.
Efforts should be made to develop consensus at regional level regarding the research agenda that is necessary to support health system objectives in the region. Finally, mechanisms to integrate research evidence in to national health policy have to be explored.
ACADEMY OF MEDICAL SCIENCES. 2008. Challenges and priorities for global mental health research in low and middle income countries. Symposium report [Online]. Available: www.acmedsci.ac.uk/download [Accessed 15th March 2011].
GLOBAL FORUM FOR HEALTH RESEARCH AND WORLD HEALTH ORGANIZATION 2007. Research capacity for mental health in low- and middle-income countries: Results of a mapping project. In: SHARAN, P., I LEVAV, OLIFSON, S., FRANCISCO, A. D. & SAXENA, S. (eds.).
MARI, J. J., PATEL, V., KIELING, C., RAZZOUK, D., TYRER, P. & HERRMAN, H. 2010. The 5/95 gap in the indexation of psychiatric journals of low- and middle-income countries. Acta Psychiatr Scand, 121, 152-6.
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SUMATHIPALA, A., SIRIBADDANA, S. & PATEL, V. 2004. Under-representation of developing countries in the research literature: ethical issues arising from a survey of five leading medical journals. BMC Med Ethics, 5, E5.