Bridging the mental health research gap in low‐ and middle‐income countries

Research can and should play a substantial role in improving the mental health situation in low- and middle-income countries (in the following: non-rich countries), where the gap between burden of mental disorders and mental health resources is the largest (1, 2). Research-generated information is essential to determine mental health needs, to propose cost-effective and culturally appropriate interventions of an individual or collective nature, to monitor the process of their implementation, to evaluate the progress made, and to explore the obstacles that prevent recommended strategies from being implemented. The difference between the research information that is needed to plan the best possible services in a given setting and what is currently available can be called the research gap. All available indications are pointing towards the fact that the research gap is particularly large in the non-rich countries. It is known that mental health research publications from non-rich countries constitute a small proportion of the total research output on mental health from the world (3-5). This finding is in consonance with health literature in general (6-8) and in biomedical publications the gap between countries with low and high level of publications is widening (9). These latter findings, specially, serve as a grim reminder that inattention to inequalities will prove a severe handicap in the long run as skill and technological advantage have a self-reinforcing character. Not only is very limited research conducted in non-rich countries but the subject matter often does not answer population needs, e.g. if one follows the criterion of burden of disorders to decide on the priority for research, mental and emotional disorders as a whole (10) and affective disorders, self-inflicted injuries and mental retardation, specifically, are under-researched topics (11). In addition, new knowledge, when it exists, is seldom applied partly because of the fact that some excellent examples of research do not come to attention of policy makers and planners because of poor dissemination opportunities (12). The problems in conducting mental health research in low- and middle-income countries have been discussed by many authors (4, 12-15). A definite barrier is the low priority accorded to mental health in general and mental health research in particular. Equally important are limitations imposed by resources (e.g. funding, facilities, support staff), research capacity (e.g. trained researchers, technical support, peer network, co-operative endeavours, migration of researchers), and research environment (e.g. research culture, availability of time, incentives, bureaucracy, isolation from networks). Preferably, the research policy for a country could be developed in harmony with all other components of the national mental health policy and strategies, as research should provide to most components with the necessary scientific inputs, and with the baseline and evaluation data they require (16, 17). Research should also safeguard ethical principles in its origin (why has the research been done?), formulation (were consumers and other relevant stakeholders involved?), purpose (how the information will advance the state of mental health of the population?), target (whom will it serve?), and operation (how the rights of the individuals, families and communities will be preserved?) (16). Kleinman and Han (18) suggest that non-rich countries should focus on practical and cost-effective research methods and intervention-oriented research that can be employed across many areas rather than prioritizing research according to topics. They argue for the development of population laboratories that integrate epidemiological, clinical, social science, and biomedical research through interdisciplinary research teams and international collaborations. This type of research not only brings to light the mental health burden locally and its underlying social, economic, and political constraints, but it also enables the design and implementation of relevant policies. Patel (19) suggests that Health Systems Research model that emphasizes action-oriented research, planned in close collaboration with a number of stakeholders, and disseminated in a variety of formats targeted to different user groups should be utilized in non-rich countries. Towards reducing the research gap in non-rich countries, World Health Organization has launched an initiative called ‘Research for Change’ (11). The initiative is supported by a broad group of stakeholders including representatives of national research institutes and research councils, international research organizations, funding agencies and donors, editors of scientific journals, policy advisors and programme planners from non-rich and rich countries. Supporting scientific publications from non-rich countries is one of the strategies of the Research for Change initiative. Publications from these countries can obviously draw attention to mental health issues that are more specific to them. But, in addition, they can inform policy making on local, regional, national and international levels; mental health reform and practice, education and research in the field of mental health that could benefit non-rich and high-income countries alike, e.g. research in primary care settings in non-rich countries, could be very useful to rich countries with under-served populations. It should also be noted that publication activity is aimed at not only generating specific information and knowledge but also in further development of research training and skills that serves as an intangible capital. Perhaps more is gained from the publication process through the investment in education of researchers, improved research techniques and membership of professional networks in comparison with the actual knowledge generated in countries where research is still in its infancy. Furthermore, improvement in research and publication capacity stimulates demand for basic research knowledge as well as resources, techniques and data. Capacity strengthening in non-rich countries also indirectly benefits rich countries in terms of creating opportunities for collaborative research. The integration of researchers/authors into an international network also enhances critical abilities of researchers from non-rich countries and tends to correct ethnocentric biases and national focus. It is not being suggested that journals should lower their standards to publish more studies from non-rich countries; on the contrary, it is vital that publication standards remain high. Instead, researchers from these countries may be assisted to achieve the requisite standards in their research and its presentation. Journals could give priority to research coming from countries that have a limited research base, for example, by letting a higher percentage of papers from these countries pass through the initial screening to the full review process. Researchers can be helped to improve their submissions through careful assessment and detailed recommendations for revision and manuscripts can be further polished through technical support (e.g. language editing). Capacity building is key to changes in the long term. This could be done through mentoring, personal encouragement, courses and research collaboration. Support for editorial boards and reviewers of journals in non-rich countries could be provided in relation to journal management, editorial procedures, peer review and setting professional standards. This could be achieved through mentorship, twinning arrangements and training workshops. The example of Acta Psychiatrica Scandinavica serves as a case in point for some of the issues discussed above. It has carried a number of editorials discussing the theme of international psychiatric research (17, 20, 21) and in particular research in relation to non-rich countries (12). The journal also has the highest representation of non-rich country papers (16%), a proportion that was three times the average of other leading psychiatry journals (4). Acta also has a very low regionalization index (5) and it draws publications from all regions of the world (4, 22). This has been achieved through proactive and author-sensitive policies, e.g. extra rounds of editing for papers from non-rich countries, organizing courses on planning and designing psychiatric research projects and participating in international multicentre studies on an equal basis (23). Having a proactive policy for research publications from these countries has not in any way lowered the standards as suggested by the two-fold rise in the impact factor of the Journal over the last decade (23). While the initiatives of a particular journal contribute to reducing the research gap and deserve to be acknowledged, the need is for a broad-based and consensus-driven international initiative to make a real, substantial and sustained difference. Towards this aim, WHO recently (November 2003) organized a meeting entitled ‘Mental Health Research in Developing Countries: Role of Scientific Journals’ in Geneva with editors of top international and selected national journals to exchange ideas and explore ways in which editors can take this agenda forward. A fair degree of agreement emerged in the meeting and the participants issued a joint statement and a catalogue of ideas to galvanize action by individual journals and editorial and international organizations. The statement can be accessed from WHO website (http://www.who.int/mental_health/evidence/en/final_joint_statement.pdf) and is also reproduced in this issue of the Journal (24). Individual journals are independent (as they should be) and differ enormously on their vision, objectives and preferences. The adoption of a uniform action plan by all journals is neither practical nor desirable. Hence, the Joint Statement (24) does not tell individual journals/editors what they should do. However, it does articulate a shared vision of the urgent needs, leaving specific action and timelines to the discretion and enthusiasm of the signatory editors and organizations. We believe that the Joint Statement is a landmark achievement in collaboration by editors publishing mental health research and this initiative has the potential to contribute to bridging the mental health research gap in low- and middle-income countries.