Psychiatric research in low‐ and middle‐income countries: the need for concrete action

It is an obvious fact that economic and scientific development tend to feed each other, and that scientific progress is increasingly concentrated in high-income Western countries. Therefore, when confronted with the information that only 6% of the scientific papers published in six high-impact psychiatric journals in the period 1996–1998 came from regions other than North America, Western Europe and Australia/New Zealand (1), one could be induced to believe that this under-representation is just a reflection of a much more general phenomenon. However, this is not exactly the case. If we look at the figures concerning the authorship of papers published in all scientific journals listed in the Science Citation Index (i.e. all indexed journals of all areas of science) in the period 1991–1998 (2), the proportion of papers originating from the various regions of the world appears indeed unbalanced, but not as unbalanced as in leading psychiatric journals: 27.3% of all papers came from regions other than North America, Western Europe and Australia/New Zealand. The comparison of the figures concerning Asia (3.5% of papers published in leading psychiatric journals vs. 15.2% of those published in all scientific journals) and Eastern Europe (0.2% vs. 6.6%) is particularly striking in this respect. Thus, it seems that non-Western countries are more under-represented in high-impact psychiatric journals than they are in all international scientific journals. Some factors which may contribute to this under-representation have been identified (1): a lower submission rate; a possible acceptance bias [which may be in part related to the very low proportion of experts from non-Western countries in the editorial and advisory boards of leading psychiatric journals – 1.9% in the 10 psychiatric journals with the highest impact factor (3)]; a possible lower quality of submitted papers. Furthermore, an additional relevant factor is the increasing emphasis of leading psychiatric journals on biological psychiatry research, which is obviously much more difficult to carry out in low- and middle-income countries. It is noteworthy, in this respect, that the leading psychiatric journals with the highest proportion of published papers from non-Western countries (Acta Psychiatrica Scandinavica, with its 15.8% in the period 1996–1998, represents a good example) are also those in which the proportion of published biological psychiatry papers has not increased remarkably or has even decreased in the last few years (in the case of Acta Psychiatrica Scandinavica, this percentage decreased from 18.7% in 1991 to 10.4% in 2001). The many possible ways by which the editors of leading psychiatric journals can facilitate the publication of worthwhile research carried out in low- and middle-income countries have been recently described (1, 4). However, even more important than facilitating the publication of ongoing research is to promote a further, significant development of good quality research in those countries (5-7). This is the domain in which international organizations and associations will have to prove, in the years to come, that they are not only ready and able to produce convincing documents and statements, but are also willing and able to convert these documents and statements into concrete programmes and actions. To this purpose, some models which have been to some extent successful in the recent past could perhaps be reconsidered and refined. The first of these models consists in the establishment of a network of centres of excellence, in both developed and developing countries, which are recognized as such by a distinguished international organization or association, and accept to honour the prestigious recognition they have received by: (a) conducting collaborative international research (see, for example, the multicentre studies carried out by some WHO collaborating centres); (b) exchanging trainers and trainees among themselves; (c) hosting promising young researchers from low- and middle-income countries for periods of training (covering local expenses, while the international organization/association covers the travel expenses, with the possible contribution of an external sponsor), and providing mentorship to these researchers when they return to their countries, so that they can apply in those countries what they have learnt, motivate other young people to follow their example, and possibly become partners in subsequent collaborative research. The success of such a model depends first of all on the motivation of the partners and the human resources that they are available to invest; second, on the effectiveness of the central coordination; and third, on the financial support which is available. In this last respect, it may be useful to emphasize that: (a) the opportunities offered by some international funding bodies (notably, the European Commission) have not been effectively exploited up to now in our field; (b) our field is of potential interest to some non-commercial donors (e.g. foundations), but the current perception by these donors of the usefulness and the quality of the research carried out within our discipline is not always very positive; (c) the collaboration of international associations/organizations with the industry in our field has not always followed, until now, pathways and modalities which are really rational and productive. A second model whose potential has not been completely exploited is that offered by the scientific sections of several international associations. These sections, when they are really able to attract the most active and influential international experts in a given scientific area, from developed as well as developing countries, may represent an important vehicle for: (a) the coordination of international research and the actual implementation of international collaborative studies; (b) the recruitment and professional development of young researchers from low- and middle-income countries; (c) the provision of support to experts in the various countries in their efforts to obtain from national authorities the human, financial and technological resources they need for research. A third relevant model is that based on the implementation of programmes of itinerant training courses, delivered by leading experts in several low- and middle-income countries, with the availability of simultaneous translation into the local language. Such a programme is being carried out by the European Psychiatric Association in collaboration with 25 national psychiatric societies in Europe, and is being successful in attracting the interest of young researchers in several low- or middle-income European countries. Some of them remain in contact with the trainers after the courses, taking advantage of their guidance and support. These are just some concrete examples of how research can be actively promoted in low- and middle-income countries. Psychiatric research does not need to be complicated and expensive. Ideas are certainly a more important ingredient for psychiatric research than technology and money. There are several areas of psychiatric research which are not very expensive, but are relevant to clinical practice and attractive to young psychiatrists worldwide. Perhaps the time has come to stop producing documents and statements on these issues and to invest human resources in concrete action.