Editorial

Towards Local Empowerment in Improving Relevance of Mental Health Research in Low and Middle Income Countries

Mental disorders are not only highly prevalent but are also highly disabling (1). Most of the global burden of mental illness falls to the poorest nations, where 80% of world’s population live (2). There are few resources available to meet mental health challenges in these countries. One third of the population of the world, i.e. 2 billion people, live in countries that spend less than 1% of their health budget on mental health (3).

Research is an essential tool to reduce the gap between the mental health need and the resources available in low and middle-income countries (4). At present most evaluative research is conducted in high-income countries, and then applied to low and middle-income countries (5). Research conducted in low and middle-income countries is often driven by industry and by high-income countries. The relevance of trials in low and middle-income countries compared with the global burden of disease is poor (6). There is evidence for cost effective treatments of certain disorders such as depression, however the process and effectiveness of scaling up mental health interventions is yet to be assessed adequately (7). Such evaluative research is needed to inform the continuing process of service reform and innovation.

Accessibility to trials from low and middle-income countries in Pub-Med is poor and worsening (6). This is due to a combination of the relative scarcity of research from low and middle-income countries in high impact journals (8) and also of relatively few journals from low and middle-income countries being indexed on Medline.

One of the criteria for indexing journals is that of quality (9). However, a survey showed that the quality of indexed trials from low and middle-income countries is poorer than that of non-indexed trials (10). In addition although the Medline Journal Selection Fact Sheet states that foreign language journals are judged by the same criteria as those in English, indexing on Medline is signifi cantly related to the language of the report being English (4). Another criteria used by Medline is that a journal will not be accepted for publication if the content is already adequately covered. However, this may inadvertently disadvantage journals from low and middle-income countries newly applying for indexing when journals from high-income countries already cover that topic.

The accessibility of research from low and middle-income countries is not only essential for maximising the utility of the research conducted but also effects the enthusiasm of local researchers for conducting research. It is recognised that journals have a responsibility to help develop mental health research and publishing capacity in low and middle-income countries (4).

Although foreign infl uence can have positive effects on service provision and mental health service reform, care must be taken to involve existing local structures. Otherwise problems such as lack of local ownership and disorganisation can occur. This has major implications for sustainability (11). This is also likely to apply to research. Data suggests that stakeholders have different agendas but that donors predominately determine the research portfolio (12). This increases the risk of research becoming vertical. Inadequate alignment of research agendas and policies means that research in low and middle-income countries can become incoherent and fragmented. It is essential that local stakeholders have a voice in setting local, national and international research agendas so that fragile research systems can be nurtured and the relevance of research maximised. This is also likely to improve local ownership of research and improve research capacity.

Conclusión

Inequalities in mental health are widening as the burden of disease due to mental and neurological conditions increases in low and middle-income countries. Urgent action is therefore necessary to ensure relevant research is conducted in low and middle-income countries to address this treatment gap. However, there is a dearth of information and investigation on research from low and middle-income countries and reliance has been on anecdotal evidence of how research is and should be conducted (13). This problem is compounded by the lack of accessibility of research from low and middle-income countries and has the knock-on effect of reducing the voice of researchers from these countries. The need to recognise the importance of local actors in setting research agendas is becoming increasingly acknowledged (14). However further research is needed to elucidate how research systems can best ensure that relevance is maximised and that fi ndings can be fed effectively back into policy.

Reference List

1. Saraceno B. The WHO World Health Report 2001 on mental health. Epidemiol Psichiatr Soc. 2002;11(2):83-7.

2. United Nations, Department of Economic and Social Affairs, Population Division. World population prospects the 2002 revision. New York: United Nations; 2003.

3. Saraceno B. Mental health: scarce resources need new paradigms. World Psychiatry. 2004;3(1):3-5.

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6. Sheriff RJ, Adams CE, Tharyan P, Jayaram M, Duley L; PRACTIHC Mental Health Group. Randomised trials relevant to mental health conducted in low and middle-income countries: a survey. BMC Psychiatry. 2008;8:69.

7.    Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, De Silva M, et al. Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet. 2007;370(9591):991-1005.

8. Patel V, Sumathipala A. International representation in psychiatric literature: survey of six leading journals. Br J Psychiatry. 2001;178:406-9.

9. United States, National Library of Medicine, National Institutes of Health. MedLine Journal Selection. Fact Sheet. Acceso: 2 de julio de 2007. Disponible en: http://www.nlm.nih.gov/pubs/factsheets/jsel.html.

10.   Sheriff RJS. Randomised trials relevant to mental health conducted in low and middle-income countries. Thesis presented to the School of Medicine as required for the degree of Masters in Clinical Epidemiology. Bogotá: Pontifi cia Universidad Javeriana; 2006.

11.   De Vries AK, Klazinga NS. Mental health reform in post-conflict areas: a policy analysis based on experiences in Bosnia Herzegovina and Kosovo. Eur J Public Health. 2006;16(3):246-52.

12.   González-Block MA. Health policy and systems research agendas in developing countries. Health Res Policy Syst. 2004;2(1):6.

13.   Smith R. Comroe and Dripps revisited. Br Med J (Clin Res Ed). 1987;295(6610):1404-7.

14.   Hanney SR, González-Block MA. Building health research systems to achieve better health. Health Res Policy Syst. 2006;4:10.

Rebecca J. Syed Sheriff Health Service and Population Research Institu te of Psychiatry De Crespigny Park London United Kingdom, SE5 8AF rebecca.syed@iop.kcl.ac.uk