Research capacity for mental health in low- and middle-income countries: results of a mapping project

Abstract

Mental and neurological disorders are responsible for 13% of the global burden of disease. In addition, more than half of the 10 leading risk factors that cause one third of premature deaths worldwide have behavioural determinants, such as unsafe sex, tobacco or alcohol consumption, etc. Despite this evidence, mental health is a neglected and an underresearched area of public health, particularly in low- and middle-income countries (LMICs). This project was initiated by the Global Forum and WHO to provide an account of the current status of mental health research in 114 LMICs in Africa (52), Asia (32) and Latin America and the Caribbean (30) by: (1) mapping actors working in the field of mental health research; (2) mapping current research agendas; (3) describing the process of setting priorities for mental health research; and (4) describing the dissemination of such research and its impact on mental health policy and practice. Researchers, decision-makers, university administrators and association officers working in the area of mental health were enumerated through an extensive, standardized search of indexed (Medline and PsycINFO databases) and non-indexed (local journals, unpublished papers, conference proceedings, and reports) literature. Over 10 000 relevant articles were identified, along with 4633 mental health researchers and 3829 other stakeholders. Surveys conducted with each of the four groups yielded information on research production, priorities and funding. In-depth interviews with key informants elicited views on the interface between policy and research. Fifty-seven per cent of the 114 LMICs were found to contribute fewer than five articles to the international mental health indexed literature for a 10-year period (1993–2003), while very few articles could be identified from non-indexed sources in almost 70% of the countries, suggesting a paucity of mental health research (and researchers) in many LMICs. Some countries, on the other hand, such as Argentina, Brazil, China, India, the Republic of Korea and South Africa contributed significantly to international mental health publications – a finding that attests to notable variations in mental health research production within as well as across regions. The survey results showed broad agreement among researchers and other mental health related stakeholders, and across regions, regarding priorities for mental health research in LMICs. Epidemiological studies of burden and risk factors, health systems research, and social science research were the highest ranked types of needed research. Depression/anxiety, substance use disorders, and psychoses were identified as the top three priority disorders, while prioritized population groups were children and adolescents, women, and persons exposed to violence/trauma. The most important criteria for prioritizing research were burden of disease, social justice, and availability of funds, although researchers and other stakeholders differed markedly regarding the importance of personal interest of researchers as a criterion for prioritizing research. Most of the in-depth interview participants reported that the mental health research output of their countries was low, lending support to the findings of the literature audit. Many reasons were cited for this. Interviewees reported that clinicians and academics faced many demands in a context characterized by poor funding, a lack of trained personnel, little infrastructural support, and a paucity of research networks, in institutions which mostly lacked a research culture. While the interviews yielded examples of research that had impacted on policy and practice, participants reported that few policies, interventions or programmes are based on information derived from mental health research conducted in their country, mainly due to a gap in communication between researchers and decisionmakers. Indeed, survey respondents indicated that for almost every example they could recall of research impacting on policy and practice, they could think of another where it had not. Lack of a critical mass of trained and informed actors on both sides and lack of baseline studies to support the development of policies were seen as factors contributing to this communication gap. These findings highlight the need to review and strengthen the management of mental health research so that it meets the national needs of LMICs as well as contributes to the global fund of knowledge. Governments and other institutions in LMICs should devise mechanisms to allocate greater funds to research, capacity and infrastructure strengthening. Although some examples of research impacting policy and practice are available, in general there is little interface between research and policy. There is a need for organizations to bridge the gap between policy and research by sensitizing researchers about the usefulness of involving other stakeholders in their research and sensitizing stakeholders about the importance of good mental health research. Finally, it should be re-emphasized that half of the LMICs in the three regions had made very little progress in mental health research and research infrastructure development. The challenge now is to develop strategies for the countries that have made the least progress. The findings of the report emphasize the need for: 1. Governments and other institutions considering mental health crucial to the overall health of their populations and an important bearing on national development. 2. Integrating mental health research within health research systems to enhance synergies and avoid inefficiencies, gaps and duplications. 3. Establishing a leading body to identify and monitor gaps in national and regional mental health research, formulate priorities, advocate for funds, assess research capacity, establish networks, disseminate information and provide technical and financial support. 4. Formulating and implementing mental health research priorities through a transparent, participatory and scientific process. The Combined Approach Matrix (CAM) of the Global Forum is an effective tool for priority setting in this regard. 5. Increasing national funding for mental health research, bringing it into line, as far as possible, with the country’s burden of mental disorders. In addition, leading research donors must include a specific mental health component in their budgetary allocations. 6. Investing in mental health research capacity strengthening, particularly through research trainings and incentives for mental health professionals. 7. Developing research networks and public-private partnerships. In particular, more LMIC researchers and other stakeholders should be connected to established research networks. 8. Mainstreaming cross-cutting issues, such as socioeconomic status and gender, in all strategies and research designs, as key variables. 9. Connecting with information networks in health research to ensure the sharing and utilization of mental health information by researchers, policy-makers, and the general population.