Priorities for research into mental illness in the developing world are not the same as those in the West, writes Katherine Nightingale.
There are 450 million people around the world living with a mental disorder.
Such illnesses lead to stigma and a poor quality of life. They can even affect a country's development because years of individuals' potential contributions are lost.
A significant proportion (76–85 per cent) of people in developing countries with a mental illness are not receiving the treatment they need, not because the treatments don't exist but because financial issues, stigma and often sheer logistics prevent it.
Many developing countries spend just one per cent of their overburdened health budgets on mental health, which is used to fund services, treatment and research.
If treatment is ever to make it to patients, methods of delivering it — from counselling for clinical depression in urban Chile, to antipsychotic drugs for schizophrenia in rural India — need to be designed, researched and rolled out.
But in the scramble for resources, the voice of mental-health research — less coordinated and quieter than its infectious disease counterparts — is losing out.
The need for research
A recent study published in The Lancet found that of all trials carried out into the treatment and prevention of specific mental disorders worldwide, less than one per cent related to the poorest developing countries, which account for 60 per cent of the world's population.
The actual capacity for low-income countries to carry out their own research is probably much lower than one per cent of global capacity, according to Vikram Patel, reader in international mental health at the UK-based London School of Hygiene andTropical Medicine and chairperson of the Sangath Society, a group researching and implementing treatment for families' emotional well-being in Goa, India.
And the figures in the study account only for material relevant to low-income countries, he says, not research carried out with that country's resources.
"These figures shouldn't actually be that surprising, it's just the extent of the difference, the inequity, that is surprising: you wouldn't expect a proportionate amount of research, but just one per cent was a surprise to even us."
Counselling with a mentally ill
When asked what they see as priorities, researchers in developing countries usually rank highest studies into the numbers of mentally ill people and the causes of their diseases.
Denise Razzouk, of the Department of Psychiatry at the Federal University of São Paulo, Brazil, is sympathetic. She told SciDev.Net that while studies about the burden and causes of mental health disorders have increased in recent years, she doesn't feel they are adequate.
Researchers also want information about treatment in local situations. "We need studies that provide scientific evidence on the effectiveness of mental health interventions in the Brazilian context," says Razzouk.
In the clinic of K. A. L. A. Kuruppuarachchi — psychiatrist and senior lecturer in the department of psychiatry at Sri Lanka's University of Kelaniya — local information is so sparse that patients are treated in accordance with British guidelines. They have no guidelines of their own.
Kuruppuarachchi told SciDev.Net that research into family-oriented care is also a necessity in Sri Lanka — and no doubt in other developing countries.
Research of a different nature
Authors of the Lancet series on mental health say that the evidence is already there for the effectiveness, and cost-effectiveness, of mental health interventions. Much of it is from developed nations, but there is growing evidence from developing countries too.
For example, a trial of group psychotherapy has been shown to help people recover from depression in Uganda, the antidepressant fluoxetine helped people with depression in India, and a combined programme of group therapy and antidepressants was successful in Chile.
A group counselling session
for mental patients in Indonesia
Earlier first-generation antipsychotic drugs were effective against first-episode schizophrenia — a disabling psychotic disease — in China, as were patient and family education programmes and counselling for patients re-entering the community.
But it's no use just having a wonder drug or effective counselling — it's how to get these treatments to people that needs investigating and scaling-up.
Jimmy Whitworth, head of international activities at the UK-based international charity the Wellcome Trust, agrees, saying that the kind of mental health research that is — and needs to be — done in developing countries is different from that carried out in developed countries.
"In the developed world, it's about new cutting-edge investigations and diagnoses," he says. "In developing countries, the research priorities are much more about how to actually deliver, effectively and equitably, known interventions, so it's much more about health-service research."
Saeed Farooq, head of psychiatry at the Pakistan-based Lady Reading Hospital, says that it's often difficult for people in the West to imagine the kind of research that's needed in developing countries.
For example, schizophrenia patients in the United Kingdom are generally treated in the community and monitored by a health worker to ensure they are taking their medication and to monitor their symptoms.
But in developing countries such as Pakistan, families often care for patients, buying and administering their treatment. This puts massive pressure on their time and finances and makes adherence difficult.
Farooq is developing a method based on the tuberculosis-treatment component DOTs ('directly observed therapies'), in which patients are supervised while taking their daily drugs, to ensure that schizophrenia treatment is followed.
A lack of resources
Part of the reason for sparse research output is a shortage of mental-health workers, which stems from a lack of funds.
An Indonesian nurse
supervises a mentally ill
girl taking her medication
"Other health areas are simply more attractive, less stigmatising; there are more career options," says Patel. "They have more resources thrown at them and the moment something has more resources — particularly in poor countries — people will be attracted to it, because survival is important to health workers as well."
Farooq agrees. "There are just 350 psychiatrists in the whole of Pakistan, for a population of over 160 million. They are focusing on providing the services rather than doing research. There's simply not the manpower."
Pakistan is not alone. Low-income countries have an average of only five psychiatrists and one-and-a-half psychiatric nurses per million people. Chad, Eritrea and Liberia have just one psychiatrist each.
Half of the developing countries studied in a report by the Global Forum for Health Research and the WHO had fewer than five mental health researchers. A similar proportion of universities had the equivalent of US$10,000 per year to spend on mental health research, and many active researchers spend only 25 per cent of their time on research.
Depending on the donor
A dependence on international funding is another factor controlling the level of research. Few funding bodies specifically support mental health in developing countries — there is no 'global fund' for mental health.
The behemoth of global health funding, The Bill and Melinda Gates Foundation, gives no money directly to mental health research, and others, such as the UK Department for International Development, do not keep track of money allocated to mental health.
It's possible that mental health research isn't as attractive to donors as, say, infectious disease, because there isn't as much potential for 'success'.
"[Infectious diseases] are things that you can cure — and if you can do research that demonstrates that you can control disease, then you make a huge impact," says Whitworth.
With chronic diseases, such as mental health, it is much harder to demonstrate an impact, and this usually requires a sustained intervention rather than a simple short one, he adds.
The agendas of Western funding bodies such as the Gates Foundation are often very different from agendas in developing countries, says Patel. In poor countries, they have to be donor-driven.
"What's ironic is that the people who are making health policy for developing countries are implying that the health needs of these countries are different to those of their own families… heart disease, depression etcetera," he says.
Patel says that once countries develop and become free of donor money, mental health is prioritised — a situation he has seen in India.
But Whitworth argues that agencies do not make their funding decisions from ivory towers. They don't dream up their own priorities without any regard for what the morbidity burden or priorities might be in developing countries, he says.
He says funding agencies often "get out and about", talking to researchers and policymakers in countries.
One of the problems is that research into how to deliver treatment, he says, is "difficult to do well" and often not particularly exciting or appealing to some funding bodies who want to be seen as at the cutting edge.
The Wellcome Trust spent five per cent of its total mental health research budget on global mental health between 1994 and 2004 — about US$55 million.
For Whitworth, it's a case of not receiving enough quality applications for mental health research in developing countries. "If we saw more quality applications in that area, then I think we'd fund more."
Getting it out there
But even when research is being carried out in developing countries, researchers often find it difficult to publish in peer-reviewed journals and are therefore unable to use their publications as scientific 'currency' to build up their reputation.
When researchers are trying to get published, limited access to quality and up-to-date information, lack of training in trial design and protocol, and writing in a foreign language (English), all compound issues already thrown up by a lack of material and financial resources.
Mental health researchers are not alone in this regard; those in all fields in developing countries suffer similar problems. But the publishing community seems to be coming to mental health researchers' aid.
In 2004, 42 editors of journals that publish mental health research signed a statement, along with the WHO, saying they aimed to reduce the gap between developed and low- and middle-income countries in published research by helping authors overcome impediments to publication (see 'Journals to bolster mental health research').
"It's probably too early to say whether this [2004 statement] has had an effect," says Patel. He studied publication rates in six journals in 2001 and then in January 2007 and found no difference in publication rates.
But journals should be careful not to publish work that is sub-standard simply because of its origin, says Patel. "When [editors] are reviewing research from a developing country, there needs to be a sensitive review group, that's a critical thing, but that cannot be in lieu of a minimum acceptable quality of research."
Finding a way forward
But how to get research done?
"I'm hoping that some of the biggest donors will adopt mental health and look at capacity building, not necessarily mental health research capacity building, but to integrate mental health into existing research programmes," says Patel.
"We're really looking at opportunities for 'piggy-backing' mental health."
Whitworth agrees, "One of the things that's important is that we get mental health into the mainstream of healthcare and research."
After all, mental health problems — and those associated with them — have long been stigmatised, isolated and made to feel different. Maybe now is the time for integration.