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Closing the 10/90 divide in global mental health research

In this issue of Acta Psychiatrica Scandinavica, Kornadsen and Munk-Jorgensen (1) report the findings of a survey of the proportion of submissions to this journal from lowand middle-income countries (LMIC) compared with submissions from high-income countries (HIC), over two consecutive observation periods (2002–03 and 2004– 05). They compare the proportion sent for external review, the proportion finally accepted for publication, and the impact of accepted publications assessed through estimating number of downloads and citations. Their survey reports that <20% of submissions originate from countries which are the home of over 80% of the global population. The acceptance rates of these articles are low – <10% are finally accepted, and although there has been a reassuring increase in the acceptance rate over the two consecutive biennial periods, the acceptance rate is significantly lower than for articles from HIC. Despite appearing iniquitous, these rates are actually higher than that reported by other highimpact general psychiatric journals (2, 3). At least part of this gap may be accounted for by the higher proportion of articles from LMIC which are not sent for external review. Finally, amongst those papers which were accepted, there is no difference in download or citation statistics, providing some indication that the quality of articles from LMIC and HIC, post-acceptance, is equivalent. These findings suggest that one reason for the lower acceptance rates is because of lower quality of the research manuscript. The principal take-home messages are of low submission and low acceptance rates of research from LMIC. These findings replicate reports of surveys of several high-impact journals and of the ISI database (2–4) and confirm that the 10/90 gap in global health research (5) is likely to be at least as significant, if not more so, in the field of global mental health. Elsewhere, authors including myself have argued about the different possible reasons for these findings and journals, including this one, have issued a Joint Statement along with the WHO to promote mental health research from LMIC (6); after all, such research is needed not only to further mental health policy and programs in LMIC, but also to add scientific validity to psychiatric research which remains severely biased through its reliance on observations and interventions with a tiny fraction of the world’s population who largely share similar social and economic environments. How does one close the 10/90 divide in global mental health research? Perhaps the single most important strategy is strengthening research capacity – both individual and institutional – in LMIC to carry out priority research. There are tremendous opportunities ahead for building capacity, building on the growing investments in public health research capacity in many LMIC. We will clearly need a range of choices for building capacity, and we must focus on both mental health and public health professionals to generate high quality research. Indeed, of these two groups, focusing only on the former is likely to be an unsustainable and ineffective strategy, not least due to the severe shortage of mental health professionals in LMIC and the overwhelming clinical service commitments for these professionals. I believe the most effective strategy to scale up priority research is by integrating mental health in general public health research training programs. To achieve this, the mental health community in LMIC must actively engage with the public health community to ensure that mental health is adequately represented in the curricula for master’s programs in public health. Similar integration has been achieved in some programs in India and the ambitious new Public Health Foundation of India’s curriculum will explicitly acknowledge mental health as a core health outcome. Who should be responsible for building capacity? Clearly, a sound basis for sustainable capacity building must be a partnership between institutions with capacity and weaker institutions. Leading institutions in both HIC and LMIC must acknowledge capacity building in less-fortunate institutions as an academic responsibility in a globalizing world. The Fogarty International Clinical, Operational and Health Services Research and Training Acta Psychiatr Scand 2007: 115: 257–259 All rights reserved DOI: 10.1111/j.1600-0447.2007.01012.x Copyright 2007 The Author Journal Compilation 2007 Blackwell Munksgaard