Capacity building in mental health research: the way forward.

INTRODUCTION

Mental illnesses constitute of 14% of the overall burden due of disease[1] as measured by the disability adjusted life years (DALYs). According to the World Health Report (2001), about 28% of non-communicable disease burden is secondary to mental illnesses. Conditions such as depression, alcohol use and schizophrenia are leading causes of the global burden due to disease. The strong association between mental disorders and social disadvantage, especially poverty, violence, gender disadvantage, conflicts and disasters is well-recognized.[2] Intimate relationships exist between physical health problems and mental disorders. One can fuel the other and adversely impact each other's outcome. This leads to the slogan “no health without mental health.”[3] There is an evidence of efficacy and cost-effectiveness of a number of pharmacological and non-pharmacological treatments for managing mental disorders.[3] These treatments are now available in the low and middle income countries (LAMICs).

We have made considerable advances in the “discovery” of new effective treatments, but the “delivery” of these interventions remains poor. The implementation of science has not progressed much. Most people with mental illnesses receive no effective treatment. This “treatment gap” exists across the developed and the developing world. In India, not even half of those with serious mental disorders receive the treatment they deserve.[2] Treatment gap for other mental health conditions are likely to be huge and can be as high as 90% for conditions like dementia.[4]

This large treatment gap in LAMICs prompted the publication of the Lancet series on global mental health.[3] The articles were on burden and impact of mental disorders, the evidence on the effective treatments, unmet needs in LAMICs, serious shortage of mental health resources and barriers for scaling up of services. A call to action for scaling up of services was also made based on the available evidence.[5] The authors recommended that such scaling up shall be necessarily based on two principles: Evidence on cost-effectiveness and respect for human rights. They have also called for greater investment in building the research evidence to guide the process of scaling up of services. Good evidence comes from good quality research. Research capacity in mental health should be strengthened. We need home-grown research to address issues which concern us most.

In the year 2008, WHO launched a landmark initiative called Mental Health Gap Action Program (mhGAP) to develop evidence based guidelines for managing mental, neurological and substance use disorders by non-specialist health-care professionals working in LAMICs. Many mental health professionals, including some of us from India, contributed to the development of guidelines for eight groups of “priority conditions” namely depression, schizophrenia and other psychotic disorders (including bipolar disorder); suicide prevention; epilepsy; dementia; disorders due to alcohol and other illicit drugs and mental disorders in children. The mhGAP — Intervention Guide (mhGAPIG) was released in the year 2010. This guide is an example of synthesis of evidence to decide “what should be scaled up.” The logical next question would be “how can we scale up these interventions?”

THE RESEARCH GAP

We need a different set of information to develop and deliver population based services. If information is unavailable or inadequate, research becomes necessary. Research generated information is crucial to establish the health needs in a given setting and to propose culturally acceptable, cost-effective interventions. The research gap refers to the “difference between the research information that is needed to develop the best possible services in a given setting and what is currently available.”[6] To bridge this gap WHO launched a program called “research for change.” This is supported by the stakeholders like policy makers and planners from LAMICs, representatives from research organizations, editors of scientific journals and funding agencies.[7] We should examine these developments and its implications for mental health care in India.

NEED TO STRENGTHEN CAPACITY FOR MENTAL HEALTH RESEARCH

We need to assume a public health approach and think in terms of populations affected by the illness; for example people affected by schizophrenia in a given population, rather than the individuals who seek our treatments when affected by schizophrenic illness. Table 1 compares the public health position with the individualized approach in clinical practice.

Table 1

Public health and clinical practice

Boosting public health capacity is needed in India across all medical specialties[8] and psychiatry is not an exception. We need to have a clear agenda for research. The priorities shall be decided by the need, relevance and implications for service development.

The biggest challenge faced by LAMICs including India, is the weak capacity for conducting high quality research capable of addressing the mental health challenges we face. A critical mass of trained manpower is necessary for this. The low levels of research capacity was evident during the mapping exercise undertaken by the Global Forum for Health Research in collaboration with the WHO.[9] Lack of funds for research, trained staff and dedicated time were common problems identified by the researchers. Lack of research culture, lack of collaborators, limited or no opportunities for mentorship and inadequate infra-structure were the other issues.

ROLE OF ACADEMIC INSTITUTIONS AND UNIVERSITIES

Building research capacity should occur as a part of medical training, more so during postgraduate training. Faculty could effectively use their mentorship obligations to enhance research capacity of trainees. Skills in critical appraisal, research methods and scientific writing require special attention and mentorship. Medical/Health Universities have a special responsibility in this regard. Strengthening and streamlining the functioning of the Institutional Research Committee and the Institutional Review Board will facilitate research. Mental health research should be linked to health research in general and public health research in particular. While there are centers with excellent track record in research, the “research culture” may vary widely, across academic institutions. An enriching institutional environment which values research contributions of its alumni and faculty will motivate both trainees and researchers.

ROLE OF THE GOVERNMENT AND SERVICE PROVIDERS

In general research is divorced from implementation. We generally expect a group of people to do research and another larger group to deliver services. This stems from the notion that the researchers “discover” solutions and market it. Policy makers and service providers use the available solutions. This is approach is inappropriate for treatments of proven efficacy and cost-effectiveness. Policy makers and service providers should be made aware of the role of “operational research” in implementation of health programs. Operational research is the search for knowledge on strategies, interventions or tools that can enhance the performance of health programs in which research is being conducted.[10]

Governments should be encouraged to develop evidence based policies and programs. It is important to develop an interface between the research and policy making. It is necessary to differentiate between what works and what does not work in the context of a program. Operational research, especially when it is embedded into the program, helps to identify barriers and the ways to overcome them. Unfortunately, very limited operational research takes place in program settings in LAMICs. This shortcoming can be overcome by integrating operational research component to health programs, like the District Mental Health Programs.

ROLE OF NETWORKING, SCIENTIFIC CONFERENCES AND JOURNALS

Researchers should co-exist and keep in touch with each other. Networking should be actively promoted between centers within and outside the country. Collaborative multi- center studies by research networks will allow “research mentoring” which is a critical process in research capacity building. Mentoring facilitates co-learning and adds to the learner's mentorship skills. Recently, Indian Psychiatric Society (IPS) has taken some steps in this direction. This possibility needs to be explored further. IPS can take more steps to facilitate research networking.

There is no better platform to showcase research than scientific conferences and scholarly publications. Locally, relevant research need to be publicized and made available in the public domain. Special programs to upgrade the critical appraisal skills and scientific writing skills for fellow psychiatrists can be organized along with IPS conferences.

Our journals could consider publishing articles, which can help research capacity building. Singapore Medical Journal published a regular series on various aspects of scientific writing over a 2 year period starting from 2008. These open access articles used an instructional style, which is helpful for capacity building. Such articles occasionally get published in other journals too. The Indian Journal of Psychiatry and the Indian Journal of Psychological Medicine could think of featuring such articles in the future.

ROLE OF PROFESSIONAL ORGANIZATIONS

The IPS and other professional organizations should acknowledge capacity building as an important priority in mental health. This paper is an attempt in that direction. Many things can be initiated by IPS. Professional bodies like IPS should be capable of giving evidence-based recommendations. Good research alone can generate good evidence. Supporting and facilitating good quality research is our obligation.

We need to convince the governments and other agencies to use research to inform and guide programs in mental health. The ongoing programs can be strengthened by the addition of operational research. This allows the best use of available resources. Another important activity would be to work with governments and policy makers to ensure that mental health research gets due importance and fund allocation.

THE WAY FORWARD

Capacity building in mental health research is an important task that demands our attention. Concerted efforts are needed. It will take time to realize the goal. The Southern Zonal Branch of IPS will work with likeminded organizations, agencies and individuals to develop a strategy and action plan. To begin with, we will focus our efforts on centers, which offer postgraduate training in psychiatry and work with the trainees and their mentors.

“This article is based on the presidential address delivered by Dr. K. S. Shaji during the annual conference of Indian Psychiatric Society — South Zone, at Madurai in 2012”