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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 3  |  Page : 296-303

International collaboration in mental health: Contributions, opportunities, and challenges


1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Newcastle University of Medicine Malaysia, Johor, Malaysia

Date of Web Publication3-Nov-2016

Correspondence Address:
Prof. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.193193

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  Abstract 

Introduction: Arising from the push for global health, the movement for global mental health has established itself as a distinct identity in the last few decades. Collaboration between donors, international agencies, institutions, and individuals of different countries has been an essential component in this endeavor. Methods: We review relevant reports in the literature that describe the process of collaboration between individuals and institutions in the area of mental health, in order to describe current patterns in international collaboration. Results and Discussion: In the last decade, international collaboration for mental health has increased substantially. Newer international professional associations; centers for global mental health at academic centers in Europe, USA, and Australia; and international health aid agencies have joined more established agencies, to provide platforms for collaboration. A number of priority-setting exercises have been undertaken that have stressed service development for mental health. International consortia for genetics and neuroimaging have demonstrated successful research collaboration. However, barriers to collaboration persist—these include a continuing failure to prioritize mental healthcare at a policy level, as well as difficulties in arriving at a consensus on conceptualization, transcultural issues, and priority-setting for mental health research. Going forward, the challenge for “global mental health” is to establish a framework that recognizes the unique contributions of all stakeholders and emphasizes equitable partnerships, while adapting knowledge across settings and health systems. Such an approach would be essential to achieve the stated aims of this movement.

Keywords: Global Mental Health, International Collaboration, Challenges


How to cite this article:
Sharan P, Krishnan V. International collaboration in mental health: Contributions, opportunities, and challenges. Indian J Soc Psychiatry 2016;32:296-303

How to cite this URL:
Sharan P, Krishnan V. International collaboration in mental health: Contributions, opportunities, and challenges. Indian J Soc Psychiatry [serial online] 2016 [cited 2019 May 19];32:296-303. Available from: http://www.indjsp.org/text.asp?2016/32/3/296/193193


  Introduction Top


The movement for international or global health has become a dominant theme among public health priorities since the last century. This evolution may represent a response to circumstances of increasing economic interdependence and the migration of people, ideas, and resources, to and from different parts of the world; the growth of evidence-based medicine that has brought ideas of measurement and cost-effectiveness into focus; and the realization that in order to achieve the goal of universal health, people in all parts of the world must work together.[1]

While early developments in the global health movement were directed primarily toward infectious diseases and vaccination, mental health has come into focus in the last two decades.[2],[3] This comes along with the global recognition of mental disorders as major contributors to the global burden of disease.[4] In this review, we will attempt to trace the role of international collaboration between individuals and institutions in the pursuit of global mental health.

International Collaboration in Health

The “global” health movement owes its origin to disciplines such as tropical medicine, that have health through the lens of western biomedicine. Western-trained medical practitioners initiated the scientific study of diseases in the colonies. Over time, the global health movement has evolved into a field in which collaboration, shared understanding, and common paths to better health are acknowledged as essential ingredients to achieve health for all.

This change was set in motion by WHO, which has served as a forum for discussion between governments around the world, to set common priorities and strategies for improved health outcomes.[3] Ng and Ruger,[5] tracing changes in the architecture of global health governance since this time, have highlighted WHO’s position as the natural leader, encouraging consultation and international collaboration. However, over time, a number of other actors have become part of the global health governance structure. These include other institutions under the UN, such as UNICEF, UNAID, UNDP, FAO; institutions focussed on development, such as the World Bank; intergovernmental groupings such as the G8 and G20; nongovernmental organizations (NGOs) with a focus on health; and governmental aid organizations. These organizations have together contributed to the growth of healthcare systems and research in various parts of the world, with complex interrelationships in their functioning-as funding agencies, in formulating initiatives, or in implementation, monitoring, and evaluation.[5]

In a system without clear hierarchies or division in functions, institutions may collaborate, but often duplicate and sometimes compete in their functions.[6] Even an organization like WHO has to balance considerations related to financing, as extra-budgetary funding provides more than half of its total budget. This has implications for policy influence within the organization.[7] Studies have shown that funding flows do not have a direct relationship with the burden contributed by diseases, and that initiatives may represent political and economic considerations relating to the funding agency, rather than to needs of the population they serve. Funding agencies have also come in for criticism, as exerting a disproportionate influence in setting the agenda for collaboration.[8]However, international collaboration in health also has some impressive achievements to its name, mostly related to the control of infectious diseases. This has involved collaboration between multiple agents, including intergovernmental organizations, international NGOs such as the Bill and Melinda Gates Foundation (BMGF),[9] Gavi,[10] The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM),[11]as well as individual national governments.

Apart from these institutions, service development closer to clinical practice has been with the involvement of individual institutions. Over the years, pathways for professionals to interact with peers with shared interests have increased radically, with increasing opportunities for training of healthcare personnel, research collaboration, and the dissemination of practices developed in one part of the world, to others.[12] More recently, international research consortia involving large number of researchers have come into being, collaborating for billion-dollar projects such as the Human Genome Project.[13]

International Collaboration in Mental Health

In the domain of mental health, collaboration is less developed when compared with other areas of global health. This assertion may be supported by a number of findings.

The Institute for Health Metrics and Evaluation (IHME)[14] publishes an annual report on financing for global health.[15] When the patterns of funding to various “focus areas” are studied, a substantial quantitative gap is seen in external funding for health services (referenced as “developmental assistance for health”). The mental health domain is subsumed by the category of “noncommunicable diseases,” which itself forms only 1% of the developmental assistance basket. Further examination of this data suggests important qualitative differences as well. Funding for infectious diseases such as HIV/AIDS, tuberculosis and malaria, or for child health (which make up the largest proportion of funding targets) is sourced from a number of large, dominant donor and policy organizations, for example, the GFATM, BMGF, or governmental aid institutions of the G8 countries. Mental health funding, on the other hand, is sourced from private philanthropic organizations and implemented through NGOs. The data does not provide information on the number of institutions involved in these services, their focus areas, or particular disorders of interest; but it may be presumed that there is no centralized organizational structure. This pattern of funding may merely be a reflection of the recent inclusion of mental health into the international health agenda. While it is possible that this diversity could lead to “democratization” of the policy space, it also places mental healthcare at risk of duplication of services, lack of efficiency, and a blurring of focus that could hamper the overall efforts to improve mental healthcare. An understanding of these issues would be important while considering collaboration at an intergovernmental or policy level.

Collaboration at a peer-to-peer level, or in terms of individual institutions, is harder to study. The best data available is in the research space, where co-authorship rates in the published literature may provide some insight into the current state of international collaboration. The most recent such study by Wu and Duan[16] looked at the most prolific authors and the highest-ranked journals publishing articles on mental health and found that collaboration was common between authors and institutions, but that the institutions that were central to collaborative networks were exclusively situated in the developed world. The authors concluded that, this further demonstrates the 10/90 skew in research work for mental health, as with other domains of health.


  Materials and Methods Top


The aim of this review is to present information on the current status of international collaboration for mental health. In order to do so, we have focussed on articles published in the last decade. This almost coincides with the publication of the influential series on global mental health in the Lancet,[17],[18],[19],[20],[21] which brought mental health into renewed focus as a public health concern.

The databases searched were PubMed, Medline, and Google Scholar, along with cross-references. English articles that focus on the process of collaboration between individuals and institutions in different countries, for the development of services and capacity building, or in research, were included. We excluded articles that were based on the outcome of collaboration, for example, cross-cultural or multicountry surveys or comparisons.


  Contributions Top


Using the parameters of the search strategy, it was difficult to identify articles on models of collaboration in mental health, particularly in the peer-reviewed literature. A number of institutions have come to lead efforts toward global mental health, most of which have been formed in the last decade. Among others, these include the Mental Health Section of WHO (since the 1960s); Grand Challenges in Global Mental Health Canada (2003).[22] The National Institute of Mental Health (NIMH) of the USA(1946).[23] the Joint Global Health Trial Scheme, jointly funded by the development fund of the government of the UK (DFID), along with the Medical Research Council (MRC) and the Wellcome Trust (2010).[24] The Centre for Global Mental Health administered by the London School of Hygiene and Tropical Medicine, King’s College, UK(2009).[25] and the Centre for Global and Cultural Mental Health, University of Melbourne, Australia (2008).[26] In addition, the Global Fund for Health Research, the International Clinical Epidemiology Network (INCLEN) and the Council for Health Research and Development (COHRED) have published reports on this topic, as has the World Bank.

Priority Setting Exercises

A number of authors and institutions have worked toward defining priorities for global mental health. These exercises have been either based on analysis of efficacy and burden data[27],[28] or by seeking consensus among stakeholders. In general, these processes have been undertaken with the institutional backing of WHO, World Bank, NIMH, or other global fora. Tomlinson et al.,[29] have described a standardized process for setting research agenda. This process, adapted from the one introduced by the Child Health and Nutrition Research Institute, conceptualizes research agenda setting as an inherently collaborative process, involving stakeholders from as wide a range as possible.

A number of reports have set about identifying research priorities for mental health, at either the international,[30],[31],[32] regional,[33] or national levels. These efforts have varied in terms of the (a) region of interest (b) methods for selecting stakeholders, and the number and diversity of stakeholders involved (c) focus of priority setting - for research or service development (d) time horizon and (e) processes involved in selecting research areas and ranking them as priority areas. They have identified a number of research questions, mostly focussing on areas of optimization of service delivery, patterns and determinants of illness, and etiology and pathogenesis.

The various exercises have certain common conclusions that are relevant to the development of collaboration. First, service development is considered a higher priority than the development of new interventions.[29] Second, priorities relating to the development and scaling up of services have been ranked above more basic research into the etiopathogenesis of mental disorders. While it must be recognized that priority setting exercises conducted thus far have limitations in terms of selection of participants and the framework chosen for priority setting,[34] a larger failing has been in terms of concerted action toward achieving these priorities and monitoring mechanisms toward the same. Priority-setting exercises have also identified a lack of indigenization and a paucity of regional and international linkages as an obstacle to the growth of research in this area.[30] This report is also significant in stating that experts in the developing world consistently prioritized research into awareness and advocacy, research capacity building, service delivery and policy over research into the etiopathogenesis of mental disorders.

Epidemiology and Monitoring

In the field of epidemiology, the most significant work of a collaborative nature has been the multicountry studies conducted under the aegis of WHO. These include early studies of severe mental illness[35],[36] and the more recent World Mental Health Survey,[37] which sought to describe the prevalence of mental disorders of various types. They provided data on the prevalence and patterns of mental disorders using the same instrument, conducted in different parts of the world. Such reports provide a basis for comparison between countries, and provide examples of successful collaboration between researchers in various institutions, in different parts of the world.

WHO has also developed a template whereby mental health services may be assessed: the Mental Health  Atlas More Details.[38] This report, which is into its third edition, provides information about systems in terms of policy and legislation, service availability, and data on outcomes. In addition to their primary monitoring and evaluation function, such initiatives are a result of collaboration via the central authority of WHO. They also prioritize key indices that collaborators may make use of, and benchmarks against which outcomes (particularly for service development) may be measured.

Interprofessional Collaboration

Collaborative Research Networks

The field of psychiatric genetics[39] and the human brain mapping projects[40],[41] may be seen as models for future collaboration in other fields of mental health. These initiatives, funded to the tune of billions of dollars, have been conceptualized as collaborative exercises with scientists of different institutions bringing their dissimilar expertise to bear on a single focus area. They exemplify a new framework for collaboration, where collaboration is no longer restricted to workers within departments or institutions. Instead, data sharing and the pooling of resources have become the norm in these fields, allowing for large amounts of data to be analyzed and results to be produced and shared.The Psychiatric Genetics Consortium, which analyzed a large US-European dataset to identify more than a 100 polymorphisms associated with schizophrenia,[42] has also opened the door to new initiatives in genetics, imaging, and biomarker research. These models would need to be studied for their broader application to other areas of mental health, including service development strategies and community psychiatry. But even now, they do provide strong evidence of the fact that collaboration across national and regional boundaries is here to stay.

A third strand in the growth of collaborative research has been the acknowledgment of the so-called 10/90 gap in research,[43] where only 10% of research is conducted in developing countries, which bear 90% of the global burden of disease. This acknowledgment, and the development of groups such as the 10/66 research group in the field of dementia,[44] serves as a model where common methods are used to study a problem and collaborators pool data in order to provide comparisons between countries and regions. The International Clinical Epidemiology Network (INCLEN), headquartered in India with collaborative centers across the Americas, Europe, and Africa, has also been working toward the development of instruments to identify mental disorders in developing countries.

At the level of individual researchers, research in psychiatry shows similar trends to other fields of medicine, with an increasing number of publications being co-written by authors from different countries.[45] In their analysis, Wu and Duan[16] performed a “social network” analysis to identify trends in co-authorship rates for publications in the field of mental health. They found that even in collaborative publications, a core contribution is from authors in the developed world. Other initiatives involve a number of formal networks of practitioners committed to global mental health, such as the World Federation for Mental Health (WFMH)[46] and more recent groups such as the Mental Health Innovation Network.[47]

Collaboration between Professional Organizations and Capacity Building

Professional associations of mental health professionals, such as the World Psychiatric Association and the World Federation of Mental Health, have also contributed to collaboration. Apart from their function as forums where professionals from different parts of the world can interact, and by including professionals from different countries in their governance structure, these organizations have also contributed to the consensus position of professionals with respect to the development and delivery of services, and broader policy positions. These statements cover areas with relevance to social psychiatry, such as on dealing with stigma, discrimination, and violence; preventive and promotive strategies for mental health; and professional ethics.

National professional associations such as the American Psychiatric Association and the Royal College of Psychiatrists have taken on the role of providing assistance for capacity building via international fellowships to train mental health professionals.

More recently, interprofessional associations have developed that are devoted to global mental health. These organizations, situated in different countries, have primarily focussed on the development of services, technical assistance to countries seeking appraisal and improvement of their services, and in adapting services to the needs of communities.

In addition, there has also been a move by universities to offer courses, fellowships, and observerships that are designed to train professionals who could go on to take leadership positions in the field of global mental health.[48],[49],[50],51]

Service Development

From a predominantly “vertical” project-oriented approach, where interventions were designed to tackle individual disorders, global health has recently come to prioritize interventions that strengthen mental health services as a whole. This alteration has been attributed to the evaluation and strategizing of organizations such as the World Bank, which entered the domain of healthcare in the 1980s. For mental health, these efforts have culminated in the creation of WHO Mental Health Gap Action Programme (mhGAP).[52]The Action Plan was devised by WHO as a model for service delivery and emphasizes the training of health workers and nonspecialist medical practitioners to handle mental health services. One integral part of the mhGAP is the mhGAP forum, an annual gathering of representatives of national and multilateral agencies, development agencies, NGOs, and academic and research personnel. These activities also highlight the need to adapt service paradigms and interventions to the needs of different populations.


  Challenges Top


Certain barriers to collaboration have been identified by previous workers. Some of these are barriers to the development of mental health services in general, for example, the low priority afforded to mental health,[53] and limitations related to mental health resources including manpower.[19],[20],[54] These contribute to specific challenges to the collaborative process, both in the long-term (strategic) and shorter-term (tactical) aspects of the collaborative framework.

The conceptualization of mental illness and treatment remains fraught with conflict. More than other medical conditions, sociocultural factors influence the presentation of mental health conditions. Contributions of biological, psychological, and social factors are acknowledged by researchers, but the underlying framework bears the stamp of a unitary perspective on the concept of health and disease. This perspective, essentially western in its origin, underlies the international diagnostic classifications, the instruments used to identify mental illnesses, and the interventions that are currently recommended for care of mental illness around the world. Critics of this approach range from those who consider this approach a part of a process of imperialism and the imposition of a western worldview,[55],[56],[57] and point to difficulties in reconciling “global” and “local” concerns.[2] to those who consider that western approaches applied without a knowledge of the subtle influences of culture could lead to misdiagnosis and mismanagement; and inappropriate service development. For example, studies[58],[59] have questioned whether instruments developed in one part of the world can be used with validity in a distinct culture. This means that collaborators may choose to retain their culture’s distinct view of mental health conditions, or adopt universalist perspectives to a greater or lesser degree. Either approach is likely to require a trade-off.

From the priority-setting exercises that have been undertaken in the past decade, it is clear that an understanding of the global priorities facing mental health is still emerging. At present, research in various parts of the world reflects markedly different concerns—some are devoted to greater understanding of etiology and neurobiology; others toward policy and prevention. The stark differences and lack of integration between these various inclinations are significant barriers to collaboration. When workers emphasize different aspects of mental health, competition becomes a greater possibility than meaningful collaboration.[60] An additional problem with these differences in the quality of research undertaken in different parts of the world is that very often, the research that is relevant to decision-makers, such as data on burden, patterns, efficacy, and cost-effectiveness of interventions, is often based on studies conducted in another community. Another is the finding that research is translated into practice with a lag of decades at times, and that evidence-based practice is thus denied to large populations.

A related issue is of the funding for research and service development. Mental health services remain grossly under-funded by governments, especially in the developing world. The gap in funding is often made up by philanthropic organizations, acting through NGOs. These organizations are, quite often, unfamiliar with the realities of mental health needs in the population; in this form of collaboration, it becomes necessary for professionals with expertise in the area to get involved in the decision-making process to ensure that funds are disbursed in a manner that reflects the needs of the community. Funding agencies must be made aware of competing interests and of the possibility of reinforcing skewed power structures by their funding patterns. Particularly, funding must flow toward implementing established interventions, and not merely to the development of novel intervention strategies that are not scaled up.

Collaboration also requires the presence of trained professionals who are able to take up these roles in different parts of the world. At present, researchers contribute to collaboration more at an individual level than at an institutional level, and these collaborations are often based on individual interest. Research capacity mapping exercises have shown that lower- and middle-income countries lack personnel and resources to conduct research into mental health.[32] Institutional mechanisms that would contribute funding, training, and guidance toward incentivizing research into conditions that are relevant to the community are needed. In addition, regulatory changes would need to be set up that permit rather than obstruct collaboration between workers in different parts of the world. It has been shown by various studies that international research collaboration is dependent on a number of factors, not only including similarities of language and the individual circumstances of the nation,[61] but also by the use of effective policy measures that incentivize collaboration.[62]

As the collaboration between various countries becomes easier, it will also be important to consider regulatory challenges and the creation of a framework that includes workers from diverse institutions and countries. This will become increasingly important as clinical trials, often funded by pharmaceutical companies, become difficult to conduct in developing countries. It would be important to ensure that collaboration does not become a cover for the globalization of ethically questionable practices.[63]

The challenge for mental health would then be to develop a mechanism for setting priorities that encourage the translation of knowledge gained in one setting, to another, while preserving the contributions of local knowledge networks, and being able to adapt this knowledge to the needs of specific communities. Mental health has had limited success in developing a framework whereby this might be achieved.


  Opportunities Top


Mapping Research Institutions and Contributions

A number of recent studies have focussed on mapping the research capabilities of institutions in different parts of the world. Past mapping exercises at the global and regional level could point a way toward establishing collaboration between those with similar interests or problems. There have been studies that assessed the abilities of institutions to collaborate, both at the international[64] and regional levels.[65] as also steps suggested in order to improve the pace of collaboration.[66],[67] There have also been reports of successful collaborative efforts, both to improve capacity for research and for service development. These may be taken as models for further improvement.

The Creation of a Collaborative Framework

The first step for a collaborative process must be a mutual recognition of contributions. At a national/policy level, this would involve the dissemination of salient features of policy and discussions aimed at establishing priorities for these. The development of meaningful collaborative networks and the identification of collaborators who are strategically placed to contribute to the disparate goals of collaboration, for example, the development of funding, nosology, policy, and legislation; collation and analysis of epidemiological and monitoring data; development of capacity in trained mental health professionals at all levels; continuing and developing associations between professional associations; the development of research networks; and the development and testing of intervention strategies. In order to develop all these connections, it would be necessary to collate and evaluate the currently available models. The International Knowledge Exchange Network[68] is one example of such an initiative, committed to bridging the gap between research and practice. This organization has assisted governmental agencies in North America and Europe, in order to provide solutions whereby practitioners could gain ready access to recent evidence. Resources of this kind, made publicly available, would provide impetus to translational research.

Collaboration may occur in various ways. At a systems level, collaboration may be through formal or informal understandings between individuals or institutions, through triangular connections in which multilateral organizations such as WHO help to facilitate partnerships, or through broader networks. Each of these measures could contribute in different ways, and it would be important to efficiently create collaborative relationships of various kinds, in order to further the cause of global mental health. Recent studies have identified systemic weaknesses in the healthcare systems of various countries, particularly those of the lower- and middle-income groups. Exercises at mapping research institutions in such countries, and the creation of nodal institutions tasked with connecting researchers, may go a long way in furthering mental health systems research.[67]There have also been formal studies of the overall research environment and the status of collaboration, such as the one commissioned by the European Commission for Science and Technology. This report mapped research collaboration at the transnational and national levels, and identified key drivers for research collaboration, both in terms of objectives and strategies.[62] Similar studies focussed on other regions, and adapted to the status of mental healthcare, would be a useful starting point in guiding future collaborative exercises.

The Role of WHO and Other Institutions in Developing Collaboration

A number of international organizations such as WHO, Global Forum for Health Research; the global mental health movement; and global mental health departments/centers at major universities have a stated goal of furthering global mental health. They often comprise (or connect to) members from diverse institutions, all interested in public mental health and service development. These could constitute a natural starting point to create forums for discussion, and the establishment of a mechanism that allows for the growth of global mental health.

Strengths and Limitations

A significant limitation of the review was the reliance on databases in the public domain, on international collaboration, and on English articles. It would be important to consider literature on collaborative efforts within a country or region independently of the broader scope of international collaboration. Reports of collaboration between institutions and individuals, or requiring cross-cultural considerations within a community, would have complemented the review, especially when they discuss the issues arising during the implementation of a paradigm that was developed within a particular setting. As the scope of this review was very broad, we were unable to comprehensively review literature on individual collaborative efforts. It is important to recognize that these endeavors may be seen as case studies in collaboration, and that insights may be gained into this field, by appraising these initiatives. As an alternative, we have tried to provide an overview of the topic, including a report on the current status of collaborative systems.


  Conclusions Top


Collaboration is an integral part of the scientific process. As the movement for global mental health matures, it provides immense opportunities for policy-makers, researchers, and practitioners to come together in order to implement mental health interventions equitably, as also to innovate in ways that were not possible hitherto. In doing so, it would be necessary to take into account the current governance architecture, which encourages collaboration, and yet imposes certain constraints. From our review, it is clear that steps must be taken to deepen the emphasis given to mental health research and services. For research collaboration to become a part of mental healthcare, it would also be necessary to ensure that all countries and stakeholders are seen as equal partners in the drive toward global mental health, and that corrective action be taken to correct currently skewed power equations between the various stakeholders.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

 
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