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The 10/90 divide in mental health research: Trends over a 10-year period

  • Shekhar Saxena (a1), Guillermo Paraje (a2), Pratap Sharan (a1), Ghassan Karam (a3) and Ritu Sadana (a4)...


A search (precision value 94%, recall value 93%) of the ISI Web of Science database (1992–2001) revealed that mental health publications accounted for 3–4% of the health literature. A 10/90 divide in internationally accessible mental health literature was evident and remained undiminished through 10 years as low- and middle-income countries (n= 152) contributed only 6%, high-income countries (n=54) 94%, and 14 leading high-income countries (with more than 1% contribution for majority of years under consideration) contributed 90% of internationally accessible mental health research. Steps should be taken to improve the research infrastructure and capacity to conduct and disseminate mental health research in general, and on a priority basis in low- and middle-income countries.

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Corresponding author

Dr Shekhar Saxena, Coordinator, Mental Health: Evidence and Research, Department of Mental Health and Substance Abuse, World Health Organization, CH-1211, Geneva, Switzerland. Fax +41 22 7914160; e-mail:


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Bulletin of the World Health Organization (2004) Galvanizing mental health research in low- and middle-income countries: role of scientific journals (joint statement). Bulletin of the World Health Organization, 82, 226228.
Canadian Medical Association Journal (2004) Western medical journals and the 10/90 problem. Canadian Medical Association Journal, 170, 5.
Horton, R. (2003) Medical journals: evidence of bias against the diseases of poverty. Lancet, 361, 712713.
Jorm, A. J., Griffiths, K. M., Christensen, H., et al (2002) Research priorities in mental health, part 1: an evaluation of the current research effort against the criteria of disease burden and health system costs. Australian and New Zealand Journal of Psychiatry, 36, 322326.
Paraje, G., Sadana, R. & Karam, G. (2005) Increasing international gaps in health-related publications. Science, 308, 959960.
Parker, G. & Parker, K. (2002) A profile of regional psychiatry publishing: homeand away. Australian and New Zealand Journal of Psychiatry, 36, 693696.
Patel, V. & Sumathipala, A. (2001) International representation in psychiatric literature: survey of six leading journals. British Journal of Psychiatry, 178, 406409.
Rochon, P. A., Mashari, A., Cohen, A., et al (2004) Relation between randomized controlled trials published in leading general medical journals and the global burden of disease. Canadian Medical Association Journal, 170, 16731677.
Saxena, S., Maulik, P. K., Sharan, P., et al (2004) Mental health research on low- and middle-income countries in indexed journals: a preliminary assessment. Journal of Mental Health Policy and Economics, 7, 127131.
Tyrer, P., (2005) Combating editorial racism in psychiatric publications. British Journal of Psychiatry, 186, 13.
US Department of Health & Human Services (1999) Mental Health: A Report of the Surgeon General. Rockville, MD: National Institute of Mental Health.
World Bank (2003) Country Classification: World Bank List of Economies. Washington, DC: World Bank Group.
World Health Organization (2001) The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva: WHO.
World Health Organization (2003) Investing in Mental Health. Geneva: WHO.
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The 10/90 divide in mental health research: Trends over a 10-year period

  • Shekhar Saxena (a1), Guillermo Paraje (a2), Pratap Sharan (a1), Ghassan Karam (a3) and Ritu Sadana (a4)...
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susanne mccabe, tai chi teacher
12 April 2006

The latest inspection of services provided to elderly people with mental health problems has highlighted that they are still 'too often'being treated in degrading, undignified and inhumane ways. (Social Care, Audit Report, Health Service Commission Reports published this week).Commonly there is lack of basic care in eg feeding, lack of rightsto be treated with dignity and respect, lack of consultation or inclusion in the design of services provided. Elderly people are often fearful of ending up in residential homes or hospitals when they are frail and dependant on others. How much can government policies really change ratherthan just monitor a culture? If there was genuine input into the design ofservices from elderly people themselves, perhaps starting from their inclusion on interviewing panels for job applications, more informal visits to homes and hospitals by groups who represent elderly people, theymight begin to bring about it is the constant scandals put off many people with genuine desires to work with elderly people. ... More

Conflict of interest: None Declared

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Yatan PS Balhara, resident, department of psychiatry
18 January 2006

Mental disorders have for long been bearning the step childly treatment from the medical fraternity. not only in terms of the funds alloted to this field for patient care, the literature on the research area is also limitd as compared to some other branches of medical science.there has been a general perception among the mental health professionals that off late the situation has improved. but this does not seem so as in a recent article series by a famous international journal, the mental health disorders again managed to miss out. the journal has brought about a series of artcles on chronic illness and the disability, but medntal health disorders failed to find a place in the journal.the editor in the editorial writes"“The reduction of chronic disease is not a Millennium DevelopmentGoal (MDG). While the political fashions have embraced somediseases—HIV-AIDS, malaria, and tuberculosis, in particular—manyother common conditions remain marginal to the mainstream ofglobal action on health. Chronic diseases are among theseneglected conditions.”-

writes Richard Horton, he goes on to say that -

“Chronic diseases represent a huge proportion of human illness.They include cardiovascular disease (30% of projected totalworldwide deaths in 2005), cancer (13%), chronic respiratorydiseases (7%), and diabetes (2%).”

"The presentation of the editor’s comments verbatim is deliberate andthe separation of the two paragraphs is also very much deliberate. While the first paragraph is something that any health professional around the globe would arguably agree to,it is the second paragraph that must raise some eyebrows- not because the conditions mentioned here are not serious and warrant serious consideration, but because it misses on to a group of conditions that for the time immemorial has faced step sisterly treatment at the hands of medicine. The statement might sound a bit harsh but the current issue of the journal highlights that.

It is an appreciable effort to bring on the issue of the chronic medical disorders to the forefront as they continue to be one of the majorcauses of morbidity and mortality to the mankind. One needs to focus the attention of the health and the government officials to these conditions for a better future management of these conditions.

The undefined burden of mental problems refers to the economic and social burden for families, communities and countries. Although obviously substantial, this burden has not been efficiently measured.The hidden burden refers to the burden associated with stigma. Mental illnesses affect the functioning and thinking processes of the individual, greatly diminishing his or her social role and productivity inthe community. Impact of the mental illness goes beyond that on the patient and because of the chronic nature of the disorders it posses a bigger burden on the care gavers and the societ at large, which may be inthe form of lost production from premature deaths caused by suicide whichis generally equivalent to or even more than deaths from road traffic accidents; lost production from people with mental illness who are unable to work and care providers for the mentally-ill person; cost of accidents by people who are psychologically disturbed, especially dangerous in people like train drivers, airline pilots, factory workers; direct and indirect financial costs for families caring for the mentally-ill person; unemployment, alienation, and crime in young people whose childhood problems and emotional burden and diminished quality of life for family members

These problems get magnified manifold because of neglect of these conditions at the beginning since the health system is unable to offer treatment and support at an early stage.

Globally, a staggering 450 million people are affected by mental and behavioural disorders. One in four people will suffer from these disorderssometime in their lives. Every year one million people commit suicide and up to 20 million people attempt to kill themselves. These disorders are among the leading causes of disability, particularly in the most productive years between 15 and 44.Depression is the 4th leading contributor to the global burden of disease(DALYs) in 2000. The disability-adjusted life-year (DALY) is a summary measure that combines the impact of illness, disability and mortality on population health. By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calcuated for all ages, both sexes. As of now, depression is already the 2nd cause of DALYs in the age category 15-44 years for both sexes combined. Among all major medical illnesses, majordepression is the leading cause of disability in the U.S. and accounts foraffecting approximately 10 million American adults, or about 5.0 percent of the U.S. population age 18 and older in a given year. According to HIAA Source Book of Health Insurance Data 1999-2000 psychiatric and emotional impairment is responsible for 12.7% of disability claims. This figure excludes an additional 3.3% associated withsubstance abuse.In context of the European countries, stress-related conditions account for more than half of all disability in some northern European countries. It has been estimated that life expectancy has in one decade decreased by 10 years in some Member States, much due to stress and conditions related to mental ill health. Mental health problems account for up to 30% of consultations with general practitioners in Europe.

The available date indicates that one in four European adolescents shows one or more mental symptoms. The neuropsychiatric disorders are responsible for 20.5% DALY in Poutgal, 24.4% in Sapin, 24.3% in Germany and 26.0% in Austria. In all these countries these conditions are the commonest cause of DALY.

According to most modest estimates the consequences of mental ill health can easily account for a third or more of all health care costs while many countries inthe European Region spend less than 3% of their health budgets on mental health care.Adding to the gloomy picture is the fact that in the WHO European Region, about 47% of people suffering from major depression remain untreated whilethe similar figures for schizophrenia ranges from 36% to 45%.

The burden of mental illness on health and productivity in the UnitedStates and throughout the world has long been underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers. Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Inestablished market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women.

It seems that the mental disorders constitute a major burden of disability among all the medical conditions and being chronic in nature they merit a placve in any discussion on chronis disabling conditions. May be such an approach give these disorders the due recognition- something that would help the whole medical fraternity in the long run.The evidence produced by the authors in this regard that roughly 4 percentof the medical literature in 1990- 2000 was related to mental health publications, one might not be surprised to find that the same trend continues in the current decade given the state of the affairs.

References- The neglected epidemic of chronic disease. The Lancet 2005; 366:1514

Preventing chronic diseases: how many lives can we save?The Lancet 2005; 366:1578-1582
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