Contribution of low- and middle-income countries to research published in leading general psychiatry journals, 2002-2004

We aimed to describe the contribution of low- and middle-income(LAMI) countries to leading general psychiatric journals. Wereviewed original research published over a 3-year period (2002–2004)in the six highest-impact general psychiatry journals and contactededitorial offices to gather data on country of origin of submittedand accepted articles. Only 3.7% of published research emergesfrom these less affluent countries, which account for over80% of the global population. Compared with the findings ofa similar review of the period 1996–1998, there has beenlittle change. The three European journals had a higher representationthan the three American journals. The proportion of psychiatristsin a country was associated with that country’s researchoutput. As much as 50% of the research from LAMI countriesis led by authors from high-income countries. The proportionof submissions from LAMI countries was very low, and articlesfrom them were more frequently rejected. Strengthening theresearch capacity of these countries and reviewing the editorialpolicies of leading journals can help increase the internationalrepresentation of LAMI countries in psychiatric research.

INTRODUCTION

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INTRODUCTION

The enormous global gap in the research output between high-income countries and low- and middle-income countries (Global Forum for Health Research, 2000)not only stunts the development of evidence-based health policiesand practice in the poorer countries, but also limits the growthof psychiatry and public health (Canadian Medical Association Journal, 2004; Saxena et al, 2006). A review of psychiatric research publishedin six leading psychiatric journals between 1996 and 1998 (Patel & Sumathipala, 2001)showed that countries outside the Western cultural world contributedonly about 6% of the published literature and the proportionof publications from low- and middle-income countries was even lower (3.2%). We assessed the contribution of the latter countriesto high-impact general psychiatric journals between 2002 and2004, with the aim of answering the following questions. Hasthere been an increase in the proportion of articles publishedin these journals since the earlier review? Which countriesaccount for this research? Is there a relationship between the output and the country’s mental health resources? Wealso sought to determine the proportion of submissions andrejections of papers from low- and middle-income countriesfrom the selected journals.

METHOD

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METHOD

We surveyed the six highest-impact journals, as listed in theISI Web of Science Database, which covered general psychiatry:Archives of General Psychiatry, American Journal of Psychiatry,Journal of Clinical Psychiatry, British Journal of Psychiatry,Acta Psychiatrica Scandinavica and Psychological Medicine.Only research articles (not including case reports or reviews)were included and supplements were not counted. The period ofsearch was January 2002 to December 2004. We searched all researcharticles and identified potential candidate articles, definedas an article containing original data collected from one ormore low- or middle-income countries, as defined by the WorldBank criteria. Multinational studies were counted if at leastone low- or middle-income country was involved in data collection.We also wrote to the editors of the journals requesting dataon the country of origin of submissions and accepted papersduring the search period.

RESULTS

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RESULTS

Our search identified a total of 2624 research articles; lessthan 4% (n=98) were from low- and middle-income countries (Table 1).We found that 111 countries had not submitted even one article.

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Table 1 Papers from low- and middle-income (LAMI) countries published by six leading psychiatric journals

The three European journals were significantly more likely topublish articles from low- and middle-income countries thanthe three American journals (OR=2.29, 95% CI 1.5–3.5,P<0.001). Two journals (the British Journal of Psychiatryand Acta Psychiatrica Scandinavica) accounted for nearly halfthe publications from such countries. When compared with thefindings of the earlier survey (Patel & Sumathipala, 2001) there was no significant increase in the proportion of papersfrom these countries, although two journals (British Journalof Psychiatry, OR=2.10, P=0.02; Archives of General Psychiatry,OR=4.02, P=0.05) had made a significant increase. A substantialproportion of articles (24.5%) were reports of multinationalstudies. The first author for half of all articles was basedin a high-income country. Of the five leading low- and middle-incomecountries contributing to research, only one (India) was amonglow-income countries; the other leading countries were Turkey, Brazil, China and South Africa. There was a moderate associationbetween the proportion of psychiatrists in the country andthe total number of research papers from that country (Spearman’s ${rho}$ =0.3, P=0.002).

Only two journals (the American Journal of Psychiatry and the British Journal of Psychiatry) provided information regardingthe national origin of submitted and accepted papers. All submissions,including editorials and letters, were counted. The classificationof countries was based on the address of the correspondingauthor. Of the total 4044 submissions to the American Journalof Psychiatry between October 2003 and early 2005, only 188(4.4%) were from a low- or middle-income country; articlesfrom high-income countries were more likely to be accepted (OR=2.6,95% CI 1.4–4.8). Of the 1369 articles submitted to the British Journal of Psychiatry during the years 2002 and 2003,only 86 (6.3%) were from a low- or middle-income country, articlesfrom high-income countries were more likely to be accepted(OR=2.1, 95% CI 1.1–3.7).

DISCUSSION

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DISCUSSION

Only 3.7% of the published research in six high-impact generalpsychiatric journals emerges from low- and middle-income countries,which account for over 80% of the global population. Acta PsychiatricaScandinavica and the British Journal of Psychiatry have thehighest international representation; the three American journalshave the lowest. Only a few of these countries, mostly thehigher middle-income countries, contribute to the literature.The proportion of psychiatrists in each country has a moderate influence on that country’s research output. As muchas half the research in low- to middle-income countries isled by authors from high-income countries. The proportion ofsubmissions from low- to middle-income countries was very low,and articles from such countries were more likely to be rejected.Our findings echo those of a recent review of all ISI journalsover a 10-year period which reported that 6% of articles werefrom low- and middle-income countries (Saxena et al, 2006).However, we note that at least two journals showed an increasein the proportion of articles published from these countrieswhen compared with a similar review carried out a few yearsearlier.

Our review suggests several reasons for the very low representationof published research from low- and middle-income countries.First, the overall proportion of submissions is low; apartfrom the possibility that authors from these countries mightbe choosing local journals for their research, this findingsuggests that the actual research output – and thus research capacity – in these countries, is low. In part, thislack of resources is associated with a lack of psychiatristsin these countries. Second, articles from these countries aremore likely to be rejected. Two reasons might be considered:the quality of research, and editorial and reviewer attitudestowards articles from such countries (Tyrer, 2005). The factthat there are large variations between journals does suggesteditorial and reviewer behaviour as a plausible reason. Oneexplanation for the large proportion of first authors beingfrom high-income countries in reports of research in low- andmiddle-income countries may be the greater familiarity of theseauthors with the publication process of journals and the recognitionof their high-income origins by reviewers.

The World Health Organization and the editors of scientificjournals issued a consensus statement expressing concern aboutthe wide gap in research evidence, and emphasised the roleof scientific journals in promoting research from low- andmiddle-income countries (World Health Organization & Joint Editors, 2004).We believe that journals must act on their commitment to reducethe inequity in the international representation of researchand that they can do so without compromising their scientific standards. Journals should monitor the country of origin ofall submissions and accepted articles, as is currently doneby the BMJ. The wider question of strengthening research capacityin poorer countries needs urgent action. Low- and middle-incomecountries with a good research output should be encouragedto take on a leading role in such capacity building.

Given the lack of improvement in international representation,despite the growing awareness of its need, we recommend high-impactjournals with relatively strong international representations(such as Acta Psychiatrica Scandinavica and the British Journalof Psychiatry) and explicitly international journals (suchas World Psychiatry, the official journal of the World PsychiatricAssociation) to researchers and advocates of internationalmental health. Moves to strengthen the quality of local journalsin low- and middle-income countries to ensure they are indexed and thus widely accessible should be encouraged. We also genuinelyhope that other journals will be able to be active partnersin the global effort to reduce the inequity in the internationalcontribution to psychiatric research.

ACKNOWLEDGMENTS

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ACKNOWLEDGMENTS

V.P. is supported by a Wellcome Trust Senior Clinical ResearchFellowship in Tropical Medicine. We thank Smita Naik and KishoriMandrekar for assistance in journal search.

REFERENCES

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