Attempting to bridge the 10/90 divide: special issue on South Asian mental health

It gives me great pleasure to bring this special issue of the International Review of Psychiatry to those interested in the mental health of South Asian communities. This project has been almost five years in the making, in that the idea for the special issue began in October 2010. The papers in this issue represent only a portion of the kind of work that is being carried out in that part of the world, and it is hoped that collections such as these will lead to a greater understanding of the mental health issues relevant to those communities. In turn, this may inspire researchers in high-income countries (from high-power individualistic or HPI cultures; see Fernando, 2012, and footnote in Fernando & Wilkins, this issue) to reach across the 10–90 divide (Patel, 2006), and collaborate with researchers engaged in community-focused projects and programmes in middle-income or low-income countries working in low-power collectivistic (LPC) cultures, to make them more accessible to the international research community.

Context of the special issue

The nascent global mental health (GMH) movement as represented in the special issue of the Lancet (2007) focuses on psychiatric morbidity such as schizophrenia and bipolar disorder; chronic and debilitating conditions that are of concern but are nevertheless far less prevalent than psychosocial issues such as substance abuse and traumatic stress. I hope that this special issue on South Asian mental health (SISAMH) can add to the momentum of the GMH movement by including research relevant to local and immigrant communities.

South Asian region

It is not easy to demarcate the world through geographic boundaries, particularly when they occur between continents. Thus the area ‘South Asia’ itself is a disputed term, with different organizations defining the term with different countries. As defined by the United Nations geographical region classification, South Asia is comprised of the countries India, Pakistan, Nepal, Sri Lanka, Bangladesh, Bhutan, the Maldive islands, Iran, and Afghanistan. The papers in this special issue locate their communities in the first four of those countries.

A brief description of the countries featured in this special issue will help to place the research in context. India is the largest geographic area represented here, with a population of over 1.252 billion in 2013, and an estimated population of 1.28 billion in 2015 (World Factbook, 2015), sharing geographic borders with Pakistan, China, Nepal, Bhutan, Myanmar, and Bangladesh; and maritime borders with Thailand and Indonesia. The 29 states and seven union territories that comprise India are highly diverse, with hundreds of ethnic groups and languages. While India's economy has the world's third largest purchasing power (World Factbook, 2015), the majority of its population live in rural areas and battle poverty and the negative life events (NLEs) associated with it, including higher incidence of psychiatric illness and lower education about mental health. India's colonization history is likely related to the ways in which Indians view themselves and each other. While many religious communities generally live in harmony in most states, in some areas the hostility between religious groups is strong, with Muslim terrrorist attacks, pogroms against Muslims by Hindu radicals, and organized attacks against Sikh communities destabilizing communities from time to time. Against this backdrop, Chakrabarti and colleagues (this issue) discuss unrecorded alcohol use in rural Sikkim, and Narayanan (this issue) discusses the resilience of disadvantaged adolescents in Indian schools.

The Islamic Republic of Pakistan became established as a country in 1947, after the horrors of the Indian fight for freedom from British rule. Pakistan has a high poverty rate among its 182.1 million people, and its economy is described as being in a ‘low-income, low-growth trap’ (World Factbook, 2015). The majority of Pakistanis are Punjabi Sunni Muslims, with a minority being Shia. The majority of the population are rural, with tribal groups often allying more with their Afghan neighbours than with urban Pakistanis. Given its dire economic circumstances, Pakistan spends little money on health in general, and mental health in particular. As Minhas and colleagues (this issue) demonstrate, ‘task shifting’ can play a key role in effective mental health care in Pakistani communities. Additionally, Naeem and colleagues demonstrate how, by paying attention to cultural factors, cognitive behaviour therapy (CBT) can be effectively adapted for use among Pakistani Muslims living in Pakistan as well as in the UK and other diaspora.

Nepal's population was estimated at 30.9 million in 2014 (World Factbook, 2015), with 125 castes and ethnic groups, and 123 languages being recorded as ‘primary’ language. The majority of Nepali (over 80%) are Hindu, with Buddhists (9%) comprising the largest minority group. The Brahmin caste is considered the highest caste. Caste has been associated with experience and expression of emotion (Cole, Tamang, & Shrestha, 2006), and therefore likely to be related to mental health. An armed conflict between Marxist Maoists and the Nepali government that began in 1996 ended in 2008 with a peace accord, but not without significant numbers of people experiencing and witnessing the bloodshed of war. Less than seven years later the earthquake that occurred in 2015 devastated the country and left over 8,800 people dead and over 23,000 injured (CNN, 2015); the majority of dead and injured people were poor. Kohrt and colleagues (this issue) attempt to delineate the gene–environment interaction effect that may help to identify Nepali at risk for mental distress, particularly post-traumatic stress reactions and depression.

Sri Lanka is the smallest country represented in these papers, an island of about 25,300 square miles with a population of approximately 20.5 million (World Factsheet, 2015). Most Sri Lankans are Sinhalese Buddhists, with Tamil Hindus (approximately 12.5%) and Muslim Moors (approximately 10%) being the largest minority ethnoreligious groups. Most Sri Lankans live in rural areas, and although literacy is one of the highest in the South Asian region (over 90%, World Factbook 2015), education about mental health and illness is still sparse. Sri Lankans have lived through a bloody armed conflict that began in 1983 and lasted for over 25 years, and the devastating tsunami of 2004. Ten years post- tsunami and six years since the end of the conflict, the people of Sri Lanka are attempting to live a ‘new normal’ life, one without checkpoints, suicide bombers, or reports of lost family members. Fernando and Wilkins (this issue) discuss the barriers faced by the different ethnocultural groups as they attempt to recover from trauma and find some stability in their lives.

Overall, although the papers in this issue are quite diverse, they all implicitly or explicitly address how socio-economic status intersects with mental health, a discussion that is often missing in the current psychological literature.

Why focus on South Asia?

South Asian populations comprise 20% of the world's population, which has now surpassed seven billion. India has the second largest population, and Bangladesh and Pakistan are among the 10 countries housing the largest numbers of people in the world (Economist, 2011). Most South Asian countries share similar colonization histories, experiences that have had a deep and lasting impact on the economy as well as the collective psyche of their peoples. Moreover, the world-views of these people are shaped by religio-cultural beliefs and practices that differ from those of HPI cultures. The majority of South Asians are Hindus (of multiple sects) and Muslims (of multiple sects), with Buddhist and other regional philosophies and religions interspersed in some areas. These world views necessarily shape beliefs and behaviours, including those relating to mental health.

Another reason to continue learning about South Asian populations is the incidence of heavy burden experienced by them. Some of the world's worst natural and human-made disasters have occurred in South Asian countries, which have led to massive numbers of mentally distressed communities. The sheer numbers of people affected call for large-scale interventions that can be carried out by non-specialists (see Minhas et al., this issue). As this special issue was being put together, the earthquake in Nepal killed over 8,000 people, and Brandon Kohrt, who authored the paper on depression and trauma among the Nepali (this issue), is currently busy getting material and mental health aid to the people there.

The human-made and natural disasters as well as other variables such as socio-economic factors have also led to massive numbers of South Asians migrating to other countries, particularly high-income countries, whose cultures differ from these immigrants in significant, and often distressing ways. Mental health researchers and practitioners in HPI cultures are increasingly studying and serving South Asian immigrants, yet few are familiar with all of the varying cultural variables that may impinge on the mental health of their clients. It is hoped that the papers in this special issue will spark more interest among these researchers and practitioners to learn more about the cultural heritage of their client base.

The need for more knowledge

Relative to the vast numbers of people living in South Asia and the enormous problems affecting the mental health and psychosocial functioning of its people, little research has been published in the area of mental health of South Asians. This knowledge gap is part of the 10/90 divide discussed by Patel (2006), that 90% of published papers are written by researchers trained in and affiliated with institutions with a Eurocentric outlook that tends to be intrapsychic-oriented and individualistic in world view. Yet it is critical that global mental health researchers understand the cultures of these people, since few South Asian countries have the resources to provide relief for their people after disasters, and interventions are regularly carried out by international organizations often led by people with a very different cultural heritage. Mental health professionals are only now beginning to understand how the religio-cultural world-views of people shape their responses to stressors and severe traumas. There are large gaps in knowledge about how world-views impact the mental health and psychosocial functioning of the people of South Asia. It is hoped that the SISAMH will provide some information that will help to fill in some of these gaps.

To provide a crude measure of the knowledge gap that exists in the social sciences on mental health and psychosocial issues relevant to South Asian populations, a literature search was conducted in June 2015 using the search terms ‘mental health,’ ‘South Asia,’ and ‘South Asian mental health’. The first term generated 428,082 references (292,693 peer-reviewed). Adding the term ‘South Asia’ reduced the number of references to 808 (452 peer-reviewed). Only two papers were generated using the term ‘South Asian mental health.’ Adding specific regions to the search was just as informative. For example adding the term ‘India’ to ‘mental health’ generated 3,400 papers, but adding the term ‘culture’ reduced that number to 230. Of course, as noted, these are only crude measures of available research, and there are some excellent sources of information on mental health and culture available (e.g. Bhui & Bhugra, 2007), but by any standard, the number of available credible publications on South Asians is low, relative to the total number of publications on mental health. Empirical studies on mental health and psychosocial issues relevant to South Asian communities appear to comprise less than 1% of published studies accessible to an international readership. Even if the number of papers relating to South Asian mental health was double the number generated by the search, the results are startling and disheartening.

Additionally, when examining the names and affiliations of the roughly 400 papers relating to South Asian mental health, it was noted that the majority of first authors were those whose names indicated that they were more likely to be male, of European ancestry, and affiliated to European, Australian, New Zealander, or North American institutions. The findings indicate that the 10/90 divide discussed by Patel almost 10 years ago may actually be widening. The argument is not that people from one culture cannot accurately reflect the perspectives of those from another; it is rather that people from certain (usually low-power) cultures appear not to have had the opportunity yet to present their research from a point of view that is authentic to their lived experience.

The six papers proposed in the SISAMH are thus an attempt to fill part of the lacunae in the field, and to bridge the 10/90 divide. As noted above, a unique feature of the SISAMH is that all first authors are South Asian or of South Asian descent, and have a ‘lived experience’ of being South Asian; the majority also currently live in the communities they study.

Diversity of authorship, methodology, and topics

Despite the small number of papers in the SISAMH, the papers are diverse with regard to authorship, profession, methodology, samples, and topics. The authors comprise a diverse body of researchers and practitioners/field workers, and include perspectives of aid organizations working with these communities. Three of the six papers are first-authored by women, which is a significantly higher proportion of women seen in academia or in authorship of peer-reviewed publications. Additionally, the topics covered in the special issue are as relevant to women as they are to men.

The special issue spans a range of topics, from traditional psychiatric diagnoses such as autism to other urgent community-oriented issues such as substance abuse and post-trauma reactions. Methodologies used range from gene x environment to qualitative examinations of narratives. A range of populations (adults, adolescents, women) is also included in this series. Cultural issues such as religious beliefs (e.g. satvic temperament) and caste, and their impact on mental health and psychosocial functioning are introduced. While the focus of the series is on psychosocial dysfunction, research on more positive constructs such as resilience are also included. One commonality of the papers is that socio-economic status is considered an important variable impacting mental health.

A comment on process: why it is difficult to bridge the 10–90 divide

Attempting to put together this special issue has proven exceedingly difficult, since I am a full-time academic and run my own research lab. I had three criteria for inclusion of papers in this issue: (1) that the first authors or principal investigators (PIs) of the research be intimately connected to South Asia, (2) that the research would be ecologically sound and useful to the communities where it is being conducted, and (3) that the papers represent many dimensions of diversity, so that underrepresented voices are included as much as possible. Hence I had resolved to solicit papers written by South Asian women, and encourage papers that were grounded in cultural ways of thinking about mental health. Having spent a considerable amount of time locating researchers in South Asian countries, written to them with my idea, and having some of them agree to participate, I wrote the proposal for this special issue in October 2010.

I sought out journals I believed would be open to considering publishing the collection, being reasonably optimistic that journal editors would welcome this effort, given the gap in knowledge. Imagine my surprise and dismay when the editor of a prominent cross-cultural journal rejected it mainly because of doubts about whether the topic would attract enough of a readership to increase the journal's Impact Factor, and because perhaps the region being focused on was unlikely to interest the journal's subscribers. The editor also voiced doubts as to whether the collection would pass the review process because of the number of qualitative studies. There seemed to be no consideration given to the issue of ecological validity. The validity of psychological constructs conceived of and validated in HPI cultures and then used in LPC cultures must necessarily be put to the test using qualitative data – this is simply good science. It was disheartening to learn that an editor of a prominent journal missed this point, and placed little value on qualitative data. It was no wonder that the 10/90 divide was so difficult to bridge.

It was therefore a relief when the International Review of Psychiatry agreed to consider the proposal. Unfortunately, by the time the proposal was accepted, several authors who had initially agreed to participate were no longer available. Nevertheless, the six papers in this special issue do adhere to the original criteria I had set. The papers are authored by people who are themselves from the communities they write about, three of the six papers are first-authored by women, and all the papers are deeply engaged in issues of culture as they relate to mental health. I hope that the special issue serves to increase the impact factor of the International Review of Psychiatry, and that the readership of the journal is interested in the communities represented here. One way to bridge the 10/90 divide is for more researchers from HPI cultures to collaborate with their counterparts in LPC cultures and provide them opportunities to be principle authors on topics relevant to their research and practice. I hope the SISAMH is a step in that direction.

I wish to thank the authors of these papers, who remained tenacious throughout the process of finding a home for the special issue and through the review process. A special thank you also to the reviewers of these papers, who provided excellent feedback, sometimes multiple times, on ways to improve the contributions in this issue. Their guidance and advice proved invaluable to the authors. Finally, I hope this special issue finds a high readership, so that more editors will feel comfortable hosting projects such as these.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.