Research for clinical practice: Focusing on the link

These are exciting times for researchers in psychiatry, behavioural sciences, and neuroscience. Opportunities abound everywhere they turn. Even though great strides have been made in classification of mental disorders, leading to the development of the hitherto elusive ‘common language’ (Sartorius et al., [1993]), there remain many nosological challenges. The boundaries between many traditional syndromes remain contentious and the distinction between normality and ill-health is itself often a puzzle. Significant developments have taken place in brain imaging where, for example, important new understanding of the basis of addictive behaviours is emerging (Volkow et al., [1997]; Wong et al., 2007). In pharmacogenetics, there are future prospects of individualized treatment of disorders, including mental disorders. But for now, the biological basis of many mental disorders remains poorly understood and the great promise of genomics, as exciting as it is, waits for breakthroughs in the identification of reliable and valid endophenotypes. New medications are being developed to provide not only relief from the symptoms of psychiatric disorders but to also avoid the side-effects that older treatments sometimes cause. However, even in this area every putative breakthrough often produces its own challenges as early enthusiasms become tempered by experience (Lieberman et al., [2005]). Epidemiological studies of mental disorders have been transformed by the availability of reliable tools that allow for huge numbers of respondents to be interviewed by lay persons (Kessler & Ustun, [2004]), thus bringing to common awareness what may be regarded as a previously hidden burden of mental disorders in the community. However, with that transformation have come new questions about the validity and even utility of the findings of community surveys (Kendel & Jablensky, [2003]; Jorm, [2006]). For example, how do we translate the findings of community-based surveys to effective policy formulation when the prevalence rates of disorders often seem implausibly high?

In the current climate of scientific opportunities and challenges, an overarching and pressing need subsists: how to link great developments in research to the reality of clinical practice. Without the identification of that link and a determination to focus on it, research in psychiatry can so easily become a purely ‘academic’ exercise with little relevance to the patients who require care. Two examples may serve to demonstrate the apparent disconnect between current research and the delivery of service to persons in need of mental health service. First, a great deal of the knowledge base for current classification of mental disorders has come from tertiary care settings. Yet, the majority of persons with mental health persons are seen by primary care providers for whom such clarification is often of poor utility. Primary care clinicians often find current classification out of touch with clinical reality and sometimes unhelpful for patient care. The debate about efficacy and effectiveness in clinical trials is another aspect of the same disconnect between where knowledge is derived from and where such knowledge is intended to be used. Selection of participants for clinical trials in psychiatry strives for the ‘ideal’ patient, typically recruiting only patients with ‘pure’ disorder, without comorbid mental and physical conditions. Such patients are different from those seen by clinicians who are engaged in the daily activity of patient care. For such clinicians it is frustrating to find that long after efficacy trials are completed for a particular intervention and patients in the ‘real world’ of clinical practice are offered the intervention, the gap between efficacy and effectiveness begins to emerge.

A second example is the global response to the burden of mental illness. While it is commonly recognized that research has a vital role to play in addressing the huge burden that mental disorders constitute for public health worldwide, there is a striking unevenness in the global mental health research endeavour. In particular, the response to the challenge of mental and neurological diseases in low- and middle-income countries is grossly inappropriate to the extent of the burden resulting from such diseases in those countries. The gap between the pressing need to find solutions to the great health challenges of the world and the research activities that are actually going on to address those challenges has been a concern to the World Health Organization and the Global Forum for Health Research, among a number of international organizations, for several years. In particular, the Global Forum for Health Research has drawn attention to the fact that only 10% of the world's medical research effort is targeted at 90% of the world's population living in low- and middle-income countries, the so-called 10/90 gap (Global Forum for Health Research, [2000]). As has been shown by others (Saxena Paraje, Sharan, Karam, & Sadana, [2006]), that gap is even wider for mental health. Given the vital role that both research and mental health have to play in development (COHRED, [1990]; Gureje & Jenkins, [2007]), this disconnection between need and global research effort in mental health is one with serious consequences for the majority of the world's population, who reside in low- and middle-income countries.

The papers in this issue provide insight into some of the major developments taking place in psychiatric and neuroscience research. They review the prospects that such research hold for clinical practice and provide important clues about how the link between research and provision of care for patients might be further strengthened. First and Westen examine the current status of the DSM-IV and ICD-10 classifications and provide suggestions on how to improve the clinical utility of future revisions. Furthering the debate, Szatmari and colleagues review the evidence suggesting that genetic epidemiology, particularly the family study method, can inform the classification of psychiatric disorders in adults and children. Eaton et al. review some common tools for the ascertainment of psychopathology in psychiatric epidemiological surveys and raise important questions about their validity. While acknowledging the remarkable contribution of epidemiological surveys to our understanding of the nature and impact of mental disorders, Kessler suggests that in order to improve the clinical relevance of such surveys, a link has to be forged between community-based epidemiology and clinical epidemiology. Along broadly similar lines, Depp and Lebowitz revisit recent discussion on translational research and offer suggestions on how best to bridge the gap between efficacy and effectiveness-orientated clinical trials. Brain imaging and molecular genetics are no doubt two of the areas in which the more engaging findings are being made in current psychiatric research. Malhotra and colleagues review some recent literature of pharmacogenetic studies of psychotropic drugs and some interesting future prospects, including those relating to the prediction of drug-induced adverse effects. Wong et al. provide a review of brain imaging research, focusing on the relevance of recent findings to clinical practice. Two papers, one by Mohan et al. and the other by Stein and Seedat, examine current research in psychiatry from the perspective of low- and middle-income countries. For the busy clinician, the challenge of sifting through the constant stream of information emanating from research in psychiatry can be daunting. Making sense of the information can be even more tasking. Using some recent examples from the literature, Cohen and Gureje discuss the issues involved.