1. Conducting Mental Health Researches in Africa: Challenges and opportunitiesExperience from Ethiopia Teshome Shibre Department of Psychiatry, School of Medicine, College of Health Sciences, AAU and Zewditu Memorial Hospital, FMoH

2. Presentation outline Brief background about mental health researches in Ethiopia Challenges of conducting MH research Opportunities to conduct MH research in low income countries, Ethiopian experience

3. Top 10 subject areas published in biomedical journals (Shibre 2009, unpublished)

4. MH researches before 1990 Clinical and community based studies, instrument validation studies (R. Giel, F. Kortman, F. Workneh) Suicide and DSH studies (,L. Jacobsson, A. Bekrey) Suicide (A. Alem, Kebede, Desta, Araya) Studies among Children and adolescents (Tafari)

5. Transition

6. Advance in Mental Health Research after 1990 Internal & External collaboration for research and capacity building International grants (SMRI, SIDA/SARCE) TAAPP collaboration Epidemiological studies External grant Validation of research tools SRQ , CIDI, DICA, IPDE, SCAN, SF-36 Use of innovative case detection methods (e.g. KI)

7. Focus of post-1990 researches Butajira Study Psychotic disorders (Schizophrenia and other psychotic disorders, and bipolar disorder) Suicide Epilepsy Alcohol and Khat Focus on special population Disorders in children Depression

8. Focus of the Butajira study Prevalence of priority disorders including maternal depression both in Butajira and other population groups Course and outcome of priority disorders Impact of priority disorders Studies on special(population )

9. Reports on priority disorders: prevalence §-Tadesse B, Kebede D, Tegegne T, Alem A. Childhood behavioural disorders in Ambo district, Western Ethiopia. I. Prevalence estimates. Acta Psychiatrica Scandinavica 1999; 100:92-97

10. Service utlisation data For those with schizophrenia and bipolar disorder: proportion who have ever received psychiatric treatment is < 10% (Kebede et al 2003; Negash et al 2005) For those with some depressive symptoms: proportion who attend for general medical attention because of these symptoms: ~40%-80% (Fekadu et al 2007 and 2008)

12. High level of unemployed and unmarried among those with schizophrenia

13. Level of general day to day disability very high

14. High level of stigmaperceived by family (Shibre et al 2003) and perceived by patients(Assefa et al 2010, unpublished)

15. High level of family burden (Shibre et al 2003)

18. The only population based studies on bipolar disorder in Sub-Saharan Africa (possibly developing countries)

19. Study results are internationally recognised and have challenged some of the major dogmas on the outcome of psychosis

20. Important data for policy makers

21. Established service programmes in research sites

22. The Butajira project runs a model outreach service

24. Challenges 1. Working environment Work load and extremely difficult situations Lack of training to plan and implement research projects Poor culture for mentoring and grooming young researchers Low salary of researchers High rate of brain drain This has forced many people who had dreamt to be researchers and scientists to devote their time to income-generating activities such as Private clinical practice or The Consultancy syndrome (Alem 2007, AAPAP meeting) Market driven education

25. Challenges 2. Institutional factors Insufficient training of staff in research protocol development fund soliciting project execution and financial management Lengthy ethical clearance process at different levels Long buearocratic process to utilise funds Lack of system for remuneration from research grants to complement their salaries Lack of the required literature Poorly developed lab facilities Shortage of basic scientists Lack of strong demand for publication by Universities * Difficulty to publish in high impact factor journal

26. Challenges 3. Intrinsic nature of psychiatric research Instruments are not validated for use in all cultures Absence of vital event registration system Recall for important life events and past episodes of illness in Illiterate society is very difficult Retrospective data collection suffers from recall problems especially with illiterate subjects Resources and logistic difficulties related to Longitudinal studies The obligation to treat those persons identified as cases through the research activity (< 10% of the Butajira cohort had access to modern psychiatric care)

27. Opportunities 1. General Low cost Possibilities for large population studies Existence of wide cultural and genetic diversity to study Willingness of people to participate in research Many unexplored areas, cultures and values Growing number of professionals

28. Opportunities 1. General … Favourable conditions for capacity building through exchange programs for researchers and residents Service related research in traditional society is not explored e.g. factors influencing integration Explore family based care system Etiological researches e.g infectious causes

29. Opportunities 3. Political commitment Political commitments to integrate MH into existing health care system and supporting research National MH Strategy 2- HEW per smallest admin unit (total over 34,000) Commitment to developed health infrastructure at all levels

30. Opportunities 4. University commitment Dramatic improvements in the University academic undertakings and commitment to research Expansion of regional universities and commitment of Postgraduate education (MSc and PhD level trainings)

31. Opportunities 5. Department Excellent track record in International Collaboration Increased donor’s interest New Ph.D program in Mental Health Epidemiology Experienced research team Availability of validated instruments Improved Research infrastructure - Guesthouse, Office

32. Conclusion Challenges to provide service and conduct mental health research in Africa are many But there are also many opportunities to make a difference in mental health of our people in the continent and improve research collaboration.

33. Thank You