Research as a Path for Educational Opportunities in Global Mental Health

Globalization has produced increasing interest in international opportunities across the education spectrum. Universities are developing majors and minors in global studies, global health, and international affairs. Medical schools and related health sciences have responded by developing international programs for education, research, and clinical outreach not only in low- and middle-income countries but also in developed countries, where differing models of health care delivery, insurance, and governance offer students alternative perspectives on medical care. Deans and program directors have recognized the high priority placed on global opportunities among applicants to medical schools and residencies, as well as the role of such programs in the recruitment and retention of the best candidates (1, 2).

At Stony Brook School of Medicine, we have witnessed a dramatic upsurge of interest in participating in a global health elective among medical students, dental students, physician assistant and nursing students, and residents from various specialties. In one program aimed at first-year medical students interested in participating in international research, application rates have tripled over the last 3 years. Demand for short-term clinical electives—particularly in Latin America, where Spanish language immersion is viewed as an invaluable ancillary benefit—has also increased exponentially. Among a class of 128 first-year students, about one-half will have participated in some international activity before starting their second year. This is a national trend, and there is mounting evidence that these popular programs have a profound effect on students’ choice of specialty, career path, and attitudes toward treating indigent patients, as well as returning to international work (3–6).

Where does mental health fit into this trend? Not surprisingly, psychiatry has lagged behind those initiatives that are based in primary care and infectious diseases, which are the traditional foundations of unmet need among developing countries (low- and middle-income countries) and historically represent the greatest burden of disease (7). This may be changing with the recent emphasis on noncommunicable diseases in global health and the impressive evidence that psychiatric and substance abuse disorders are among the greatest contributors to the global burden of disease (8, 9). For this reason, it behooves leaders of global health education to consider ways to cultivate opportunities in mental health at international sites.

Nevertheless, most global health programs remain grounded in the more traditional interest in pediatrics or in tropical medicine, HIV, or chronic medical conditions such as diabetes and heart disease. For medical students seeking a global health opportunity, placement in a specialty mental health program does not fit these expectations, and a specific interest in mental health is rare. There are, no doubt, several reasons for this. Perhaps most notable is the low level of interest in psychiatry among medical students (<5%) (10, 11). With the exception of the occasional medical student who attends medical school with the goal of becoming a psychiatrist, most students seeking a global health experience are drawn to more traditional areas of medicine. Even when a student is receptive to placement in a psychiatric setting, there are distinct challenges to identifying appropriate mental health opportunities that do not run aground on the prevailing stigma, lack of comprehensive services, potential human rights abuses, and the generally low priority assigned to mental health in most low- and middle-income countries. For this reason, the most likely clinical context for the global mental health student’s experiences is the primary care setting, in which screening for common disorders, integration of care that relies on collaborative models, and training of nonspecialty providers may have a positive effect on a local population. At the same time, because of the often overwhelming clinical challenges that arise in under-resourced primary care settings, these sites may not be conducive to a specialized interest in the pervasive unmet needs for mental health education, screening, and treatment.

This article aims to propose some starting points for developing educational opportunities in global mental health that can serve to introduce medical students to psychiatry early in their career and to acquaint them with the prevalence and importance of mental health issues both domestically and globally.

Collaborating With International Universities, Nongovernmental Organizations, Private Clinics, and Hospitals

From the standpoint of a university, school of medicine, health sciences center, or global health institute, there are a variety of strategies for building international collaborations. Roughly, these collaborations may be divided into the following: (a) study abroad and student exchange programs; (b) clinical outreach, which may take the form of establishing a clinical campus overseas, providing clinical expertise and consultation, or conducting short-term clinical missions typically sponsored by nongovernmental organizations (NGOs); and (c) collaborative research. Each of these strategies has a place and may afford students unique opportunities to gain understanding of the global burden of disease, to recognize health disparities and challenges to well-being in under-resourced settings, to appreciate the role of health systems and governance, to gain cultural and language competencies that expand professional horizons, and to foster a commitment to social justice. These opportunities will better prepare our students as physicians in the globalized world of the 21st century.

At Stony Brook School of Medicine, we offer a philanthropy-sponsored program to second-year medical students; this program enables them to spend 2 months engaged in research at an international site. For >10 years, students have participated in a variety of projects around the globe, and they have conducted our research in all areas of medicine. Some students developed their own miniproject capable of being executed in a short time frame, and others joined existing research initiatives. Although students have benefited from these experiences, which were sometimes transformative, there was almost no cumulative benefit to the institution. Each year, students were faced with the prospect of seeking an international site, project, and mentor, and there was minimal carryover from one year to the next. Only in a few instances did students return to a previous site or prior project.

In an effort to rectify this shortcoming, and to build an enduring portfolio of opportunities of proven quality, we have devoted considerable resources to identifying reliable international partners and securing a memorandum of understanding (MOU) that allows for a range of collaborations, educational exchanges, clinical rotations, and research scenarios. This is a superior approach that facilitates a mutually beneficial relationship between the institutions and organizations and allows for progressive refinement and depth in the experience. The inherent reciprocity of such agreements makes additional demands on the home institution, but there is considerable value in hosting international students and integrating them into the educational culture of the university. Students thus gain new perspectives both during their international elective and by virtue of interacting with international students at home (12).

Identifying Opportunities for Mental Health Research

In the context of this medical student international research fellowship program, we have sought opportunities for mental health research. Such opportunities may be found in dedicated psychiatric settings, such as university-affiliated clinics and hospitals, but these specialized care environments are often not conducive for students, especially early in their training. The language barrier presented by an acutely ill psychiatric patient may be insurmountable for any students other than a genuinely native speaker of the patient’s language. Moreover, our students have not yet embarked on clinical rotations and have generally not been exposed to psychotic illness. For students who do not plan on a career in psychiatry, a focus on severe and chronic psychiatric illness may be less relevant and instructive than gaining some familiarity with more prevalent conditions such as depression, alcoholism and substance abuse, posttraumatic stress disorder (PTSD), and dementia. For these reasons, mental health issues encountered in community settings or in a focused research project are more amenable to student involvement. Surveys, epidemiological studies, and data analysis of completed projects are also appropriate avenues for students to learn about global mental health. Because language and cultural barriers may limit direct contact with patients, it is crucial to define a meaningful role that is both educational for the student and contributes to the project. In all cases, there needs to be an international site supervisor or faculty member who will work closely with students to ensure that they gain a meaningful experience.

Here we present four examples of research projects on topics in mental health that were carried out (summer 2013 and 2014) or planned (summer 2015) by medical students. None of the students were well acquainted with the language or culture of their research site, but each plays a key role in carrying out the project.

PTSD and Depression Among Sexually Exploited Victims in Thailand

A senior student sometimes participates in this program. Two years ago, available funding was sufficient to sponsor an intrepid project in Bangkok, Thailand. Dr. Michelle Dumond, currently a resident in family medicine at the University of Washington, was interested in evaluating the prevalence of PTSD and depression among sex workers over age 18 and working in Bangkok bars. She identified an NGO, the Tamar Center, that offers occupational training and counseling to prostitutes, and she successfully established a collaboration that allowed her to carry out a small study of their clients. She elected to use child versions of the Children’s Depression Inventory Depression Index and the University of California, Los Angeles PTSD screening questionnaire, and she arranged for them to be translated into the local dialect. Dumond developed an informed consent process that was approved by the Stony Brook Institutional Review Board and relied on voluntary participation of clients at the center. She was able to screen 33 participants and found that 58% and 45% met criteria for PTSD and depression, respectively. Risk and severity were correlated with the length of time the individuals had worked as prostitutes.

The small sample size limits the generalizability of the data; however, this is typical of projects undertaken by individual students in a 2-month time frame. For this reason, Dumond’s results have not yet been published, but the project was highly educative and informative. She gained real-world experience in confronting the challenges of field research in a foreign setting, and her analysis of the data and discussion was expertly done. She was impressed that her structured interviews appeared to offer real cathartic relief to the clients in the study, and this accorded with independently published findings that contradicted PTSD research on debriefing. Overall, this project was a fruitful introduction to mental health issues in a low- to middle-income country (13).

Dementia Prevalence in Cartagena and Assessment of the Eight-Item Interview in Differentiating Aging and Dementia

In 2014, two second-year students, Kelly Summers and Sonia Bharel, collaborated with me and Dr. James Galvin on a prevalence study of dementia in some of the poorest barrios of Cartagena, Colombia. The project was made possible through an MOU with a private school of medicine, the Corporaciòn Universitaria Rafael Nuñez. We initially planned to recruit participants over age 60 in the city’s public health (CAP) clinics, but it turned out that the clinic sites were not conducive to carrying out research. The waiting rooms were crowded, there was a preponderance of children, and the clinicians were too rushed to accommodate research interventions. By serendipity, we found that adjacent to the CAP clinic was a day program for elderly adults who required nutritional supplementation and socialization. Nearly all of the clients in these programs met the criteria for the proposed study, and the director of the Centro de la Vida became an enthusiastic collaborator on the project. Because of the language barrier, the dean of the faculty of medicine, Dr. Juan Carlos Lozano, assigned five medical students to the project to interpret and assist in the administration of the screening instruments (Jose Juliar Garcia Paredes, Susan Quintana Pinedo, Deivis Marroquin Castilla, Cindy Medina Gomez, and Zully Garcia Carreazo). Our assessment included the Eight-Item Interview to Differentiate Aging and Dementia, the Mini-Cog Assessment, the Montreal Cognitive Assessment, and the Four-Item Patient Health Questionnaire. Our intent was to administer the Clinical Dementia Rating as a gold standard, but its length and complexity was impractical in this setting because many of the clients had minimal education. The Stony Brook students served as study coordinators and entered the data into SPSS software.

We evaluated 221 participants and the data are currently being analyzed. This study presented special challenges because of the participants’ low socioeconomic and education level. It raised interesting questions about the utility of accepted instruments in unfamiliar settings. The students gained insight into the effects of demographic factors and aging on cognitive performance, along with familiarity with research methods and analytic tools. Again, the challenges of exploring social and cognitive dimensions of a clinical population in a low- to middle-income country was enormously rewarding for the students and introduced them to core questions in the domain of mental health.

Assessing Drug Use Among School Children in Santiago, Chile, With Peer Methodology

Stony Brook School of Medicine has executed an MOU with the University of Chile Faculty of Medicine in Santiago, Chile. In summer 2015, two second-year students, Brianna Morgan and Sarah Brovender, assisted Dr. Jorge Rodríguez from the University of Chile School of Public Health with a project of his design and execution. This study examined the prevalence of drug use among teenage students, relying on a methodology designed to improve the reliability of the informants. Previous estimates of drug use among students ages 14–16 are believed to significantly undercount the true prevalence owing to the lack of veracity of students completing anonymous questionnaires. To establish peer rapport and extract more reliable data, Dr. Rodríguez has recruited students with a history of drug use to conduct the interviews of students in this study. In addition, a supplementary study of medical student substance use was undertaken. The medical students will largely focus on analyzing the data, carrying out a search and review of the relevant English literature, assisting in the preparation of a report, and participating in presenting the findings at an international meeting. They are now submitting their findings for publication.

Neural Network Activity Among Patients With Mild Cognitive Disorder and Early Alzheimer’s Disease, Compared With Healthy Siblings and Healthy Nonrelatives

We have an active MOU with Ege University in Izmir, Turkey, where we have exchanged medical students for clinical and research electives. In summer 2015, Swati Chandhoke, a second-year student, spent 2 months working with a psychiatrist, Dr. Ali Gonul, on a project on the neuroimaging of Alzheimer’s disease. The goal of this study is to define and measure the activity of the pathological and compensatory neural networks that are related to minimal cognitive impairment and early Alzheimer’s disease. The student will acquire an understanding of the known pathology, genetics, and putative mechanisms of the dementing process associated with Alzheimer’s disease. She will participate in several phases of the study and will play a significant role in data capture, entry, and analysis. As a result, the student will develop a better understanding of cognitive functions in health and disease, and she will gain perspective on the role of psychiatry in the research, diagnosis, and management of neurodegenerative disorders. In addition, they carried out a project that involved the neuro-imaging signatures of late onset depression, and the student is currently submitting a paper reporting these findings for publication.

Discussion

Global mental health is a hugely important issue from the standpoint of global burden of disease, and it offers an excellent opportunity for medical students to gain early acquaintance with psychiatry and career opportunities in mental health. In meeting individually with each student who expresses an interest in participating in a global health opportunity, the prima facie ranking of factors that influence the selection of a project seems to be (a) location, which may be a product of preexisting experience, interest in learning about a particular language and culture, or some other factor such as family of origin; (b) general area of research, with infectious diseases, cancer, and women’s health topping the list and mental health only rarely cited without coaching; and (c) availability of a strong mentor and project (i.e., the student states that he or she will “go anywhere” and “do anything,” as long as it promises to be a good educational experience). Occasionally, and in the distinct minority, are those students who want to carry out a specific project in which they are keenly interested (e.g., attitudes toward female genital mutilation in Ethiopia, depression among sex workers in Bangkok, or the effect of low vitamin D levels on maternal fetal health in Northern Ireland). Not surprisingly, global mental health has not been a frequent topic because the role it plays in the global burden of disease is not common knowledge outside of the field.

An interest in learning or improving Spanish language skills was the most frequently reported motivation for study abroad. For this reason, we have active MOUs in Colombia, Ecuador, Peru, and Chile, and students have also carried out projects in Mexico and Argentina. Students from India, China, South Korea, and Japan sometimes seek projects in those countries where their language skills can be an asset to the project. Many students express an early interest in infectious disease research. In summer 2015, there were projects related to HIV in Mexico and Argentina, treatment-resistant malaria in the Amazon, tegumentary leishmaniasis in Peru, and mycetoma infection in Madagascar. As a result of established MOUs, bilateral student exchange, and longitudinal involvement at specific study sites, we have cultivated a cadre of outstanding and committed mentors that ensures a rewarding educational experience for the students.

These four projects represent the intersection of student interest and available projects in mental health research at our international partner sites. It is notable that global health represents one track in our Scholarly Concentration Program available to medical students who want to make a 4-year commitment to research (medicine.stonybrookmedicine.edu/firstyearresources/mdscholar). Other tracks include research (basic, translational, and clinical), education, and humanities. Of 55 students (of a class of 128) who applied for the Scholarly Concentration Program last year, 33 applied for the research track, 5 for the education track, 4 for humanities, and 13 for global health. Explicit interest in doing research in psychiatry or mental health among all of the tracks was rare, except in the humanities track, which tends to capture those students who are interested in psychosocial and behavioral issues. The student who studied depression and PTSD in Thai sex workers was actually in the humanities track. Other studies of PTSD among returning veterans, as well as the clinical characteristics of “difficult patients,” were also situated in the humanities track. The above-described students conducting projects on neuroimaging of Alzheimer’s disease and on adolescent drug abuse are in the global health track, but their overriding interest was in pursuit of an international experience and not specifically psychiatry.

This naturalistic finding supports the idea that the humanistic elements of psychiatry often appeal to students entering the field. Even as leaders in the profession argue that psychiatry’s future equals clinical neuroscience, it is debatable whether neuroscience research alone will succeed in successfully recruiting students to the field, especially as clinicians and educators. M.D./Ph.D. applicants to research-oriented psychiatry residencies may increase, and “brain camp” neuroscience retreats may encourage a select few to enter the field; however, these candidates will have little impact on the shortage of clinical psychiatrists that is expected in the wake of retirements by a disproportionately aging workforce (14–16). Developing opportunities in global mental health research for medical students offers another path to specialty interest in psychiatry, one that operates in the context of public health, rather than neuroscience. This approach highlights the importance of the global burden of disease, surveillance, and development and implementation of innovative models of care as well as the need to address the challenges of cultural diversity, poverty, stigma, human rights, health systems, and governance. From this perspective, psychiatry looms as a major potential contributor on the global public health scene and can offer benefits to populations in need today, rather than promissory notes for the future. The psychiatrist with an M.D./M.P.H. dual degree may find immediate opportunities to make a difference because there are real-world problems that are amenable to advances in public mental health programs around the globe, both in low- and middle-income countries, as well as in advanced settings where improvements in screening and models of care are still forthcoming. Creating opportunities for students and residents to engage these challenges can contribute a new perspective on the role of psychiatrists in the modern world.