For much of the world, the term "globalization" captures a perceived acceleration in the development of social and economic interconnection and assimilation. These changes have also penetrated the daily life of academic medical centers, with increasing international collaboration in research, service provision, consultation and training. Growing attention, particularly in the past decade, to the crucial role of public mental health as a part of public health in both the developed world and the developing world has resulted in the increase of data suggesting that mental disease is one of the most prominent causes of disability (1—3). However, in order for such a broadened appreciation of the geography and relevance of mental health to be effective and constructive, it will need to be thoughtfully put into operation as U.S. academic centers seek to contribute their expertise and assistance. A globalization of psychiatry by academic departments of psychiatry reflect what we call bidirectional internationalism. As psychiatrists, our emerging roles as global clinicians and researchers should be channeled in ways that not only export to others what is familiar to us but should also enhance understanding of how our familiar set of research priorities and clinical paradigms may narrow our vision. We must be open to new perspectives from different parts of the globe in order to face the range of challenges at home, especially to underresourced and disadvantaged populations.
Internationalism presents, as an issue, the role of psychiatry in society at large and the impact of culture and social experience on the trajectory of biologically mediated illness. From an internationalist perspective, there are four related but distinguishable challenges facing our profession and the dominant lines of investigation and patterns of capital and research investment that shape it: public health, biosocial pendulum, cultural competence, and evidence-based medicine.
Psychiatric expertise has had an unclear and varying role in fashioning public health strategies and health policy. Scientific investment and attention given to assessing and implementing community-based interventions barely approach the investments made in many other treatment interventions. The development of properly trained and experienced professionals, an academic infrastructure, and a research-base necessary to generate mental health promotion and mental illness prevention as central components of public health services and planning all need to be addressed.
Psychiatric practice has regularly vacillated between emphasis on biological versus social/psychological explanations of behavior and treatment. This swinging of the pendulum sets up a false and often destructive polarity between realms of experience and phenomena that contribute to behaviors and emotional suffering. Prominent researchers in neuroscience and psychopharmacology will often be the first to caution against biological reductionism and the importance of environment and culture on the expression of genotypes and neurobiological functioning. We have more than ample evidence suggesting that environment is biology. For example, environmental stress reduces neurogenesis in the hippocampus, while nurturance increases this neurogenesis (4). Eating certain nutrients affects the methylation process required for the expression of certain genes (5). Thus, environment is biology. However, a steady platform for the skills, policies, reimbursement, and research methods, upon which more integrated practices and interventions can flourish, has yet to be established.
One symptom of a shaky platform is a flowering of interest in the importance of cultural competence, which tends to be general and variably incorporated into models of research or service delivery and is, unfortunately, often reduced to a focus on a few specific, frequently stereotyped if not idiosyncratic, conclusions about supposedly unique features of a particular ethnic group or culture.
Crucial to testing hypotheses on treatment, large, standardized clinical trials also reflect the use of measures and arrangements of manpower (e.g., follow up, infrastructure, values of de-stigmatization) that are not always reproduced in the real world, particularly in economically disadvantaged settings. In our communication as psychiatrists about which clinical practices we believe to be best, we should be cognizant of and benefit from attention to the impact of socioeconomic context, culture, history, and resources on measurement outcomes and priorities. We must acknowledge the wide range of research questions left unasked due to the set of interests and investments specific to any political-economic environment, from which resources for research and important research questions arise.
We believe that service and research in international psychiatry can help address the important issues facing U.S. psychiatry as it enters the 21st century and, at the same time, can improve the effectiveness of care for those with mental illness worldwide. Adherence to the concept of bidirectionality is key. In this context, bidirectionality means that our methods of scientific analysis, delivery of care, and identifying illness can be enhanced to the same degree that they can influence and enhance the methods of others. Bidirectional internationalism means repositioning ourselves as partners with others rather than as the sole experts at the top of a hierarchy. The universality of our nosology of disease and our choice to essentially focus treatment development through neurophysiological paradigms must be tested and adapted through self-reflection in response to the diversity of culture, experience, and circumstance in the rest of the world. Our patients, and those in the rest of the world, will benefit from this. The universe of relevant, useful knowledge about illness and treatment must genuinely include the universe of experience.
Exchange with the rest of the world would benefit and broaden our own efforts, which would then further strengthen our value to others. However, while other parts of the world are meeting critical needs, our systems of research and practice have often distracted us from a more comprehensive view of the range of interventions and levels of analysis possible in meeting public mental health goals (such as including more serious attention on community as a unit of intervention). It is equally as beneficial for U.S. clinicians and mental health planners to learn about how community mental health services work in Jamaica, for example (6), as it is for Jamaican clinicians to learn about the latest information on the polypharmacy of bipolar disorder from U.S. clinicians. The development and study of the effectiveness of mental health interventions in many other parts of the world highlight and capture issues too often eclipsed in the U.S. (e.g., the role of different manpower, low-tech primary care settings, community-action interventions, alternative methods of delivering psychotherapeutic and psychopharmocological interventions) (7—20). A robust, curious, bidirectional international psychiatry has the potential to transform psychiatric practice everywhere, equipping it with a rigorous eclecticism, cosmopolitanism, responsiveness and relevance.
As a result of bidirectional internationalism, we expect the four challenges identified (public health, biosocial pendulum, cultural competence, and evidence-based medicine) to be significantly impacted.
Regarding public health, the logistical and service demands involved in reducing global mental illness burdens will require more serious efforts to bridge the chasm between clinical practice, research, and training, and population-based mental health promotion and prevention programs. Enhanced opportunities for psychiatrists to become skilled and experienced in translating both scientific knowledge and systems planning globally into effective, locally appropriate and feasible interventions will benefit the profession as a whole. It will enhance the attention given to public mental health considerations in social policy making in the U.S. and abroad and expand the empirical base describing the role of psychiatric morbidity in social and economic development.
Concerning the biosocial pendulum, current disparities of care between developed and developing nations will require far more serious attention to and sophisticated study of population-based, social, environmental, and community-based factors and an appreciation of the impact of such factors on neurobiological development if international psychiatry should expand. This may allow for more substantive and relevant efforts to develop new, effective models that integrate the network of physical terms useful in describing disease with the network of mental and spiritual terms that are most useful in helping us understand the experience of illness that, in turn, has effects on disease.
Bidirectional exchange, context-relevant research, assessment, and services promise more cultivated and practical insight into the impact and meaning of culture on mental illness, which will influence cultural competence.
Regarding evidence-based medicine, we suggest that constructive efforts to help impoverished and nascent systems of mental health care will require rethinking the generalizability and fundamental purposes of what we expect from enunciating best practices. An emphasis on nurturing local infrastructures capable of identifying priority outcomes and methods for assessment rather than merely exporting techniques justified in the U.S. can more effectively promote systems change and clarify public and practitioner choices abroad. Such efforts may also allow us to step back and reconsider the various types of evidence-based practices and their use in shaping practice and policy in our own settings. Along the way, locally specific best practices (with universal and unique characteristics and new ideas about how to build and sustain such structures in widely different settings) can emerge.
The Massachusetts General Hospital (MGH) Department of Psychiatry recently established a division of international psychiatry. It did so in an attempt to make concrete the framework and purposes outlined in this study. Building upon strengths of the department in training, clinical research, and breadth of clinical services, three general initiatives were outlined, each framed within the overall objectives of bidirectional internationalism described in our report. The education initiative will include efforts to improve the training of MGH-McLean residents in public mental health and international psychiatry, to help establish psychiatry training programs in developing countries as well as other mental health caregiver training programs, and to sponsor scholars from abroad seeking assistance with specific projects aimed at furthering locally relevant educational initiatives in their countries of origin. The clinical initiative is designed to include consultative roles to clinical programs in the developing world, and the research initiative endeavors to train skilled clinical researchers as well as to collaborate in the study of effective interventions for disorders as they appear in these countries. To be successful, each initiative must address teaching and learning. In our everyday work, we hope to achieve the approach to internationalism described in this study, while exploring other approaches from abroad.
We advocate a thoroughgoing internationalization of our working and thinking in psychiatry. Bidirectional internationalism identifies a framework for achieving this in ways that enhance the relevance, creativity, and coherence of our profession’s growing global awareness.