Research as a Path for Educational Opportunities in Global Mental Health

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).

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.

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.

Mark J. Sedler, M.D., M.P.H., Associate Dean for Global Medical Education, Professor of Psychiatry and Public Health, Stony Brook School of Medicine, Stony Brook, NY

The author reports no competing interests.