On a regional scale, Europe has one of the best mental health resource allocation levels in the world, with a good supply of trained professionals, as well as policies and systems that are coordinated to support their interventions. However, investment in mental health research is clearly insufficient. Neuropsychiatric disorders account for 35% of the overall burden of illness in Europe, and are more costly than diabetes and cancer put together. Reference Olesen, Baker, Freund, di Luca, Mendlewicz and Ragan1 Depression alone is the second largest component in the total burden of illness. Recent reviews have confirmed the disparity between disease burden and the scale of research funding, even though it has been shown that past investment in mental health has provided substantial health and economic gains. 2 It is obvious that mental illness is not a high enough priority for politicians, the media or the general public.
There is still a wide gap between European mental health needs and the services meeting them, despite better provision, and there is now a greater need to understand, through high-quality research, the factors underlying this situation. Policymakers in the European Union are becoming more aware of the mental health gap. The 2005 European Union Green Paper Improving the Mental Health of the Population: Towards a Strategy on Mental Health for the European Union, 3 while acknowledging that medical interventions play a central role in addressing mental ill health (in both the acute phase and long term), points out that Europe's mental health system must address the wide range of factors contributing to the enormous burden of mental disorders.
More recently, the European Parliament's February 2009 Resolution on Mental Health 4 put this issue even further up on the European agenda, encouraging national action in ‘five priority areas for the promotion of the mental health and well-being of the population, […] strengthening preventive action and self-help and providing support and adequate treatment to people with mental health problems and to their families and carers’. The Resolution then went on to give recommendations to meet requirements of evidence-based and cost-effective actions for a comprehensive and integrated European mental health strategy.
The Madrid Declaration
In recent years, several national governments in the European Union have taken the strategic step of funding formal, nationwide mental health research networks, with the general goal of improving research capacity and quality. Typically, these networks provide an infrastructure linking health service sites and universities, making it possible to run large-scale studies, as well as emphasising translational research. Using these infrastructures, it has been possible to address important research questions. Reference Arana, Wentworth, Ayuso-Mateos and Arellano5–Reference Tyrer, Oliver-Africano, Ahmed, Bouras, Cooray and Deb7 Collaboration among national networks is already taking place, mostly involving one-off, multisite projects, that could serve as the basis for a structured and coordinated European-wide effort, able to define the research agenda and substantially contribute to reducing the disease burden of mental disorders. However, this kind of collaboration is very fragmented and project-specific, usually focusing on a scale of only 3 to 5 years; lacking a stable collaborative infrastructure, the lessons learnt are often lost when the period of collaboration comes to an end.
To address this problem, the Spanish Mental Health Research Network CIBERSAM hosted the second International Mental Health Research Network Meeting in Madrid on 30 October 2009, inviting representatives from seven nationally funded mental health research networks, along with leaders of ongoing European Union-funded mental health projects. The meeting's participants subscribed to the Madrid Declaration, aimed at promoting a coordinated European-wide effort in mental health research. 8
What is the benefit?
The Madrid Declaration's key message is to call for a formal cooperation system built on existing European Union-funded projects as well as national initiatives, which will enable us to respond in a timely way to scientific priorities and to optimise the resources generated by our research. These include: pooling deoxyribonucleic acid (DNA) and neuroimaging banks and databases; developing joint analytical strategies, meta-analyses and web-based clinical data-entry systems across networks; establishing common standard operating procedures in translational and clinical research; and promoting cross-border translational research by linking sites that have complementary clinical and preclinical expertise.
There are also very tangible benefits almost immediately. National networks have already dramatically improved the recruitment process for participants in collaborative mental health projects – in England alone, the Mental Health Research Network reached a recruitment level of nearly 60 000 people in the past year. Building a more efficient European-wide structure would further improve recruitment in terms of time as well as sample size, building new knowledge much more quickly. A cross-national effort is particularly important for research concerning uncommon psychiatric conditions, in order to achieve sufficient sample sizes, as well as for those projects requiring large and diverse populations to study the interaction of biological, environmental and social factors in mental disorders.
Across Europe, there is a very wide diversity of mental healthcare systems and policies. However, these have yet to be subjected to serious comparative analysis, in order to establish which are the best for improving population mental health and preventing mental disorders and suicide in Europe. A coordinated cross-continental effort in comparative analysis would provide scientific evidence on issues such as the impact, effectiveness, efficiency, sustainability, feasibility and acceptability of mental health policies.
A long-term perspective is the key to the success of this future network of organisations. Therefore, its objectives and research topics should be determined within a stable and sustainable framework. The best vehicle for this is the creation of a Network of Excellent Networks, which could provide cost-effective platforms for mental health research by establishing a dynamic and adaptive cross-European network of distinctly qualified research centres. Such an approach is intrinsically collaborative and, driven by representatives of the scientific community, should actively engage both national funders and the European Commission.
These research platforms would not only be made available for people within the existing networks; one of their key activities would be to provide training and capacity-building for researchers and clinicians, making an impact on the entire European mental health research community.
What are the chances of this effort, led primarily by European researchers, having a significant impact? In the past, other international declarations in the area of health research have shown that they can indeed make a difference. For example, in 1990, the Commission on Health Research for Development estimated that health problems accounting for more than 90% of the worldwide total were receiving less than 10% of global health research resources. A few years later, the Global Forum coined the term ‘10/90 gap’ to capture this huge imbalance between the magnitude of the problem and the resources devoted to addressing it. 9 Since its foundation in 1998, the Global Forum has been advocating effectively to close the ‘10/90 gap’, and explicit methods for priority setting are gradually replacing previous models, which were driven by a mix of implicit as well as explicit criteria, including: potential for publication in high-impact journals, financial or political interests of donors, biases of members of policymaking panels and media exposure.
Following this same path, the European researchers behind the Madrid Declaration want to highlight that, because resources for research are scarce (particularly in these times of economic difficulty), priority setting is vital to ensure that resources are well used, and focused on addressing the most pressing population needs in order to enhance health and health equity. Today, European mental health research is clearly beset with a mismatch between needs and investment.
Nevertheless, there is a strong political and economic rationale in Europe for higher investment in mental health research. The Madrid Declaration is sending a strong message to policymakers and the scientific community: the lion's share of the total cost of mental disorders arises outside the health sector, because the psychosocial difficulties associated with mental disorders are not only responsible for substantial labour and medical expenses, but can also have a number of often substantial economic consequences. These costs also fall to the social care, education, housing, criminal justice and social security systems and often they are especially felt by individuals with mental health problems and their families. Reference Knapp10
If Europe is to meet these challenges, it needs to move forward on the basis of closer cooperation between countries, greater collaboration among industry, academia and patient organisations and increased investment in mental health research. All those involved should take advantage of existing project-specific and national networks, which could serve as examples of best practice in managing a wider-ranging and more inclusive European network in the future. This would bring enormous economic returns, and might easily pay for itself by lightening the burden on healthcare systems and increasing the productivity of affected individuals.
The human and social returns of such an investment are inestimable. If the obstacles we face in tackling the future of mental disorders are massive, so is the potential of this Network of Networks, and the attendant benefits that its success can bring to populations across the continent in improving their health and quality of life.
Acknowledgements
The Madrid Declaration was signed by the following Mental Health Research Networks and Projects: Centre for Biomedical Research Network on Mental Health and Red de Trastornos Adictivos, from Spain; Mental Health Research Network, from England; Mental Health Research Network Cymru, from Wales; SMHRN, from Scotland; FondaMental, from France; Genetic Risk and Outcome of Psychosis, from The Netherlands; the European Mental Health Initiative; Pediatric European Risperidone Studies; Optimization of Treatment In the Management in Schizophrenia in Europe; The Netherlands Study of Depression and Anxiety; Collaborative Research on Ageing; European Alliance Against Depression; Optimizing Suicide Prevention Programmes and their Implementation in Europe; Psychosocial fActors Relevant to brAin DISorders in Europe; European Network of Bipolar Research Expert Centres; Reinforcement-related Behaviour in Normal Brain Function and Psychopathology; European Joint National Schizophrenia Networks for the Identification of Gene-Environment Interactions.
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