Mental Health Research and Philanthropy: Possible Partnerships?

Abstract

Mental health research has received relatively little philanthropic support in Australia compared with other areas of health research. Philanthropic trusts do not generally provide recurrent funding or make grants for that perceived to be the responsibility of the state or the market. The emergence of ‘strategic philanthropy’ however, provides potential for mental health researchers to form partnerships with philanthropic foundations, particularly on initiatives that are focused on prevention and innovative and sustainable models with the capacity to ‘go to scale’ across the service system.

The major sources of financial support for mental health research in Australia and New Zealand are pharmaceutical companies and government funded competitive research grants and contracts. The potential for support from philanthropic foundations and private individuals has not been fully tapped. While the philanthropic sector in Australia and New Zealand is small compared with that of North America, it is undergoing significant growth, and philanthropic foundations typically have greater flexibility than the state or the market.

There is growing interest in ‘strategic philanthropy’ or what might be thought of as ‘venture capital for the common good’. This can take several forms, the most visible being very large grants for capital works or major research initiatives which achieve leverage by being conditional on matching funding being obtained by the grant recipient. In this way some research institutes have received ‘a large leg up to leap ahead’. The recent grants made by Atlantic Philanthropies to several Australian medical research institutes reflect this style of philanthropy.

Strategic philanthropy can also have a major impact on a field by acting as the ‘yeast’ for innovation and reform. A recent example of this is the philanthropic support received by the Australian Research Alliance for Children and Youth led by Professor Fiona Stanley to promote cross-disciplinary research and facilitate its translation into ‘whole of government’ policy and service reform relating to children.

Mental health has benefited less from philanthropy than many other areas of medical research. The most notable example of a major philanthropic initiative in mental health in Australia is the $12.5 million grant by the Colonial Foundation to the ORYGEN Research Centre in Melbourne which specializes in the mental health problems of young people. The Australian Rotary Health Foundation has also made mental health its major priority. The generally low level of philanthropic support for mental health research may reflect the low priority given to mental health research generally, with mental disorders contributing 19.1% of disease burden and 9.8% of health system costs but receiving only 8.9% of National Health and Medical Research Council (NHMRC) funding [1].

Enhancing the profile of mental health issues and mental health research is obviously a long-term strategy for increasing funds from all sources, but the lack of philanthropic support for mental health research may also be the result of limited understanding about philanthropy by the mental health field.

It is not widely understood that philanthropic foundations rarely provide recurrent funding, so a major initiative usually needs to have sound prospects of being sustainable if it is to secure philanthropic support. Some foundations are also reluctant to support research that is eligible for competitive research grants. Furthermore, philanthropic foundations are sometimes wary about providing support for research which could attract commercial investors.

Given that resources are always going to be limited, where might philanthropic foundations concentrate their efforts in mental health research? Should it be basic biomedical research which carries the hope of significant breakthroughs in relation to serious mental illness or areas of mental health research that have been particularly neglected, such as primary care, prevention and mental health promotion, evaluation of services, or the mental health needs of indigenous communities and other socially disadvantaged people [2]?

Some of these areas overlap with the traditional concern of philanthropy with social disadvantage while others such as research on service delivery or populationbased mental health strategies are less familiar to the philanthropic sector. This knowledge gap needs to be closed if the potential for philanthropic support in mental health research support is to be fulfilled.

Innovation-evaluation-dissemination-replication

One form of strategic philanthropy can be described as ‘innovation, evaluation, dissemination and replication’. If a promising and innovative approach can be identified, and subjected to rigorous external evaluation, new models may have the potential to be disseminated and if cost-effective, ‘taken to scale’ across a whole field or service system. One of the best examples of this in the history of Australian philanthropy is The Potter Farmland Plan, a demonstration farm established in western Victoria by The Ian Potter Foundation in the 1980s to advance environmentally sustainable agriculture in Australia. It developed and evaluated innovative land management methods to reduce the risk of salinity and soil erosion, and worked in close partnership with farming communities to disseminate these practices. A similar process of innovation, evaluation and dissemination has been applied by The Ian Potter Foundation in fields as diverse as the arts, education, health and social welfare.

Perhaps mental health practitioners and researchers could be partners with philanthropic foundations in this model of philanthropy. This approach to grant-making raises a complex set of questions which those seeking philanthropic support would be well advised to address in their grant applications.

On what basis does one assess a ‘promising initiative’?

This question has a number of sub-questions. Is the proposed initiative really innovative? Is it possible to assess its potential impact? What might be the ‘lost opportunity cost’ of supporting one initiative over another?

How can the effectiveness of the initiative be assessed?

Both a summative (outcome) evaluation as well as a formative (process) evaluation is necessary to know if an approach is effective and why this might be so. Both of these questions are methodologically very challenging in some parts of the fields of health, education and social services.

In the varied topography of professional practice, there is a high, hard ground where practitioners can make effective use of research-based theory and technique, and there is a swampy lowland where situations are confusing ‘messes’ incapable of technical solution. The difficulty is that the problems of the high ground, however great their technical interest, are often relatively unimportant to clients or the larger society while in the swamp are the problems of greatest human concern [3].

Mental health research has its high, hard ground where evidence-based practice can prevail. It also has some methodologically ‘messy’ swampy lowlands where one can find problems of great human concern. For example, psychotherapy, family therapy, the therapeutic use of the creative arts, adjustment to illness and loss, and transcultural psychiatry are domains which are essentially hermeneutic. They are about meaning construction and not easily reduced to measurement as they typically draw upon concepts which are not readily falsifiable and thus cannot conform to a hypothetico-deductive model of science. This is reflected in an increasing interest in qualitative research in the field of mental health.

Most of the mental health landscape is probably somewhere between the high ground and the lowland. One of the challenges then is to create terraces which link the two parts of the terrain, integrating quantitative and experimental research with qualitative and naturalistic inquiry. The current interest in community-based intervention trials such as the Communities That Care initiative of the Centre for Adolescent Health at the University of Melbourne reflects a growing willingness to combine ‘hard medical sciences’ such as epidemiology with ‘soft social sciences’ underpinning strategies aimed at strengthening social cohesion and social capital in high-risk communities.

How can one assess the potential of an initiative to be replicated or adapted in different geographical, demographic, service system and cultural contexts?

‘Technology transfer’ in the human services is poorly understood. Rarely is there a sophisticated grasp of the context in the original site of an initiative. To use an environmental metaphor, one needs to know the soil and climatic conditions under which the plant first grew successfully to determine the chances of it growing elsewhere and what one might need to add to the soil to increase the probability of its growth under different conditions.

Grant-seekers should therefore choose the site(s) of any proposed pilot programs very carefully and identify the broadest possible range of factors relating to organizations, personnel, the service system, demography, culture, and so on that would allow for the assessment of the program's potential usefulness and transferability to other settings.

What is the prospect of an effective initiative achieving sustainability and how long should a funder continue supporting a promising initiative?

Perhaps the most challenging of all questions in the ‘innovation-evaluation-dissemination-replication’ model of philanthropy is sustainability. Rarely do researchers explore questions of sustainability but it is a key consideration. Currently resources are wasted on initiatives with a low chance of achieving sustainability. They can do more harm than good by raising hopes and then demoralizing organizations and communities, so draining social capital where it is most needed.

The reality is that unless an approach has strong voter appeal, is immediately cost-effective or can demonstrate likely savings in the short to medium term, it is probably not going to attract recurrent funding from government. The success of the strategies to reduce road trauma and introduce tobacco control demonstrate the importance of evidence and this can only be obtained if there is a sophisticated system of surveillance, applied and basic research and cost benefit analysis.

Systemic reform rather than more models?

It can be argued that rather than create and test new models, it would be better to concentrate on identifying the successful models that currently exist and how they might be successfully transplanted. Often it is more a matter of having the resources to do what works or having the right policy framework to allow it to happen rather than the obstacle being major deficits in knowledge about what is effective.

Instead of developing and evaluating the effectiveness of more models which have little prospect of sustainability or going to scale, we might do better to put the priority on research which leads to reform of service delivery systems. Philanthropic foundations could be partners in this. In the field of child welfare a number of Victorian philanthropic foundations in the late 1980s supported non-government organizations to test whether North American models of intensive in-home interventions with families at immediate risk of having a child removed by child protection authorities, could prevent costly and potentially damaging placement of children. A favourable political and policy climate enabled this service to spread across the state and beyond.

The health and well-being of indigenous communities is also an area in which philanthropic foundations have had a significant involvement. The very recent announcement of the creation of the Cape York Institute at Griffith University with the support of the Myer Foundation, Westpac, Boston Consulting Group and The Body Shop, as well as government, reflects the new face of philanthropy in indigenous affairs.

The recently released report of the Aboriginal and Torres Strait Islander Research Agenda Working Group of the NHMRC stated that: ‘mental health in Aboriginal and Torres Strait Islander populations comprises only 1% of mental health research publications, and attracts only 2% of mental health research funding. This is despite a high and growing incidence of mental health conditions among Aboriginal and Torres Strait Islander populations evidenced in high rates of imprisonment, hospital admissions for substance abuse, self harm and injury, and youth suicide [4].’

In relation to both indigenous and non-indigenous socially disadvantaged communities, it is very obvious that psychopathology cannot be disconnected from the social context in which it is embedded. Mental health researchers who can think holistically and work collaboratively across disciplinary boundaries could be an asset to philanthropic foundations wishing to respond to the needs of such communities.

Prevention projects

There may also be significant potential for partnerships with philanthropic foundations in the area of prevention. One area which may be ripe for research is how to broaden the role of primary health care providers so that they perform ‘mental health’ functions at a preventive level [5]. For example, broadening the role of universal maternal and child health nurses beyond paediatric surveillance to encompass maternal emotional and social well-being can facilitate the transition to parenthood and strengthen social connectedness [6]. The latter is of particular significance given the importance of social support as a protective factor in relation to some psychiatric disorders and can be applied to a broad range of service provider roles.

While prevention is still at an embryonic stage in relation to mental health, rapid progress is occurring in our knowledge of the complex bio-psycho-social causal pathways involved in certain mental health and related problems. This knowledge is not yet matched with knowledge of successful interventions. It is worth remembering that the great advances in mortality and morbidity from infectious diseases in the nineteenth century did not come about as a result of breakthroughs in medical treatment but from epidemiologically informed sanitation reform and improved housing conditions. What might the equivalent public health strategy be in relation to mental health?

In a meta-analysis of prevention programs targeting a broad range of psycho-social problems such as school failure, child abuse and neglect, child and adolescent mental health problems, teenage pregnancy, drug use and juvenile crime, it was found that those interventions that were multifaceted and addressed the underlying risk factors and crossed the silos of health, education and social welfare, were far more effective than narrowly focused prevention strategies [7]. Hence initiatives such as the North American program ‘Communities that Care’ introduced to Australia by the Centre for Adolescent Health at the University of Melbourne, and the crime prevention program ‘Pathways to Prevention’ at Griffith University, are designed to address multiple risk and protective factors.

The argument that the best outcomes in mental health will come from well-targeted ‘upstream’ interventions underpins the approach of the Victorian Health Promotion Foundation in giving priority to initiatives such as those aimed at increasing social cohesion and preventing bullying.

The chief executive officer of this Foundation has recently criticised mental health specialists for their narrow conceptualization of the issues and encouraged them to share the ‘ownership’ of mental health with those who promote mental health [8]. The resistance to a public health perspective is not unique to the field of mental health. ‘Inappropriately focusing on individual level determinants of health while ignoring more important macrolevel determinants is tantamount to obtaining the right answer to the wrong question [9].’ Even when a public health perspective is present, it tends to stop at the production of what might be called descriptive rather than prescriptive knowledge.

Translating research into practice

Philanthropic foundations, along with other funding sources, are beginning to ask why they should fund more research when much of the research which has already been done is not being used. For many researchers the publication of their research has become an end in itself, with academic promotion and university performancebased funding providing little incentive to becoming involved in translating research into policy and practice.

Perhaps 1% of the money allocated to mental health research, and for applied research in the behavioural and social sciences generally, should be allocated to investigating the conditions under which research is utilized. That may allow us to capitalize on the investment in mental health research that has already been made and enable us to prioritize further research which has a higher chance of being utilized. There is relatively little known about research utilization in clinical practice or in community initiatives although this may be an emerging area of interest [10].

One of the challenges in prevention in mental health is the permeability of the boundary around the domain ‘mental health’. For example, if western society is facing an epidemic of depression, we need to consider the contribution of contemporary social structures, as biochemical correlates of mental states are not necessarily causes.

This leads to consideration of constructs that are not easily operationalized in public health strategies. For example, what are the limits of western individualism, secularism and materialism that are consistent with the emotional and social well-being of human populations? Are high levels of anxiety and depression inevitable in a spirit of the age characterized by fear and despair? In short is it time to put the ideas about social anomie and suicide formulated by the nineteenth century father of sociology, Emile Durkhiem, on to the twenty-first century mental health research agenda? It is not suggested that mental health strategies can turn the historical tide on western individualism, secularism and materialism, as such social phenomena have the force of an ocean behind them. However, posing these deeper questions may well generate exciting ideas and creative cross-disciplinary responses to some of the most significant issues facing modern society.

Conclusion

Philanthropy in North America and in the United Kingdom has played a significant role in nurturing intellectual debate about a broad range of societal issues. There are signs that philanthropic trusts and foundations in Australia may be developing an interest in ‘big ideas’ central to health and well-being. Mental health researchers who can see the wood as well as the trees may be valuable partners in such initiatives.