As an Israeli-born Sabra, I clearly remember the overwhelming effect of what I perceived as exceptional and almost wasteful affluence, when I first visited the US in 1987. Having been trained to make good with whatever was available, seeing kilograms of candies spent to decorate shopping windows, having hundreds of products to choose from in shopping malls, and experiencing the seemingly inexhaustible computational resources of research centers were very imposing experiences. Coming from a world of constraints, there I was, in the realm of choices.

Yet, the encounter was also saddening, since the principles that governed the ‘world of choices’ were far from explicit. Specifically, the balance between self and community was enigmatic, and the sense of social purpose elusive. For a medical doctor, this immediately translated into questions regarding patient care.

Similar feelings emerge when I now come to write about academic psychiatry in Israel. Used to make do under severe constraints, academic psychiatrists in Israel are but amazed by the magnitude of operations and resources available elsewhere. Many are equally saddened by the enormity of the apparent gap between resources and achievements—at least when it comes to patients' health and well-being—and by the apparent fragmentation of the whole effort. This feeling has obvious roots in the stark realities of psychiatric research in Israel.

Difficulties are all too obvious in Israel, where academic psychiatry is almost a formality: The country's four medical schools do bestow academic titles, but do not have a single, full-time, tenured track for psychiatry. Consequently, almost all academic psychiatrists get their salary as clinicians and only a secondary salary as teachers and researchers. This has obvious implications: an ad hoc questionnaire, distributed before writing this editorial, reveals that academic psychiatrists allocate about 20% of their time to teaching, 27.5% to administration, 26% to clinical work and 26.5% to research (range: 15–30%!). ‘Protected time is our scarcest resource,’ writes Professor Haim Belmaker. ‘The freedom of having a day or two a week without clinical responsibilities is rare in Israeli academic psychiatry.’

Funding is also limited: Israel does not have a National Institute of Health, and the State does not allocate funds for mental health research. About two-thirds of research funding comes, therefore, from foreign institutions (eg, the NIH; NARSAD; the Stanley Foundation, European programs). Local agencies provide additional 10–20%, and the rest comes from scattered sources such as pharmaceutical corporations, patents, charities and donations.

The brain drain is another problem, but curiously, the last few years saw several Israeli researchers return from positions in academic institutes in North America, and take leading positions in Israel. To these one must add the major contribution of scholars and scientists who came to live in Israel from North America, Europe, South Africa and other countries.

Yet, several conditions make it advantageous to do research in Israel. A major strength of academic psychiatry in Israel is that it is based in public hospitals. Israel has a universal, state-sponsored health-care system, within which all hospitals are publicly owned, and academic centers are based in these facilities. Consequently, academic psychiatrists are not cut off from the day-to-day practices. Indeed, they currently hold many top clinical and administrative positions.

Additionally, the country has a comprehensive psychiatric admission registry, which has been used in epidemiological studies, and there are several junctions (such as the compulsive military service draft), in which data on population trends and mental health is systematically collected. Privacy protection strategies have been put in place in these data sets, and the country can now be seen as a paradise for ascertainment and validation of population-wide studies.

Partially because of their involvement in clinical work, researchers in Israel do not encounter forbidding difficulties to obtain colleagues' and patients' consent for research. The country's small size, the relative stability of employment and residence and the easy access to clinical care make it possible to effectively follow the longitudinal course of mental disorders in highly representative samples. The rate of substance abuse—a major confound in other countries—is limited. Indeed, social drift, dehumanizing poverty and social alienations are rare—but growing. Finally, despite all pressures—or because of them—there is a hovering sense of common destiny, which somewhat eases social boundaries. Most importantly, there is human capital and cross-fertilization between cultures and traditions, such that Israeli academic psychiatrists are exposed to North American and European traditions in clinical psychiatry, psychopharmacology and neuroscience.

This might explain how, despite constraints, significant research takes place in Israel. Of 983 publications on mental disorders by Israeli authors, since 2000, 949 concerned humans. Schizophrenia was the leading subject (225 publications) followed by affective disorders (n=167), anxiety disorders (n=106), Alzheimer disease (n=83) and personality disorders (n=57). The record shows 101 publications identified as genetics, 163 involving brain research and 138 trials of medication—most of which in small samples and with open labels. Only a small proportion of this work (n=62; 6.3%) is published in Israeli periodicals, and most of it finds its way to international publications (eg, J Clin Psychiatry=33; Am J Med Genet=30; Am J Psychiatry=27; Mol Psychi-atry=23; Eur Neuropsychopharm=21; Clin Neuropharm=21; Schiz Res=20; Biol Psychiatry=19; Int J Psychopharm=17; Int J Geriatric Psychi-atry=16; Psychiatry Res.=13). Academic psychiatry has also been responsive to needs, and research on traumatic stress disorder, for example, is carried by all four university departments.

However, this record has to be qualified: While there is a strong level of innovation and capacity for developing translational research (as can be seen from publications and also by the level of grant support from agencies such as the Stanley Foundation and NARSAD), Israeli groups have more success with focused, ‘smart’, innovative-type applications than with agencies that require longer term and comprehensive research programs, such as the NIH, the German Israeli Foundation and the US–Israel Binational Science Foundation. Large international collaboration have started and are clearly a most exciting perspective.

But do we also fulfill a mission? Academic psychi-atrists clearly link their mission to patient care—but they are skeptical. ‘Academic psychiatry should clearly bring to Israeli patients as rapidly as possible information that will improve the level of treatment throughout the country. In that we have only been partly successful’ writes professor Belmaker. Professor Lerer adds ‘The mission of academic psychiatry in Israel is, also, to raise the standard of the profession as a whole by introducing innovative ideas and concepts and to generate a cadre of psychiatrists who appreciate and understand research and are able to implement what they understand. In practice, there is a positive influence but much less than there should be and this is waning rather than increasing.’

Indeed, there is a constant reduction in the number of doctors at university hospitals who are eligible for academic appointments, and when they are eligible this is for the clinical rather than the research track. Unless something is done, predicts professor Lerer, ‘this might lead to the virtual demise of academic medicine in Israel as a major player in international biomedical science.’ Success, in Israel, has always baffled pessimists.

Most importantly, Israel increasingly depends on international developments. In that sense, we cannot escape market pressures, which, nowadays, include both products and ideas. Along with others, we are constrained by an unsatisfactory delineation of phenotypes, lack of robust endophenotypes, delay in implementing array statistics (to symptoms as well as to genes), and unscrupulous reification of the current nosology.

People often ask, these days, how do Israelis live under continuous terror. A parsimonious answer resembles the one given here to the query about academic psychiatry in Israel: through a very fragile balance between surviving adversity and keeping a sense of purpose.