Brazilian academic psychiatry aims to have a more effective role in the international effort to understand and curb the ‘invisible plague’ of mental disorders.1 Increasing numbers of well-trained and competent clinical scientists are prepared to meet the challenges, but face local structural problems. Brazil contributes only 0.5% of the world's ISI publications in medicine, even though more than 40% of the Thomson-Institute for Scientific Information (T-ISI) listed articles originate from Latin America. Astoundingly, less than 3% of Brazil's 0.5% came from psychiatry and mental health, which primarily reflects 3.4% of the US $100 million overall public investment in health research.2 This is actually an improvement compared to the past. The Ministry of Education, through CAPES (‘Fundação Coordenação de Aperfeiçoamento de Pessoal de Nivel Superior’—Foundation and Coordination for the Development of Scientific Personnel), coordinated a national system for funding master and doctorate post-graduate programs, investing US $145 million in scholarships and teaching in 2000, with additional support from other official agencies such as the CNPq (‘Conselho Nacional de Desenvolvimento Científico e Tecnológico’—National Council for Scientific and Technological Development).

Having graduated from medical school in 1970, I belong to the first generation of Brazilian psychiatrists trained within a formal residency program structure. In comparison, 227 physicians entered the 51 Brazilian psychiatry residency training programs in 2004. My instructors were outstanding clinicians, influenced by American psychodynamic psychiatry, and acquainted with the German, French, and Hispanic schools of thought. Within bleak research environments, residents submitted at least three different theses supported with previously unpublished material, in order to reach the most prestigious academic positions. Theses developed from many years of single-handed work, devoid of financial support, without peer-review publication. Large private libraries were the pride, instruments of power, and hallmarks of the most influential professionals. Geographic and language barriers added to a sense of isolation in those pre-Internet years. Currently, CAPES provides electronic access to a reasonably large number of journals, but the institutional libraries remain deficient.

In my own case, I was interested in psychopharmacology, but aware of the lack of opportunities for formal clinical research training in Brazil (doctorate programs in psychiatry were established after 1975). My academic career started with a full-time appointment in Pharmacology, which led to a scholarship to study for a Ph.D. degree at the Institute of Psychiatry, London. Similar career paths were followed by colleagues who went to France, Germany, and Spain. However, because academic employment in Brazil requires a doctorate, colleagues returning from clinical fellowships in the USA and other countries had to complete a doctoral program before being eligible for an academic appointment. Several outstanding psychiatrists remained abroad after their training.

In 2004, CAPES recognized 183 master and doctoral post-graduate programs in medicine. Only six of those are Psychiatry-holds-only programs, but two rank among the top 15%. The future is promising: this year, 116 medical schools admitted 10,000 first-year students. In all, 27 of the medical schools are public, linked to university hospitals, and tend to offer a better education. Only 16 schools perform consistent research. Eight draw more than 90% of the top medical Brazilian scientists.3

The British system used to be the most frequent provider of high-quality Ph.D. training for Brazilian psychiatrists, until it became unaffordable. The stimulating British research environments and efficient approaches prepared clinical scientists to conduct independent research upon their return to various centers across this country. CAPES, CNPq, The British Council, FAPESP (‘Fundação de Amparo à Pesquisa do Estado de São Paulo’—Foundation for the Support of Research in the State of São Paulo), and some other grants supported such training and related exchange programs. Professor Robin Murray once remarked that, with more than 20 psychiatrists holding British PhD degrees, Brazilian academic psychiatry strongly compared to some of the best university departments in Britain.

Basic science departments in Brazil offered excellent training through post-graduate programs in Pharmacology, Biochemistry, Physiology, and Psychobiology. Elisaldo Carlini, Jandira Masur, Frederico Graeff, Ivan Izquierdo, and Mayana Zatz not only supervised but also personally engaged in multidisciplinary collaborative work. Local post-graduate programs in psychiatry and mental health, additionally supplemented by post-doctoral fellowships abroad, ensured that a critical mass was reached in several medical centers.

FAPESP and other official agencies provided financial support and initial career grants to attract recent doctors to the Universities. Few remained in full-time academic work for more than a few years though, due to low salaries and an ever increasing demand for private practitioners in the context of a limited mental health system. Fortunately, most continued to teach and perform research, working longer than 12 hours per day. This is not ideal, but helps to prevent the ‘burnout’ induced by working under pressure, underpaid, and under unstable funding.4

Industry-sponsored trials and meetings offer additional opportunities for training and international exposure. A number of psychiatrists within and outside the academic settings are able to conduct studies maintaining good clinical practice. Drug trials can be used to supplement salaries, as well as improve public services, particularly when the Brazilian National Health System pays USD $9–12 per day for inpatient psychiatric care, and USD $1–2 for outpatient appointments. However, drug-development trials halted when CONEP (‘National Commission on Research Ethics’) prohibited virtually all placebo-controlled studies 4 years ago, dismissing opposing scientific and ethical arguments.

Bressan et al.2 analyzed scientific publications by surveying the annual reports of the six accredited post-graduate programs in psychiatry, neuropsychiatry, and mental health between 1998 and 2002. Three were in the State of São Paulo, the others in Rio de Janeiro, Porto Alegre, and Recife. The students and/or their 83 supervisors (with 124 doctoral and 185 master degrees) published 376 papers in T-ISI journals with an average impact factor of 2. By March 2004, there were 496 Brazilian articles in psychology/psychiatry in the Journal Citation Reports for that same period of 5 years, with an average citation of 5.02 per paper. This rivals the average citation of the more prevalent French (5.59) and Spanish (3.14) articles in this area. As in most other fields of science, a substantial portion of the Brazilian psychiatric output is not published in T-ISI journals.

Academic psychiatrists are leading multidisciplinary research, often with significant international help and collaboration, in more than 10 departments of psychiatry, preventive medicine, pharmacology and psychobiology, and within eight different universities. Original studies are conducted in epidemiology, community, geriatric, or child psychiatry, genetics, neurochemistry and molecular biology, psychopharmacology and neurophysiology, functional imaging, addiction, cognitive and behavior therapies, in addition to more traditional subjects of psychiatric research. A number of important problems in the area of social psychiatry require investments and interdisciplinary collaboration. Collaborations are also required to integrate sophisticated laboratory and clinical investigation. Brazilian academic psychiatry can establish relevant collaboration with Portugal and Portuguese-speaking African countries with limited health services, in the search for scientific and humanitarian solutions unattainable elsewhere.5

Unfortunately, Brazil has to face its own shortcomings. With an estimated population of 181.5 million in 2004 (twice as many as in 1970, and projected to 260 million in 2050), Brazil faces an epidemiological transition characterized by increased lifespans and fast urbanization (83%; 40 million living in the 14 largest metropolitan areas). Indeed, we currently face the ‘double-burden’ problems of the developed and the underdeveloped countries. To exacerbate the situation, an ill-informed, poorly conceived, and disastrously implemented deinstitutionalization policy modeled upon the ‘democratic psychiatry’ of Franco Basaglia, resulted in an example of ‘the largest failed social experiment in the twentieth century’.6 Fortunately for the medical field, that policy failed to completely deconstruct psychiatry, and several modern inpatient and outpatient care units remain in university hospitals. For instance, the Institute of Psychiatry at the University of Sao Paulo Medical Center (www.hcnet.usp.br/ipq) just opened its new wards, outpatient, rehabilitation and research facilities, modernized with technical assistance from the Western Psychiatric Institute & Clinic (Pittsburgh) and the Institute of Psychiatry/Maudsley Hospital (London).

In conclusion, Brazilian academic psychiatry aims for increasing proficiency, while acknowledging its duties, challenges, and limitations. We welcome advice, seek partnerships, and look forward to fruitful collaborations.