EUREXIT? High time to consider the merits of European collaboration in child and adolescent psychiatry
As editors of European Child and Adolescent Psychiatry (ECAP), the official journal of the European Society of Child and Adolescent Psychiatry (ESCAP), we have been witnessing the aftermath of the British referendum in 2016, which ended with a slight majority voting for Brexit. We are also keenly aware of the growing nationalistic and populist movements across Europe and beyond. Thus, we eagerly await the results of the upcoming European elections.
As editors and researchers, we are all largely removed from politics in our respective countries. Just like everyone else we have opinions, feelings and visions related to the future of Europe. However, within our professional lives—and in particular as editors of a European journal—we feel an obligation to make ourselves heard to promote European collaboration for the advancement of research and its dissemination in child and adolescent psychiatry, which forms the basis for improvement of our clinical work helping children with mental disorders and their families.
European science is already threatened by the recent political developments. A recent Nature editorial published in April 2019 commented on how Brexit has already irreparably damaged science in the United Kingdom (UK) . Vice versa, science in continental Europe, too, suffers substantially from a loosening of the tight link to the excellent research community in the UK and its many individual scientists themselves. Overall, potential reductions of the amount of and the access to EU research funding are to be deplored. The creation of barriers to immigration of overseas researchers negatively impacts collaborations and poses a risk to the solid worldwide reputation of European research.
Our field has lots to lose. In many countries, the scientific basis of child and adolescent psychiatry is still rather limited. Accordingly, we require collaborations at the European level to obtain funding, recruit sufficient sample sizes, and gain access to different technologies among other advantages brought on by cross-country co-operations. Our Journal ECAP figures prominently with respect to publications of articles based on European collaborations or dwelling on trans-European clinical issues [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 19].
Eurexit (we use this term to describe a cessation of efforts to enable European collaborations) would entail that we stay glued to our well-established national academic and clinical routines. We have all made our careers within our national scenarios, which accordingly have worked well for us. We know our ways around in the respective health care systems. We do, however, realize that the career opportunities are not equal throughout Europe (and across the globe) and we also perceive a thinning out of individuals willing to embark on an academic career within our field even in European countries that have a solid infrastructure for child and adolescent psychiatry.
Only few of us have worked in more than one country entailing that a thorough bi- or even multinational assessment of both the clinical and research environments is not part of most of our scopes. Indeed, in a recent editorial, we probed possible explanations for discrepant rates of particular diagnoses between child and adolescent psychiatry hospitals located in The Netherlands and Germany . We acknowledge that efforts to truly dissect and understand such national differences with the goal of initiating changes in our clinical systems are very ambitious and obviously time consuming. We are in many ways stuck within our national systems, which in themselves are complex and at times require our maximal attention. Idealism as the motor for pursuit of a European dream does not really represent a foundation for scientists. Therefore, why should we in pragmatic terms aspire to work together within the framework of Europe?
Competition is stiff. A brief look at the scientific output of the USA with its population of 327 million inhabitants is sufficient to understand that no European country by itself can in any way successfully compete. Another country with an increasingly strong output is China. Chinese authored articles submitted to ECAP a decade ago were frequently difficult to read; accordingly, the poor English was one of the reasons leading to rejection of these papers. Nowadays, articles submitted by Chinese researchers are often written in superb English; unfortunately, this high standard is frequently not met by the authors from European countries (excluding the UK). Moreover, to scientifically compete in the rapidly evolving digital and technological revolutions will require large-scaled collaborations. The recent success in elucidation of genetic loci for mental disorders would not have been possible without collaborations initiated many years ago to come up with sample sizes sufficiently large for detection of variants with small effect sizes. Similarly, imaging projects are now geared to investigate thousands of patients. Only strong European research teams can have a high impact within these environments. Such teams also need to exert pressure at both the national and European levels to ensure that funding will continue for our field.
Our time is too precious to pursue redundant projects at the national levels. Clinical guidelines serve as an excellent example. Some countries are able to come up with national guidelines for the treatment of mental disorders, but only some of them are specific for children and adolescents and even in larger countries not all diagnoses and themes are covered by guidelines. In the UK, the National Institute for Health and Care Excellence (NICE) Guidelines are sponsored by the Department of Health and Social Care. We are not aware of any other country with such a systematic source of funding. Clinician researchers within most European countries with national guidelines need to do the underlying work themselves. Would it not be in the best interest of all parties involved to establish European collaborations to come up with the framework for disorder-specific guidelines especially for children and adolescents? European expert groups could perform the relevant literature searches, meta-analyses and interpretations, which could then be used in each country to adapt the contents of the framework guidelines to the national health care systems, thus overall strongly reducing the work load. Such collaborations would likely stand a better chance of obtaining funding at the European level even for less common or more specific topics; the political pressure would build up across different medical fields.
Other possibilities to make best use of the resources available in Europe include establishing European training programs for specializations. It is difficult to find experts for infrequent conditions even in large European countries; why not join forces to for instance coordinate specialization in transgender issues relevant for our field? Such a European program would generate substantial interest and could ensure a quality control via for instance certifications. Similarly, joint training of early career investigators in for instance the ESCAP Research Academy  promotes enthusiasm and initiates networking thus contributing to urgently required recruitment of academic offspring.
Child and adolescent psychiatry is becoming more complex due to the need to accommodate the influx of ever increasing amounts of research results. We need to break this information down to the clinicians. Doing all these works in parallel in different countries even for less common disorders represents a waste of our already limited resources and limits the probability of receiving adequate funding.
Novel technologies such as high-throughput screening and artificial intelligence are already beginning to influence medicine; there is no doubt that they will also impact child and adolescent psychiatry. Self-learning devices will potentially represent a sine qua non for future therapy. The rapid advances in the field of psychiatric genetics may promote stratified/personalized medicine in our field. We need to integrate these novel technologies into our work and at the same time be vigilant as to side effects at the individual and societal levels. Only a strong European collaboration can reduce the probability that single countries go astray in the complexity of the issues at hand.
In conclusion, we perceive the need to optimally make use of the resources available in Europe. We need individuals to initiate chain reactions within their fields. We need academic and administrative input, we need joint financial resources. We would be more than happy to promote European exchange in every and in any way we as individuals or we as Editors of European Child and Adolescent Psychiatry can do. It is now up to you—contact us.
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