Journal of Traumatic Stress, Vol. 20, No. 1, February 2007, pp.

8995 ( C 2007)

BRIEF REPORT

The Increasing Internationalization of Mainstream Posttraumatic Stress Disorder Research: A Bibliometric Study
Ivan Figueira and Mariana da Luz
Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Raphael J. Braga
Psychiatry Research Department, The Zucker Hillside Hospital, Glen Oaks, New York

Mariana Cabizuca
Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Evandro Coutinho
Department of Epidemiology, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

Mauro V. Mendlowicz
Department of Psychiatry and Mental Health, Fluminense Federal University, Niter oi, Brazil The aim of this study was to quantify changes in the national contributions to research related to posttraumatic stress disorder (PTSD) from 1983 through 2002. Using the Web of Science database (Thomson Scientic, Philadelphia, PA), we classied articles according to the year of publication and the country of the authors. The number of publishing countries increased from 7 between 1983 and 1987 to 39 between 1998 and 2002. Meanwhile, the U.S. output share declined from 87.6% in the rst period to 62.4%. Although the number of countries publishing on PTSD has steadily increased, research is still dominated qualitatively and quantitatively by developed countries. These ndings suggest a growing international acceptance of this diagnostic category. However, the immaturity of PTSD research is demonstrated by the concentration of publications in a few countries.

Posttraumatic stress disorder (PTSD) is a common illness, with estimated lifetime prevalence of 7.8% in the general population of the United States (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Since 1980, when it was formally recognized, PTSD has been the focus of increasing attention from researchers. Palmer and colleagues reported that the output of PTSD literature has increased by an average of 24% every 2 years (Palmer, Kagee, Coyne,

& DeMichele, 2004). Dugas (2000) presented data showing that in 1994 PTSD surpassed panic disorder as the most common topic of anxiety disorders research. Recently, Bedard and colleagues analyzed the author afliations of 13,865 trauma publications from 1987 through 2001 indexed in the PILOTS database (National Center for Post-Traumatic Stress Disorder, White River Junction, VT; Bedard, Greif, & Buckley, 2004). They found that

Correspondence concerning this article should be addressed to: Raphael Braga, Department of Psychiatry Research, The Zucker Hillside Hospital, North ShoreLIJ Health System, 7559 263rd Street, Glen Oaks, NY 11004. E-mail: rjacques@dr.com.
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2007 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20183

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the frequency of articles from outside North America has steadily increased: In 1987, authors from only 18 countries were represented as compared with 44 countries in 2001. Although anecdotal and indirect evidence suggests that PTSD is gaining international acceptance, to date there has been no quantitative analysis of the national origin of published research articles on PTSD. Nancy Andreasens (2004) statement in a recent editorial that . . . the concept of PTSD took off like a rocket . . . (p. 1322) is part of the conventional wisdom, but is not yet supported by empirical data. To the best of our knowledge, the only bibliometric study of the trauma eld covered the entire range of stress trauma literature, including nonresearch articles, without a specic focus on the diagnosis of PTSD (Bedard et al., 2004). Previous geographic studies of countries contribution to research on other diseases have consistently shown that the U.S. share of scientic literature relative to other countries has declined over the last two decades (Figueredo, Sanchez, & Munoz, 2003; Kessler et al., 1995; Nahrwold, Pereira, & Dupuis, 1995; Rahman & Fukui, 2002). The main objectives of the present study are (a) to map changes in national contributions to PTSD research over the last two decades as an indicator of the diagnosis international acceptance, (b) to assess whether the share of research from countries other than the United States has increased in PTSD as it has in other areas, and (c) to compare the quality of the research conducted in each country using scientic articles number of citations as an indicator of excellence.

the country of the corresponding author. We did not limit our search in terms of language. We used the expression ptsd OR stress disorder* exclusively for the Title eld. Only research and notes articles were counted in our study. Correspondence, news, editorials, and reviews were preliminarily excluded. Whenever the country of origin was not specied, we looked for the authors names in other relevant Web sites. We determined each countrys absolute and relative production of PTSD literature over the entire two-decade period (19832002) and in 5-year blocks (19831987, 19881992, 19931997, and 19982002). We also calculated citation rates for each country over the same periods. The countries were ranked in descending order by their share of articles published and by share of citations. The trends throughout this 20-year period were also analyzed. Finally, we calculated the total number of countries that contributed to PTSD research output in each 5-year period. We performed nonparametric tests for trends using Stata software (Version 7.0; StataCorp, 2001) to identify any signicant change in each countrys participation in the 20-year period of study. The overall two-tailed criterion for rejection of the null hypothesis was set at p .05. To overcome problems related to low statistical power, we considered cases where p > .05, but .10 as presenting borderline statistical signicance.

RESULTS
We identied 2400 original articles on PTSD published between 1983 and 2002 that met our inclusion criteria. After excluding articles whose country of origin could not be ascertained, our sample was reduced to 2377 articles. Table 1 shows the countries and their respective shares in the total number of articles over the past two decades. In the rst quinquennium (19831987), 161 original articles were published, with the United States dominating world production with an overwhelming 87.6% (141 articles) of total articles. In this period, only seven countries were responsible for the entire scientic production on PTSD. Israel was ranked second, with 7.5%

METHOD
A search was run on two Web of Science databases (Science Citation IndexExpanded and Social Science Citation Index; Thomson Scientic, Philadelphia, PA) in June 2003, aiming to identify all original articles on PTSD published in the period from 1983 through 2002, as well as their respective countries of origin. We examined the international publication trends by recording the national origin of the corresponding author who is usually the rst author. Hence, articles with multiple authors are credited only to

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Table 1. Number of PTSD-Related Articles by Country in Each 5-Year Period

Number of articles by period 19831987 Country USA Israel Australia England Canada Netherlands Germany Iran Belgium Sweden New Zealand Japan Ireland Wales North Ireland Croatia South Africa Norway Switzerland France Spain Scotland Singapore Italy Finland Lebanon Denmark Saudi Arabia Turkey Russia Austria Brazil South Korea Yugoslavia Morocco Mexico Kenya Taiwan Czechoslovakia Total n 141 12 2 1 3 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 161 % 87.6 7.5 1.2 0.6 1.9 0 0 0 0 0 0 0 0.6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.6 19881992 n 255 39 14 16 6 4 1 3 0 0 3 0 3 0 2 0 2 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 352 % 72.5 11.1 4.0 4.6 1.7 1.1 <0.5 0.9 0 0 0.9 0 0.9 0 0.6 0 0.6 0.6 0 <0.5 0 0 0 0 0 0 0 0 0 0 0 0 0 <0.5 0 0 0 0 0 19931997 n 545 38 35 47 16 11 5 4 2 6 7 3 0 1 0 2 2 1 2 8 6 3 1 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 749 % 72.8 5.1 4.7 6.3 2.1 1.5 0.7 0.5 <0.5 0.8 0.9 <0.5 0 <0.5 0 <0.5 <0.5 <0.5 <0.5 1.1 0.8 <0.5 <0.5 0 0 <0.5 0 <0.5 0 <0.5 0 0 0 0 0 <0.5 0 0 0 19982002 n 696 46 71 86 27 25 38 3 6 11 3 7 1 4 4 26 8 0 11 12 5 6 1 3 1 0 5 1 1 1 1 1 1 0 1 0 1 1 0 1,115 % 62.4 4.1 6.4 7.6 2.4 2.2 3.4 <0.5 0.5 1.0 <0.5 0.6 <0.5 <0.5 <0.5 2.3 0.7 0 1.0 1.1 <0.5 0.5 <0.5 <0.5 <0.5 0 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 0 <0.5 0 <0.5 <0.5 0 19832002 n 1,637 135 122 150 52 40 44 10 8 17 13 10 5 5 6 28 12 3 13 21 11 9 2 3 1 1 5 2 1 2 1 1 1 1 1 1 1 1 1 2,377 % 68.8 5.7 5.1 6.3 2.2 1.7 1.9 <0.5 <0.5 0.7 0.5 <0.5 <0.5 <0.5 <0.5 1.2 0.5 <0.5 0.5 0.9 0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5

Note. PTSD = Posttraumatic stress disorder; = share of articles went up signicantly over time.

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(12 articles), followed by Canada (1.9%), Australia (0.6%), England, Ireland, and Czechoslovakia (0.3% each). In the following 5 years (19881992), the total number of articles more than doubled (from 161 to 352), as did the number of countries participating in the production of knowledge on PTSD (from 7 to 15). At the same time, we observed a decrease in the U.S. share of articles from 87.6% to 72.5%. In the last 5-year period studied (1998 2002), 34 countries published original research articles on PTSD, pointing to an apparent widespread growth in the recognition of this diagnostic category by the international scientic community. Thirty-nine countries contributed to PTSD literature over the two decades studied. During this period, the U.S. share of articles declined from 87.6% in 19831987 to 62.4% in 19982002, although its absolute number of publications increased steadily. Conversely, England, Australia, Germany, and the Netherlands showed a statistically positive trend toward increasing their share in the PTSD literature (Table 1). Latin America and Eastern Europe authors produced only 31 (1.3%) articles out of the 2377 published over the whole period. A similar analysis was applied to the articles citation rates, as shown in Table 2. The 2377 articles analyzed had 44,461 citations over the period studied (19832002). The United States topped the ranking, with 80.4% of total citations, although this share steadily declined over time, from 91.9% in the rst 5-year period (19831987) to 65.1% in the most recent one (19982002). Conversely, the non-U.S. proportion of citations rose, generating statistical trends in two casesEngland and Iran (Table 2). These trends corroborate the results observed in the analysis of number of articles published and suggest that noteworthy research on PTSD is being carried out in an increasing number of countries around the world.

DISCUSSION
To the best of our knowledge, this is the rst empirical study to correlate quality of research and international afliation. This study relies on two indicators to measure the PTSD scientic output of different countries: number of publications and number of citations per article. The

former is taken as a measure of the basic productivity of a scientist, a group, an institution, or a country; whereas the latter provides an indirect measurement of the impact of an article on fellow researchers (Cartwright & McGhee, 2005). Citation analysis is an imperfect surrogate for article quality, but is seen as preferable to journal impact factor by a consensus of scientometric researchers (Schoonbaert & Roelants, 1996; Vishwanatham, 1998). The number of countries publishing original articles on PTSD increased steadily over the period studied (1983 2002), ranging from 7 in the rst quinquennium to 34 in the last. In all, 39 countries contributed to PTSD scientic output during the last two decades. Bedard and colleagues found a similar increase in the number of countries publishing articles on trauma in general (Bedard et al., 2004). This trend seems to indicate increasing acceptance of the PTSD diagnosis by the international scientic community. Although the number of countries actively publishing on PTSD has steadily increased, research is still quantitatively and qualitatively dominated by developed countries. The qualitative dominance of developed countries measured by the number of citationsis even higher than the one based on quantitative parameters. Several factors, such as abundant economic resources, sound scientic policies, and the existence of trained manpower, can account for these concentrations phenomena. In fact, a recent analysis has demonstrated that gross national product per capita and expenditure on research and development are strongly correlated to productivity in biomedical research (Rahman & Fukui, 2003). However, the virtual monopolization of PTSD research by Western English-speaking nations may be a source of bias. For instance, (Morlino, Polese, Bruni, and Renato (2005), after probing the relative weight of the contribution of particular countries to the global scientic output on mental health, cautioned that The under-representation of non-Anglo-Saxon cultural models on PubMed plays a negative role for bringing about a truly multicultural literature in psychiatry. One important limitation of this study is its reliance on a single database (Web of Science). Furthermore, we did not use the PILOTS database, considered the most inclusive international catalogue of publications in the

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Table 2. Number of Citations of PTSD-Related Articles by Country in Each 5-Year Period

Number of citations by period 19831987 Country USA Israel Australia England Canada Netherlands Germany Iran Belgium Sweden New Zealand Japan Ireland Wales North Ireland Croatia South Africa Norway Switzerland France Spain Scotland Singapore Italy Finland Lebanon Denmark Saudi Arabia Turkey Russia Austria Brazil South Korea Yugoslavia Morocco Mexico Kenya Taiwan Czechoslovakia Total n 5,871 406 14 7 62 0 0 0 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,386 % 91.9 6.4 <0.5 <0.5 1.0 0 0 0 0 0 0 0 <0.5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19881992 n 10,828 815 569 407 269 198 12 94 0 0 30 0 37 0 54 0 13 18 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,345 % 81.1 6.1 4.3 3.0 2.0 1.5 <0.5 0.7 0 0 <0.5 0 <0.5 0 <0.5 0 <0.5 <0.5 0 <0.5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19931997 n 13,631 708 695 514 206 198 16 47 28 63 52 40 0 58 0 8 10 27 2 17 18 9 14 0 0 4 0 1 0 0 0 0 0 0 0 0 0 0 0 16,366 % 83.3 4.3 4.2 3.1 1.3 1.2 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 0 <0.5 0 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 0 0 <0.5 0 <0.5 0 0 0 0 0 0 0 0 0 0 0 19982002 n 5,445 404 690 967 178 64 240 29 84 26 3 43 15 6 4 47 29 0 36 15 4 11 0 13 7 0 3 0 1 0 0 0 0 0 0 0 0 0 0 8,364 % 65.1 4.8 8.2 11.6 2.1 0.8 2.9 <0.5 1.0 <0.5 <0.5 0.5 <0.5 <0.5 <0.5 0.6 <0.5 0 <0.5 <0.5 <0.5 <0.5 0 <0.5 <0.5 0 <0.5 0 <0.5 0 0 0 0 0 0 0 0 0 0 Total 19832002 n 35,775 2,333 1,968 1,895 715 460 268 170 112 89 85 83 78 64 58 55 52 45 38 33 22 20 14 13 7 4 3 1 1 0 0 0 0 0 0 0 0 0 0 44,461 % 80.4 5.2 4.4 4.3 1.6 1.0 0.6 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 <0.5 0 0 0 0 0 0 0 0 0

Note. PTSD = Posttraumatic stress disorder; = share of articles went up signicantly over time.

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traumatic stress eld (Bedard et al., 2004). We chose to work with the Web of Science database for three reasons: (a) it is restricted to publications from prominent journals, giving a better picture of mainstream scientic contribution than PILOTS, which also includes non-peerreviewed publications; (b) it covers journals from both medical and psychology elds and provides a more comprehensive sample of PTSD-related work than either PubMed (National Institutes of Health, Bethesda, MD) or PsycLIT (American Psychological Association, Washington, DC) alone; and (c) the Web of Science database is the only database that provides information on citation rates, often taken as a quantitative indicator of quality. Another potential limitation stems from our sample selection strategy. We used a title-only search as opposed to a topic search (title, keyword, and abstract), increasing specicity at the cost of a loss of sensitivity. Although this method may have excluded some valid articles, we produced empirical evidence demonstrating that our sample was sufciently representative to draw dependable conclusions about trends in PTSD research. Using the terms ptsd OR stress disorder*, we compared the ndings of our original focus-on-the-title approach with those of a broader topic search (covering title, keyword, and abstract) and observed that the ranking of the countries and their share were consistently similar (data available at request). Additional support for the validity of our search strategy comes from the experience in other elds of study, in which the title search strategy was shown to be a very effective means of retrieving pertinent documents (Ghosh, 1977). Therefore, our data indicate patterns of PTSD research and is not meant to provide an exhaustive inventory of all PTSD research. Future studies should make a judicious use of Web of Science qualitative indicators such as citations analysis to help policy makers monitor the evolution of their countries strengths and weaknesses in health sciences and to better inform decision-making processes, such as establishing funding priorities (Fava, Guidi, & Sonino, 2004). In conclusion, mainstream PTSD research is no longer a nearly exclusive American phenomenon, as it had been during the early years of this diagnosis. A growing number

of countries are now represented in the literature in terms of publication as well as citation. This trend indicates a widespread interest in the diagnosis of PTSD, and suggests that it is becoming widely recognized as a relevant condition. Thus, bibliometric investigations such as the present one can help to verify the level of acceptance of the PTSD diagnosis, and monitor how its acceptance is changing over time.

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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.