In this discussion, I (possibly teejai) and perhaps others will be examining the results of three studies carried out by the World Health Organization in which it was found that the recovery rate for schizophrenia was better in non-Western counties.

If anyone knows of any other links that may be applicable to this discussion, please do share.

Thank you




Most Americans are unaware that the World Health Organization (WHO) has repeatedly found that long-term schizophrenia outcomes are much worse in the USA and other developed countries than in poor ones such as India and Nigeria, where relatively few patients are on anti-psychotic medications. In undeveloped countries, nearly two-thirds of schizophrenia patients are doing fairly well five years after initial diagnosis; about 40% have basically recovered. But in the USA and other developed countries, most patients become chronically ill. The outcome differences are so marked that WHO concluded that living in a developed country is a strong predictor that a patient will never fully recover.

Source: Mad In America


The World Health Organization International Study of Schizophrenia
The WHO Study of Schizophrenia is a long-term follow-up study of 14 culturally diverse, treated incidence cohorts and 4 prevalence cohorts comprising 1,633 persons diagnosed with schizophrenia and other psychotic illnesses. Global outcomes at 15 and 25 years were assessed to be favorable for greater than 50% of all participants. The researchers observed that 56% of the incidence cohort and 60% of the prevalence cohort were judged to be recovered. Those participants with a specific diagnosis of schizophrenia had a recovery rate which was close to 50%. Geographic factors were significant in terms of both symptoms and social disability. Certain research locations were associated with greater chance of recovery even in those participants with unfavorable early-onset illness courses. The course and outcome for persons diagnosed with schizophrenia were far better in the “developing countries” than for such persons in the “developed” world of Western Europe and America.

The first of the WHO studies, the International Pilot Study of Schizophrenia (IPSS), assessed 1,202 persons diagnosed with schizophrenia in nine countries. The results showed that persons with schizophrenia in the “developing” world (e.g., Columbia, India, Nigeria) had better outcomes than persons in the “developed” countries (e.g., Moscow, London, Washington, Prague, Aarhus, Denmark). Overall, 52% of persons in the developing countries were assessed to be in the “best” category of outcome (defined in this study as an initial episode only, followed by full or partial recovery) compared with 39% in the developed countries. This finding was also reported in a 5-year follow-up research study. In this study, 73% of those participants from the developing world were in the best outcome group compared with 52% in the developed world. A second study called the Determinants of Outcome of Severe Mental Disorder (DOSMD) used more rigorous criteria and followed more than 1,300 patients in 10 countries and, similar to the IPSS, discovered that the highest rates of recovery occurred in the developing world. At a 2-year follow-up, 56% of those in the developing world were in the best outcome group compared to 39% of the participants from the developed countries. The finding of better outcome for persons in the developing countries applied whether the illness was either acute or gradual in onset.

These findings by the WHO have been critiqued on the basis of differences in follow-up, arbitrary grouping of centers into developed or developing, diagnostic ambiguities (e.g., narrow versus broad definition of schizophrenia), selective outcome measures, gender-related factors, as well as age. However, a recent reanalysis of the data by Kim Hopper and Wanderling (2000) convincingly demonstrates that not a single one of these criticisms is sufficient to explain away the findings of differential course and outcome in schizophrenia favoring persons in the developing countries. These are surprisingly robust findings.

The findings of the WHO studies demonstrating better courses and outcomes for people in the developing world have been attributed to the following factors: family environment and expressed emotion; social role expectations; stigma and discrimination, etc.

Source: Long Term Follow Up Studies


We read with interest the article in the November issue by Srinivasan and Tirupati (1) reporting on their study of cognition and work functioning among patients with schizophrenia in India. We were fascinated by their finding that 67 percent of the 88 patients in the study were employed and that most of them were in full-time employment in mainstream jobs with minimal or no disability or support in the workplace.

These findings will seem alien to most psychiatrists in the Western world, particularly in the United States. Schizophrenia in Western societies is conceptualized as a "chronic debilitating illness" with a poor prognosis and a poor functional outcome. However, this conventional wisdom is not entirely true. At least two major international studies, the International Pilot Study of Schizophrenia (2) and the Determinants of Outcome of Severe Mental Disorders (3), have provided convincing evidence for a better outcome in India and other "less developed" countries than in the West. The multisite study of factors affecting the course and outcomes of schizophrenia in India found that 64 percent of the participants were in remission at a two-year follow-up and only 11 percent continued to be ill (4). Such numbers are likely to be reversed in the United States.

The emphasis in Western psychiatry is on symptom control or elimination and rarely on functional recovery. Patients with schizophrenia also face severe stigma, which makes it difficult for them to find mainstream jobs and very often keeps them on the fringes of society. In addition, the general public strongly associates schizophrenia with violence. Some of the stigma has been propagated by psychiatrists and other mental health professionals. The characterization of schizophrenia as a biological "disease" that needs to be managed mostly by pharmacologic means may also contribute to poor prognosis.

It is also possible that in Western societies, expectation and beliefs about mental illness and the operation of the health care system serve to alienate patients with schizophrenia from normal roles in society and to prolong illness. In contrast, beliefs and practices in non-Western societies may encourage short-term illness and a quick return to premorbid status. Thus prognosis may also be the result of culturally based self-fulfilling prophecies (4).

It is obvious that although schizophrenia may have a biological basis, good outcomes depend on a pharmaco-psycho-social approach, and the psychosocial aspect may well have the greatest impact on improved outcomes.

Maju Mathews, M.D., M.R.C.Psych., Biju Basil, M.D. and Manu Mathews, M.D.

Source: Better Outcomes for Schizophrenia in Non-Western Countries


RAIPUR RANI, India: Psychiatrist Naren Wig crossed an open sewer, skirted a pond and, in the dusty haze of afternoon, saw something miraculous.

Krishna Devi, a woman he had treated years ago for schizophrenia, sat in a courtyard surrounded by religious pictures, exposed brick walls and drying laundry. Devi had stopped taking medication long ago, but her articulate speech and easy smile were eloquent testimony that she had recovered from the debilitating disease.

Few schizophrenia patients in the United States are so lucky, even after years of treatment. But Devi had hidden assets: a doting family and an embracing village that never excluded her from social events, family obligations and work.

Devi is a living reminder of a remarkable three-decade-long study by the World Health Organization -- one that many Western doctors initially refused to believe: People with schizophrenia, a deadly illness characterized by hallucinations, disorganized thinking and social withdrawal, typically do far better in poorer nations such as India, Nigeria and Colombia than in Denmark, England and the United States.

The astounding result calls into question one of the central tenets of modern psychiatry: that a "brain disease" such as schizophrenia is best treated by hospitals, drugs and biomedical interventions.

European and U.S. psychiatrists were so shocked by the initial findings in the 1970s that they assumed something was wrong with the study. They repeated it. The second trial produced the same result. The best explanation, researchers concluded, is that the stronger family ties in poorer countries have a profound impact on recovery.

"If you have a cardiovascular problem, I would prefer to be a citizen in Los Angeles than in India," said Benedetto Saraceno, director of the department of mental health and substance abuse at WHO's headquarters in Geneva. "If I had cancer, I would prefer to be treated in New York than in Iran. But if you have schizophrenia, I am not sure I would prefer to be treated in Los Angeles than in India."

Source: Culture and Mind: Psychiatry's Missing Diagnosis - Part 2