My Support Forums - View Single Post - Schizophrenia & The Developing World (Attn: teejai)

spiritual_emergency · 03:23 PM

Quote:

In 1967, WHO initiated a set of studies investigating the manifestation, consequences, and course of schizophrenia and related disorders. Since then, nearly 30 research sites in 19 countries have participated. These studies -- specifically, the International Pilot Study of Schizophrenia (1967) and the Determinants of Outcome of Severe Mental Disorders (1978) with initial followup periods ranging from 2 to 5 years -- have consistently found persons clinically diagnosed with schizophrenia and related disorders in the industrialized West (chiefly Europe and the United States) to have less favorable outcomes than their counterparts in "developing" countries (countries in Africa, Asia, and Latin America).

Although the number of distinctive "cultures was small and there were a few anomalies, the durability of this finding, extensively documented and assessed with increasingly sophisticated instruments is quite remarkable... By the late 1980's the documentation that persons diagnosed as suffering from schizophrenia consistently do better in the long-run in non-Western settings was being hailed as possibly "the single most important finding of cultural differences in cross-cultural research on mental illness".

But it was far from clear whether the pronounced differences seen in short-term followup would hold up over time. Questions have been raised as well about the conceptual adequacy of such labels as "developed" and "developing"; a point implicitly illustrated by the anomalous refusals of a few centers to group with their assigned class. Diagnostic ambiguities invariably cloud the picture when so many different investigators, some hailing from distinctive psychiatric traditions, are included; the ambiguities are compounded when as much as a quarter-century has elapsed since the initial assessment. Most relevant here, what accounts for the apparent "benefits" of underdevelopment was not at all apparent. Speculation ranged widely. Cultural signposts certifying the expectations of recovery, self-exempting modes of illness attribution, the therapeutic benefits of accommodating work, kind-based stores of supportive social capital, the relative anonymity of life in the industrialized world -- all of these have been proposed as explanatory mechanisms.

Hence the timelines of the recently completed ISoS, the latest of the WHO Collaborative Projects. In early 1997, investigators completed data collection in followup interviews of both the original IPSS prevalence cohort (26 years after the episode of inclusion) and the DOSMeD cohort (13-16 years after the initial episode), as well as two other groups of subjects -- an incidence cohort from each of three centers of the WHO Reduction and Assessment of Psychiatric Disability Study and a mixed set of subjects (two treated incidence cohorts, one prevalence) from three additional invited centers.

This article has a modest aim: to examine as closely as the available data permit the durability and soundness of that provocative finding of a differential advantage in course and outcome for the developing countries. Has the differential outcome survived the 13 years since the last reported for (some of) these same subjects? If so, are the results demonstrably not attributable to artifactual confounding.

... We first review the consistency of the finding of a "developed versus developing" differential in course and outcome in three WHO studies. Next, we examine a variety of course and outcome measures for the ISoS incidence cohorts that bear upon differences for illness trajectory for the two groups. We analyze five potential sources of bias and assess their likely impact on these reported differences. We conclude with some directions for further analyses.

Findings: Consistency of the Developed versus Developing Differential in Course and Outcome
... the finding of a consistent outcome differential favoring the "developing" centers is remarkably robust. It extends across all three WHO collaborative projects. It holds for followup periods ranging from 2, to 5, to 15 years. It applies when various diagnostic groupings are usied. It holds when country groupings shift. It even appears to be relatively constant, as indicated by the odds ratios for recovery calculated in the far right column of table 2.

Note that the above are mere excerpts from the 12 page report. A full copy of that report can be downloaded for free here. I included excerpts from the introduction and a brief statement on the findings (Table 2 is found on page 4 of the report). The actual report goes into far more detail and is worthy of a read for those who are so inclined.

Meantime, as I understand it, the three studies took place over three decades; the first one taking place in 1967; the second in 1978, and the third in 1999. The studies do consistently demonstrate that recovery rates are better in non-Westernized nations but the authors could not pinpoint exactly why that was so.

I expect to return to this report many times over in the course of any ensuing discussion that takes place from this point forward.

See also: Recovery From Schizophrenia: An International Perspective (It's a shame this book is almost $100.)

.