[spiritual_emergency]

Hello to those of you who I haven't seen in a while. Note that this discussion is being shifted here from another site. The focus of the discussion is schizophrenia and the developing world.

Relevant background material includes the following:

http://spiritualrecoveries.blogspot....enia-hope.html

http://spiritualrecoveries.blogspot....follow-up.html

http://spiritualrecoveries.blogspot....comes-for.html

http://spiritualrecoveries.blogspot....s-missing.html

http://www.scielo.br/pdf/rbp/v28n2/29784.pdf

http://www.schizophreniaforum.org/fo....asp?liveID=59

If anyone is aware of other information/studies as related to the course and outcome of schizophrenia in developing nations, please share.

teejai, I've already read through the PDF brief and I'm slowly making my way through the forum conversation. I'll be back to comment as time permits and I hope others will offer their comments and perspectives as well.

~ Namaste

[spiritual_emergency]

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

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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

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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

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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

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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

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[pachyderm]

WHO says mental health treatment in developing countries is lacking:

http://news.smh.com.au/world/who-see...1011-4yl2.html

http://www.voanews.com/english/2008-10-09-voa43.cfm

Wonder what treatment they have in mind...

[spiritual_emergency]

Thanks pachyderm. If you come across any others, drag 'em in here.

My purpose in initiating this thread is because I want to know if the above statements are true or not, and the only way to know is to take a good look at the data.

Three international studies that consistently demonstrate a higher recovery rate is nothing to sneeze at but I have heard criticisms of late. One of the things I'm wondering is are those criticisms tied in in any manner with big pharma? Certainly, they would stand to lose a great deal if it was discovered that more people can recover with minimal medication or no medication at all, which is surely the case in some of these developing nations.

I'm also eager to see what psychosocial factors can possibly be identified that others could then attempt to replicate to further their own recovery. As but one example, the article on Culture and Mind (shown in green) notes that there is a shortage of nursing staff in hospitals in India and for this reason, family members are sometimes pressed into providing in-hospital care. I do know that not every parent is a good parent, but I believe that most are and certainly, individuals in crisis often benefit from maintaining or strengthening their social ties. Having family members provide "in-hospital nursing care" is a very different approach from Westernized nations where family members are restricted to visiting during specific hours and may not be provided any information related to treatment due to various privacy laws.

Given the scope and diversity of these studies, I'm expecting it might be difficult to interpret all the data but I'm willing to give it a shot. I will surely learn something in the process and hope that others will as well.
Continuing in that vein, I've tracked down the study by Hopper and Wanderling that was cited above. I'll post that next.

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[spiritual_emergency]

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.)

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[pachyderm]

You can get the book on Amazon from $64.98 (probably used) plus shipping.

[spiritual_emergency]

spiritual_emergency: 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.

Correction. As best I can determine (at this time) the three studies took place as indicated below:

1967: The International Pilot Study of Schizophrenia
1978: The Determinants of Outcome of Severe Mental Disorder (DOSMeD)
1992: The International Study of Schizophrenia (ISoS)

The question whether schizophrenia occurs in similar forms in different populations and cultures was first raised by Kraepelin at the turn of the century. However, methodological difficulties have impeded for decades the development of comparative cross-cultural research, and it was not until the 1960s that investigations of the kind Kraepelin envisaged became feasible. A major role in launching multi-centre clinical and epidemiological studies of schizophrenia in over 20 countries in different parts of the world has been played by the World Health Organization. The WHO studies have demonstrated that: (I) syndromes of schizophrenia occur in all cultures and geographical areas investigated; (II) their rate of incidence is very similar in the different populations; (III) the course and prognosis of schizophrenia is extremely variable, but outcome is significantly better in the developing countries. These findings have fundamental implications for the conceptualization of schizophrenia and for designing strategies of new research.

Source: Is Schizophrenia Universal?

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[spiritual_emergency]

Some considerations from the field of anthropology...

... what we know about culture and schizophrenia at the outset of the twenty-first century is the following: Culture is critical in nearly every aspect of schizophrenic illness expereince: the identification, definition and meaning of the illness during the prodromal, acute and residual phases; the timing and type of onset; symptom formation in terms of content, form and constellation; clinical diagnosis; gender and ethnic differences; the personal experience of schizophrenia illness; social response, support and stigma; and perhaps, most important, the course and outcome of disorders with respect to symtomatology, work and social functioning. ...

Introduction to the Three Parts: Themes and Cross-Currents
This volume is intended to bring the puzzle of schizophrenia under scrutiny from the standpoint of the social sciences; that is, those disciplines that take as their central concern the problem of human life as such. And while the chapters represent perspective that combine social and medical sciences broadly, the overarching conceptual framework for the volume hinges largely on culture theory from contemporary anthropology. The volume is organized in three parts that elaborate cultural analyses of the problem, each of which constitutes a piece of the puzzle of the psychoses.

In the first part, authors outline state-of-the-art understandings of culture, self and experience that are critical to a cross-culturally comparative and global understanding. Each of the four chapters in the second part sets out a methodological strategy, in turn, developing the ethnographic, sociolinguistic, clinical and historical dimensions of schizophrenia and related psychotic disorders. The third part plumbs the depth of subjectivity and emotion, withou an understanding of which the daily lived experience of schizophrenia must remain unnecessarily imcomprehensible. We will summarize each of the parts in turn, and conclude our introduction by reflecting on the clinical impressions of the work collected here.

The first part deals with a number of critical issues that confront all studies of human experience, and culture and schizophrenia in particular. One is the relationship between the ordinary and the extraordinary; another is the nexus between subjectivity and culture; and a third is the tension between general and specific concepts of culture. These problematics, elaborated through studies of schizophrenia, define the broader terms for analysis that are developed more fully in the ensuing parts.

Chapter 1 (Jenkins) argues that schizophrenia itself offers a paradigm case for understandings of culturally fundamental and ordinary processes and capacities of the self, the emotions and social engagement. She also shows how the experiences of people with schizophrenia can be quintessentially extraordinary just as they can be exquisitely ordinary. As a consequence, people who suffer from the disorder have a unique capacity to teach us about human processes that are fundamental to living in a world shared with others.

A single-minded focus on the similarities between those who have schizophrenia and those who do not carries the risk of negating what is so extraordinary about this illness, underestimating the intensity of suffering it entails, and overlooking the resilience of those who grapple with it. But if the focus is restricted to understanding differences between abnormal and normal, the risk is one of devaluing the person with schizophrenia. Difference may lean to diminution and decomposition of the person into an object. Jenkins embraces the extraordinary and the ordinary in schizophrenia, the abnormal and the normal, and gives no quarter to those who would play down the insights that people with the illness offer, nor to those who would characterize them as flawed and emotionally empty humans.

Chapter 5 (Lucas), in exploring some of the cultural processes at work around this ordinary/extraordinary interface, carries this analyses further. Drawing on ethnographic work in Australia among people with schizophrenia and juxtaposing these data with classical formulations of the disorder within the psychiatric literatre, he locates schizophrenia both outside and inside the bounds of culture. Psychiatric discourse identifies the source of this illness in the body and in nature, thereby placing it beyond culture. On the other hand, schizophrenia itself is a cultural category, replete with cultural tropes.

It is sometimes construed as a primitive state in which archaic sources of violent energy erupt through surface laters of control; or a state of confusion and alienation that mirrors the complex modern society in which we live; or a form of creative power akin to artistic genius. Such images are not only invoked by psychiatrists, but also by people so diagnosed when representing schizophrenia to themselves...

Source: Schizophrenia, Culture and Subjectivity: The Edge of Experience [PDF File]

The above is just a brief excerpt of a 20 page brief. Those who wish to know more can click on the link above or, order the book linked below.

See also: Schizophrenia, Culture and Subjectivity: The Edge of Experience [Book]. This book is substantially less than the last one I linked. It's $30 - $35 with used versions beginning at $20.

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