Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World?

Abstract

Introduction: That schizophrenia has a better course and outcome in developing countries has become an axiom in international psychiatry. This is based primarily on a series of cross-national studies by the World Health Organization (WHO). However, increasing evidence from other research indicates a far more complex picture. Methods: Literature review and tabulation of data from 23 longitudinal studies of schizophrenia outcomes in 11 low- and middle-income countries. Results: We reviewed the evidence about the following domains: clinical outcomes and patterns of course, disability and social outcomes (marital and occupational status, in particular), and untreated samples and duration of untreated psychosis. Outcomes varied across the studies and the evidence suggests a need to reexamine the conclusions of the WHO studies. Additionally, assessments of outcomes should take excess mortality and suicide into account. Conclusions: It is time to reexamine presumed wisdom about schizophrenia outcomes in low- and middle-income countries.

Dispelling a myth: developing world poverty, inequality, violence and social fragmentation are not good for outcome in schizophrenia

“…Cohen and colleagues addressed this obvious problem in a review of 23 longitudinal studies of schizophrenia from 11 countries defined as low-and middleincome by the World Bank. 7 These countries included 3 in Africa (Nigeria, Ethiopia and South Africa), 2 in South America (Brazil and Colombia), 2 in the Caribbean (Jamaica and Trinidad), 3 in Asia (India, China and Indonesia) and 1 in Eastern Europe (Bulgaria.) To provide a basis for comparison, these authors included developing world sites from both the DOSMeD and the ISoS.…”

“…Studies from China, Ethiopia, India (Chennai) and Indonesia reported high percentages of subjects who had never received biomedical treatment (with long duration of untreated psychosis) and this was associated with poor outcome. Cohen and colleagues 7 argue that this evidence suggest that good outcome cannot be assumed for schizophrenia in low-and middle-income (LMI) countries -a belief popularized by the WHO studies. These authors also address the issue of mortality and show markedly higher mortality rates in people with schizophrenia in LMI countries compared with the general population.…”

“…These studies have been hailed as epidemiological triumphs and this result described as "the single most important finding of cultural differences in cross-cultural research on mental illness." 4 While the finding of improved outcome has been critiqued on the basis of definitions of 'developed' versus 'developing', diagnostic ambiguities and methodological biases 5,6,7 , it has withstood three decades of scrutiny and is regarded as something of an 'axiom' in psychiatric lore. However, recent reviews and analyses of other (non-WHO) studies of outcome have questioned the axiom and suggested that this issue be revisited.…”

“…However, recent reviews and analyses of other (non-WHO) studies of outcome have questioned the axiom and suggested that this issue be revisited. 7 Interestingly this doubt is occurring in the context of another challenge to established epidemiological beliefs about schizophrenia -a belief also emanating from the WHO studies -namely that the incidence of schizophrenia is constant worldwide. McGrath and colleagues have reviewed new data that points to significant variability in incidence rates in relation to variables such as geographical site, urban versus rural location, immigrant status and socio-economic status.…”

Atitudes de profissionais de saúde mental em relação a indivíduos com esquizofrenia: uma comparação transcultural entre Suíça e Brasil

“…A more favourable outcome was found in patients from developing countries, once placed in a social context both more heterogeneous and less competitive, they would be less stigmatized for their illness. However, this hypothesis has previously been challenged 27 and a growing body of evidence suggests that this axiom should be re-examined 27 . Other authors have emphasized the differential characteristics of cultures: they suggest that in Latin cultures the society is more protective and supporting than in Anglo-American cultures and thus less stigmatizing, which may also improve the course of schizophrenia 28,29 .…”