Forum Discussion: Truly Better Prognosis in the Developing World?
View Comments By:
In our Forum discussion “journal club” series, the editors of Schizophrenia Bulletin provide access to the full text of a recent article. A short introduction by a journal editor gets us started, and then it's up to our readers to share their ideas and insights, questions, and reactions to the selected paper. So read on…
|Cohen A, Patel V, Thara R, Gureje O.
Free Full Text
Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World?
Schizophr Bull. 2007 Sep 28; [Epub ahead of print]
Digvijay Goel — Posted 17 October 2007
Amresh Shrivastava — Posted 24 October 2007
Nirmala Srinivasan — Posted 1 November 2007
Jonathan Burns — Posted 5 November 2007
Patricia Estani — Posted 20 November 2007
Arthur Kleinman — Posted 17 December 2007
John McGrath — Posted 21 December 2007
John Strauss — Posted 8 January 2008
Julian Leff — Posted 25 January 2008
Assen Jablensky, Norman Sartorius — Posted 31 January 2008
Evelyn J. Bromet — Posted 1 February 2008
Karl-Ludvig Reichelt — Posted 27 February 2008
Robert Lemelson — Posted 25 April 2012
By William Carpenter, Maryland Psychiatric Research Center, and Editor, Schizophrenia Bulletin
The field should celebrate each time an important concept is challenged by data and modification of a theory or hypothesis is required. A nice recent example was John McGrath’s “data versus dogma” piece detailing variations in incidence and prevalence of schizophrenia across geographic location and other socio-demographic variables (McGrath, 2006). [Ed. Note: See also SRF Live Discussion led by McGrath.] Alex Cohen and colleagues now review 23 reports that challenge the view that schizophrenia has a more benign course in developing countries. The view that course of illness is better in developing countries emerged from the International Pilot Study of Schizophrenia (IPSS) where patient subjects in Nigeria, Colombia, and India fared better at 2- and 5-year follow-up than patient subjects in five developed countries (WHO, 1979). Taiwan was an exception, but also not easily classified in the developing/developed dichotomy. The IPSS could not address sampling bias (e.g., acute, florid psychoses may have better prognosis and may also be more likely to be admitted to a clinical facility in poor countries), but the subsequent Determinants of Outcome WHO study addressed sampling issues more effectively and again found better outcome in developing countries (Jablensky et al., 1992). Together with other reports from the WHO studies (Harrison et al., 2001; Hopper et al., 2007), many of us accepted the view that the interaction between environment and the disease was more favorable in the developing world. There were interesting and compelling hypothetical explanations. My favorite came from Lin and Kleinman (Lin et al., 1988), who suggested that the developing world was more likely to provide a sociocentric culture that would be less demanding and more accepting of disabilities associated with schizophrenia compared to the egocentric western, developed countries with emphasis on autonomy and individual accomplishment. Given the cognitive and motivational challenges associated with schizophrenia, a less demanding and more inclusive society would seem to have specific advantages.
Cohen and colleagues find a more textured landscape in the 23 studies they consider. Good and poor outcomes occur in the same nations. Explanations do not fit neatly into wealth, industrialized, urbanized, or other common explanations. Methodological issues may explain why some data suggest a more favorable course in developing countries. Other patterns emerge, and the authors identify seven questions to be addressed in future research.
The Schizophrenia Bulletin will carry a series of commentaries addressing selected critical issues from several vantages. These will also appear as “Comments” in SRF. The paper, Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World? is available through the Schizophrenia Research Forum and the Schizophrenia Bulletin Advanced Access page. Commentaries will appear online as they are accepted at Schizophrenia Bulletin.
McGrath, JJ. Variations in the incidence of schizophrenia: data versus dogma. Schizophr Bull. 2006;32:195–197. Abstract
WHO. Schizophrenia: an international follow-up study. Chichester: John Wiley and Sons; 1979.
Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, Day R, Bertelsen A. Schizophrenia: manifestations, incidence and course in different cultures: a World Health Organization ten-country study. Psychological Medicine Monograph Supplement. 1992; 20; 20:1-97. Abstract
Harrison G, Hopper K, Craig T, Laska E, Siegel C, Wanderling J, Dube KC, Ganev K, Giel R, an der Heiden W, Holmberg SK, Janca A, Lee PW, Leon CA, Malhotra S, Marsella AJ, Nakane Y, Sartorius N, Shen Y, Skoda C, Thara R, Tsirkin SJ, Varma VK, Walsh D, Wiersma D. Recovery from psychotic illness: a 15- and 25-year international follow-up study. British Journal of Psychiatry. 2001;178:506-517. Abstract
Hopper K, Harrison G, Aleksandar J, Sartorious A. Recovery From Schizophrenia. Oxford University Press, New York, 2007.
Lin KM and Kleinman AM. Psychopathology and clinical course of schizophrenia: a cross-cultural perspective. Schizophr Bull. 1988;14(4):555-67. Abstract