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Updated 15 October 2007 E-mail discussion
Printable version

Forum Discussion: Truly Better Prognosis in the Developing World?

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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]

View Comments By:
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

Background Text
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

Comments on Online Discussion
Comment by:  Digvijay Goel
Submitted 17 October 2007 Posted 17 October 2007

While the research issues raised by Cohen and colleagues are relevant/plausible, it is unlikely that any such study will ever be funded again. I am also unable to understand what will be gained by such research. Neither the pace, nor the direction of the social-economic-political changes taking place across the world are going to be influenced by psychiatric research, which has not been able to influence even mental health policy, as Norman Sartorius pointed out many years ago. This is an exercise in futility, and I am tempted to ask, so what?

The three reasons cited by the authors as justification for yet more, hugely costly, research in several repeatedly researched domains do not bear scrutiny. It is naive to believe that "identifying the processes that promote good prognosis," or "accurate information about the realities of the day-to-day lives of persons with schizophrenia" will ever inform national policy anywhere, least of all in low- and middle-income group countries where over a third of the population still live on less than a dollar a day and where the provision...  Read more

View all comments by Digvijay Goel

Comment by:  Amresh Shrivastava
Submitted 19 October 2007 Posted 24 October 2007

Outcome of schizophrenia in India
Responding to the conclusion in the present meta-analysis, which questions that schizophrenia may not have a good prognosis in developing countries, I seem to agree with the evidence.

Before any other point, the question that needs to be examined is, what is “developing country” in the context of outcome? And why should the outcome be any different, considering the etiopathology of schizophrenia and available treatment?

India is, as we believe, a developing country and may figure by some criteria largely undeveloped, while by other criteria it is quite advanced. Western/developed countries also have seen good outcomes in schizophrenia recently, particularly in the areas of early psychosis studies and first episode psychosis.

We need to be careful about very old studies of schizophrenia conducted when the concept of diagnostic classification was evolving, whether that influenced the studies, and whether old and new studies are comparable at all.

Indian society is full of diversities and very complex. By and large,...  Read more

View all comments by Amresh Shrivastava

Comment by:  Nirmala Srinivasan
Submitted 24 October 2007 Posted 1 November 2007

I am delighted to share my comments on this topic in my dual capacity: as an activist from the caregiver consumer lobby, and also as a professional in social sciences person, with rich research experience. I am in ground zero and hence contact with reality is unavoidable. I know of families who can afford $300 to $400 a day for aftercare facilities—these may be the Rockefellers of India. At the other extreme, less-than-a-dollar-a-day families have no access to medication and wander homeless. I know of patients living in positive family environments but with very poor outcomes. The reverse is the amazing case of patients from highly dysfunctional families with fair if not good progress. So the genetic factors play a decisive role; while we must give due credits to other factors, we cannot use the myopic developed-developing dichotomy in a scenario characterized by global flow of capital. As a famous Marxist economist mentioned, we have circles of development engulfing the global economy.

In that sense, I appreciate the comments of Dr. Amresh Srivastava. Family is no...  Read more

View all comments by Nirmala Srinivasan

Comment by:  Jonathan Burns
Submitted 2 November 2007 Posted 5 November 2007

Developing world poverty, inequality, violence, and social fragmentation are not good for outcome in schizophrenia!
The WHO studies concluded that course and outcome of schizophrenia was better in developing countries. This has become psychiatric lore. However, the reality is that significant political, social, and economic ills that characterize many countries in Africa, Latin America, and Asia constitute psychosocial stressors that mediate strongly against recovery. Economic and social underdevelopment translates into inadequate or even no access to mental health services for many patients with schizophrenia. In many regions, no services exist at all, or where they do exist, they are desperately poor. For example, throughout Africa the majority of patients have no ready access to novel antipsychotics and the prevalence of tardive dyskinesia is shockingly high. Stigma, too, abounds in the developing world—employers and communities are not tolerant and benevolent toward individuals with mental illness.

The belief that community and family life in the...  Read more

View all comments by Jonathan Burns

Comment by:  Patricia Estani
Submitted 3 November 2007 Posted 20 November 2007

I think it is mostly impossible to compare the two samples that the article’s study compared. The definition of the variables are poorly operative, so that the comparisons are confused. The most salient example is the variable of the relationships between the occupations of the patients, the outcomes of these patients and the occupations in the developed and in the developing countries.

The study mentions the occupational demands of the recovered patients with schizophrenia in the developed and in the developing countries. The article concluded that the outcomes of the patients are better in the developing countries because the occupational market is more favorable to these patients. But, this is not possible to conclude. The social and occupational market is less demanding in the developing countries. The subject is less occupied or the subject has less work, so the prognosis could be better in this wrong sense, but this is not really a better prognosis.

In this sense, this is not only NOT a measure of a good outcome, but is a measure of a very poor outcome. This is...  Read more

View all comments by Patricia Estani

Comment by:  Arthur Kleinman
Submitted 17 December 2007 Posted 17 December 2007

Reprinted courtesy of Schizophrenia Bulletin
Kleinman A. Commentary on Alex Cohen et al.: "Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World" Schizophr Bull. 2007 Dec 3; [Epub ahead of print].

In the 1950s, ’60s, and ’70s, the field of cross-cultural (or transcultural) psychiatry provided what was largely Euro-American psychiatry with several useful alternatives. Based on limited research, it balanced the near hegemonic American and British research materials and conclusions with data from the non-Western world, and with new findings about established psychiatric disorders that challenged diagnoses, programs, and treatments. Cultural psychiatry still provides those contributions, but psychiatry itself has changed. We are now in an era of global psychiatry, where psychiatrists from Asia, Latin America, and Africa are contributing numerous studies on mental illness and mental health care, and these are now becoming part of psychiatric science. Not surprisingly, over the past few decades, studies of depression, suicide, psychosis,...  Read more

View all comments by Arthur Kleinman

Comment by:  John McGrath, SRF Advisor
Submitted 21 December 2007 Posted 21 December 2007

Reprinted courtesy of Schizophrenia Bulletin

Dissecting the heterogeneity of schizophrenia outcomes
Goethe believed that data are the natural enemy of hypotheses. As new data accumulate, only a few lucky hypotheses survive the fresh empirical onslaught. Over time, most hypotheses eventually need amendment or outright rejection. Schizophrenia epidemiology has been a particularly fertile field in recent years, with new data leading to the revision of several long-standing dogmatic beliefs (McGrath, 2005; McGrath, 2006; McGrath, 2007). The target article by Cohen and colleagues (Cohen et al., 2007) questions another of the oft-repeated tenets of schizophrenia epidemiology. After close inspection of the schizophrenia outcome studies based in low- and middle-income countries, the authors reject the notion that outcomes in these sites are superior to comparable published data...  Read more

View all comments by John McGrath

Comment by:  John Strauss
Submitted 8 January 2008 Posted 8 January 2008

Is Prognosis in the Individual, the Environment, the Disease, or What?
This wonderful title was suggested by Will Carpenter. It provides a perfect context for considering the problem of prognosis in general, and more specifically, the report by Cohen et al. on the question of cultural differences in prognosis.

Often unrecognized currently, prognosis has for centuries been one of the foundations of scientific medicine. Hippocrates, Sydenham, and in psychiatry, Kraepelin, utilized prognosis as the basis for identifying disease processes. This contrasted strongly with the tendency to use the clinical picture or ‘‘syndrome’’ at one moment in time as the basis for defining various diseases. In fact, Kraepelin put together three very different syndromes, considering them one disease (dementia praecox) because of what he believed to be their common inexorable downhill course. Aside from its use for identifying disease processes, prognosis also serves as a basis against which treatment effectiveness can be measured and for identifying healing processes. In fact,...  Read more

View all comments by John Strauss

Comment by:  Julian Leff
Submitted 25 January 2008 Posted 25 January 2008

Reprinted courtesy of Schizophrenia Bulletin

Methodological issues
I agree with the authors’ criticism of the use of the dichotomy between developed and developing countries, partly because of the difficulty in defining these terms and partly due to the myriad different social, cultural, and economic factors subsumed by them. While ‘‘low income’’ and ‘‘middle income’’ can be reasonably accurately defined, they also encompass a great diversity of factors, both within and between countries. In addition, the authors have aggregated 23 studies including prevalence and incidence samples and prospective and retrospective designs. They acknowledge that a meta-analysis is ruled out by this diversity of sampling procedures and methods but nevertheless proceed to treat these studies as providing equally informative findings. An incidence study is likely to miss a small proportion of individuals fulfilling the selection criteria—11 percent in the AESOP study (Morgan et al., 2006), which used case finding procedures...  Read more

View all comments by Julian Leff

Comment by:  Assen JablenskyNorman Sartorius
Submitted 31 January 2008 Posted 31 January 2008

Comment by Assen Jablensky and Norman Sartorius

Reprinted courtesy of Schizophrenia Bulletin

What did the WHO studies really find?
The article by Cohen et al. raises important issues and provides a useful synopsis of published studies on schizophrenia outcomes in 11 low- and middle-income countries. The authors use of this material to challenge what they claim to be an ‘‘axiom’’ (i.e., a self-evident proposition requiring no proof) of better course and outcome in developing countries which has been ‘‘embraced’’ by international psychiatry. They impute the origin of this belief primarily to World Health Organization (WHO)-led international collaborative research conducted over the past 30 years (WHO, 1973; WHO, 1979; Jablensky et al., 1992; Harrison et al., 2001) and caution that the publication of the final report from the International Study of Schizophrenia (ISoS) (Hopper et al., 2007) might even further...  Read more

View all comments by Assen Jablensky
View all comments by Norman Sartorius

Comment by:  Evelyn J. Bromet
Submitted 1 February 2008 Posted 1 February 2008

Reprinted courtesy of Schizophrenia Bulletin

Cross-national comparisons: problems in interpretation when studies are based on prevalent cases
Cohen et al. challenge the belief, stemming largely from the World Health Organization (WHO) schizophrenia research program, that ‘‘schizophrenia has a better course and outcome in countries of the developing world’’ compared with developed countries. They thus examine findings on illness course, mortality, and social and occupational outcomes across an array of studies conducted in low- or middle-income countries throughout the world. They consider findings from all follow-up studies of schizophrenia conducted in these countries, without regard to case identification specification or length of follow-up. The outcome results across the studies identified by Cohen et al. were variable, and in some cases, the samples fared very poorly indeed. Because none of the studies had control groups, cross-national disparities in the social and occupational trajectories of the patients with schizophrenia compared with...  Read more

View all comments by Evelyn J. Bromet

Comment by:  Karl-Ludvig Reichelt (Disclosure)
Submitted 19 February 2008 Posted 27 February 2008

One of the dominant differences between the developed world and developing world is food types. Already Prof. F Dohan pointed out that schizophrenia was rare where grains are rare (Dohan et al., 1984) Rice and maize are staple foods in large parts of the developing world. In other parts manioc, kasawa, etc., have a substantial role in the countryside. This could explain the faster recovery when patients in these countries are returned to their native villages (Lehtinen, 1987). Also, the acculturation following transition to grain-based diet makes sense (Lorenz, 1990). Thus, the increased rate when poor people move from developing countries to developed countries where grains and milk products are the cheaper foods.

It would also fit our data on the levels of exorphins in schizophrenic patients (Reichelt et al., 1996). (See also an example of data on intervention with diet [Singh and Kay,...  Read more

View all comments by Karl-Ludvig Reichelt

Comment by:  Robert Lemelson
Submitted 23 April 2012 Posted 25 April 2012

Our film series "Afflictions: Culture and Mental Illness in Indonesia" is the first film series on serious mental illness in the developing world. Three of the films in the series directly address issues of differential outcome for thought disorders/schizophrenia, issues raised by the IPSS and DOSMD studies. The series has won a number of awards, and should be useful for anyone teaching transcultural psychiatry, psychiatric anthropology, and related fields. Information on the series is available here.

View all comments by Robert Lemelson

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