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Updated 15 October 2007
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...  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...  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...  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...  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...  Read more

View all comments by Patricia Estani

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

Reprinted courtesy of Schizophrenia...  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...  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...  Read more

View all comments by John Strauss

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

Reprinted courtesy of Schizophrenia...  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...  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...  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...  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...  Read more

View all comments by Robert Lemelson
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