Is the prognosis for schizophrenia really better in low-income countries than in the West? CrossCurrents Summer 2003

CrossCurrents

The Last Word

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During the last 30 years, cross-cultural psychiatry has embraced, almost without question, the notion that the prognosis for schizophrenia is better in low-income countries than in the wealthy countries of the West. Close examination of the evidence, however, suggests a surprising, collective willingness on the part of cross-cultural psychiatrists and medical anthropologists to accept what must be considered, at least by this author, as Rousseauian notions about the perniciousness of the modern and the beneficence of the traditional. Perhaps the current acceptance of this axiom is not so surprising given the curious history of cross-cultural research on schizophrenia.

In the 1920s, physician and anthropologist Charles Seligman claimed that nothing resembling schizophrenia had existed in New Guinea prior to European contact. In an article reprinted in Littlewood and Dein's 2000 book, Cultural Psychiatry and Medical Anthropology, Seligman claims that even after contact, financial debt to Europeans was the sole cause of "fatal instances of insanity." In 1940, anthropologist Alfred Kroeber suggested that shamans were individuals with schizophrenia, but that the cultures in which they lived provided them with socially acceptable roles that minimized the functional consequences of the disorder.

In 1971, psychiatrists H.B.M. Murphy and A.C. Raman were the first to carry out a systematic comparison of the course of schizophrenia in two different sociocultural contexts. Through a retrospective comparison of hospital records, they concluded that schizophrenia was less chronic among people in Mauritius than among a matched sample in the United Kingdom. Around the same time, anthropologist Nancy Waxier studied schizophrenia among Sinhalese Buddhists in Sri Lanka. Again, course of illness in this so-called traditional society was found to be better than in industrialized western societies. To demonstrate the opposite - that the "modern" cultures of the West are pernicious - Nancy Scheper-Hughes in 1979 conducted ethnographic fieldwork to explain the high rates of schizophrenia in western Ireland.

While these studies are intriguing, none stand up under close scrutiny. Kroeber's hypothesis is now largely abandoned. The others, to some extent, all depended on hospital data, samples of hospital patients or both, which is problematic, since hospital samples do not represent the general population of persons with schizophrenia. Littlewood and Dein indicate that Seligman did not look beyond the evidence he found in a hospital, an institution whose patients and their disorders certainly did not represent the indigenous population. Murphy and Raman, as well as Waxler, depended on hospital samples and records for information about course of illness. Even Scheper-Hughes, whose research focused on the lives of people in a small town, relied on hospital statistics to substantiate claims of higher rates of schizophrenia in western Ireland. However, M. R. Cabot's 1990 epidemiological research found that hospital statistics in Ireland were inflated and that the rates of schizophrenia were not particularly high in western Ireland.

The most compelling and oft-cited evidence of the better prognosis for schizophrenia in low-income or traditional societies comes from two cross-national studies conducted by the World Health Organization: the 1979 International Pilot Study of Schizophrenia and the Determinants of Outcome of Severe Mental Disorder (DOSMeD), published in 1992. The DOSMeD research represents the most ambitious and methodologically sophisticated cross-cultural study of schizophrenia. Over two years, investigators attempted to identify all persons suffering from a first episode of schizophrenia in 13 catchment areas in 10 countries. They found that schizophrenia occurred throughout the world, that the cross-cultural similarities of its clinical characteristics were notable, that most people with schizophrenia followed a remitting pattern of course over a two-year period, and that the incidence of narrowly defined schizophrenia was constant throughout the world. Perhaps the most important finding was that the research found "consistent and marked differences in the prognosis of schizophrenia between the centres in developed countries [where prognosis was relatively poor] and the centres in developing countries [where prognosis was relatively good]."

The DOSMeD research has largely remained unchallenged despite methodological problems that include: 1) potential bias as a result of extensive case-finding problems; 2) the use of outcome variables such as percentage of the follow-up period spent in the hospital or on psychotropic medication that reflected differences in socio-economic environments rather than variations in course of illness; and, 3) over-reliance on long-term recall to recreate complicated course of illness patterns.

Various sociocultural factors have been cited as contributing to variation in the course of schizophrenia in different settings. In their 2001 article in Psychiatric Clinics of North America, Kulhara and Chakrabarti indicate family support and styles of interaction, industrialization and urbanization. Yet we have little evidence from low-income countries that clearly demonstrates the beneficent influence of these variables. Indeed, as Edgerton and Cohen point out in a 1994 article in the British Journal of Psychiatry, the DOSMeD research did not provide direct sociocultural evidence to support its conclusions. At the same time, much evidence suggests that course and prognosis for schizophrenia should be worse in low-income countries. Severe stigma, lack of treatment and human rights abuses in large custodial asylums, all of which are well documented in many low-income countries, are associated with poor course and outcome.

The curious history of cross-cultural research on schizophrenia continues. There is insubstantial evidence to support the notion of better prognosis for schizophrenia in low-income countries. But, there is also substantial evidence that suggests that the prognosis for schizophrenia in low-income countries is relatively poor. In either case, we must not continue to allow Rousseauian notions to shape our perceptions of the relationship between social worlds and illness. A task remains: to undertake empirical research into how sociocultural environments in low-income countries shape the lives and illness experiences of people with schizophrenia.

Alex Cohen, PhD, is an anthropologist and an instructor in the Department of Social Medicine at Harvard Medical School in Boston, Massachusetts

 

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