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The Last Word
Is the prognosis for schizophrenia really better
in low-income countries than in the West?
Editorials do not necessarily reflect the views of CAMH. We welcome submissions
from our readers. For information, contact: The Editor, CrossCurrents,
33 Russell St., Toronto, Ontario M5S 2S1, tel (416) 595-6714, e-mail hema_zbogar@camh.net.
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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