People with schizophrenia are more likely to get better if they live in poor countries: that's been known for about 25 years. In the 1980s, a series of pioneering World Health Organization (WHO) studies looked at the prognosis for people diagnosed with schizophrenia around the world.
All of the data showed that people in developed countries were less likely to recover than those from poorer areas.
This paradoxical finding sparked no end of debate. What is it about these countries that makes them a better place to get schizophrenia? Patients in richer countries tend to have access to more and "better" psychiatric care, the latest drugs, and so on. Does this mean that those treatments are useless - worse, harmful? That's been the interpretation of some people.
But is it true? Not always, says a new study, W-SOHO. It's out in the British Journal of Psychiatry.
The authors compared schizophrenia outcomes in 37 countries. They recruited outpatients who were starting, or changing, antipsychotic medication. They found that in terms of "clinical" remission - i.e. improvement in the delusions, hallucinations, and other symptoms of schizophrenia - people in the developing world did indeed fare better than those from rich countries.
Over a 3 year period, 80-85% of patients from East Asia, the Middle East, and Latin America who started off ill, showed clinical remission, compared to 60-65% in Europe. That's not new: it confirms what the old WHO data showed.
But the new study also looked at "functional" remission - essentially, being able to participate in society:
having good social functioning for a period of 6 months. Good social functioning included those participants who had: (a) a positive occupational/vocational status, i.e. paid or unpaid full- or part-time employment, being an active student in university or housewife; (b) independent living; and (c) active social interactions, i.e. having more than one social contact during the past 4 weeks or having a spouse or partner.For functional remission, Northern Europe (e.g. the UK, France, Germany) was the best place to get sick, with 35% achieving it. Not a very high figure, but better than elsewhere: it was just 18% in the Middle East and 25% in East Asia, despite these areas having the highest chances of clinical remission. Latin America did pretty well, however, at 29%.
This is a very important finding if it's true. Is it solid?
First off, were Northern European patients just less ill to start with? Not really. They had the highest rates of suicide attempts. They tended to be older, and to have been diagnosed at a later age, which was correlated with worse functional remission. Regression analyses confirmed that region was a predictor of remission controlling for all the other variables.
However, Northern European patients did tend to have better function at baseline. They were more likely to be employed, living independently, and socially active when they entered the study. 63% were living independently which is much higher than anywhere else: it was 24% in Middle East and Latin America. 23% had a paid job compared to 17-19% in developing countries.
That's not a flaw in the study as such but it does suggest that the differences, whatever they are, are already in place before people get treated.
One concern I have is that the definition of "functional remission" may be North Europe-centric. "Living independently" is something we aspire to but in other places, with a strong tradition of the extended family household, the idea that it would be a bad thing for someone with schizophrenia to be living with their family might seem silly. If that means they'll be cared for and supported, what's wrong with it?
And in terms of paid employment, Northern Europe just has a stronger economy than most other places (erm... well, it did back in 2000 when these data were collected), so maybe it's no surprise that people with schizophrenia were more likely to have paid jobs.
In terms of the study itself, it was extremely large with over 17,000 patients enrolled. But here's the thing: this study was run by Lilly, the drug company who make olanzapine, an antipsychotic used in schizophrenia. Three of the authors on the paper are Lilly employees, and the lead author was a consultant for them. The study deliberately sampled lots of people taking olanzapine, presumably in order to find out whether they did better.
None of this necessarily means that the data aren't valid, but I'm just not sure I trust Lilly over the WHO.
Haro JM, Novick D, Bertsch J, Karagianis J, Dossenbach M, & Jones PB (2011). Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. The British journal of psychiatry : the journal of mental science, 199, 194-201 PMID: 21881098
13 comments:
Once again: thank you for examining (mis)information.
I'll take the WHO over Lilly any day.
Did they measure and control for substance abuse? That would be a huge factor IMHO.
There is simply no such thing whatsoever as "schizophrenia." Another major drawback to this "study". *ahem*
Anonymous: Yes, they measured substance abuse ever as present or absent. And alcohol abuse too.
Alcohol misuse ever ranged from 4% to 13%. North Europe was middle of the road on both, Latin America was the same, East Asia very low.
Also they entered that into the regression analyses.
They're probably too busy surviving in developing countries to participate in schizophrenia research. There's a stigma attached to mental disorders, it's more likely they'll see a witch doctor then consult an unaffordable physician who probably won't refer them to another unaffordable mental health specialist.
UN WHO get their health stats from govts - again unreliable because govts fudge figures for handouts.
Having worked on the ground in developing countries, I was surprised at how prevalent mental disorders were even in places where people live in mudhuts. They have local dialect terms instead of DSMIV classification systems.
Very interesting. Thanks. There’s a chapter in “Crazy like us: The globalization of the American psyche” on schizophrenia in Zanzibar, where diagnosed patients do better than those in the US. In fact, it mentions that people with schizophrenia appear to do better over time in developing countries than they do industrialized ones. There are also interesting differences between highly urban and rural settings in developed countries, rural having a lower incidence and better prognosis.
The chapter describes the research of a cultural anthropologist who thinks the observed differences may be due to the way patients are treated by their families and caregivers. Also by the “local understanding” of the illness, which affects the patient’s beliefs, behaviors, and self-conception. Much of the chapter can be read online at Google books http://bit.ly/nFrWUR (chapter 3).
I haven't read the study, but France and Germany is not part of Northern Europe. Germany is Western or Central Europe. France is Western Europe. Northern Europe is Iceland, Ireland, UK, Norway, Sweden, Finnland, Denmark and the Baltic states (Lithuania, Latvia, Estonia).
I too want to thank you for your thoughts. I suffered a psychotic brek of some kind ten years ago and was offered every possible dignosis under the sun depending on who i went to. "Maybe it's bipolar with temporal lobe epilepsy. Take some depakote. Maybe it's onset of schizophrenia, take some anti-psychotics. Maybe it's clinical depression. maybe it's PTSD with psychotic features"
Well I said fuck it I don't trust any of these mother fuckers because giving some one a diagnosis of schizophrenia with a maybe attached is a big deal-- clearly not to the doctors who don't care if your stuck on drugs with terrible side effects and low efficacy that might make you worse over your lifespan.
So I did some neurofeedback, body awareness, mind/body meditation. I asked my body what was up, and it seemed like the issues I needed to process were right there, ready to be processed.
I ceased having IBS, ceased having abnormal EEG, ceased having panic attacks with wierd symptoms, ceased having tunnel vision where reality turns "weird", ceased having .. symptoms.
I still find it hard to work and my memory/cognition sucks. My family helps support me. You know what makes me feel unable to regulate the symptoms? having to sit in front of a psychiatrist who is sure there is psychosis present. that's one sure way to make sure someones symptoms stay there. What's that word, where you project symptoms onto your patients and basically manifest them?
Oh I should add what I figured out was basically that my mother had been biologically wrecked by trauma, violence, parental death, sexual abuse, and drug use in her childhood and immediately preceding getting pregnant and during the pregnancy (meth exposed pregnancy)-- I was not breastfed, by immune system never worked right, I was raised by kind of messed up people in the middle of a cedar forest who were terrified of emotions and had no idea how to be available for a child who could have used some big time parental support, went through a bunch of peer and family alienation followed by a bunch of trauma in highschool and then did a bunch of drugs to escape relity and did a stellar job of wrecking my brain.
No thanks to western mental health professionals putting it all together and trying to repair my brain. I'll put in another way, I can notice "weird symptoms" start to happen and I have learned how to work with my body to resolve them before they become anything. We have learned that people can do this with panic attacks and I think we'll find that people are more capable of pulling themselves back into reality than we currently give them credit.
What's the best way to make a panic attack full blown and horrific? Believe in the symptoms and that they are uncontrollable. I think psychosis operates the same way. You can tke a deep breath and say "Ok I've been through a lot of trauma and my brain/psyche is stuggling. We can work through this and pull back to reality." I think we're making people worse by believing in the power of their symptoms over the power they have internally to work through them with support.
Then again we'll do just about anything to avoid ongoing support for people with a whole lot of life pain, particularly during developmental periods, who might genuinely need more social support than others throughout their lives.
SF, woah. Given major hospitals can't even afford incubators, mental health is definitely a treatment scheme unheard of in poor countries I'd say unless it's attached to HIV/AIDS/Disease related treatment scheme centres or, NGOs treating assaults on women, depressed children etc.
Even with nontrained counselling sessions for disease related treatment schemes, most of it is about mental health awareness and fostering understanding within families and communities. Fancy mental health medication is for European/West folks to put it crudely. Schizophrenia would be impractical to diagnose on the average citizen residing in a developing country.
Jan Henderson: Thanks. I'm a big fan of Crazy Like Us, see my review of it here.
"having good social functioning for a period of 6 months. Good social functioning included those participants who had: (a) a positive occupational/vocational status, i.e. paid or unpaid full- or part-time employment, being an active student in university or housewife; (b) independent living; and (c) active social interactions, i.e. having more than one social contact during the past 4 weeks or having a spouse or partner."
I cannot imagine a more culture-centric description of functioning than this one: Oriented towards gainful employment or educational pursuits, which may be scarce in developing countries.
Interesting that this study is done on a point Robert Whitaker used in Anatomy of an Epidemic -- the Silent Spring of psychiatry -- and attempted a weak refutation.
Psychiatry must always rationalize its reliance on medications.
Point being, the patients in developing countries were diagnosed as schizophrenic by whatever vague diagnosis (vague diagnosis being constant throughout psychiatry all over the world), and diagnosed as "remitted" later.
One minus one equals zero, case closed.
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