During the past 30 years, international psychiatry has embraced the notion that the course and outcome of schizophrenia is better in so-called “developing” countries.2–5,13,14
We believe our review of 23 studies in 11 low- and middle-income countries—a much greater range of sociocultural environments than in ISoS—provides enough evidence to justify a reexamination of this axiom.
First, there appears to be great variation in clinical outcomes and patterns of course. Whereas, some studies in India strongly support the “better prognosis” hypothesis,15,20,21
outcomes do not appear to be nearly as positive in Brazil64
Additionally, limited evidence suggests that gender effects vary cross-nationally.
Second, similar patterns are found in the domains of disability and social functioning: good in most studies in India15,20,21
but poorer in Nigeria,35,53
and much poorer in a cohort of untreated persons in Chennai, India.43
Social functioning by gender also varied: in the MLS, women had high levels,26,45
while in Nigeria women fared poorly.35,63
Outcomes in occupational and marital status also varied. A more important point, however, is that status in these 2 domains must be interpreted in the context of sociocultural norms and assessed, at least to some degree, qualitatively. Viewed from this perspective, the data in suggest that rates of marriage for people with schizophrenia are relatively low and rates of divorce/separation are high.
With regard to occupational status, “the crude distinction between ‘employment’ and ‘unemployment’”39
is uninformative because the role of work in shaping the course and outcome of schizophrenia has not been explored adequately.56
For example, what are the effects on outcome of farm work in rural Ethiopia42
Did jobs “in the unorganized/informal sector [as] street vend[ors], shops assistants, and domestic help” impel good outcomes in the MLS?44
Furthermore, assessment of social functioning is, in general, “fraught with problems”27
given variation in sociocultural environments, norms, and attitudes.3
Unfortunately, neither the research reviewed above nor the WHO studies provide the evidence that allows us to evaluate the quality of family and social interactions, the nature of employment, and the meaning of marriage for the subjects in the various studies. Ethnographic methods are needed to gain a better understanding of the social functioning of persons with schizophrenia in a range of sociocultural environments.18,19
Third, the WHO studies have led “to the ironic observation that abundance cripples” and that “scarcity” and “collaborative social world[s]” are responsible for better outcomes.56
Yet, our review of the research suggests a different conclusion: wherever it is found, lack of care is associated with relatively poor outcomes and that accessing care is associated with improved outcomes. Because the individuals in many of the studies were receiving care at leading academic psychiatric facilities, one might even say that their relatively good clinical, occupational, and social outcomes reflected the effects of quality care as much as, if not more than, the effects of sociocultural environments. Thus, the favorable outcomes that have been found by some studies cannot be assumed to be representative of outcomes in low- and middle-income countries where the majority of persons with schizophrenia have little or no access to care.
Fourth, the evidence about excess mortality must not be ignored. We agree with Ran et al.51
: “It may be premature to suggest that there is a better prognosis for schizophrenia in [developing] countries if withdrawals or attrition due to death…are not included in follow-up analyses.”
Fifth, further research into the role of families is necessary. Although expressed emotion studies are informative about the nature of family interactions, such research provides little understanding of the processes that for example, lead Indian families to keep members with schizophrenia out of care, or that bring about the breakdown of family support for subjects in Nigeria, or that force homelessness upon some persons with schizophrenia in China. Surveys of public attitudes in Nigeria65,66
as well as qualitative and survey research with families in India60,68–70
suggest high levels of stigma about mental illness. These negative attitudes, at least in Africa, are believed to result in families abandoning mentally ill members.71
Appalling conditions in psychiatric facilities in Asia72–74
also raise questions about whether presumed tolerance translates into better outcomes.
Sixth, variability in outcomes is evident in high-income countries, too. Reviews of long-term studies16,75,76
show variability from study to study, and ISoS15
shows variability in outcomes across high-income countries. One analysis of DOSMeD data77
indicates that 2-year outcomes in Prague and Nottingham were similar to those in India, while outcomes in Cali were close to those in high-income countries. Given this variation, we need to find a better framework for comparing schizophrenia outcomes in different sociocultural environments.
Seventh, the evidence provided by this review suggests that the sampling methods utilized in the WHO studies may have resulted in overly optimistic perceptions of course and outcome in low- and middle-income countries. Except for the China ISoS site, sampling in all the WHO studies relied on a variety of help-seeking agencies to identify potential subjects.10,11,15
However, community surveys in rural China,29
and Ethiopia have shown that large proportions of persons with schizophrenia (between about 25% and almost 90%) never receive biomedical treatments. Furthermore, outcomes in these samples, whether or not subjects received treatment following inclusion in the studies, tended to be poor. Therefore, there is the possibility that case-finding methods which focus exclusively on help-seeking agencies will miss large proportions of seriously ill, poor prognosis individuals.
This review has 2 main limitations. First, our strategy to identify studies—searches of bibliographic databases and locating references cited in journal articles—may not have been comprehensive, and it is possible that we did not find all the studies that met our criteria. It is also possible that reliance on English language articles excluded a number of reports about other outcome studies. Nevertheless, because this was a narrative review and not a meta-analysis, we do not believe these potential shortcomings would have substantially influenced our conclusions. Second, a more serious limitation is the possibility that apparent variations in course and outcome were the function of methodological heterogeneity among the studies. We do not believe this was the case because the methods and instruments used in the studies were generally consistent with each other.
In conclusion, we suggest it is time to revisit the hypothesis that the course and outcome of schizophrenia is better in low- and middle-income countries. Although a host of sociocultural factors have been cited as contributing to variation in the course and outcome of schizophrenia—eg, family support and styles of interaction, industrialization, and urbanization4
—there is little direct evidence, and what exists provides little help in unpacking the “black box” of culture.79
Clinical, epidemiological, and ethnographic research are required to better understand how neuropsychiatric processes and social worlds interact to shape the lives of persons with schizophrenia in low- and middle-income countries.
The questions in need of investigation include:
- Of the prevalent cases in each catchment area, how many are receiving psychiatric care? How many are receiving alternative forms of treatment? How many are receiving no care at all?
- What are the biomedical and other treatment effects on outcome? How do variations in treatment influence variations in outcomes within and across research sites?
- What are the clinical outcomes in terms of positive and negative symptomatology of incident and prevalent cases?
- How might employment and nonpaid occupations influence or be influenced by clinical factors?
- What is the quality of family life (natal and marital) of persons with schizophrenia and how does this influence (or is influenced by) outcome?
- What are the pathways to care (biomedical and traditional) and what are the clinical and sociocultural factors associated with help-seeking decisions?
- What are the circumstances that lead to suicidality and excess mortality among persons with schizophrenia?
The knowledge that will come from answering these and other questions is important for at least 3 reasons. First, identifying the processes that promote good prognosis will inform the care and treatment of persons with schizophrenia wherever they live. Second, accurate information about the realities of the day-to-day lives of persons with schizophrenia in low- and middle-income countries will inform advocacy efforts to: (a) close the enormous gap between the numbers of people in need of care and the small number who actually receive it80
; and (b) provide greater supports for families. Finally, globalization is bringing about enormous sociocultural and socioeconomic changes to the societies of low- and middle-income countries. In turn, these changes will, inevitably, transform the nature of families and the communities in which they live, the epidemiological profile of nations and regions, and the services provided by health systems. No doubt, globalization will have significant consequences for the lives of persons with schizophrenia. To prevent or at least limit the potential harm that may result, it is essential that we have detailed understandings about how sociocultural and psychiatric processes interact. For these reasons, it would make sense to put aside presumed wisdom and reexamine the question of the prognosis of schizophrenia in low- and middle-income countries.