RICHARD WARNER

C O M M E N T A R Y O N C O H E N , P R O G N O S I S F O R

S C H I Z O P H R E N I A IN T H E T H I R D W O R L D

Alex Cohen, one suspects, might have made a fine defense attorney. He has certainly shown a willingness to expend a great deal of effort on what many would consider a weak case. Most judges, I believe, would conclude that outcome from schizophrenia has been proved by clear and convincing evidence to be substantially better in the Third World than in the West. Virtually every Third World outcome study points to this conclusion. Third World samples that reveal a substantially higher recovery rate in schizophrenia than is typically seen in Western studies include Mauritius (Murphy and Raman 1971); Hong Kong (Lo and Lo 1977); Chandigarh, India (Kulhara and Wig 1978); Sri Lanka (Waxier 1979); Agra, India; Ibadan, Nigeria; Cali, Colombia; Taipei, Taiwan (WHO 1979); and a sample drawn from five Third World settings for the WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders (Sartorius et al. 1986).

I can find only one example of an outcome study which fails to support the general finding. In 1957, Dr. J. De Wet, the physician superintendent of a South African mental hospital run along traditional and somewhat restrictive Western lines, concluded that recovery from schizophrenia was no more frequent among his Bantu patients than among Europeans. The hospital treatment, however, appears to have been somewhat restrictive and not particularly conducive to recovery. Many patients stayed in hospital for over a decade; others received 15 to 30 electro-convulsive treatments and were detained for months following treatment to "ensure that sudden relapses did not take place at home" (1957: 745). By contrast, anecdotal reports (Laubscher 1937; Simons 1958) describe excellent recovery from schizophrenia-like psychoses among the Bantu in their own communities. De Wet 's report might be seen as a good advertise- ment for community treatment of schizophrenia (rather than institutional care) or it may describe a select population of more chronic, poor outcome cases who ended up in hospital because they failed to recover in their own community.

The scale of the difference in recovery rates in schizophrenia between the Third World and the West is so great that it must compensate for minor concerns about methodology. An average figure for complete symptom-free recovery from first-break schizophrenia in European and North American studies since 1956 is 22% (Warner 1985): the equivalent figure from the Mauritius study is 64% at 12-year follow-up (Murphy and Raman 1971). On average, 45% of Western first-break schizophrenic patients recover to a level of unimpaired or

Culture, Medicine and Psychiatry 16: 85-88, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

86 RICHARD WARNER

mildly impaired social functioning (Warner 1985): in Hong Kong the com- parable social recovery rate is 66% after 10 years (Lo and Lo 1977), and in Sri Lanka 71% after 5 years (Waxier 1979). In the WHO International Follow-up Study of Schizophrenia (WHO 1979), the best outcome group at 2-year follow- up included 35% of the patients from the developing countries, but only 15% of patients from the developed countries. I f these findings are the result of a methodological problem, it would have to be a powerful and consistent bias to produce effects of this magnitude.

Sampling bias, an area of concern for Cohen, might conceivably produce a spurious effect of this size. Acutely ill but better-prognosis patients might comprise a larger proportion of admissions to psychiatric hospitals in the Third World. For many researchers, however, this concern has been alleviated by the WHO Determinants of Outcome Study (Sartorius et al. 1986). The problem of selection bias was overcome in this multi-center project by defining as the study sample all individuals with signs and symptoms of possible schizophrenia making a first lifetime contact with a variety of "helping agencies" in the community. These helping agencies included indigenous healers and religious institutions. The samples selected by this broad case-finding approach displayed substantially better outcome for the Third World subjects, as in prior studies. Whereas only 39% of the subjects in the developed countries exhibited a mild course of illness, 56% of those in the developing world fell into this category.

Cohen is concerned that even this case-finding strategy was not comprehen- sive enough, though his anxiety appears to be based less on concrete evidence than on hypothetical concerns. There are good grounds to believe that his apprehension is unnecessary. If case-finding had been inadequate in the Third World settings, as Cohen suggests, then the discovered incidence of cases in those locations would almost certainly have been lower. In fact, the incidence of broadly diagnosed cases was highest in the Third World sample - nearly three times greater in rural Chandigarh, India than in Aarhus, Denmark. The incidence of narrowly defined schizophrenia was amazingly similar in all of the centers, and certainly no lower in the Third World.

Cohen minimizes the achievements of the Determinants of Outcome Study when he claims that "without more complete information about the case-finding networks" the results are "difficult to evaluate." In fact, the authors of the report go into some detail in describing the case-finding process and the effort invested in the control of "leakage" of eligible cases. Centers were required to conduct additional surveys of the case-finding network and any other agencies which were not originally included, in order to identify missed cases. Leakage of eligible cases was no greater in samples in the developing countries than in the developed world. The case-finding network, in most cases, produced "a regular and uninterrupted inflow of cases" and, to guard against short-term disruptions

and fluctuations in case-finding, the process was extended over two or more

years.

COMMENTARY III 87

Cohen's other major concern, that "follow-up studies are inherently unreli- able," has some truth, but is a counsel of perfection. A prospective study of the type envisaged by Cohen, conducted simultaneously in multiple centers in the developed and developing world with sufficiently large and representative samples, low attrition, reliable raters, and frequent contact with subjects, would be so difficult logistically and so inordinately expensive as to be next to impossible (WHO 1979).

It is difficult to see, moreover, why inaccuracies introduced by the follow-up method would introduce a consistent bias towards finding better outcome in Third World samples, let alone one of sufficient power to produce the outcome differences in schizophrenia which have so consistently been observed.

There is serious reason to question the finding of superior outcome from schizophrenia in the Third World, however, which is scarcely touched on by Cohen. Is the condition which is being called "schizophrenia" in the Third World actually the same illness which we call by that name in the West, or is it something that looks the same on initial presentation but is, in fact, some mixture of organic and functional psychoses? True, the WHO CATEGO diagnostic system demonstrated that patients with the classic schizophrenic syndrome may be found in centers around the globe presenting with similar symptom pictures (WHO 1973). But it is still possible that the Third World samples include more cases of, say, malarial psychosis, nutritional disorders or drug-induced psychoses which would tend to have a better outcome than

schizophrenia. The Determinants of Outcome Study (Sartorius 1986) raises our level of

concern over this issue because, as noted above, it reveals that, although the incidence of narrowly-defined schizophrenia is very similar around the world, the incidence of broadly defined schizophrenia is much greater in the Third World sample. It is in the large pool of less clearly defined schizophrenic cases that there may be lurking organic and other atypical psychoses with a tendency to acute onset and superior outcome. The study shows, moreover, that patients with an acute type of illness are four times as common in the Third World samples (40% of cases) as in the developed countries (11% of cases).

The Determinants of Outcome Study, however, while raising our fears, provides the antidote. The study presents a finding of considerable importance. Subjects in the Third Worm samples have a milder pattern of illness regardless of the type of onset of the illness. Thus, patients with a gradual onset of illness, who are most likely to suffer from a "core" type of schizophrenia with poor outcome, exhibit a mild course of illness in 40% of the cases in the developing countries but in only 30% of the cases in the developed world. Similarly, only 43% of gradual-onset cases in the developing countries display a severe course of illness compared to 53% in the developed countries. Similar differences in favor of Third World subjects are found for those with acute and subacute types

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of onset. The importance o f this finding can hardly be overemphasized, but it is

still not exactly what we need to know. We must awai t the publication o f the full

results of the Determinants of Outcome Study to learn the answer to the key

question. Is the outcome for patients with narrowly defined schizophrenia, the "central" schizophrenic syndrome - the condition which occurs with surpris-

ingly similar probabil i ty around the globe - superior in the Third World? If the answer is "Yes", it will be difficult to argue any longer with the conclusion that schizophrenia is a more benign condition in the non-industrial w o r d .

Mental Health Center of Boulder County 1333 Iris Avenue Boulder, CO 80304, U.S.A.

REFERENCES

De Wet, J.S. Du T. 1957 Evaluation of a Common Method of Convulsion Therapy in Bantu

Schizophrenics. Journal of Mental Science 103: 739-757. Kulhara, P., and N.N. Wig.

1978 The Chronicity of Schizophrenia in North West India: Results of a Follow-up Study. British Journal of Psychiatry 132:186-190.

Laubscher, B.J.F. 1937 Sex, Custom and Psychopathology: A Study of South African Pagan Natives.

London: Routledge & Kegan Paul. Lo, W.H., and T. Lo.

1977 A Ten-Year Follow-up Study of Chinese Schizophrenics in Hong Kong. British Journal of Psychiatry 131: 63-66.

Murphy, H.B.M., and A.C. Raman. 1971 The Chronicity of Schizophrenia in Indigenous Tropical Peoples. British

Journal of Psychiatry 118: 489---497. Sartorius, N., A. Jablensky, A. Korten, et al.

1986 Early Manifestations and First-Contact Incidence of Schizophrenia in Different Cultures. Psychological Medicine 16: 909-928.

Simons, H.J. 1958 Mental Disease in Africans: Racial Determinism. Journal of Mental Science

104: 371-388. Warner, R. 1985 Recovery from Schizophrenia: Psychiatry and Political Economy. London:

Routledge & Kegan Paul. Waxier, N.E.

1979 Is Outcome for Schizophrenia Better in Nonindustrial Societies? The Case of Sri Lanka. Journal of Nervous and Mental Disease 167:1A.'!. 158.

World Health Organization 1973 The International Pilot Study of Schizophrenia, Volume 1. Geneva: World

Health Organization. World Health Organization

1979 Schizophrenia: An International Follow-up Study. New York: John Wiley.