Recovery from schizophrenia in the Third World

Nonmedical Interventions for Schizophrenia: A Review of Diet, Exercise, and Social Roles

Schizophrenia is a major mental illness with a disease course that is influenced by lifestyle. The risk-benefit ratio for alternative interventions is more favorable than for antipsychotics in long-term treatment. Dietary interventions may target autoimmune features, vitamin or mineral deficiencies, abnormal lipid metabolism, gluten sensitivity, or others. Examples of interventions involving diet, physical activity, or physical processes or social interventions including talk therapy exist in the literature. Notwithstanding, the general utility of these types of interventions remains inconclusive, awaiting long-term randomized trials. A perspective that separates the cause of the disease from its symptoms may be helpful in treatment planning and is warranted to distinguish between short-term and long-term recovery goals.

Outcome, recovery and return to work in severe mental illnesses

The assessment of outcomes of severe mental illnesses has become recently an important line of research in psychiatry, leading to distinguish different levels of outcomes and a diversity of underlying factors. The focus has shifted from a traditional medical notion of 'disease outcome' to a wider notion of 'functional outcome', and even to an inquiry about the fate of the person and its determinants. Recovery, rather than cure or remission, is regarded as the good outcome, with its own underlying factors. Return to work, as a vocational outcome, represents in research one of the good functional outcomes. It is generally understood as a sign of social recovery. But may work be regarded as a good outcome in its broader sense, i.e. as a means of full recovery? Several theoretical and empirical arguments are in favor of considering work as a privileged way toward recovery, but this does not mean it is the only way.

[Schizophrenia and culture: reality and perspectives based on the Tunisian experience]

Despite notable advances in the field, schizophrenia is still considered a major public health problem on international level. The combination of frequency, chronicity and severity make it, for some authors, the "cancer of mental disorders". However, according to the many cross-cultural studies, in particular, the two mammoth research projects of the WHO (IPSS and DOSMED, it is now irrefutable that the course and outcome of schizophrenia are better in patients from developing countries. The reasons for better outcome and more favorable course of schizophrenia in developing countries are still far from clear and remain speculative.

AIM OF THE STUDY

We have carried out a study among a population of schizophrenic patients admitted to our hospital during the past year, to question the issues of outcome, course and prognosis in Tunisia, which is an emerging country, ranking half-way between the most and the least developed countries.

RESULTS

It appears that the outcome of schizophrenia is similar to that of developed countries. A community survey reported an annual prevalence of 5.7 and an incidence of 3. 266 patients with schizophrenia were admitted between August 2003 and 2004, representing 40% of the whole hospitalized population; 80% were former patients who had been hospitalized an average of 8 times. One patient out of five will be readmitted at least once within the same year. Only 16.5% were married, and 10% had a regular job, in spite of a high level of education. A chronic course without remission is not unusual and long stay patients now account for a fourth of the hospital population.

COMMENTS

It seems clearly and paradoxically that the course and outcome of schizophrenia is deteriorating and getting closer to what is observed in the industrialized societies. The same trend was observed in the western countries during the last centuries, leading some authors to claim that schizophrenia is a modern disease, which appeared in the XIX(e) century and spread in the XX(e). Besides, other than the controversy regarding the recent evolution of its incidence, it seems that we are not witnessing the anticipated decrease in incidence that comes with the therapeutic progress and the decline in fertility among individuals with schizophrenia.

DISCUSSION

We shall discuss three hypotheses to try to explain the aggravation of schizophrenia along with the economic development: the heterogeneity of the disease with two clinical presentations: a benign form (good prognosis), more frequent in developing countries, and a severe form, observed mainly in developed societies. The progress in medicine and gynecology-obstetrics, which contributes to the survival of patients with serious schizophrenia and the vulnerable newborn exposed to multiple assaults and risk factors related to birth. The progress in psychiatry that is selecting the more serious subtypes of schizophrenia, which are overrepresented today. Research issues pertaining to course and outcome of schizophrenia are still unresolved. It is likely that prognosis of schizophrenia varies according to the economic development rather than to the culture. This observation could open new research and prevention perspectives.

Popular conceptions of schizophrenia in Cape Verde, Africa

INTRODUCTION

It has been well documented that schizophrenia presents a better clinical course in developing countries. Although there are many epidemiological studies showing this association, little research has been conducted to investigate the local representation systems for schizophrenia in these countries.

OBJECTIVES

This study focuses on cultural factors of schizophrenia, namely the local representation systems for the disease, as well as what is locally understood as deviant behavior and its acceptability, and mechanisms of social-cultural insertion or exclusion of patients with schizophrenia in Cape Verde, Africa.

METHODS

Randomized open interviews were carried out with the relatives of patients under treatment at the mental health out patient service of the Batista de Sousa Hospital (São Vicente Island) between the years 1994 and 1995. Interviews dealt with patients' life histories and disease related to problems, strategies employed by the family to cope with such problems, and comments on the social and family burden.

RESULTS

20 interviews with close relatives of 10 patients were analyzed. The study focused on three main categories explaining schizophrenia: "tired head" (cabeça cansada), "nervous" (nervoso), and supernatural categories (like "sorcery" or "witchcraft"). The interviewees expressed their opinions, either explicitly or not, on whether their relatives truly had a disease.

CONCLUSION

Characteristics of local categories for schizophrenia found in Cape Verde can be regarded as a less stigmatized way of dealing with the disease. It is reasonable to suppose that the understanding of such cultural factors could lead to better outcomes in the treatment for schizophrenia in this country, and also in others, where similar conditions can be identified.

The neurosociology of schizophrenia: vulnerability and functional disability

It has been maintained that becoming a schizophrenic is essentially "a social and interpersonal process, not an inevitable consequence of primary symptoms and neurochemical abnormality" (Estroff 1989). It is the intent of this paper to elaborate on this theme by exploring how the neuropsychological deficits of schizophrenia relate to the observed social handicaps of people who carry the diagnosis. We argue that a better understanding of schizophrenia requires inquiry into the handicaps as well as the process whereby schizophrenic and preschizophrenic men and women try and fail to negotiate socially mandated roles. Of necessity, such an inquiry will require mixing levels of explanation (Meehl 1990) and will draw upon insights from the disciplines of psychiatry, neuropsychology, and sociology.

The interaction of popular and clinical diagnostic labeling: the case of embrujado

This paper explores the effect of a popular diagnosis of distress, "bewitchment," on diagnosis, treatment and outcomes of psychiatric illness in a small group of Hispanic patients in New Mexico. Two major approaches to such "culture-bound" illnesses in clinical settings are critiqued and synthesized in suggesting a practical way to understand how both folk and psychiatric explanations can affect experience with, and of psychiatric patients who present with their own culturally patterned diagnoses. Further study suggests that clinically focused ethnography can address the issue of change or persistence in both lay and clinical explanations of illness as they interact in a clinical setting.

The influence of ethnicity and family structure on relapse in first-episode schizophrenia. A comparison of Asian, Afro-Caribbean, and white patients

There is overwhelming evidence that the outcome for people with schizophrenia in Western industrialised countries is inferior to that of those living in the Third World. Extended family structures, greater opportunities for social reintegration, and more positive constructions of mental illness have been offered as possible explanations for this effect. The Asian community in the UK retains many of these features as well as strong links with native cultures of origin. The issue arises as to whether similar differences in outcome may be observed in the UK. An exploratory study was undertaken, examining the early progress of schizophrenia in a first-episode sample (n = 137), and based on systematic examination of case-note data. A lower rate of relapse/readmission in the first 12 months after discharge was found in the Asian (16%) as compared with white (30%) and Afro-Caribbean (49%) patients. Available evidence suggested that speed of access to care, living with a family, and employment may account for this effect. Medication compliance may have contributed to differences in relapse between white and Afro-Caribbeans but was not a factor influencing the low rate among Asians. The limitations and strengths of case-note studies are discussed at length, and it is concluded that a prospective study is warranted and would be highly instructive.

On the significance of an anthropological approach to schizophrenia

Psychotic disturbances like those termed schizophrenia are universal in human groups. Anthropological and social historical studies underscore the varied appearance and significance of such disturbances. In contemporary psychiatry, neurobiological emphases and the exigencies of positivistic research have tended to standardize the picture of schizophrenia. This is reflected in the rationale, methodology and results of the International Pilot Study of Schizophrenia (IPSS), which have tended to support the validity of diagnostic criteria that have evolved in modern Western European societies. Thus, contemporary psychiatric theory appears to stipulate a homogeneous picture of a phenomenon that abounds with social, cultural and psychological complexity as well as human poignancy. There are reasons for challenging this picture of schizophrenia and the biases and limitations in it. Reductionistic and standardized accounts may further immediate, short-range, and practical needs, but they be-cloud academic questions having wide-ranging significance in psychiatry, the social sciences, and the humanities.

Professional ideology and the construction of western psychiatry in Southeast Asia

This article provides a critical examination of the professional ideology associated with the expansion of psychiatric treatment in the ASEAN countries of Southeast Asia. Four components of professional ideology are identified: appeal to "modernization"; medicalization of social problems; integration of psychiatry with primary health care; and panhuman uniformity of mental illness. However, the adoption of psychiatric technology has been a significant factor in the erosion of indigenous systems of social and psychological support since the colonial period. Contemporary psychiatric practices are also shown to exacerbate social inequalities, enhance state control of the populace, and continue to operate without adequate validation of diagnoses and treatments.