Outcome of schizophrenia: the Madras longitudinal study

Predicting first-episode psychosis patients who will never relapse over 10 years

BACKGROUND

Although relapse in psychosis is common, a small proportion of patients will not relapse in the long term. We examined the proportion and predictors of patients who never relapsed in the 10 years following complete resolution of positive symptoms from their first psychotic episode.

METHOD

Patients who previously enrolled in a 12-month randomized controlled trial on medication discontinuation and relapse following first-episode psychosis (FEP) were followed up after 10 years. Relapse of positive symptoms was operationalized as a change from a Clinical Global Impression scale positive score of <3 for at least 3 consecutive months to a score of ⩾3 (mild or more severe). Baseline predictors included basic demographics, premorbid functioning, symptoms, functioning, and neurocognitive functioning.

RESULTS

Out of 178 first-episode patients, 37 (21%) never relapsed during the 10-year period. Univariate predictors (p ⩽ 0.1) of patients who never relapsed included a duration of untreated psychosis (DUP) ⩽30 days, diagnosed with non-schizophrenia spectrum disorders, having less severe negative symptoms, and performing better in logical memory immediate recall and verbal fluency tests. A multivariate logistic regression analysis further suggested that the absence of any relapsing episodes was significantly related to better short-term verbal memory, shorter DUP, and non-schizophrenia spectrum disorders.

CONCLUSIONS

Treatment delay and neurocognitive function are potentially modifiable predictors of good long-term prognosis in FEP. These predictors are informative as they can be incorporated into an optimum risk prediction model in the future, which would help with clinical decision making regarding maintenance treatment in FEP.

Schizophrenia outcome measures in the wider international community

Background

Outcome of schizophrenia has been described as favourable in low-and middle-income countries. Recently, researchers have questioned these findings

Aims

To examine the outcome studies carried out in different countries specifically looking atthose from low-and middle-income countries

Methods

Long-term course and outcome studies in schizophrenia were reviewed

Results

A wide variety of outcome measures are used. The most frequent are clinical symptoms, hospitalisation and mortality (direct indicators), and social/ occupational functioning, marriage, social support and burden of care (indirect indicators). Areas such as cognitive function, duration of untreated psychosis, quality of life and effect of medication have not been widely studied in low-and middle-income countries

Conclusions

The outcome of schizophrenia appears to be better in low-and middle-income countries. A host of sociocultural factors have been cited as contributing to this but future research should aim to understand this better outcome. There is a need for more culture-specific instruments to measure outcomes

Religion involvement and quality of life in patients with schizophrenia in Latin America

OBJECTIVE

The aim of the study was to explore the relationship between religion involvement (RI) and quality of life (QoL) in patients with schizophrenia from three countries in Latin America, while considering key confounding factors such as socio-demographic and clinical characteristics.

METHODS

This cross-sectional study was conducted in the public mental health services in La Paz, Bolivia; Arica, Chile; and Tacna, Peru. The data collected included RI, socio-demographic information, clinical characteristics, type of treatment and QoL using the S-QoL 18 questionnaire. A multivariate analysis using multiple linear regressions was performed to determine variables associated with QoL levels.

RESULTS

Two hundred and fifty-three patients with schizophrenia were enrolled in our study. Significant positive associations were found between RI and QoL (the S-QoL 18 index: β = 0.13; p = 0.048; autonomy dimension: β = 0.15; p = 0.027). Other socio-cultural and economic factors were also associated with low QoL level: being a woman, older patient, low education level and being Aymara. Severity of the psychotic symptoms was associated to a lower QoL for all the dimension (β from 0.15 to 0.31), except for the resilience.

CONCLUSION

Our study found that socio-cultural and economic factors including RI were associated with QoL in patients with schizophrenia in Latin America, suggesting that these factors may influence positively health outcome. However, these relationships were moderate in strength, especially in comparison to symptoms severity which remained the most important features associated with QoL.

Assessing the needs of siblings of persons with schizophrenia: A qualitative study from India

There is a lack of studies on siblings of persons with schizophrenia (SOPS) in Asia. This study aims to explore the needs of SOPS in India. 15 SOPS participated in this qualitative explorative study. All the interviews were audio recorded and later transcribed. Data analysis was carried out using General Inductive Approach. Five themes emerged from the data: managing illness or socio-occupational functioning; follow up services; informational needs; personal needs; and miscellaneous needs. SOPS in India have some distinctive needs. Identifying these needs might help in developing and designing specific psychosocial interventions for better management.

A preliminary investigation into theory of mind and attributional style in adults with grandiose delusions

INTRODUCTION

A preliminary cognitive model of grandiose delusions has been put forward suggesting that persecutory and grandiose delusions shared distinct, yet overlapping psychological processes. This study aims to test this model and hypothesises that participants experiencing grandiose delusions may demonstrate a theory of mind (ToM) impairment and differences in attributional style compared to a control group.

METHODS

A cross-sectional design compared the performance of 18 individuals with grandiose delusions to a control group of 14 participants with depression. ToM was measured using a non-verbal joke appreciation task and a verbal stories task. Attributional style was measured using the internal, personal and situational attributions questionnaire.

RESULTS

Participants experiencing grandiose delusions performed significantly worse on both ToM tasks compared to controls. Furthermore, these participants provided significantly more atypical answers when explaining the joke behind the ToM cartoons. No differences for subjective funniness ratings or attributional style were found.

CONCLUSIONS

This preliminary study indicated participants experiencing grandiose delusions have ToM impairments which may contribute to the maintenance of this symptom.

History of religious delusions and psychosocial functioning among Mexican patients with paranoid schizophrenia

The association between global functionality and religiosity among patients from developing and predominantly Catholic countries warrants attention. To compare religiosity and psychosocial functioning in Mexican schizophrenia patients with and without a history of religious delusions, seventy-four patients with paranoid schizophrenia were recruited. Patients with a history of religious delusions had more psychiatric hospitalizations and poorer psychosocial functioning compared with those without a history of religious delusions. No differences emerged between groups in the total scores of religiosity scales. A history of religious delusions rather than religiosity itself may have an influence on psychosocial functioning among Mexican patients with schizophrenia.

Religion, spirituality, and schizophrenia: a review

Religion and spirituality exert a significant role in the lives of many individuals, including people with schizophrenia. However, the contribution of religion and spirituality to various domains (psychopathology, explanatory models, treatment seeking, treatment adherence, outcome, etc.) has not received much attention. In this article, we review the exiting data with regards to the relationship of religion, spirituality, and various domains in patients with schizophrenia. Available evidence suggests that for some patients, religion instills hope, purpose, and meaning in their lives, whereas for others, it induces spiritual despair. Patients with schizophrenia also exhibit religious delusions and hallucinations. Further, there is some evidence to suggest that religion influences the level of psychopathology. Religion and religious practices also influence social integration, risk of suicide attempts, and substance use. Religion and spirituality also serves as an effective method of coping with the illness. Religion also influences the treatment compliance and outcome in patients with schizophrenia.

Prospective relationship between duration of untreated psychosis and 13-year clinical outcome: a first-episode psychosis study

BACKGROUND

The adverse effects of a long duration of untreated psychosis (DUP) have been explored in numerous short-term studies. These studies support the development of early interventions that reduce treatment delay and promote recovery. However, the enduring impact of DUP is largely unknown, partly due to the paucity of prospective long-term studies. Although the DUP-outcome relationship is commonly assumed to be linear, the threshold effect has not been adequately examined.

OBJECTIVE

To explore the relationship between DUP and long-term symptomatic remission.

METHODS

This was a prospective study of a cohort of 153 first-episode psychosis patients in Hong Kong at the 13-year follow-up. The patients were categorized into short (≤30days), medium (31-180days) and long (>180days) DUP groups.

RESULTS

The long-term outcome was ascertained in 73% of the patients. Nearly half of the patients (47%) fulfilled the criteria for symptomatic remission. The short DUP group experienced a significantly higher remission rate over the course of the illness. The odds of long-term symptomatic remission was significantly reduced in the medium DUP (by 89%) and long DUP (by 85%) groups compared with the short DUP group. Further analysis showed that DUP had a specific impact on negative symptom remission.

CONCLUSION

The findings support the threshold theory that DUP longer than 30days adversely impacts the long-term outcome. The present study is one of the few studies that confirmed the enduring impact of DUP on long-term outcomes based on well-defined criteria and adequate statistical adjustment.

Sex differences in lipid peroxidation and fatty acid levels in recent onset schizophrenia

Sex differences in the symptomatology and course of illness have been reported among schizophrenic patients. Hence, the principal objective of the present study was to investigate sex differences in the concentrations of the lipid peroxidation metabolites MDA and 4-HNE, and in the membrane phospholipid levels of ARA, EPA and DHA in patients with schizophrenia. A total of 46 paranoid schizophrenics (25 women) with short-term evolution who were in an acute psychotic stage and 40 healthy controls (23 women) participated in the study. Psychopathology was evaluated by BPRS and PANSS. Lipid peroxidation sub-products (MDA, 4-HNE) and fatty acid levels (ARA, EPA, DHA) were determined in erythrocyte membranes. The men in both groups showed higher lipid peroxidation levels and those values were higher in schizophrenic patients than controls, with only EPA fatty acid concentrations found to be lower in the former than the latter. These results suggest that men may suffer greater oxidative neuronal damage than women, and that this could worsen the course of illness and result in greater disease severity.

Psychosurgery for schizophrenia: history and perspectives

Following the early studies of Moniz and Lima, psychosurgery had considerable scientific credibility until the advent of modern antipsychotics in the mid 1950s. Thereafter, psychosurgery was almost abandoned in large medical centers as a common treatment for schizophrenia, although is still used for some affective and anxiety disorders. We reviewed relevant papers cited in the Medline/Index Medicus, Cochrane, and Scielo databases from 1930 to 2012. In our review of the literature, we show from recent studies that there are still many patients with schizophrenia who have serious deficits even after being treated with current noninvasive therapies. The value of psychosurgery remains controversial. There are no data available to support the use of stereotactic procedures for schizophrenia. Well designed controlled trials are needed to establish the effectiveness of psychosurgery in patients with schizophrenia.

Twenty-five years of schizophrenia: The Madras longitudinal study

AIM

To determine the 25 year follow-up of subjects originally enrolled in the Study of factors associated with course and outcome of schizophrenia (SOFACOS) at Chennai.

MATERIALS AND METHODS

All subjects who were followed up were administered the same research tools which were done at inclusion, namely the PSE & PPHS.

RESULTS

At the end of 25 years, 47 of the original ninety subjects were assessed completely. Twenty five (26%) had died and 18 (20%) were lost to follow-up during the 25 year period. 32 of the 47 followed up were in partial or total remission. Outcome was good in 27.7%, intermediate in 52% and poor in 19%. More men were single and more women were either married or separated. Gender differences were not marked.

CONCLUSIONS

This is one of the few prospective, long term follow up studies from India. Although outcome was good in those followed up, the numbers who died and could not be followed up causes concern.

Grandiose delusions: a review and theoretical integration of cognitive and affective perspectives

Grandiose delusions (GDs) are found across a wide range of psychiatric conditions, including in around two-thirds of patients diagnosed with bipolar disorder, half of patients diagnosed with schizophrenia, as well as in a substantial proportion of patients with substance abuse disorders. In addition, over 10% of the healthy general population experience grandiose thoughts that do not meet full delusional criteria. Yet in contrast to other psychotic phenomena, such as auditory hallucinations and persecutory delusions, GDs have received little attention from researchers. This paper offers a comprehensive examination of the existing cognitive and affective literature on GDs, including consideration of the evidence in support of 'delusion-as-defence' and emotion-consistent' models. We then propose a tentative model of GDs informed by a synthesis of the available evidence designed to be a stimulus to future research in this area. As GDs are considered to be relatively resistant to traditional cognitive behavioural techniques, we then discuss the implications of our model for how CBT may be modified to address these beliefs. Directions for future research are also highlighted.

Culture, stress and recovery from schizophrenia: lessons from the field for global mental health

This cultural case study investigates one U.S. psychosocial rehabilitation organization's (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons' "recovery-oriented" initiatives unwittingly mobilized stressful North American discourses of valued citizenship. At times, efforts to "empower" people diagnosed with schizophrenia to become esteemed self-made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia's sensitivity to stress and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to "better" outcomes in the developing world may rely on the availability of locally relevant techniques to address stress.

Preliminary findings from a study of first-episode psychosis in Montreal, Canada and Chennai, India: comparison of outcomes

BACKGROUND

This article reports preliminary findings from a multi-year investigation of onset and course of previously untreated first-episode psychosis in two similarly structured treatment programs in Canada and India. Specifically, the aim of this study was to examine whether one year clinical and functional outcomes of first-episode psychosis varied between these two programs.

METHOD

Patients with first-episode non-affective psychosis receiving similar treatment in Chennai, India (N=61) and in Montreal, Canada (N=88) were evaluated for demographic variables, duration of untreated psychosis, and baseline diagnosis, and for positive, negative, and general psychopathology symptoms and overall functioning at baseline and one year.

RESULTS

At both sites, there was a significant improvement in symptoms and functioning over the one year course of treatment. There was also a significant time-by-site interaction on negative symptoms and functioning, after controlling for age, sex, and marital status. On these domains, patients in India showed greater improvement over time than their Canadian counterparts. The time-by-site interactions were not significant for positive symptoms and general psychopathology.

CONCLUSION

First-episode patients in the Indian program demonstrated higher rates of improvement at one year in negative symptoms and functioning than patients receiving similar treatment in Canada. There was no difference in improvement between the sites on positive symptoms and general psychopathology. These results suggest that the sociocultural context of treatment can influence outcomes early in the course of psychotic disorders. Further, outcomes are not uniformly better or worse in one sociocultural context compared to another, but seem to vary from one outcome domain to another.

Indian psychiatry, research and Asian countries

Asia has some of the largest conglomerations of human populations and also the fastest growing economies of the world. About 23% of the world's population lives in the South Asian region, and one-fifth of psychiatrically ill patients in the world live in this part of the world. Despite vast cultural, religious, geographical, and political diversities, the factors influencing mental health remain the same throughout this wide region, as highlighted at the recently concluded Asian summit, where the slogan, 'One vision, one identity, one community,' was launched. Thus, the need to strengthen regional cooperation in the field of mental health has always been felt. This article highlights facts about influence of Indian Psychiatry research as well as of some Asian countries in the world psychiatry and vice versa.

From local to global - Contributions of Indian psychiatry to international psychiatry

Indian psychiatrists have actively engaged with world psychiatry by contributing to understanding and care of persons with mental disorders based on the religious, cultural and social aspects of Indian life. The contributions are significant in the areas of outlining the scope of mental health, classification of mental disorders, understanding the course of mental disorders, psychotherapy, traditional methods of care, role of family in mental health care and care of the mentally ill in the community settings.

The abilities of improved schizophrenia patients to work and live independently in the community: a 10-year long-term outcome study from Mumbai, India

BACKGROUND

The outcome of first episode schizophrenia has several determinants. Socioecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socioecological condition that has several challenges for mental health. The present study reports on the long-term status of patients with schizophrenia in such a mega city: Mumbai, India.

AIM

This study aims to reveal the long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning.

METHODS

The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalisation were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided.

RESULTS

Of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission into long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10 years, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment.

CONCLUSION

With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% of patients lived in the community, 72.9% of patients lived independently, and 40% of patients obtained employment. However, 60% of patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socioecological factors have played a role in this outcome.

Design and clinical characteristics of a homogeneous schizophrenia pedigree sample from Tamil Nadu, India

OBJECTIVE

The genetic complexity of schizophrenia may be compounded by the diagnostic imprecision inherent in distinguishing schizophrenia from closely related mood and substance use disorders. Further complexity may arise from studying genetically and/or environmentally diverse ethnic groups. Reported here are the ascertainment, demographic features and clinical characteristics, of a diagnostically and ethnically homogeneous schizophrenia pedigree sample from Tamil Nadu, India. Also reported is the theoretical power to detect genetic linkage in the subset of affected sibling pairs.

METHOD

Affected sibling pair and trio pedigrees were identified by caste/ethnicity. Affected probands and siblings fulfilled DSM-IV criteria for schizophrenia or schizoaffective disorder.

RESULTS

The present sample consisted of 159 affected sibling pairs and 187 parent-offspring trios originating primarily from the Tamil Brahmin caste, but also incorporating pedigrees from genetically similar, geographically proximal caste groups. Consistent with previous studies in Tamil Nadu, a very low prevalence of affective psychoses such as schizoaffective disorder, was observed, with most affected individuals having schizophrenia (499/504). Also observed were extremely low rates of nicotine (12.4%), alcohol (1.1%) and illicit drug use (0%). Most affected individuals exhibited negative symptoms (>90%) and a severe, chronic course. All participants lived in the same geographic and climatic region and most affected individuals resided with close family members, increasing uniformity of the sociocultural environment. In affected sibling pairs, power to detect linkage to small-effect risk loci was modest, but this homogeneous sample may be enriched for loci of larger effect.

CONCLUSIONS

This Indian schizophrenia sample exhibits diagnostic and ethnic homogeneity with high consistency of sociocultural environmental features. These characteristics should assist efforts to identify risk genes for schizophrenia.

Is the course and outcome of schizophrenia better in the 'developing' world?

Historically, poor outcome has often been considered to be an integral part of the concept of schizophrenia, though in recent times this has been challenged by many cross-cultural studies. In this article, we review various studies pertaining to course and outcome of schizophrenia to have an understanding about variations in course and outcome of schizophrenia across cultures and nations. For better appraisal, the research studies have been divided into studies prior to cross-cultural World Health Organization (WHO) sponsored studies (Pre-WHO studies), WHO sponsored cross-cultural studies, and studies on course and outcome of schizophrenia not sponsored by WHO. We believe that the evidence arising from various studies across the globe largely supports the 'favorable outcome hypothesis in developing countries', i.e. developing countries have a larger proportion of patients with a good outcome and lesser percentage with a worst outcome as compared to developed countries, albeit amidst the controversies discussed by us. We suggest that in course and outcome studies, culture should not be used as a synonym for unexplained variance and research designs focusing at other potential factors impacting course and outcome of schizophrenia are much needed.

Research on religion, spirituality, and mental health: a review

Religious and spiritual factors are increasingly being examined in psychiatric research. Religious beliefs and practices have long been linked to hysteria, neurosis, and psychotic delusions. However, recent studies have identified another side of religion that may serve as a psychological and social resource for coping with stress. After defining the terms religion and spirituality, this paper reviews research on the relation between religion and (or) spirituality, and mental health, focusing on depression, suicide, anxiety, psychosis, and substance abuse. The results of an earlier systematic review are discussed, and more recent studies in the United States, Canada, Europe, and other countries are described. While religious beliefs and practices can represent powerful sources of comfort, hope, and meaning, they are often intricately entangled with neurotic and psychotic disorders, sometimes making it difficult to determine whether they are a resource or a liability.

Questioning an axiom: better prognosis for schizophrenia in the developing world?

INTRODUCTION

That schizophrenia has a better course and outcome in developing countries has become an axiom in international psychiatry. This is based primarily on a series of cross-national studies by the World Health Organization (WHO). However, increasing evidence from other research indicates a far more complex picture.

METHODS

Literature review and tabulation of data from 23 longitudinal studies of schizophrenia outcomes in 11 low- and middle-income countries.

RESULTS

We reviewed the evidence about the following domains: clinical outcomes and patterns of course, disability and social outcomes (marital and occupational status, in particular), and untreated samples and duration of untreated psychosis. Outcomes varied across the studies and the evidence suggests a need to reexamine the conclusions of the WHO studies. Additionally, assessments of outcomes should take excess mortality and suicide into account.

CONCLUSIONS

It is time to reexamine presumed wisdom about schizophrenia outcomes in low- and middle-income countries.

Religious delusions: finding meanings in psychosis

BACKGROUND

Religious delusions have been reported with varying prevalence from cultures around the world. Their contents, context and significance vary according to cultural and economic mores. In this review we discuss the potential relationship between religious delusions and aspects of culture, in particular religious symbols. We suggest that religious rituals and expectations of the family play a major role in the genesis and maintenance of delusions. We consider the roles of religious signifiers in the formation and maintenance of these important phenomena.

SAMPLING AND METHODS

Evidence relating to the clinical significance of religious delusions is reviewed. The real clinical significance of religious delusions varies from violence to others to self-harm. The implications of these issues are discussed in relation to their management.

RESULTS AND CONCLUSIONS

It is argued that there should be a reassessment of the importance of religious delusions in the light of new ethnographic and clinical evidence.

Research, empiricism and clinical practice in low-income countries

Mental health problems are relevant for every country. They are particularly important for low-income countries which face a high burden of illness due to infectious disease, greater socio-economic disparities, and have limited resources for mental health care. There is a great mismatch in the areas of mental health research, practice, policy and services in comparison to developed countries. There have been a few studies that have investigated major mental health problems prevailing in these countries but missed out significant health problems. Studies have tended to be more donor driven and conducted in tertiary centres. The low priority accorded to mental health by the policy makers, scarcity of human resources, lack of culture-specific study instruments, lack of support from scientific journals have been some of the impediments to mental health research in these countries. In addition, lack of community participation and absence of sound mental health policies have deprived the vast majority of the benefit of modern psychiatric treatments. Recently, with increase in collaboration in research, availability of treatment including low-priced psychotropics, and a growing emphasis on the need for mental health policy in some low-income countries, the bleak scenario is expected to change.

Relationship of cognitive function in patients with schizophrenia in remission to disability: a cross-sectional study in an Indian sample

BACKGROUND

Cognitive deficits in various domains have been consistently replicated in patients with schizophrenia. Most studies looking at the relationship between cognitive dysfunction and functional disability are from developed countries. Studies from developing countries are few. The purpose of the present study was to compare the neurocognitive function in patients with schizophrenia who were in remission with that of normal controls and to determine if there is a relationship between measures of cognition and functional disability.

METHODS

This study was conducted in the Psychiatric Unit of a General Hospital in Mumbai, India. Cognitive function in 25 patients with schizophrenia in remission was compared to 25 normal controls. Remission was confirmed using the brief psychiatric rating scale (BPRS) and scale for the assessment of negative symptoms (SANS). Subjects were administered a battery of cognitive tests covering aspects of memory, executive function and attention. The results obtained were compared between the groups. Correlation analysis was used to look for relationship between illness factors, cognitive function and disability measured using the Indian disability evaluation and assessment scale.

RESULTS

Patients with schizophrenia showed significant deficits on tests of attention, concentration, verbal and visual memory and tests of frontal lobe/executive function. They fared worse on almost all the tests administered compared to normal controls. No relationship was found between age, duration of illness, number of years of education and cognitive function. In addition, we did not find a statistically significant relationship between cognitive function and scores on the disability scale.

CONCLUSION

The data suggests that persistent cognitive deficits are seen in patients with schizophrenia under remission. The cognitive deficits were not associated with symptomatology and functional disability. It is possible that various factors such as employment and family support reduce disability due to schizophrenia in developing countries like India. Further studies from developing countries are required to explore the relationship between cognitive deficits, functional outcome and the role of socio-cultural variables as protective factors.

[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.

Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here

The history of the way schizophrenia has been conceptualized in American psychiatry has led us to be hesitant to explore the role of social causation in schizophrenia. But there is now good evidence for social impact on the course, outcome, and even origin of schizophrenia, most notably in the better prognosis for schizophrenia in developing countries and in the higher rates of schizophrenia for dark-skinned immigrants to England and the Netherlands. This article proposes that "social defeat" may be one of the social factors that may impact illness experience and uses original ethnographic research to argue that social defeat is a common feature of the social context in which many people diagnosed with schizophrenia in America live today.

Size of burden of schizophrenia and psychotic disorders

Schizophrenia is a severe mental disorder characterised by fundamental disturbances in thinking, perception and emotions. More than 100 years of research have not been able to fully resolve the puzzle that schizophrenia represents. Even if schizophrenia is not a very frequent disease, it is among the most burdensome and costly illnesses worldwide. It usually starts in young adulthood. Life expectancy is reduced by approximately 10 years, mostly as a consequence of suicide. Even if the course of the illness today is considered more favourable than it was originally described, it is still only a minority of those affected, who fully recover. The cumulative lifetime risk for men and women is similar, although it is higher for men in the age group younger than 40 years. According to the Global Burden of Disease Study, schizophrenia causes a high degree of disability, which accounts for 1.1% of the total DALYs (disability-adjusted life years) and 2.8% of YLDs (years lived with disability). In the World Health Report [The WHO World Health Report: new understanding, new hope, 2001. Geneva], schizophrenia is listed as the 8th leading cause of DALYs worldwide in the age group 15-44 years. In addition to the direct burden, there is considerable burden on the relatives who care for the sufferers. The treatment goals for the moment are to identify the illness as early as possible, treat the symptoms, provide skills to patients and their families, maintain the improvement over a period of time, prevent relapses and reintegrate the ill persons into the community so that they can lead as normal a life as possible.

Twenty-year course of schizophrenia: the Madras Longitudinal Study

OBJECTIVE

To follow up 90 first-episode schizophrenia patients after 20 years and to study the course of symptomatology, work, social functioning, and pattern of illness during this period.

METHODS

The Present State Examination and the Psychiatric and Personal History Schedule were administered at fixed points during follow-up. The measures adopted to ensure a good follow-up rate (67%) after 20 years under adverse conditions are described.

RESULTS

Complete data were obtained from 61 subjects; 16 had died, and 13 could not be traced. After 20 years, 5 patients had recovered completely, and another 5 were continuously ill. Most of the cohort had multiple relapses with or without complete remission between them. The Global Assessment of Functioning Scale showed that symptoms and social functioning in this sample approximated results from developing countries and were much better than those of developed nations. There were not many sex differences. Marriage and occupational rates were higher than those observed in many published reports.

CONCLUSIONS

This is one of the few long-term follow-up studies from the developing world. It reveals a pattern of course and functioning distinctly better than that found in many such studies from the developed nations.

Focus on psychiatry in India

India is a country with a population of over 1 billion, and immense diversity in the languages spoken, levels of literacy, and social and cultural practices. Organising mental health services for this predominantly rural population is indeed a daunting task. Compounding this problem are low budgetary resources, the presence of competing and conflicting healing systems, scarcity of mental health personnel, ‘brain drain’, and the stigma of seeking help for problems related to the mind. This paper looks at the mental health scene in India with respect to services and research. It deals with conditions such as schizophrenia, acute psychoses, minor mental morbidity and drug misuse, highlighting aspects unique to the Indian scene. Indian families exhibit great tenacity in caring for relatives who are ill, and are a great resource in treatment and rehabilitation.

Quality of life of community-based chronic schizophrenia patients in Penang, Malaysia

OBJECTIVE

This is a study of the quality of life (QOL) of 174 community-based chronic schizophrenia patients in Penang, Malaysia.

METHOD

The study samples were selected from the Out Patient Department, Department of Psychiatry, Penang General Hospital, Malaysia. The data was collected through personal interviews with the respondents. A questionnaire prepared by the research team was used to collect data on background characteristics. Lehman's (1988) Quality of Life Interview was used to collect data on patients' QOL.

RESULT

Equal number of males and females participated in the study. The interviews on QOL indicated problems in the areas of life in general, place of living, daily activities, social relations, finance, work and general health. The results also revealed that community-based schizophrenia patients had acute poverty and experienced social isolation, discrimination and exploitation in the workplace.

CONCLUSION

Implications of these results on the implementation process of National Mental Health Policy in Malaysia are discussed. The research paper also discusses the negative impacts of limited rehabilitation facilities available in the community and its implications on the QOL of severely mentally ill patients. The need for immediate research attention on QOL of such patients in the South-east Asian region has been highlighted.

A 20-year follow-up study on schizophrenia in Singapore

OBJECTIVE

To assess the outcome and predictors of patients with schizophrenia 20 years later.

METHOD

The patients, aged 15-39 years, with diagnosis of schizophrenia and first admitted to a national mental hospital in Singapore in 1975 were included. In 1980, 1985, 1990 and 1995, their hospital records were examined and the patients were interviewed to determine their working and treatment status. Possible predictors of good outcome and suicide data were determined.

RESULTS

A total of 402 patients were included. Over 20 years, there was lower percentage of patients working full time and proportionately more patients were receiving out-patient treatment. Overall, about two-third of the patients had a good/fair outcome. Shorter illness duration before admission was significantly associated with a good outcome. The suicide rate was the highest in the first 10 years.

CONCLUSION

Most patients with schizophrenia had a good/fair outcome at 20 years.

Recovery from psychotic illness: a 15- and 25-year international follow-up study

BACKGROUND

Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia.

AIMS

To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables.

METHODS

Historic prospective study. Standardised assessments of course and outcome.

RESULTS

About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery.

CONCLUSIONS

A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Outcome of marriage in schizophrenia

Marriage is a social process requiring certain social abilities for it to be successful. Schizophrenia, which can lead to a reduction of such abilities, has been associated with a low marital rate, especially in men. Data on long-term marital outcome are, however, sparse. This paper deals with changing marital status in a cohort of 76 first-onset schizophrenic patients followed-up for 10 years. A fairly high marital rate of 70% was observed in this sample, with more men remaining single and more women facing broken marriages. It was observed that good marital outcome, in terms of getting married and keeping the marriage intact, was associated with a number of clinical and sociodemographic variables. Duration of illness, type of onset, auditory hallucinations and simple depression at intake, unemployment and economic slide during the course of illness and a relapsing course of illness were all related to marital outcome. Outcome in other areas such as clinical, social and occupational functioning discriminated between the groups of good and poor marital functioning.

How do men with schizophrenia fare at work? A follow-up study from India

Occupational activity, an indicator of the functional status of an individual, is a major component in the long-term management of schizophrenia. The work functioning of 40 first-episode male schizophrenic patients was assessed prospectively every year over a period of 10 years. The comprehensive evaluation of occupational outcome measured in terms of duration of employment, quality of work done, and level of earned income was good in 53% of the patients, comparable to figures from developed countries. This outcome was not related to many of the socio-demographic and clinical variables but was strongly associated with overall clinical, social and marital outcome. The educational and economic status of the study group, the type of work available to them, and the compelling need for men to be the wage-earners in the Indian situation are discussed as influencing the findings of the study.