Diagnostic systems for schizophrenia. A cross-sectional study of concordance from India

Psychopathology of Schizophrenia in South Asia: Has there been a change over the last few decades?

INTRODUCTION

There have been a number of studies reporting on psychopathology of schizophrenia from South Asia, with the last study being reported about twenty five years back. The present study reports the clinical profile and frequency of symptoms in patients with schizophrenia and discusses the changing trends in psychopathology.

MATERIAL AND METHOD

Three hundred and thirty two patients with schizophrenia, aged 16-55, diagnosed as per DSM-IV-TR, were assessed for psychopathology on operational criteria OPCRIT checklist. The findings were compared with the previous studies on psychopathology of schizophrenia reported from South Asia.

RESULTS

Delusions (82.8%) followed by hallucinations (69.9%) were the most frequent psychopathology. First rank symptoms (FRS) were present in about three fourth of the subjects. Third person auditory hallucinations (68.6%) were the most common and thought echo (2.9%) was the least common FRS. One FRS was present in 31.7%, two in 24.7%, three in 17.7% and four in 6.8% of the subjects having FRS. A comparison with studies A comparison revealed that the prevalence of FRS were inbetween those reported in studies from Pakistan and India but higher than in the samples evaluated in Sri Lanka.

CONCLUSION

Delusions and hallucinations with persecutory themes and FRS continue to be a common symptom in patients with schizophrenia.

Searching for psychosis: INTREPID (1): systems for detecting untreated and first-episode cases of psychosis in diverse settings

PURPOSE

Our understanding of psychotic disorders is largely based on studies conducted in North America, Europe and Australasia. Few methodologically robust and comparable studies have been carried out in other settings. INTREPID is a programme of research on psychoses in India, Nigeria, and Trinidad. As a platform for INTREPID, we sought to establish comprehensive systems for detecting representative samples of cases of psychosis by mapping and seeking to engage all professional and folk (traditional) providers and potential key informants in defined catchment areas.

METHOD

We used a combination of official sources, local knowledge of principal investigators, and snowballing techniques.

RESULTS

The structure of the mental health systems in each catchment area was similar, but the content (i.e., type, extent, and nature) differed. Tunapuna-Piarco (Trinidad), for example, has the most comprehensive and accessible professional services. By contrast, Ibadan (Nigeria) has the most extensive folk (traditional) sector. We identified and engaged in our detection system-(a) all professional mental health services in each site (in- and outpatient services-Chengalpet, 6; Ibadan, 3; Trinidad, 5); (b) a wide range of folk providers (Chengalpet, 3 major healing sites; Ibadan, 19 healers; Trinidad: 12 healers); and c) a number of key informants, depending on need (Chengalpet, 361; Ibadan, 54; Trinidad, 1).

CONCLUSIONS

Marked differences in mental health systems in each catchment area illustrate the necessity of developing tailored systems for the detection of representative samples of cases with untreated and first-episode psychosis as a basis for robust, comparative epidemiological studies.

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.

Competing definitions of schizophrenia: what can be learned from polydiagnostic studies?

The contemporary diagnoses of schizophrenia (sz)-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV) and International Classification of Diseases, 10th Revision(ICD-10)-are widely considered as important scientific achievements. However, these algorithms were not a product of explicit conceptual analyses and empirical studies but defined through consensus with the purpose of improving reliability. The validity status of current definitions and of their predecessors remains unclear. The so-called "polydiagnostic approach" applies different definitions of a disorder to the same patient sample in order to compare these definitions on potential validity indicators. We reviewed 92 polydiagnostic sz studies published since the early 1970s. Different sz definitions show a considerable variation concerning frequency, concordance, reliability, outcome, and other validity measures. The DSM-IV and the ICD-10 show moderate reliability but both definitions appear weak in terms of concurrent validity, eg, with respect to an aggregation of a priori important features. The first-rank symptoms of Schneider are not associated with family history of sz or with prediction of poor outcome. The introduction of long duration criteria and exclusion of affective syndromes tend to restrict the diagnosis to chronic stable patients. Patients fulfilling the majority of definitions (core sz patients) do not seem to constitute a strongly valid subgroup but rather a severely ill subgroup. Paradoxically, it seems that a century after the introduction of the sz concept, research is still badly needed, concerning conceptual and construct validity of sz, its essential psychopathological features, and phenotypic boundaries.

Outcome of schizophrenia: some transcultural observations with particular reference to developing countries

The present paper provides a description of data based and methodologically sound studies of outcome of schizophrenia from developing and non-Western countries and compares the results. Major studies reviewed include the 2- and 5-year follow-up of the cohort of the International Pilot Study of Schizophrenia, the patients of the World Health Organization Collaborative Study on the Determinants of Outcome of Severe Mental Disorders, a few Indian studies including the study sponsored by the Indian Council of Medical Research and some studies from Colombia and South-East Asia. The studies are compared in terms of the quality of methodology and the rate of attrition. Although the outcome criteria of these studies are not similar, it is obvious that the outcome of schizophrenia in developing countries is generally more favourable. The reasons for this are far from clear. Research concerning the issues pertaining to better outcome of schizophrenia in developing countries in the context of socio-cultural differences in woefully lacking. This is an area that deserves research attention.

Positive and negative subtypes of schizophrenia. A follow-up study from India

98 schizophrenic patients who were initially studied to examine the concept of positive and negative subtyping, were followed up for a period ranging from 18 to 30 months. Follow-up data were available for 79 patients. The major findings of the study are significant reduction in positive symptom scores and the number of patients in the positive subtype of schizophrenia. The mixed subtype of schizophrenics increased in number and at follow-up there were significantly more mixed subtype schizophrenics who did not meet criteria for either the positive or negative subtype, i.e., who had little of either type of symptomatology. The number of schizophrenics categorized as negative subtype, as well as negative symptom scores did not change appreciably. The results of the study indicate that the negative symptoms seem to become more stable over a period of time.

Negative and depressive symptoms in schizophrenia

Ninety-five schizophrenic patients were assessed using the Present State Examination, the Brief Psychiatric Rating Scale and the Scale for the Assessment of Negative Symptoms. Negative and depressive symptoms were frequent, and significant relationships among negative symptom complexes and depressive syndromes were noted. Retardation, lack of energy, slowness, and other symptoms of depression were significantly associated with the negative symptoms of schizophrenia. Depressed affect per se did not have a significant correlation with negative symptoms.

Outcome of schizophrenia in India using various diagnostic systems

A group of 112 patients diagnosed to be suffering from schizophrenia according to ICD-9 concept of this disorder were followed-up for a period of 18-30 months. Five diagnostic systems for schizophrenia: CATEGO, Research Diagnostic Criteria, Feighner's Criteria, DSM-III and Schneider's First Rank Symptoms were also applied to the study group at the beginning of the investigation. The outcome was assessed in the areas of clinical improvement, course, severity of illness and work. The course of the disorder and outcome in various definitions did not reveal significant variability though patients diagnosed to be schizophrenics according to DSM-III tended to display more psychopathology and impaired work efficiency at the time of follow-up.

Positive and negative subtypes of schizophrenia. A study from India

Ninety-eight schizophrenic patients were studied to examine the concept of positive and negative subtyping. Using a cross-sectional phenomenological approach, the relationship of this subtyping with six definitions of schizophrenia was also investigated. The study provides support for this subtyping. Principal components analysis of the data and correlational structure of positive and negative symptom complexes lend further support to this notion.