Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive partitioning re-analysis of the WHO DOSMD data

Neurological soft signs in first episode psychosis among psychiatric hospital patients and its relationship with dimensions of psychopathology: A comparative study

Background

Neurological soft signs (NSS), as subtle, nonlocalising neurological abnormalities, are considered as the potential markers of psychosis. However, comparative studies of antipsychotic-naïve patients with first-episode psychosis (FEP) and first degree relatives (FDRs) are uncommon. We compared the prevalence and pattern of NSS in FEPs, their healthy FDRs and a healthy non-relatives' control group (HC), highlighted the relationship between NSS and psychopathology and proposed cut-off scores for prevalence studies.

Materials and Methods

Two hundred and two participants per group were recruited. The FEPs were consecutive attendees; FDRs were accompanying caregivers; while the HC were from hospital staff. The Brief Psychiatric Rating Scale and the Neurological Evaluation Scale were used to assess psychopathology dimensions and NSS, respectively.

Results

Using an item score of two ('substantial impairment'), the prevalence of at least one NSS was: 91.5% (95% confidence interval [CI]: 86.7%-94.9%), 16.8% (95% CI: 11.8%-22.7%) and 6.5% (95% CI: 3.5%-10.9%), respectively, for FEP, FDRs and HC. FEPs were impaired in a broad range of signs. The noteworthy relationships were as follows: (i) a significant correlation between the negative symptoms' dimension versus number of NSS (r = 0.4), and NSS total score (r = 0.3), (ii) the anxiety/depression dimension correlated negatively with number of NSS (r = -0.3) and (iii) NSS cut across psychosis categories. We propose a cut-off score of ≥ 4 for the number of signs signifying probable impairment.

Conclusion

The findings indicate that, subject to further studies, NSS could be regarded as a broader phenotype of neurologic dysfunction associated with psychosis proness.

Schizophrenia: the new etiological synthesis

Schizophrenia has been an evolutionary paradox: it has high heritability, but it is associated with decreased reproductive success. The causal genetic variants underlying schizophrenia are thought to be under weak negative selection. To unravel this paradox, many evolutionary explanations have been suggested for schizophrenia. We critically discuss the constellation of evolutionary hypotheses for schizophrenia, highlighting the lack of empirical support for most existing evolutionary hypotheses-with the exception of the relatively well supported evolutionary mismatch hypothesis. It posits that evolutionarily novel features of contemporary environments, such as chronic stress, low-grade systemic inflammation, and gut dysbiosis, increase susceptibility to schizophrenia. Environmental factors such as microbial infections (e.g., Toxoplasma gondii) can better predict the onset of schizophrenia than polygenic risk scores. However, researchers have not been able to explain why only a small minority of infected people develop schizophrenia. The new etiological synthesis of schizophrenia indicates that an interaction between host genotype, microbe infection, and chronic stress causes schizophrenia, with neuroinflammation and gut dysbiosis mediating this etiological pathway. Instead of just alleviating symptoms with drugs, the parasite x genotype x stress model emphasizes that schizophrenia treatment should focus on detecting and treating possible underlying microbial infection(s), neuroinflammation, gut dysbiosis, and chronic stress.

Culture and the Trajectories of Developmental Pathology: Insights from Control and Information Theories

Cognition in living entities-and their social groupings or institutional artifacts-is necessarily as complicated as their embedding environments, which, for humans, includes a particularly rich cultural milieu. The asymptotic limit theorems of information and control theories permit construction of a new class of empirical 'regression-like' statistical models for cognitive developmental processes, their dynamics, and modes of dysfunction. Such models may, as have their simpler analogs, prove useful in the study and re-mediation of cognitive failure at and across the scales and levels of organization that constitute and drive the phenomena of life. These new models particularly focus on the roles of sociocultural environment and stress, in a large sense, as both trigger for the failure of the regulation of bio-cognition and as 'riverbanks' determining the channels of pathology, with implications across life-course developmental trajectories. We examine the effects of an embedding cultural milieu and its socioeconomic implementations using the 'lenses' of metabolic optimization, control system theory, and an extension of symmetry-breaking appropriate to information systems. A central implication is that most, if not all, human developmental disorders are fundamentally culture-bound syndromes. This has deep implications for both individual treatment and public health policy.

Comprehensive Integrated Primary Mental Health Care in South Africa. The Need for a Shift in the Discourse of Care

In this article, I argue that the add on approach to Integrated primary mental health care, characterised by the training of primary health care personnel in the identification and management of psychiatric disorders, will fail to deliver the vision of comprehensive mental health care that has been struggled for over the years in South Africa. I suggest that what is needed is a paradigm shift in the dominant biomedical discourse which characterises the primary health care relationship. To this end, an alternative discourse of care, shaped by an integration of cultural and critical understandings of illness and healing, is advanced.

Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China

BACKGROUND

The long-term outcome of never-treated patients with schizophrenia is unclear.

AIMS

To compare the 14-year outcomes of never-treated and treated patients with schizophrenia and to establish predictors for never being treated.

METHOD

All participants with schizophrenia (n = 510) in Xinjin, Chengdu, China were identified in an epidemiological investigation of 123 572 people and followed up from 1994 to 2008.

RESULTS

The results showed that there were 30.6%, 25.0% and 20.4% of patients who received no antipsychotic medication in 1994, 2004 and 2008 respectively. Compared with treated patients, those who were never treated in 2008 were significantly older, had significantly fewer family members, had higher rates of homelessness, death from other causes, being unmarried, living alone, being without a caregiver and poor family attitudes. Partial and complete remission in treated patients (57.3%) was significantly higher than that in the never-treated group (29.8%). Predictors of being in the never-treated group in 2008 encompassed baseline never-treated status, being without a caregiver and poor mental health status in 1994.

CONCLUSIONS

Many patients with schizophrenia still do not receive antipsychotic medication in rural areas of China. The 14-year follow-up showed that outcomes for the untreated group were worse. Community-based mental healthcare, health insurance and family intervention are crucial for earlier diagnosis, treatment and rehabilitation in the community.

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

BACKGROUND

Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This study's goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress.

METHODS

The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category.

RESULTS

Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders.

CONCLUSIONS

Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.

Cultural aspects of schizophrenia

Over the past 50 years, schizophrenia as a disorder has been widely studied across cultures throughout the world. There are differences not only in the symptoms and presentation but also in outcome and prognosis. Various authors have tried to explore and explain such variation but the reasons for this are not always clear. In this paper, we review some of the cultural aspects of schizophrenia.

Course and outcome of psychosis in black Caribbean populations and other ethnic groups living in the UK: a systematic review

BACKGROUND

A higher incidence of psychosis has repeatedly been reported in black Caribbean populations in the UK. This has been attributed to a number of biological, psychological and sociocultural causes, including black Caribbean populations having a different illness course and outcome compared to other ethnic populations living in the UK.

AIMS

A systematic review of UK-based quantitative studies, which compared at least two aspects of outcome in black Caribbean populations and other ethnic populations living in the UK, was conducted to assess whether the current body of research suggests that there are differences in the course and outcome of psychoses for these populations.

METHOD

A wide variety of databases were searched using MeSH terms and keywords. Studies were evaluated according to specified inclusion criteria and analysed using predefined scoring criteria.

RESULTS

Searches yielded a heterogeneous collection of studies. Large variances in methodological approaches and the quality of studies were reported. Many studies reported little or no difference between black Caribbean and other ethnic populations living in the UK.

CONCLUSIONS

Emphasis is placed on the unreliability of these findings given the methodological limitations of the studies, and the need for higher-quality research in this area is highlighted.

Five-year clinical course and outcome of schizophrenia in Ethiopia

BACKGROUND

Findings from the WHO sponsored multicenter studies done a few decades ago, which reported favorable outcome of schizophrenia in developing countries both in 2 and 5 year follow-up studies, dominated the world view until recently. Emerging evidence from Low and Middle Income countries (LAMIC) started to challenge this long held view, also called 'dogma' by some authors. We reported the short-term follow-up which showed unfavorable outcome. We followed-up the cohort further to determine the 5-year outcome of schizophrenia and to compare the results with the WHO reports.

METHODS

Patients with schizophrenia (n=321) were identified systematically after screening 68378 adults, ages 15-49 years, in rural Ethiopia. The majority (74.9%) had chronic illness at entry and were treatment naïve (89.6%).

RESULTS

During 5-year follow-up, 96% had received treatment at least once although only about 6% had received antipsychotic treatments continuously. Forty five percent of participants were continuously symptomatic with 30.3% having had continuous psychotic episode. About 20% had experienced continuous remission. Being single (OR=3.41, 95% CI=1.08-10.82, P=0.037), on antipsychotic treatment for at least 50% of follow up time (OR=2.28, 95% CI=1.12-4.62, P=0.023), and having a diagnosis of paranoid subtype of schizophrenia (OR=3.68, 95% CI=1.30-10.44, P=0.014) were associated with longer period of remission

CONCLUSION

The findings from this 5-year outcome were consistent with our previous short term report which was unfavorable. Treatment has been a consistent predictor of a favorable outcome. Therefore, ensuring availability of treatment and adherence is an essential pragmatic step to improve outcome in this setting.

[Analysis of the Structure of Acute Psychotic Disorder]

INTRODUCTION

Schizophrenia is a clinically heterogeneous disorder. A multifactorial structure of this syndrome has been described in previous reports. The aim of this study was to evaluate what are the possible diagnostic categories in patients having acute psychotic symptoms, studying their clinical characteristics in a cross-sectional study.

METHODS

An instrument for measuring psychotic symptoms was created using previous scales (SANS, SAPS, BPRS, EMUN, Zung depression scale). Using as criteria statistical indexes and redundance of items, the initial instrument having 101 items has been reduced to 57 items. 232 patients with acute psychotic symptoms, in most cases schizophrenia, attending Clínica Nuestra Señora de la Paz in Bogotá and Hospital San Juan de Dios in Chía have been evaluated from April, 2008 to December, 2009. Multivariate statistical methods have been used for analyzing data.

RESULTS

A six-factor structure has been found (Deficit, paranoid-aggressive, disorganized, depressive, bizarre delusions, hallucinations). Cluster analysis showed eight subtypes that can be described as: 1) bizarre delusions-hallucinations; 2) deterioration and disorganized behavior; 3) deterioration; 4) deterioration and paranoid-aggressive behavior; 5) bizarre delusions; 6) paranoia-anxiety- aggressiveness; 7) depressive symptoms and bizarre delusions; 8) paranoia and aggressiveness with depressive symptoms

CONCLUSION

These subtypes allow a more exhaustive characterization that those included in standard classification schemes and should be validated in longitudinal studies.

Predicting future depression in adolescents using the Short Mood and Feelings Questionnaire: a two-nation study

BACKGROUND

Adolescence is a key life period for the development of depression. Predicting the development of depression in adolescence through detecting specific early symptoms may aid in the development of timely screening and intervention programmes.

METHODS

We administered the Short Mood and Feelings Questionnaire (SMFQ) to 5769 American and Australian students aged 10 to 15 years, at two time points, separated by 12 months. We attempted to predict high levels of depression symptoms at 12 months from symptoms at baseline, using statistical approaches based upon the quality, as well as the quantity, of depression symptoms present. These approaches included classification and regression trees (CART) and logistic regression.

RESULTS

A classification tree employing four SMFQ items, such as feelings of self-hatred and of being unloved, performed almost as well as all 13 SMFQ items at predicting subsequent depression symptomatology.

LIMITATIONS

Depression was measured using a self-report instrument, rather than a criterion standard diagnostic interview.

CONCLUSION

Further validation on other populations of adolescents is required: however the results suggest that several symptoms of depression, especially feelings of self-hatred, and being unloved, are associated with increased levels of self-reported depression at 12 months post baseline. Although screening for depression can be problematic, symptoms such as the ones above should be considered for inclusion in screening tests for adolescents.

Validation of Social Cognition Rating Tools in Indian Setting (SOCRATIS): A new test-battery to assess social cognition

Social cognition is a cognitive domain that is under substantial cultural influence. There are no culturally appropriate standardized tools in India to comprehensively test social cognition. This study describes validation of tools for three social cognition constructs: theory of mind, social perception and attributional bias. Theory of mind tests included adaptations of, (a) two first order tasks [Sally-Anne and Smarties task], (b) two second order tasks [Ice cream van and Missing cookies story], (c) two metaphor-irony tasks and (d) the faux pas recognition test. Internal, Personal, and Situational Attributions Questionnaire (IPSAQ) and Social Cue Recognition Test were adapted to assess attributional bias and social perception, respectively. These tests were first modified to suit the Indian cultural context without changing the constructs to be tested. A panel of experts then rated the tests on likert scales as to (1) whether the modified tasks tested the same construct as in the original and (2) whether they were culturally appropriate. The modified tests were then administered to groups of actively symptomatic and remitted schizophrenia patients as well as healthy comparison subjects. All tests of the Social Cognition Rating Tools in Indian Setting had good content validity and known groups validity. In addition, the social cure recognition test in Indian setting had good internal consistency and concurrent validity.

Temporal relationships between Gulf War deployment and subsequent psychological disorders in Royal Australian Navy Gulf War veterans

BACKGROUND

Although much has been published on the effects of the 1990/1991 Gulf War on the psychological health of veterans, few studies have addressed the pattern and timing of post-war development of psychological disorders. Our study aims to identify the most common psychological disorders that first appeared post-Gulf War, the period of peak prevalence and the sequence of multiple psychological disorders.

METHODS

The temporal progression of psychological disorders in male Australian naval Gulf War veterans with no prior psychological disorders was calculated across each year of the post-Gulf War period. DSM-IV diagnoses were obtained using the Composite International Diagnostic Interview.

RESULTS

Psychological disorder rates peaked in the first 2 years (1991-1992) following the Gulf War. Alcohol use disorders were the most likely to appear first. Classification and regression tree analysis found that risk of disorder was exacerbated if veterans had been exposed to a high number of potential psychological stressors during their military service. Lower military rank was associated with increased risk of alcohol disorders, particularly during the first 2 years post-Gulf War. In veterans with two or more disorders, anxiety disorders and alcohol disorders tended to appear before affective disorders.

CONCLUSIONS

Our study found that psychological disorders occur in sequence following Gulf War deployment. Our findings may help clinicians to anticipate, and better manage, multiple symptomatology. The findings may also assist veteran and defence organisations in planning effective mental health screening, management and prevention policy.

Factors associated with achieving minimally symptomatic status by patients with schizophrenia: results from the 3-year intercontinental schizophrenia outpatients health outcomes study

OBJECTIVE

The aim of this study was to describe factors associated with achieving a minimally symptomatic status outcome in outpatients with schizophrenia.

METHODS

Data were analysed from a 3-year, prospective observational study that examined outcomes in 7658 patients with schizophrenia. Minimally symptomatic status was defined as a postbaseline score of 1 or 2 on the Clinical Global Impressions Severity Scale-Schizophrenia version (CGI-SCH).

RESULTS

Baseline CGI-SCH score had the strongest association with minimally symptomatic status followed by age, geographical region and hospitalisation status. The probability of becoming minimally symptomatic was consistently higher in the olanzapine and risperidone monotherapy groups compared with the clozapine, quetiapine or haloperidol groups [corrected]. The olanzapine group achieved the minimally symptomatic status in a shorter period of time than the other treatment groups (p < or = 0.016).

CONCLUSION

The likelihood of patients achieving a minimally symptomatic status was greater in younger patients with lower baseline clinical severity and in patients whose treatment included olanzapine.

Local suffering and the global discourse of mental health and human rights: an ethnographic study of responses to mental illness in rural Ghana

BACKGROUND

The Global Movement for Mental Health has brought renewed attention to the neglect of people with mental illness within health policy worldwide. The maltreatment of the mentally ill in many low-income countries is widely reported within psychiatric hospitals, informal healing centres, and family homes. International agencies have called for the development of legislation and policy to address these abuses. However such initiatives exemplify a top-down approach to promoting human rights which historically has had limited impact at the level of those living with mental illness and their families.

METHODS

This research forms part of a longitudinal anthropological study of people with severe mental illness in rural Ghana. Visits were made to over 40 households with a family member with mental illness, as well as churches, shrines, hospitals and clinics. Ethnographic methods included observation, conversation, semi-structured interviews and focus group discussions with people with mental illness, carers, healers, health workers and community members.

RESULTS

Chaining and beating of the mentally ill was found to be commonplace in homes and treatment centres in the communities studied, as well as with-holding of food ('fasting'). However responses to mental illness were embedded within spiritual and moral perspectives and such treatment provoked little sanction at the local level. Families struggled to provide care for severely mentally ill relatives with very little support from formal health services. Psychiatric services were difficult to access, particularly in rural communities, and also seen to have limitations in their effectiveness. Traditional and faith healers remained highly popular despite the routine maltreatment of the mentally ill in their facilities.

CONCLUSION

Efforts to promote the human rights of those with mental illness must engage with the experiences of mental illness within communities affected in order to grasp how these may underpin the use of practices such as mechanical restraint. Interventions which operate at the local level with those living with mental illness within rural communities, as well as family members and healers, may have greater potential to effect change in the treatment of the mentally ill than legislation or investment in services alone.

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.

Clinical course and outcome of schizophrenia in a predominantly treatment-naive cohort in rural Ethiopia

The established view that schizophrenia may have a favorable outcome in developing countries has been recently challenged; however, systematic studies are scarce. In this report, we describe the clinical outcome of schizophrenia among a predominantly treatment-naive cohort in a rural community setting in Ethiopia. The cohort was identified in a 2-stage sampling design using key informants and measurement-based assessment. Follow-up assessments were conducted monthly for a mean duration of 3.4 years (range 1-6 years). After screening 68 378 adults, ages 15-49 years, 321 cases with schizophrenia (82.7% men and 89.6% treatment naive) were identified. During follow-up, about a third (30.8%) of cases were continuously ill while most of the remaining cohort experienced an episodic course. Only 5.7% of the cases enjoyed a near-continuous complete remission. In the final year of follow-up, over half of the cases (54%) were in psychotic episode, while 17.6% were in partial remission and 27.4% were in complete remission for at least the month preceding the follow-up assessment. Living in a household with 3 or more adults, later age of onset, and taking antipsychotic medication for at least 50% of the follow-up period predicted complete remission. Although outcome in this setting appears better than in developed countries, the very low proportion of participants in complete remission supports the recent observation that the outcome of schizophrenia in developing countries may be heterogeneous rather than uniformly favorable. Improving access to treatment may be the logical next step to improve outcome of schizophrenia in this setting.

Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.

Acute treatment response and its predictors in patients with first-episode psychosis in Iran

OBJECTIVE

The aim of this paper was to investigate the acute treatment response and its predictors in a sample of patients with first-episode psychosis admitted to a psychiatric hospital in Iran.

METHOD

A total of 163 patients with first-episode psychosis were treated with antipsychotics and other medications as prescribed by their treating psychiatrists. Sociodemographic and premorbid data at baseline and clinical data at both baseline and discharge (6+/-1 weeks after admission) were collected.

RESULTS

Patients showed a response rate of 71.4% for negative symptoms, 91.5% for positive symptoms and 67.5% for functioning. Those having a positive family history and less severe negative symptoms at baseline were less likely to respond in terms of negative symptoms. Higher premorbid and lower baseline functioning as well as acute onset were associated with the treatment response.

CONCLUSIONS

Acute treatment response of first-episode psychosis in a clinical sample of a developing country seems to be higher than that of developed countries. However, predictors of response are comparable.

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.

Evidence of a latitudinal gradient in the age at onset of schizophrenia

Variation in the age at onset of a multifactorial disease often reflects variation in cause. Here we show a linear latitudinal gradient in the mean age at onset of schizophrenia in 13 northern hemisphere cities, ranging from 25 years old in Cali, Columbia (at 4 degrees north) to 35 years old in Moscow, Russia (at 56 degrees north). To our knowledge, this striking association has not been previously reported. We consider several explanations, including the effects of pathogen stress, natural selection, sexual selection, migration, life-history profiles, or some combination of these factors, and we propose a test of competing causal hypotheses.

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.

Posttraumatic stress disorder and treatment seeking in a nationally representative Canadian military sample

This study aimed to identify predictors of treatment seeking in military members with posttraumatic stress disorder (PTSD) using data from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (Statistics Canada, 2003). To identify predictors, two complementary analyses (binary logistic regression and recursive partitioning of independent variables) were conducted in military members with PTSD (N = 509). Results indicate that trauma-related (index traumatic event type, cumulative trauma exposure), demographic (marital status), enabling (income), and need (PTSD interference) factors predict treatment seeking in military members with PTSD, and that treatment seekers and nontreatment seekers are both comprised of distinct subgroups. Interventions aimed at increasing treatment-seeking behaviors should be tailored to the specific needs of various subgroups of nontreatment seekers.

The relationship of premorbid functioning to illness course in schizophrenia and psychotic mood disorders during two years following first hospitalization

Studies suggest that better premorbid functioning is associated with better outcomes in chronic schizophrenia. Yet first admission studies, which are more appropriate to examine this, are less conclusive. Also, little attention has been given to whether these findings hold for other psychoses. We examined the relationship of premorbid functioning using the Premorbid Adjustment Scale and outcomes in first admission psychoses (schizophrenia, N = 177; bipolar disorder, N = 106; major depression, N = 68) in the Suffolk County-wide mental health project. Poor premorbid functioning was associated with worse outcomes in all three diagnostic groups. Specifically, it was associated with more negative symptoms early in the course of illness, less improvement in negative symptoms, poorer overall clinical functioning, and poorer social functioning. Consistent with new epidemiological research, early assessment of premorbid functioning could provide an avenue for targeted interventions that might improve outcomes.

Hazardous or harmful alcohol use in Royal Australian Navy veterans of the 1991 Gulf War: identification of high risk subgroups

Elevated alcohol use disorders have been observed in 1991 Gulf War veterans from a variety of countries. This study used a self-report instrument, the Alcohol Use Disorders Identification Test (AUDIT), to ascertain whether any subgroups of 1232 male Royal Australian Navy (RAN) Gulf War veterans were at higher risk of hazardous or harmful alcohol use. Recursive partitioning/classification and regression tree (CART) analysis, followed by logistic regression, found five subgroups among the veterans, with differing risks of AUDIT caseness. The highest risk subgroup comprised current smokers. The other two high risk groups both consisted of former or never smokers of lower rank who were (1) not married, or (2) married, with a current diagnosis of major depression. The above subgroups were over three times as likely to exhibit AUDIT caseness than those who were former or never smokers of higher rank. The findings have important implications for effective development of public health initiatives designed to encourage safe alcohol use among veterans.

Is the outcome of schizophrenia really better in developing countries?

That schizophrenia has a better prognosis in non-industrialized societies has become an axiom in international psychiatry; the evidence most often cited comes from three World Health Organization (WHO) cross-national studies. Although a host of socio-cultural factors have been considered as contributing to variation in the course of schizophrenia in different settings, we have little evidence from low-income countries that clearly demonstrates the beneficial influence of these variables. In this article, we suggest that the finding of better outcomes in developing countries needs re-examination for five reasons: methodological limitations of the World Health Organization studies; the lack of evidence on the specific socio-cultural factors which apparently contribute to the better outcomes; increasing anecdotal evidence describing the abuse of basic human rights of people with schizophrenia in developing countries; new evidence from cohorts in developing countries depicting a much gloomier picture than originally believed; and, rapid social and economic changes are undermining family care systems for people with schizophrenia in developing countries. We argue that the study of the long-term course of this mental disorder in developing countries is a major research question and believe it is time to thoroughly and systematically explore cross-cultural variation in the course and outcome of schizophrenia.

Prevention of oxidative stress-mediated neuropathology and improved clinical outcome by adjunctive use of a combination of antioxidants and omega-3 fatty acids in schizophrenia

Schizophrenia is associated with a broad range of neurodevelopmental, structural and behavioral abnormalities that often progress with or without treatment. Evidence indicates that such neurodevelopmental abnormalities may result from defective genes and/or non-genetic factors such as pre-natal and neonatal infections, birth complications, famines, maternal malnutrition, drug and alcohol abuse, season of birth, sex, birth order and life style. Experimentally, these factors have been found to cause the cellular metabolic stress that often results in oxidative stress, such as increased cellular levels of reactive oxygen species (ROS) over the antioxidant capacity. This can trigger the oxidative cell damage (i.e., DNA breaks, protein inactivation, altered gene expression, loss of membrane lipid-bound essential polyunsaturated fatty acids [EPUFAs] and often apoptosis) contributing to abnormal neural growth and differentiation. The brain is preferentially susceptible to oxidative damage since it is under very high oxygen tension and highly enriched in ROS susceptible proteins, lipids and poor DNA repair. Evidence is increasing for increased oxidative stress and cell damage in schizophrenia. Furthermore, treatments with some anti-psychotics together with the lifestyle and dietary patterns, that are pro-oxidant, can exacerbate the oxidative cell damage and trigger progression of neuropathology. Therefore, adjunctive use of dietary antioxidants and EPUFAs, which are known to regulate the growth factors and neuroplasticity, can effectively improve the clinical outcome. The dietary supplementation of either antioxidants or EPUFAs, particularly omega-3 has already been found to improve some psychopathologies. However, a combination of antioxidants and omega-3 EPUFAs, particularly in the early stages of illness, when brain has high degree of neuroplasticity, potentially may be even more effective for long-term improved clinical outcome of schizophrenia.

Association of Rorschach and MMPI Psychosis Indicators and Schizophrenia Spectrum Diagnoses in a Russian Clinical Sample

In this study, I investigated the relationships among psychological test variables and schizophrenia spectrum diagnoses in a Russian sample of 180 psychiatric patients. Schizophrenia is understood somewhat differently in Russia than in the West. Analyses compared Rorschach (SCZI, PTI; Exner, 2001) and MMPI (Berezin, Mitroshinkov, & Sokolova, 1994) psychosis indicators (Sc, Sc3, Sc6, and BIZ) and 3 diagnostic systems: (a) Russian traditional, (b) the Russian-modified International Classification of Diseases (9th ed. [ICD-9]; Ministerstvo Zdravokhraneniya SSSR, 1982), and (c) the nonmodified ICD-10 (World Health Organization, 1992; comparable to the Diagnostic and Statistical Manual of Mental Disorders [4th ed.], American Psychiatric Association, 1994). Results showed modest support for the SCZI and PTI but not the MMPI indicators. While the field awaits further evidence, psychologists should proceed with caution when using the Rorschach and MMPI to assess for psychosis among Russians.

Finding a fit: psychiatric pluralism in south India and its implications for WHO studies of mental disorder

This article examines reports of improvement and decline in short-term follow-up interviews and long-term recollections among patients in three forms of therapy for mental illness in south India: ayurvedic (indigenous) psychiatry, allopathic (western) psychiatry, and religious healing. Interviews indicate that patients of all three therapeutic systems showed improvement after follow-up assessments and that several patients had radically divergent experiences with each of the three therapies; each therapy was found by some to be helpful and by others to be ineffective. These findings suggest that a greater availability of distinct forms of therapy makes it more likely that an individual will find a therapy to which he or she responds well, an insight that helps interpret World Health Organization-sponsored studies which examined mental disorders in developed and developing country sites and found a better outcome for these disorders in developing country centers. Although several studies have attempted to account for this difference in outcome, none have done so by considering that the 'developing' country sites in the World Health Organization studies are all places that have a greater availability of diverse forms of therapy when compared with the 'developed' sites.

On the relation between neuroticism, self-esteem, and depression: results from the National Comorbidity Survey

There is evidence that neuroticism and self-esteem, two commonly used personality constructs, are associated with depressive illness. Previous studies on this issue have produced mixed results. Some studies found that neuroticism was a stronger predictor of risk for major depression than was self-esteem. The aim of the current report is to analyze the relationship between neuroticism, self-esteem, and depressive disorders in representative community sample. Data from the National Comorbidity Survey (NCS) were reanalyzed. The diagnostic data were coded using the criteria of DSM-III-R based on a modified version of the Diagnostic Interview. Self-esteem was assessed by an empirically abbreviated form of the Rosenberg Self-Esteem Scale. Neuroticism was measured using the 10-item scale from the Transparent Bipolar Inventory (TBI). Logistic regression analysis and classification and regression tree (CART) analysis were used to determine the associations between neuroticism, self-esteem, sociodemographic variables, and past-year depression disorders. Neuroticism and self-esteem were strongly associated with past-year depression disorders. Significant interactions between the two personality constructs and sociodemographic variables were observed. The results suggest that neuroticism and self-esteem should be evaluated simultaneously when analyzing depression disorders. The assessment of both personality constructs may contribute to further understanding of personality-depression correlation. Such knowledge might prove valuable in designing early interventions and treatment.

A 15-year follow-up of schizophrenia in Ireland

OBJECTIVES

Psychiatric hospitalisation rates in Ireland have been high. Recent studies indicate that this is not a consequence of raised incidence. This study explored the possibility that poor outcome may have been responsible for this high hospitalisation prevalence.

METHOD

Through participation in the WHO Study, Determinants of Outcome of Severe Mental Disorders (DOSMeD), we followed up a cohort of 67 first-onset schizophrenic patients over 15 years to determine symptomatic and functional outcomes and to compare these with outcomes of the cohorts recruited to the International Study of Schizophrenia (ISoS).

RESULTS

Thirty-seven (55%) of the original 67 were successfully followed up over 15 years and, of these, 43% were continuously psychotic for most of the period; a similar proportion had recurrent episodes of illness; two-thirds of subjects had moderate to severe symptoms for most of the time; and, in terms of functional outcome, over four-fifths were unemployed at follow-up.

CONCLUSIONS

Outcome for the majority of followed-up patients was poor in symptomatic and functional terms. While this outcome was one of the poorest among the DOSMeD groups the question whether functional psychotic illness outcome is inherently poorer in Ireland than elsewhere remains unanswered. The high rate of attrition (45%) from the group during the follow-up period vitiated interpretation of outcome overall. The high number of suicides among the group was noteworthy.

Screening Chinese patients with eating disorders using the Eating Attitudes Test in Hong Kong

OBJECTIVE

To evaluate the Chinese Eating Attitudes Test (EAT-26) in screening patients with anorexia nervosa (AN) and bulimia nervosa (BN) in Hong Kong.

METHOD

A consecutive series of Chinese patients with BN (N = 67) and typical (fat phobic; N = 65) and atypical (nonfat phobic; N = 44) AN underwent clinical assessment and completed the EAT-26. Results were compared with those of Chinese female undergraduates (N = 646).

RESULTS

The mean EAT scores for bulimic and typical AN patients were significantly higher than those of undergraduates, but the scores of atypical AN patients were anomalously low. The dieting and bulimia factor, scores and body mass indices entered the classification tree. When compared with using the conventional EAT-26 cutoff, the misclassification rate for typical AN, atypical AN, and BN changed from 41.4% to 52.3%, 88.6% to 43.2%, and 23.9% to 29.9%, respectively.

DISCUSSION

Using the EAT-26 in the conventional manner would lead to an underestimate of atypical AN in community surveys. Complementary use of a classification tree improved the prediction of atypical AN, but the EAT-26 remains a suboptimal screening instrument for the community epidemiological study of AN.

Culture and schizophrenia and other psychotic disorders

The comparative study of schizophrenia and related disorders across cultures has come a long way since Kraepelin advocated its cause, following his trip to Java at the beginning of the last century. The principal development since then has been the burgeoning of interest in the field, culminating in innovative and ambitious international collaborative research by the WHO. Despite reservations about covert ideology or about the more overt methodologic difficulties, the balance of evidence from these and similar studies suggests that: It is feasible to conduct such research despite the numerous hazards. There is a certain uniformity to the way schizophrenia presents globally; there are equally significant cultural differences. The outcome of schizophrenia appears to be better in developing, than developed cultures; reasons for this are far from clear, nevertheless, it can be safely assumed that culturally-determined processes, whether social or environmental, are partly responsible. Overall, the study of schizophrenia in different cultures has proved useful in establishing the pancultural and the culture-specific properties of this and related disorders.

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.

Quality of life in treated and never-treated schizophrenic patients

OBJECTIVE

To evaluate quality of life (QOL) among treated and never-treated schizophrenic patients.

METHOD

QOL ratings were obtained for (a) 112 Moroccan participants with schizophrenia who had never received neuroleptic medications, (b) matched samples of chronically-medicated schizophrenic patients in Morocco and the United States and (c) matched community controls in both countries.

RESULTS

QOL ratings were generally higher for US groups, although Moroccan controls obtained higher ratings than US controls for some domains. QOL ratings were higher for controls compared to patients within each country, although US patients' scores were similar to controls on some dimensions. We found no differences between treated and untreated Moroccan patients for any QOL domain, although relationships among predictors were different.

CONCLUSION

Within the context of Moroccan culture, benefits of medications alone are not evident in QOL scores. QOL appears to be a complex construct influenced by different factors within each of the groups studied.

Epidemiology and natural history of schizophrenia

The present review explores the descriptive epidemiology of schizophrenia. Risk factors and correlates are divided into three groups based on whether the available evidence is consistent and strong, consistent and potentially strong, or inconsistent. The paper then considers epidemiologic studies of the course of illness, including a description of findings from the Suffolk County Mental Health Project. Given renewed attention to the need for preventive interventions for individuals at high risk for developing a psychotic illness, epidemiologic values have become more and more central to the conduct of clinical research.

Ethnicity and outcome of psychosis

BACKGROUND

An excess of psychotic illness in Black people has been found in cross-sectional studies. Little is known about the outcome of psychosis in different ethnic groups in the UK.

AIMS

To compare the incidence, nature and long-term outcome of psychosis in different ethnic groups.

METHOD

A five-year, prospective study of an epidemiological cohort of people with a first contact for psychosis.

RESULTS

Age-standardised incidence rates for schizophrenia and non-affective psychosis were higher for Black and Asian people than Whites. Stability of diagnosis and course of illness were similar in all ethnic groups. During the fifth year, Black people were more likely than others to be detained, brought to hospital by the police and given emergency injections.

CONCLUSIONS

The nature and outcome of psychotic illness is similar in all ethnic groups but Black people experience more adverse contacts with services later in the course of illness.

A 16-year follow-up study of schizophrenia and related disorders in Sofia, Bulgaria

A total of 60 patients with functional non-affective psychoses were assessed 16 years after their inclusion in the WHO co-ordinated study on reduction and assessment of psychiatric disability. All patients at inclusion had a recent onset of a psychotic disorder. About one-third of the patients had a good outcome. The rest showed moderate to severe psychiatric symptoms and social disability. Comparison with other similar studies suggested that our results show a low mortality rate, high levels of clinical symptoms, high levels of social disability and a low percentage of institutionalized patients. These findings are discussed in the context of the high level of family involvement in patients' care, which could reflect a cultural factor.

History of violent behaviour and schizophrenia in different cultures. Analyses based on the WHO study on Determinants of Outcome of Severe Mental Disorders

BACKGROUND

Information on patterns and correlates of the violent behaviour of individuals with schizophrenia is largely limited to populations in developed countries. Data from a World Health Organization epidemiological study of schizophrenia and related disorders, the Determinants of Outcome of Severe Mental Disorders (DOSMD), presented an opportunity to study patterns of violence across multinational settings.

METHOD

Centres in 10 countries participated in the DOSMD study. An incidence sample of 1017 patients with schizophrenia who had their first-in-lifetime contact with a helping agency as a result of their psychotic symptoms was obtained. Data were available on their history of violent behaviour, substance use, and demographics.

RESULTS

The occurrence rate of assault in the entire cohort was 20.6 per hundred, but the rate was three times higher in the developing countries (31.5 per hundred) than in developed countries (10.5 per hundred). History of assault was associated with positive symptoms, such as excitement and auditory hallucinations, and with serious alcohol problems.

CONCLUSIONS

The cultural context and the specific characteristics of the disease in individuals with schizophrenia may interactively affect rates of violent behaviour.