One of the surprising discoveries of international psychiatric research is that people with schizophrenia in developing countries seem to have better outcomes than those living in industrialized countries. “This has been one of the central findings of cultural psychiatry for 30 years,” said Alex Cohen, HMS assistant professor of social medicine. But a review by Cohen and researchers in England, India, and Nigeria casts doubt on this conception. The paper, published online Sept. 29 in Schizophrenia Bulletin, evaluates nearly two dozen studies on schizophrenia in the developing world and concludes that outcomes are not always so rosy.
Cohen said that the notion that schizophrenia is more benign in poorer countries came from a series of studies, including two large investigations from the World Health Organization, that compared outcomes among a small group of developed and developing countries. Both studies found that patients in developing countries fared better over time. The studies led to theories that less developed societies had close-knit family structures and social support that helped to lessen the severity and impact of the disease and that people with schizophrenia are better integrated into these societies through work and marriage.
But after reviewing data from 23 longitudinal studies in 11 low- and middle-income countries, Cohen and his colleagues found a picture that is much more complex. Outcomes, for example, varied widely across and even within countries. Measures of how well people with the disease functioned socially were also highly varied.
Furthermore, the review revealed important gaps in knowledge about schizophrenia in the developing world. For instance, mortality rates for people with schizophrenia are high, but deaths are often not incorporated into study results. And although relatively high marriage rates have been cited in support of the theory, the researchers found that marriages are still less frequent than in the general population, and divorce and separation rates are much higher.
There is also limited knowledge about how medical intervention or lack of it affects the outcomes of patients in developing countries. “The real revelation to me was that treatment is never mentioned in any of these studies,” Cohen said. He pointed out that in some cases, patients enrolled in studies were receiving care from clinics that provide the best possible care in the country, which may have just as much to do with their success as their family support.
Though the authors agree that the social environment might affect the course of disease, they call into question the idea that a country’s wealth alone is a useful distinction. “I don’t mean to totally deny that some societies have better outcomes than other societies, but to lump the entire developing world together does not stand up to the evidence. Even within India, there is tremendous variation,” Cohen said. Further research, he added, should compare sites with good outcomes and poor outcomes, and look for social, biological, or medical factors to explain the differences.
