Do patients with
schizophrenia have a better prognosis in traditional cultures of the
Is abundance crippling? Or are the stronger social bonds believed to exist
in traditional cultures a romantic fancy? Do the more advanced biomedical
treatments available in the industrialized world trump those family and social
bonds, in any case?
Is the epidemiological evidence about prognosis conclusive? Is it even
These questions have raised some dust in schizophrenia research
circles—especially among the relatively small group of highly committed
epidemiologists and anthropologists who have pursued these questions for
years—following the online publication of an article in the September
2007 Schizophrenia Bulletin titled "Questioning an Axiom:
Better Prognosis for Schizophrenia in the Developing World?" by Alex
Cohen, Ph.D., Vikram Patel, Ph.D., R. Thara, M.D., and Oye Gureje, M.D.
Alex Cohen, Ph.D., says that to clearly delineate the effects of
sociocultural factors, it is necessary to control for "exposure"
to biomedical treatment.
Photo courtesy of Alex Cohen, Ph.D.
Since then, the article, which was also the subject of an article in
Psychiatric News (November 2, 2007), has prompted responses from a
number of quarters appearing as commentary in the "advanced
access" section of Schizophrenia Bulletin's Web site at<http://schizophreniabulletin.oxfordjournals.org/>.
The original study by Cohen and colleagues will appear, along with the
commentaries, in the print version of Schizophrenia Bulletin next
The debate has also been played out on Schizophrenia Research Forum at<www.schizophreniaforum.org/>.
(The goal of this Web site "is to foster collaboration among researchers
by providing an international online forum where ideas, research news, and
data can be presented and discussed.")
If there is any resolution to the debate about prognosis in different
cultures, it may be that comparisons at the national level have yielded all
the evidence they are going to, and that epidemiologists must now "drill
down" to the local and family levels to determine the cultural
mechanisms that impact on outcome.
"I think the evidence supports the proposition that outcomes vary in
different settings, but the nation is not the key to understanding the
mechanism," William Carpenter, M.D., editor of Schizophrenia
Bulletin, told Psychiatric News. "If the mechanisms that
affect prognosis reside in the local culture—in the family or community
setting—it would be good to understand what those mechanisms are so that
we might know why some cultural settings are bad, good, or a little of
"We don't know if some local cultures are therapeutic or simply less
adverse," Carpenter continued. "If the mechanisms were understood,
they might translate into new clinical approaches to treatment."
In the September article, Cohen and colleagues reviewed literature and
tabulated data from 23 longitudinal studies of schizophrenia outcomes in 11
low- and middle-income countries and examined evidence on the following
domains: clinical outcomes and patterns of course; disability and social
outcomes, especially focusing on marital and occupational status; and
untreated samples and duration of untreated psychosis.
In general, and most strikingly, they found wide variation in outcomes from
study to study and within countries. The finding challenged a long-held
assumption—what Cohen termed "an axiom"—deriving from
three prominent studies by the World Health Organization (WHO) that people
with schizophrenia appear to have a better outcome in developing countries
than in developed countries.
The three WHO studies are the International Pilot Study of Schizophrenia
(IPSS), the Determinants of Outcome of Severe Mental Disorder (DOSMed), and
the International Study of Schizophrenia.
Norman Sartorius, M.D., Ph.D., believes the high rates of chronic
disability and dependency associated with schizophrenia in high-income
countries suggest that "something essential to recovery is missing in
the social fabric."
Photo courtesy of Norman Sartorius, M.D., Ph.D.
Responses to Cohen's article—from Arthur Kleinman, M.D., John
Strauss, M.D., Evelyn Bromet, M.D., Assen Jablensky, M.D., Norman Sartorius,
M.D., John McGraft, M.D., and Julian Leff, M.D.—have agreed that
prognosis across cultures is generally more complex than anyone's favorite
theory. And most have congratulated Cohen for raising important research
But Bromet cited methodological problems in the studies that Cohen and
colleagues chose to review. And Leff, Jablensky, and Sartorius pointed to
oversights by Cohen and his colleagues in the way they interpreted the WHO
findings and vigorously defended those studies and the role of family and
community bonds in schizophrenia outcome.
As for Cohen, he welcomes the debate and appears to be at home with
scholarly controversy. But he acknowledges that he might have more explicitly
recognized in his September publication the enormous role the WHO studies have
played in advancing the understanding of cultural
"I was remiss in the review in not acknowledging the enormous
importance of the WHO studies," he said. "Those studies laid the
groundwork for the other research projects we reviewed on course of disease in
low-income countries. That the WHO studies did this must be considered a great
But Cohen also stands by his findings, especially the failure to consider
lack of access in the developing world to the kind of advanced biomedical
treatments that are commonly available in the developed countries.
"Several of the commentaries raise important methodological issues
about our review," he said. "But one issue that was not considered
was the lack of attention to the effects of treatment in many of these
studies—an issue that we raise in the review. To clearly delineate the
effects of sociocultural factors, it is necessary to control for 'exposure' to
But Assen Jablensky, M.D., and Norman Sartorius, M.D., who offered one of
the most vigorous rebuttals to Cohen, said the September report erroneously
described the methodology in the WHO studies and generally oversimplified
their conclusions, imputing an "axiom" about better prognosis in
developing countries that the WHO studies did not, in fact, uniformly find.
Also, they asserted again that the role of culture in shaping disease outcome
is a crucial contribution from the WHO studies.
"We do not argue that the prognosis of schizophrenia in developing
countries is group-wise uniformly milder, or that the existing huge gaps in
mental health service provision between high- and low-income countries are
irrelevant," wrote Sartorius and Jablensky. "On the contrary, the
erosion of social support systems, likely to be associated with the processes
of globalization, should be a matter of grave concern.
"The sobering experience of high rates of chronic disability and
dependency associated with schizophrenia in high-income countries, despite
access to costly biomedical treatment, suggests that something essential to
recovery is missing in the social fabric."
Sartorius led the WHO studies while director of the division of mental
health at WHO, a position he held until mid-1993. Jablensky worked with the
WHO studies and is now with the School of Psychiatry and Clinical
Neurosciences at the University of Western Australia.
Sartorius told Psychiatric News that the study of long-term course
and outcome of mental illness is a neglected area of research. "I also
hope that the fact that there are differences of outcome will contribute to
the willingness of readers to examine their practice and the system of care in
which they work so as to identify factors that are important for the success
of treatment," he said.
In his response, Leff, a British psychiatrist, M.D., echoed Carpenter's
conviction that comparisons of outcome at the national level may be too gross
a measure to yield any meaningful information about the effect of culture on
Rather, he said, investigators need to focus more closely on small family
groups and stressed that research on the role of"
EE"—expressed emotion, or the amount of criticism and
anxious overinvolvement on the part of parents and family members of a
patient—has been illuminating.
Leff worked in the London center of the IPSS and Carpenter and John
Strauss, M.D., worked in the Washington center of the IPSS in the 1970s.
For instance, Leff noted that a family study in Chandigarh, India, in the
DOSMeD study yielded powerful information about the role of expressed emotion,
and that there were significant differences in the rates of high family
EE—which is implicated in poorer prognosis—between rural and urban
sites in Chandigarh, and nationally between industrialized and agrarian
"The proportion of urban relatives of first-onset patients with
schizophrenia who were rated as high EE was found to be 30 percent, while the
comparable proportion for rural relatives was only 8 percent," Leff
wrote. "A comparison across a wide variety of countries has shown that
the prevalence of high EE households is greatest among the most industrialized
and urbanized societies and least among rural agrarian societies.
"Recent research indicates that socioenvironmental factors are
implicated in the etiology of schizophrenia as well as influencing its
course," Leff wrote. "However, the role of these factors is
unlikely to be elucidated at the national level. Focusing research on the
local social environment for specific groups, particularly at the familial
level, will prove more productive. The EE studies provide an example of the
level of analysis that is likely to advance our understanding of
cross-national differences in outcome." ▪