Schizophrenia Outcomes in the Wider International Communit

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1 : Schizophrenia Outcome Measures in the Wider International Community Mohan Isaac*, Prabhat Chand & Pratima Murthy *Community Culture and Mental Health Unit School of Psychiatry and Clinical Neurosciences The University of Western Australia, Perth, Australia British Journal of Psychiatry (2007), 191 (Suppl 50) 71-77
2 : Background Schizophrenia (SZ) may have a better outcome in low and middle income countries (IPSS; WHO 1979, DosMed; Jablensky et al 1992, ISoS; Harrison et al 2001) It was not possible to tease out from these studies specific cultural factors which may influence these favourable outcomes ISoS study by the WHO (15 – 25 year follow-up in 14 culturally different SZ cohorts , 2000) showed that low & middle income countries had consistently more favourable outcomes, but there was marked heterogeneity across the centres. (3 centres in India were in this category) It might be helpful to examine what cultural aspects of the Indian subcontinent contributed to the improved outcomes
3 : Factors that may contribute to better prognosis of SZ in low & middle income countries Established: Lower expressed emotion, good social supports, tolerance by society and family, and marriage Doubtful: Lower industrialisation and urbanisation, early death of those with poor outcomes and increased prevalence of acute psychosis To be studied: Co morbid substance use, duration of untreated psychosis and pharmacological interventions
4 : Clinical Symptoms Thara (2004) reported a 20 year longitudinal study from India and found that all syndromes under the PSE (present state examination) declined except slowness & loss of interest whilst concentration and depression showed an increase in the last 10 years
5 : Acute Psychosis Debate Kulhara & Chakrabarti (2001) argued that many people with acute psychosis were included in the samples from low and middle income countries Patients with a diagnostic criteria of 1 month duration with acute psychosis which remits completely, may have contributed to the good outcomes Reanalysis of the data excluding these patients did not change the results appreciably (Hopper & Wanderling 2000)
6 : DUP (Duration of Untreated Psychoses) Drake et al (2000) showed tha poorer outcomes are associated with DUP, the relationship being strongest in the initial period of illness In low and middle income countries, DUP is very relevant as significant numbers of patients present late for treatment (Isaac et al 1981, Padmavathi et al 1998) Tirupati et al (2004) showed that patients with DUP of less than 5 years had good outcomes following one year of treatment
7 : Hospitalisation/treatment - seeking In low and middle income countries hospitalisation is more a reflection of policy and resource availability than an indication of need, hence its utility in these countries is low (Harrison 2001) Unemployment in males, family awareness of SZ are strongly linked to treatment seeking behaviour in these countries Gender, level of literacy, economic status, florid positive symptoms, were not associated with seeking treatment or hospitalisation in these countries Neglect seems to lead to treatment (embarrassed family into seeking treatment) Impact of tradition medicine on behaviours is unknown
8 : Mortality Mortality rates often neglected in outcome studies High mortality rates now reported in low to middle income countries (Patel et al 2006) Thara et al (2004) found 10% mortality rate at 10 years which increased to 17% at 20yrs with mean age at death of 34.2yrs In another N Indian study a mortality rate of 47% reported at 15 years Kebede et al (2005) reported 10% mortality and suicide accounted for 50% deaths (Ethiopia)
9 : Social Functioning In low and middle income countries, SZ has been shown to have better outcomes in terms of social and occupational functioning: social function rather than clinical status influenced functional competence of people with SZ (Harrison & Wanderling2001) Currently there are few studies using social functional outcome measures from low and middle income countries and need to be incorporated as a regular outcome measure
10 : Employment People with SZ in low and middle income countries are more likely to be employed than in western countries Thara (2004) reported 63- 73% employment rate at 10 years Padmavathi et al (1998) reported that 33% of untreated SZ were employed In India, colleagues at work place were supportive of patients and rarely made an issue of unusual behaviours Employment is a critical factor for perceived recovery from SZ in countries where families are reliant on the members for support
11 : Marriage In countries such as India, marriage can be considered both a measure of support and stress Most western studies report low rates of marriage (Nanko 1993) whereas Thara (1996) found a high marital rate of 70% There are conflicting reports on marital status as an outcome measure as few follow up studies have been done Impact of SZ not being disclosed needs further study Marriage breakdown in India gives additional stress of hostility from families and rejection by society, as well as issues around maintenance from husbands
12 : Social/family Support Social support as a predictor of outcome in low & middle income countries has attracted lots of interest. Supportive and favourable attitudes among family and community contribute to improved outcomes (Kulhara et al 2000,2005) Mean time in hospital for SZ in Bali is 1/5th that of Tokyo (Kurihara 2000) Ganev (1998) reported that studies from Asia show that <10% patients with SZ are hospitalised Migration, urbanisation, changing family structure and social networks and widening social inequalities in low and middle income countries will change the support available for people with SZ
13 : Illness Beliefs Research from low and middle income countries consistently show that there is a significant delay in seeking treatment for people with SZ. Srinivasan (2001) showed that few people name supernatural factors alone as a cause of schizophrenia which challenges the misconceptions of illness, superstition and ignorance as reasons for delaying treatment seeking
14 : Burden of Care Overall burden of care might be comparable across cultures, but there are different patterns reflecting different sociocultural factors The issue of burden of care is especially important in low to middle income countries, where the majority of patients stay with their caregivers Pai (1982) found that caregivers burden decreases with reduction in patients symptoms and improved drug adherence. Reduction of family burden is associated with better outcome and social functioning
15 : Substance Misuse Few epidemiological studies from low and middle income countries on the prevalence of substance misuse in general population and even fewer with SZ Carey(2003) reported alcohol disorders less in severe mental illness than general population Chennai showed 38% of males were current smokers, similar to general population
16 : CONCLUSIONS Low & middle income countries are characterised by a poorly organised healthcare sector, limited access to psychiatrists and longer DUP – yet outcomes of SZ appear better Difficult to identify what has contributed to these outcomes – prevailing cultural factors, nature of care and support might play a part. Factors such as role of family and caregivers need further study as they play a vital role in these countries Measures of diagnosis and assessment of outcome developed in western countries might not be suitable With the changing pattern of society in low and middle income countries, further prospective studies are needed to investigate sociocultural patterns associated with good outcomes


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