7

Schizophrenia

DEFINITION

Although schizophrenia is likely to have originated early in the evolution of man, it was identified as a disease only about 100 years ago by Kraepelin [1] under the name dementia praecox (early “mental enfeeblement”). In 1911, Bleuler [2] renamed the condition schizophrenia, suggesting that its salient characteristic was the “splitting” of mental functions. Whereas Kraepelin emphasized the deteriorating long-term course of the illness, Bleuler highlighted its fundamental symptoms: the inability to maintain coherence of ideas (loosening of associations); blunting or incongruity of affect; loss of the capacity for goal-directed action or coexistence of incompatible volitional impulses (ambivalence); and withdrawal into an inner world populated by private fantasies (autism). These symptoms were thought to be more closely related to the neuro-biological substrate of the disease than its more conspicuous accessory phenomena, such as hallucinations, delusions, and bizarre behavior. At present, the manifestations of schizophrenia are commonly classified into “positive” symptoms and signs, including hallucinations, delusions, and disorganized thought, and “negative” disorders, such as blunted affect, amotivation, poverty of speech, and social withdrawal.[3]

Current diagnostic concepts of schizophrenia are descendants of Kraepelin 's and Bleuler's ideas. Since the 1970s, the World Health Organization (WHO) and the American Psychiatric Association (APA) have been instrumental in promoting standard rules and criteria designed to improve the reliability of diagnostic assessment and enhance the comparability of mental health statistics and research data worldwide. The products of this work, the Tenth Revision of the



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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 7 Schizophrenia DEFINITION Although schizophrenia is likely to have originated early in the evolution of man, it was identified as a disease only about 100 years ago by Kraepelin [1] under the name dementia praecox (early “mental enfeeblement”). In 1911, Bleuler [2] renamed the condition schizophrenia, suggesting that its salient characteristic was the “splitting” of mental functions. Whereas Kraepelin emphasized the deteriorating long-term course of the illness, Bleuler highlighted its fundamental symptoms: the inability to maintain coherence of ideas (loosening of associations); blunting or incongruity of affect; loss of the capacity for goal-directed action or coexistence of incompatible volitional impulses (ambivalence); and withdrawal into an inner world populated by private fantasies (autism). These symptoms were thought to be more closely related to the neuro-biological substrate of the disease than its more conspicuous accessory phenomena, such as hallucinations, delusions, and bizarre behavior. At present, the manifestations of schizophrenia are commonly classified into “positive” symptoms and signs, including hallucinations, delusions, and disorganized thought, and “negative” disorders, such as blunted affect, amotivation, poverty of speech, and social withdrawal.[3] Current diagnostic concepts of schizophrenia are descendants of Kraepelin 's and Bleuler's ideas. Since the 1970s, the World Health Organization (WHO) and the American Psychiatric Association (APA) have been instrumental in promoting standard rules and criteria designed to improve the reliability of diagnostic assessment and enhance the comparability of mental health statistics and research data worldwide. The products of this work, the Tenth Revision of the

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World International Classification of Diseases (ICD-10) [4] and the APA Diagnostic and Statistical Manual, fourth edition, DSM-IV, [5] now serve as a common language for psychiatry and mental health care worldwide. The two systems identify schizophrenia in a broadly similar manner (see Table 7-1). Notwithstanding international agreement on diagnosis, it is important to bear in mind that schizophrenia remains a clinical syndrome and that the neuro-biology underlying its manifestations is not yet fully understood. There is at present no biological test or marker that can identify the disease (or a predisposition to it) independently of clinical assessment. Furthermore, the clinical TABLE 7-1 Overview of the ICD-10 and DSM-IV Criteria for Diagnosis of Schizophrenia ICD-10 Schizophrenia (F20) DSM-IV Schizophrenia (295) One month or more of at least one of the following symptoms: thought echo, withdrawal, insertion, broadcasting delusions of control and passivity voices; 3rd person, commentary, coming from part of body persistent delusions or at least two of the following: persistent hallucinations accompanied by delusions incoherence, irrelevant speech, neologisms catatonic signs negative symptoms significant consistent change in personal behavior One month or more of at least two of the following symptoms: delusions hallucinations disorganized speech grossly disorganized or catatonic behavior negative symptoms Social and occupational dysfunction One or more areas affected (work, relationships, self-care) Duration Continuous symptoms and signs for ≥ 6 months These 6 months must include: At least 1 month of symptoms meeting criterion A Various combinations of prodromal and residual symptoms Exclude: Exclude: Full manic or depressive episode preceding the onset of schizophrenic symptoms Organic brain disease Alcohol or drug intoxication or withdrawal Schizoaffective and mood disorder Substance use or a medical condition Autism or pervasive developmental disorder Source: [4,5]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World concept of schizophrenia does not tell us whether one or several pathological processes are involved or whether the causes of schizophrenia are the same in all cases. These gaps in the biological characterization of schizophrenia reflect the complexity of the disease, as well as our incomplete understanding of the basic neurobiology underlying psychological functions—such as memory, multimodal sensory integration, self-monitoring, and goal-directed action—that are impaired in those with schizophrenia. Neuroscience research in the next decade is likely to contribute substantial new insights into the causes of the disorder. The question of whether cases clinically diagnosed as schizophrenia in developing countries are homologous with similarly diagnosed cases in Western cultures is of critical importance, considering that the biological basis of the disorder still eludes reliable identification. To accept that schizophrenia is universal implies that its essential features can be reliably identified in different populations; that the constellation of symptoms is coherent and replicable; that consistent associations with age and gender are present; and that the course, outcome, and response to treatment show a common pattern. Cross-cultural similarities in the clinical presentation of disorders broadly corresponding to the diagnostic entity of schizophrenia have been reported by numerous researchers.[6] Yet until recently, the belief has been widespread that schizophrenia is a Western disease with no counterpart in indigenous populations untouched by modern technology and lifestyles.[7] That such beliefs are mistaken has been demonstrated by the fact that no human group has yet been found to be free of schizophrenia, provided that the size of the population is sufficient for a disorder of low incidence to become manifest. Research systematically addressing these issues was conducted within the WHO program of schizophrenia studies in some 27 developing and developed countries over the last three decades.[8,9,10,11,12 and 13] The results of these studies support the clinical validity of the diagnostic concept of schizophrenia in diverse populations, and reveal that the symptoms and syndromes accepted as characteristic of schizophrenia can be found in patients in all cultures and geographical areas covered by the research. Although no single symptom can be pinpointed as characteristic of schizophrenia in all patients and all settings, the overall pattern of the clinical presentation of the disorder is remarkably invariant across cultures. For example, acutely ill patients in very different cultural settings describe strikingly similar positive symptoms, such as hallucinatory voices commenting on their every thought and action, the experience of their thoughts being taken away by some alien agency or broadcast at large, or their surroundings being imbued with special meaning. Negative symptoms, such as psychomotor poverty, social withdrawal, and amotivation, are found to occur in varying proportions of patients irrespective of the cultural setting.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World The conclusion that patients diagnosed with schizophrenia in different cultures suffer from the same disorder is further supported by the similarity in the age- and sex-specific distribution of the onset of symptoms, which in all settings has a high peak in early adulthood (in both males and females) and a second, lower peak at age 35 and over (females only). Considering the variety of social norms, attitudes, and beliefs about illness across cultures, the similarity of the subjective experience of core schizophrenic symptoms and of the age at which they first occur in males and females is striking. The findings suggest that the disorders of perception, thought, and self-awareness characteristic of schizophrenia are likely to have a common pathophysiological basis across various cultures. Notwithstanding such overall similarity, there are variations in the clinical presentation of schizophrenia in different cultures that may influence recognition and treatment of the disease. Lambo [13] described a characteristic symptom complex in Nigeria consisting of anxiety, depression, vague hypochondriacal symptoms, bizarre magico-mystical ideas, episodic twilight or confusional states, atypical depersonalization, emotional lability, and retrospective falsification of memory based on hallucinations or delusions. Pfeiffer,[14] drawing on observations in Indonesia, concluded that the disease pictures are essentially the same as in Central Europe, but he also described several local characteristics, such as frequent confusion, an admixture of manic features, and rarity of systematized delusions. Certain subtypes of schizophrenia, such as the acute onset form and the catatonic subtype (characterized by bizarre movement disorders) are more common in developing countries than in the West. In the WHO 10-country study.[11] acute onset characterized 40.3 percent and catatonic schizophrenia 10.3 percent of the cases in developing countries, compared with 10.9 and 1.2 percent, respectively, in the developed world. In isolated groups, such as island, highlands, or tribal populations, schizophrenic psychoses may present with certain atypical features, most likely as a result of ancestral founder effects and genetic drift. A more common clinical problem in developing countries may be the differentiation of schizophrenia from psychoses due to infectious or parasitic diseases. Lambo [13] has drawn attention to the observation that in Africa, psychosis associated with trypanosomiasis often has a slow, insidious onset and may mimic “Western” schizophrenia, whereas acute schizophrenia in Africa, often characterized by confusion and agitation, may resemble “European ” psychoses accompanying physical disease. Since a variety of infectious, parasitic, and nutritional diseases are endemic in the developing world, it has been suggested that a high proportion of the cases of schizophrenia in those populations may in fact be symptomatic psychoses accompanying physical diseases such as malaria or typhoid fever.[15] The available evidence does not support this view. In the WHO 10-country study,[11] only 11.7 percent of a large number of individuals with psychotic symptoms who were screened for inclusion in India and Nigeria were excluded

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World on the grounds of having an acute or chronic physical disease that might explain their psychotic symptoms. On the other hand, common febrile illnesses may be among the factors precipitating the onset of acute, brief transient psychoses that are relatively frequent in developing countries, but bear no relationship to schizophrenia.[ 16] A more likely brain pathology contributing to cases of psychosis with schizophrenia-like features is epilepsy. The association between temporal lobe epilepsy and a chronic, interictal psychosis that is difficult to distinguish from schizophrenia has been well documented clinically.[17] Recent epidemiological studies in Europe point to a tenfold increase in the risk of schizophrenia-like psychosis among people suffering from epilepsy.[18,19] No comparable data are available from developing countries, but considering that epilepsy is a frequent disorder in many regions of the developing world, it is to be expected that undiagnosed and untreated epilepsy may account for some cases of schizophrenia-like psychoses, especially in areas where epilepsy is endemic (see Chapter 6). SCOPE OF THE PROBLEM Mortality In both developing and developed countries, schizophrenia is associated with excess mortality from a variety of causes. In Taiwan, data collected over a 15-year period indicate that of all mental disorders followed up, schizophrenia was associated with the highest mortality, representing an 80 percent increase over the mortality of the general population.[ 20] In the WHO International Pilot Study of Schizophrenia (IPSS),[21] the percentages of patients in Agra and Ibadan who died during the 5-year follow-up were 9.0 and 7.1, respectively, and were higher than the percentage (4.9) for the total study cohort. Whereas in the past, the excess mortality among individuals with schizophrenia was due mainly to communicable diseases such as tuberculosis, the leading causes of premature death among patients with schizophrenia at present are suicide, accidents, and common physical diseases. In developed countries, the suicide risk associated with schizophrenia is now nearly as high as that associated with major depression (4 –6 percent lifetime risk).[22] In persons with schizophrenia, suicide may occur at any stage of the progression of the disorder, but the risk is particularly high in the first 6 months after the first psychotic episode, as well as following periods of frequent hospital admission and discharge.[ 23] Although depressive symptoms often underlie suicide in people with schizophrenia, a sense of hopelessness, negative assessment of the future, and heavy alcohol use may drive suicidal behavior in the absence of marked mood disorder.[24,25] In the developing world, suicide-related mortality is a problem as well, but the majority of deaths among those suffering from schizophrenia are due to physical illness and accidents. In both developed and developing coun-

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World tries, schizophrenia is associated with excess mortality from respiratory, gastro-intestinal, and cardiovascular diseases, which are likely to be caused or exacerbated by poor self-care, inadequate nutrition, heavy smoking (common in schizophrenia patients), and medical neglect. At least part of this excess mortality is preventable.[26] Social and Economic Costs Schizophrenia is associated with greater chronic disability than any other mental disorder. Both the positive and negative symptoms of the disease interfere seriously with a person's capacity to cope with the demands of daily living. Patients with schizophrenia experience particular difficulty in dealing with complex demands and environments, especially those that involve social interaction and decoding of social communication.[27] Moreover, the onset is usually at a developmental stage of incomplete social maturation, educational attainment, and acquisition of occupational skills. The intervention of schizophrenia at this stage results in a severely truncated repertoire of social skills and lifelong socio-economic disadvantage. These factors are exacerbated by the societal reaction to individuals manifesting the behavior associated with “insanity, ” which generally involves stigma and social exclusion.[28] The above adverse factors interact to cause a “social breakdown syndrome” [29] that results in the loss of social support networks and a greatly diminished quality of life for a substantial proportion of those affected by schizophrenia.[30] Many schizophrenic patients end up on the streets or in the criminal justice system and are exposed to abuse, even in psychiatric hospitals. Such outcomes are not uncommon in either developed or developing countries, although in the latter settings, traditional family and community structures are still capable of providing a protective environment, and probably fewer patients are marginalized by society.[ 31] The social and economic costs of schizophrenia are disproportionately high relative to its incidence and prevalence. According to tentative estimates by WHO and the World Bank, in 1990 schizophrenia accounted for 2.3 percent of the burden of disease (disability adjusted life years [DALYs]) in established market economies and 0.8 percent in demographically developing regions. The projections for 2020 are 2.0 and 1.2 percent, respectively. In terms of DALYs, predicted demographic trends include more than a 50 percent increase in the disease burden attributable to schizophrenia in developing countries, a burden approaching that of malaria and nutritional deficiency. The total cost of illness for schizophrenia is disproportionately high relative to the population point prevalence of the disease (on average, 5 per 1000) or lifetime morbid risk (on average, 1 percent). In developed market economies, the direct costs of schizophrenia, incurred by hospital or community-based treatment, supervised accommodation, and related services, amount to 1.4 to 2.8

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World percent of the national health care expenditure and up to one-fifth of the direct costs of all mental disorders.[32,33 and 34] Although estimates of the indirect costs of schizophrenia vary greatly depending on the method of analysis and the underlying assumptions, these costs are likely to be comparable in scale to the direct costs, considering lost productivity and employment, the economically devastating long-term impact of the illness on the patient's family, other caregivers ' opportunity costs, the increased mortality of people with schizophrenia, the costs to the criminal justice system, and other issues related to public concerns about safety. Estimates based on the Epidemiological Catchment Areas study in the United States put the direct costs of schizophrenia in 1990 at $17.3 billion and the indirect costs at $15.2billion.[35] An important aspect of the economics of schizophrenia is the so-called funding imbalance effect: studies indicate that 97 percent of the total lifetime costs of schizophrenia are incurred by fewer than 50 percent of the patients diagnosed with the disorder.[32] While this finding points to a hard-core subset of cases with severe chronic illness, multiple disabilities, and excessive dependence on services and other support, it also suggests that in more than 50 percent of those with schizophrenia, the disorder is less disabling or treatment more effective. Most of the economic evidence on schizophrenia comes from studies conducted in the Western market economies. However, mental health economics is a young discipline. Thus evidence on the costs of schizophrenia even in developed countries is at present limited, and such data are quite scarce for the majority of developing countries, although individual studies provide some insight into the likely economic impact of the disease.[36] Since both the direct and indirect costs of schizophrenia are context-bound, extrapolations not only from the developed to the developing world but also across countries at comparable levels of gross domestic product (GDP) per capita must be made with caution, given the diversity of cultures, social structures, and health care systems. Thus although the generic cost-driving factors associated with schizophrenia are likely to be similar around the world (management of the chronic or relapsing symptoms and impairments, provision of inpatient and outpatient care and medication, mortality, lost productivity and unemployability, impact on the family, and impact on the community), their relative weight and hence the structure of the direct and indirect costs of the illness are likely to vary considerably. Hospital or other residential care, which generates more than 75 percent of the direct costs of schizophrenia in high-income countries,[33,34] is likely to account for a smaller fraction in developing countries because of lower staffing and equipment costs. On the other hand, the proportion of direct costs attributable to dispensing of antipsychotic medication, which is less than 5 percent of the total direct costs in developed countries,[33] is likely to be higher in developing countries. It is difficult to estimate the economic impact of schizophrenia on families in developing countries. A study conducted in Nigeria [37] revealed that care-

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World giver opportunity costs (e.g., family members' lost productivity or income) were not of a different order from those in the developed world. Yet the aggregate family costs in developing countries may, in fact, be substantially higher since (1) a larger proportion of schizophrenic patients live with their families as compared to patients in Western societies; (2) the family, not mental health services, is likely to be the first line of treatment and management of psychotic episodes; and (3) the cost of purchasing prescribed maintenance medication is usually borne by the family. Additional direct costs may be incurred by the necessity to travel, often long distances, to the nearest hospital or clinic, as well as by payment for the services of traditional healers. In many traditional communities, the stigma associated with mental illness may affect the family as a whole and restrict, for instance, marital opportunities for younger family members. While lost educational opportunities are likely to be a problem, lost paid employment is more difficult to quantify, and therefore less likely to appear prominently in estimates of the indirect illness burden in developing countries. On the other hand, reintegration of a family member who has suffered a psychotic episode into the domestic economy may be much easier to achieve than formal employment, and this may be one factor in the better and longer remissions of patients with schizophrenia observed in developing countries.[11] Another aspect of the social and economic costs of schizophrenia is the commonly perceived association between the disease and criminal behavior alluded to above. Crimes committed by persons with schizophrenia tend to receive wide media coverage and to reinforce popular ideas about dangerousness associated with mental illness. It is important to dispel such prejudicial attitudes.[38] Carefully designed studies in Europe and elsewhere indicate that a small proportion of patients with schizophrenia tend to be overrepresented among the perpetrators of violent offenses, including homicide. However, the population-attributable fraction of such offenses committed by persons with schizophrenia is negligibly small compared with the total number of offenses in the community. Moreover, the rate of apprehension and incarceration is likely to be high among patients with schizophrenia because of their conspicuous behavior and appearance, rather than the seriousness of the offense. Issues of protecting patients' rights must therefore be an important part of anti-stigma campaigns in both developing and developed countries. Recommendation 7-1. Governments, development agencies, and other sponsoring bodies should be made aware of the fact that schizophrenia and other psychotic illnesses are treatable conditions, and that significant returns in terms of symptom control, quality of life, and reintegration into the community can be achieved if increased funding is provided for local and regional programs that incorporate best-practice procedures and criteria.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World PREVALENCE AND INCIDENCE Epidemiological research reveals that schizophrenia is a disorder of low population incidence (2–4 new cases per 10,000 population per year), relatively high point prevalence (5 per 1000), and a very high disablement rate (in Western societies up to 70 percent of patients become severely disabled). The average lifetime risk of schizophrenia is about 1 percent and is approximately the same for males and females. Although a proportion of cases (estimated at 15 to 20 percent) do recover or improve, in the majority the disorder runs a chronic or recurrent course. Prevalence The availability of epidemiological data on schizophrenia in developing countries is uneven. While the prevalence of schizophrenia has been explored by numerous surveys in regions such as the Indian subcontinent, China, and South-east Asia, the data on Africa and parts of Latin America are limited. Results of prevalence studies carried out in developing countries since the 1960s are presented in Table 7-2. For comparison, the table also includes selected studies from developed countries. The majority are point prevalence surveys in which case finding and enumeration are likely to have been fairly complete. However, some of the communities studied are small, and the rates may be unstable since they are based on only a few cases of schizophrenia. Where larger populations have been studied, as in India and China, it appears possible to discern certain trends. Indian psychiatrists have carried out an impressive number of epidemiological investigations that include a large-scale study sponsored by the Indian Council of Medical Research,[39] covering a total population of 146,380. Given a methodological caveat about direct comparisons across studies, the survey data from India and Sri Lanka indicate a prevalence of schizophrenia ranging from 1.1 per 1000 [40] to 5.9 per 1000.[41] Since these two studies deal with relatively small populations, a range of 2.2–2.5 per 1000, supported by the two large-scale surveys, is more likely to be consistent and representative for the population of the Indian subcontinent as a whole. This range is similar to that obtained in the majority of European surveys.[42] However, if the lower life expectancy in India, as compared with European populations, is taken into account, the true age-standardized Indian prevalence rates are likely to be higher than the European rates. In 1981–1982, a comprehensive survey was carried out across several provinces of China in which a sample of 51,982 individuals were interviewed with standardized instruments.[43] The study revealed a point prevalence of 6.1 per 1000 in urban areas and 3.4 per 1000 in rural settings. Given that two-thirds of China's population was living in rural areas, it was estimated that there were more than 4.5 million persons with schizophrenia nationwide. In 1993, another

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World multisite epidemiological study showed a prevalence rate of 6.6 per 1000. With a population of 1.3 billion, this meant there were as many as 7.8 million schizophrenic patients in China.[44] According to the Chinese studies, of all patients with mental disorders, 49 percent were diagnosed with schizophrenia, making it the most prevalent disorder, responsible for an estimated 80 percent of all disability attributed to mental illness (mental disorders in their entirety were estimated to account for 18 percent of the total burden of disease in China). Few systematic surveys of psychoses have been carried out in Africa, although there is no dearth of clinical, service-based descriptive studies. An exception is a recent well-designed community survey in an area of Ethiopia with a population of 100,000 in the age range 15–49 years. The results of this survey indicated a point prevalence of schizophrenia of 4.8 per 1000; with adjustment for underascertainment, the estimated “true” prevalence was 7.1 per 1000.[45] In conclusion, the reported point prevalence of schizophrenia in most areas of the developing world where epidemiological surveys have been conducted is comparable to that in the developed world. Taking into account factors such as higher mortality among people with serious mental disorders and incomplete ascertainment of a proportion of cases, it is likely that the reported rates are underestimates of the true prevalence of the disorder. Incidence Data on the incidence of schizophrenia (new cases per 10,000 population ascertained over a defined period, usually a year) in developing countries are scarce. Table 7-3 lists the results of several such studies, along with findings on the incidence of schizophrenia in developed countries. To date, the only direct comparison of incidence rates across geographically defined areas in developing countries and areas in developed countries is provided by the WHO 10-country study.[11] Standardized procedures and diagnostic instruments were applied in each area by well-trained local psychiatrists, and inter-center reliability of data collection was monitored. A total of 1379 persons who met criteria for schizophrenia and related disorders were identified at their first contact with any medical or nonmedical “helping agency ” (which included indigenous healers in developing countries). A 15-year follow-up has now been completed.[12] The highest rates for ICD-9 schizophrenia (0.35 and 0.42 per 1000) across the study sites were found in two Indian areas. However, when the comparison was restricted to cases manifesting “first-rank” symptoms (see ICD-10 criteria, Table 7-1), there were no significant differences in incidence rates among various settings. In recent years, replications of the design of the WHO 10-country study, including its research instruments and procedures, have been carried out with very similar results by investigators in India,[46] the Caribbean,[47,48] and the United Kingdom.[49,50]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World RISK FACTORS Genetic There is strong evidence that genetic vulnerability plays an important role in the causation of schizophrenia.[51,52] A person's risk of developing the disorder increases steeply with the degree of genetic relatedness to an individual with the disease. Follow-up studies of children adopted away early in life have shown that their risk of developing schizophrenia as adults is predicted solely by having a biological parent with the disorder and not by the characteristics of the adoptive family. However, the pattern of occurrence of schizophrenia in families is not compatible with the transmission of a single gene; rather, it indicates that multiple genes are involved, each having a relatively small effect on the probability of developing the disease.[53,54] Furthermore, the evidence indicates that having the predisposing genes is not sufficient for the development of clinical disease. Such genes may remain unexpressed unless some other factor, most likely an environmental one, triggers their activity. Environmental Many environmental influences have been examined as possible risk factors for the development of schizophrenia.[55,56] These range from complications of pregnancy and birth to early viral infection, urban birth, malnutrition, head injury, toxic effects of psychoactive substances such as cannabis, and psychosocial adversity (see Table 7-4). None of these putative risk factors has been unequivocally validated, and it is possible that different environmental exposures may interact with the predisposing genes at different developmental stages.[57] Few risk factors have been specifically identified or validated in developing countries, although obstetric complications and early brain injury due to neuro-infection, toxic effects, other trauma, or maternal malnutrition during gestation are likely to be involved in a greater proportion of cases of adult schizophrenia in the developing than in the developed world. Among the potential psychosocial risk factors, migration stress has been suggested by studies in India [58] and Taiwan [59] in which refugees or migrants were found to be overrepresented among schizophrenic patients. Some support for a role of psychosocial adversity in the causation or precipitation of schizophrenia is provided by studies that have highlighted an unusually high incidence of the disorder among the offspring of Afro-Caribbean migrants in the United Kingdom. Since the excess schizophrenia morbidity is limited to the U.K.-born second generation, loss of traditional social support systems and demoralization stress linked to societal stereotyping and prejudice are being explored as possible risk factors interacting

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 7. G. Devereux. Basic Problems in Ethnopsychiatry. University of Chicago Press : Chicago, 1980. 8. World Health Organization. Report of the International Pilot Study of Schizophrenia, vol.1. World Health Organization: Geneva, 1973. 9. World Health Organization. Schizophrenia. An International Follow-Up Study. Wiley & Sons: Chichester, 1979. 10. A. Jablensky, R. Schwarz and T. Tomov. WHO collaborative study of impairments and disabilities associated with schizophrenic disorders. Acta Psychiatrica Scandinavica Supplement 285,152–163, 1980. 11. A. Jablensky, N. Sartorius, G. Ernberg, M. Anker, A. Korten, J. E. Cooper, et al. Schizophrenia: Manifestations, Incidence and Course in Different Cultures. A World Health Organization Ten-Country Study. Psychological Medicine, Monograph Supplement 20, Cambridge University Press: Cambridge, 1992. 12. N. Sartorius, W. Gulbinat, G. Harrison, E. Laska, and C. Siegel. Long-term followup of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization. Social Psychiatry and Psychiatric Epidemiology 31: 249–258, 1996. 13. T.A. Lambo. Schizophrenia and borderline states. In Transcultural Psychiatry, A.V. De Reuck and S.R. Porter, eds. CIBA Foundation Symposium. Churchill: London, 1965. 14. W.M. Pfeiffer. Psychiatrische Besonderheiten in Indonesien. In Beiträge zur vergleichenden Psychiatrie, N. Petrilowitsch, ed., Karger: Basel, pp. 102–142, 1967. 15. B.O. Osuntokun, O. Bademosi, K. Ogunremi and S.G. Wright. Neuropsychiatric manifestations of typhoid fever in 959 patients. Archives of Neurology 27: 7–13, 1972. 16. P.Y. Collins, V.K. Varma, N.N. Wig, R. Mojtabai, R. Dat, and E. Susser. Fever and acute brief psychosis in urban and rural settings in north India. British Journal of Psychiatry 174: 520–524, 1999. 17. J.D.C. Mellers, B.K. Toone, and W.A. Lishman. A neuropsychological comparison of schizophrenia and schizophrenia-like psychosis of epilepsy. Psychological Medicine 30:325–335, 2000. 18. T. Makikyro, J.T. Karvonen, H. Hakko, P. Mieminen, M. Joukamaa, M. Isohanni and M.R. Jarvelin. Comorbidity of hospital-treated psychiatric and physical disorders with special reference to schizophrenia: A 28 year follow-up of the 1966 Northern Finland general population birth cohort. Public Health 112:221–228, 1998. 19. S.R. Bredkjaer, P.B. Mortensen, and J. Parnas. Epilepsy and non-organic non-affective psychosis. National epidemiologic study British Journal of Psychiatry 172:235–238, 1998. 20. T.Y. Lin, H.M. Chu, H. Rin, C. Hsu, E.K.Yeh, and C. Chen. Effects of social change on mental disorders in Taiwan: Observations based on a 15-year follow-up survey of general populations in three communities. Acta Psychiatrica Scandinavica 79, Supplement. 348,11–34, 1989. 21. J. Leff, N. Sartorius, A. Jablensky, A. Korten, and G. Ernberg. The International Pilot Study of Schizophrenia: Five-year follow-up findings. Psychological Medicine 22,131–145, 1992. 22. H.M. Inskip, E.C. Harris, and B. Barraclough. Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia British Journal of Psychiatry 172:35–37, 1998.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 23. C.D. Rossau and P.B. Mortensen. Risk factors for suicide in patients with schizophrenia: Nested case-control study. British Journal of Psychiatry 171:355–359, 1997. 24. C.B. Caldwell and I.I. Gottesman. Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin 16:571–589, 1990. 25. H. Heilar, E.T. Isometsa, M.M. Henriksson, M.E. Heikkinen, M.J. Marttunen, and J.K. Lonnqvist. Suicide and schizophrenia: A nationwide psychological autopsy study on age-and sex-specific clinical characteristics of 92 suicide victims with schizophrenia. American Journal of Psychiatry 154:1235–1242, 1997. 26. S. Brown. Excess mortality of schizophrenia. A meta-analysis. British Journal of Psychiatry 171:502–508, 1997. 27. H.B.M. Murphy. The schizophrenia-evoking role of complex social demands. In Kaplan, A.R., ed. Genetic Factors in Schizophrenia. Charles C. Thomas: Springfield, IL, 1972. 28. R. Cancro and A.T. Meyerson. Prevention of disability and stigma related to schizophrenia: A review In Schizophrenia, Maj, M. and Sartorius, N., eds., vol 2, WPA Series Evidence and Experience in Psychiatry, Wiley: Chichester, pp.243–278, 1999. 29. E.M. Gruenberg. The epidemiology of schizophrenia. In Arieti, S., ed. American Handbook of Psychiatry, Second Edition, vol. 2. Basic Books: New York, pp.448–463, 1974. 30. A. Jablensky, J. McGrath, H. Herrman, D. Castle, O. Gureje, M. Evans, et al. Psychotic disorders in urban areas: An overview of the Study on Low Prevalence Disorders. Australian and New Zealand Journal of Psychiatry 34: 221–236, 2000. 31. R.S. Murthy, K. Kumar, and S. Chatterji. Schizophrenia: Epidemiology and community aspects. In Schizophrenia: the Indian Scene, Kulhara, P., Avasthi, A. and Verma, S., eds. Postgraduate Institute of Medical Education & Research: Chandigarh, pp.39–65, 1997. 32. L.M. Davies and M.F. Drummond. Economics and schizophrenia: The real cost. British Journal of Psychiatry 165, Suppl 25: 18–21, 1994. 33. M. Knapp, S. Almond, M. Percudani. Costs of schizophrenia: A review. In Schizophrenia, Maj, M. and Sartorius, N., eds. vol 2, WPA Series Evidence and Experience in Psychiatry, Wiley: Chichester, pp.407–453, 1999. 34. P.J. Weiden and M. Olfson. Cost of relapse in schizophrenia. Schizophrenia Bulletin 21: 419–429, 1995. 35. S.J. Keith, D.A. Regier, and D.S. Rae. Schizophrenic disorders. In: Psychiatric Disorders in America, The Epidemiologic Catchment Area Study. Robins, L.N. and Regier, D.A.,eds., The Free Press: New York, 1991. 36. A. Shah and R. Jenkins R. Mental health economic studies from developing countries reviewed in the context of those from developed countries. Acta Psychiatrica Scandinavica 100: 1–18, 1999. 37. I.S. Martyns-Yellowe. The burden of schizophrenia on the family: A study from Nigeria. British Journal of Psychiatry 161: 779–782, 1992. 38. P.J. Taylor and J. Gunn. Homicides by people with mental illness: Myth and reality. British Journal of Psychiatry 174: 9–14, 1999. 39. Indian Council of Medical Research. Multi-Centered Collaborative Study of Factors Associated with Course and Outcome of Schizophrenia. ICMR: New Delhi, 1988. 40. B. Sethi, S.C. Gupta, R. Rajkumar, and P. Kumari. A psychiatric study of 500 rural families. Indian Journal of Psychiatry 14:183–196, 1972.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 41. Sen, D.N. Nandi, S.P. Mukherjee, D.C. Mishra, G. Banerjee, and S. Sarkar. Psychiatric morbidity in an urban slum-dwelling community. Indian Journal of Psychiatry 26: 185–193, 1984. 42. A. Jablensky. Epidemiology of schizophrenia: A European perspective. Schizophrenia Bulletin 12,52–73, 1986. 43. C.H. Chen. Incidence and prevalence of schizophrenia in a community mental health service from 1975 to 1981. Zhonghua Shen Jing Jing Shen Ke Za Zhi Dec;17(6):321–324, 1984. 44. B.Y. Rhi, K.S. Ha, Y.S. Kim, Y. Sasaki, D. Young, Woon, et al. The health care seeking behavior of schizophrenic patients in 6 East Asian areas. International Journal of Social Psychiatry Autumn;41(3):190–209, 1985. 45. D. Kebede, A. Alem, T. Shibre, A. Fekadu, D. Fekadu, A. Negash, et al. The Bitaijir Ethiopia study of the course and outcome of schizophrenia and bipolar disorders. I. Description of study settings, methods and cases. Unpublished manuscript 1999. 46. S. Rajkumar, R. Padmavati, R. Thara, et al. Incidence of schizophrenia in an urban community in Madras. Indian Journal of Psychiatry 35:18–21, 1993. 47. F.W. Hickling. Psychiatric hospital admission rates in Jamaica, 1971 and 1988. British Journal of Psychiatry 159,817–821, 1991. 48. E. Many, R. Mallett, J. Leff, and D. Bhugra. First contact incidence rate of schizophrenia on Barbados. British Journal of Psychiatry. July 175:28–33, 1999. 49. A. McNaught, S.E. Jeffreys, C.A. Harvey, A.S. Quayle, M.B. King, and A.S. Baird. The Hampstead Schizophrenia Survey 1991. II. Incidence and migration in inner London. British Journal of Psychiatry 170,307–311, 1997. 50. J. Brewin, R. Cantwell, T. Dalkin, R. Fox, I. Medley, C. Glazebrook, et al. Incidence of schizophrenia in Nottingham. British Journal of Psychiatry 171,140–144, 1997. 51. Gottesman II. Schizophrenia Genesis: The Origin of Madness. Freeman: New York, 1991. 52. K.S. Kendler and S.R. Diehl. The genetics of schizophrenia: A current, geneticepidemiologic perspective Schizophrenia Bulletin 19: 261–285, 1993. 53. N. Risch. Genetic linkage and complex diseases, with special reference to psychiatric disorders. Genetic Epidemiology 7: 3–16, 1990. 54. S.V. Faraone, M.T. Tsuang, and D.W. Tsuang. Genetics of Mental Disorders. Guilford: New York, 1999. 55. A. Jablensky and W.W. Eaton. Schizophrenia. In: Epidemiological Psychiatry, Jablensky, A., ed. Bailliere Tindall: London, p. 294, 1995. 56. J. Kelly and R.M. Murray. What risk factors tell us about the causes of schizophrenia and related psychoses. Current Psychiatry Report Oct;2(5):378–385, 2000. 57. E. Fuller-Torrey, R. Rawlings, and R.H. Yolken. The antecedents of psychoses: A case-control study of selected risk factors. Schizophrenia Research Nov 30;46(1):17–23, 2000. 58. M.K.C. Dube and N. Kumar. An epidemiological study of schizophrenia. Journal of Biosocial Science 4(2), 187–195, 1972. 59. H. Rin and T.Y. Lin. Mental illness among Formosan aborigines as compared with the Chinese in Taiwan. Journal of Mental Science 198,134–146, 1962. 60. C. Brugger. Versuch einer Geisteskrankenzählung in Thüringen. Zeitschrift für die gesamte Neurologie und Psychiatric 133,252–390, 1931.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 61. E. Strömgren. Beiträge zur psychiatrischen Erblehre, auf Grund von Untersuchungen an einer Inselbevölkerung. Acta Psychiatrica et Neurologica Scandinavica 19, 1938. 62. S. Bøjholm and E. Strömgren. Prevalence of schizophrenia on the island of Bornholm in 1935 and in 1983. Acta Psychiatrica Scandinavica 79, Supplement 348,157–166, 1989. 63. P. Lemkau, C. Tietze, and M.Cooper. A survey of statistical studies on the prevalence and incidence of mental disorder in sample populations. Public Health Reports 58,1909–1927, 1943. 64. E. Essen-Möller, H. Larsson, C.E. Uddenberg and G. White. Individual traits and morbidity in a Swedish rural population. Acta Psychiatrica et Neurologica Scandinavica, Supplement 100, 1956. 65. O. Hagnell. A Prospective Study of the Incidence of Mental Disorder. Svenska Bokforlaget: Lund, 1966. 66. G.J. Crocetti, P.V.Lemkau, Z. Kulcar, and B. Kesic. Selected aspects of the epidemiology of psychoses in Croatia, Yugoslavia, II. The cluster sample and the results of the pilot survey. American Journal of Epidemiology 94,126–134, 1971. 67. V.G. Rotstein. Material from a psychiatric survey of sample groups from the adult population in several areas of the USSR (in Russian). Zhurnal nevropatologii I psikhiatrii Korsakov 77,569–574, 1977. 68. L.N. Robins, J.E. Helzer, M.M. Weissman, H. Orvaschel, E. Gruenberg, J.D. Burke, D.A. Regier. Lifetime prevalence of specific psychiatric disorders in three sites Archives of General Psychiatry 41,949–958, 1984. 69. S.E. Jeffreys, C.A. Harvey, A.S. McNaught, A.S. Quayle, M.B. King, and A.S. Bird. The Hampstead Schizophrenia Survey 1991. I: Prevalence and service use comparisons in an inner London health authority, 1986–1991. British Journal of Psychiatry 170:301–306, 1997. 70. A. Jablensky, J. McGrath, H. Herrman, D. Castle, O. Gureje, V. Morgan, and A. Korten: People Living with Psychotic Illness: An Australian Study 1997–98. National Survey of Mental Health and Wellbeing Report 4. Commonwealth of Australia, 1999. 71. T.Y. Lin, H.M. Chu, H. Rin, C. Hsu, E.K.Yeh, and C. Chen. Effects of social change on mental disorders in Taiwan: Observations based on a 15-year follow-up survey of general populations in three communities. Acta Psychiatrica Scandinavica 79, Supplement. 348,11–34, 1989. 72. K.W. Bash and J. Bash-Liechti. Psychiatrische Epidemiologie in Iran. In: Perspektiven der heutigen Psychiatrie, Ehrhard, H.E., ed. Gerhards: Frankfurt, 1969. 73. M.K.C. Dube and N. Kumar. An epidemiological study of schizophrenia. Journal of Biosocial Science 4,187–195, 1972. Indian Council of Medical Research. Multi-centered Collaborative Study of Factors Associated with Course and Outcome of Schizophrenia. ICMR: New Delhi, 1988. 74. R. Padmavathi, S. Rajkumar, N. Kumar, A. Manoharan, and S. Kamath. Prevalence of schizophrenia in an urban community in Madras. Indian Journal of ‘Psychiatry 31,233–239, 1987. 75. R. Salan. Epidemiology of schizophrenia in Indonesia (the Tambora I study). ASEAN Journal of Psychiatry 2: 52–57, 1992.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 76. C.K. Lee, Y.S. Kwak, J. Yamamoto, H. Rhee, Y.S. Kim, J.H. Han, et al. Psychiatric epidemiology in Korea. Part I. Gender and age differences in Seoul. Part II. Urban and rural differences. Journal of Nervous Mental Disorders 178: 242–252, 1990. 77. C.N. Chen, J. Wong, N. Lee, M.W. Chan-Ho, J. Tak-Fai Lau, and M. Fung. The Shatin community mental health survey in Hong Kong. II. Major findings. Archives of General Psychiatry 50, 125–133, 1993. 78. M.C. Waldo. Schizophrenia in Kosrae, Micronesia: Prevalence, gender ratios, and clinical symptomatology. Schizophrenia Research 35: 175–181, 1999. 79. D. Kebede and A. Alem Major, mental disorders in Addis Ababa, Ethiopia. I. Schizophrenia, schizoaffective and cognitive disorders. Acta Psychiatrica Scandinavica, Supplement 397: 11–17, 1999. 80. O. Ødegaard. A statistical investigation of the incidence of mental disorder in Norway. Psychiatric Quarterly 20, 381–401, 1946. 81. H. Häfner and H. Reimann. Spatial distribution of mental disorders in Mannheim, 1965. In: Psychiatric Epidemiology, Hare, E.H. and Wing, J.K., eds. Oxford University Press: London, 341–354, 1970. 82. Y.I. Lieberman. The problem of incidence of schizophrenia: Material from a clinical and epidemiological study (in Russian). Zhurnal nevropatologii i psikhiatrii Korsakov 74, 1224–1232, 1974. 83. T. Helgason. Epidemiology of mental disorders in Iceland. Acta Psychiatrica Scandavica Supplement 173, 1964. 84. D. Castle, S. Wessely, G. Der, and R.M. Murray. The incidence of operationally defined schizophrenia in Camberwell, 1965–84. British Journal of Psychiatry 159, 790–794, 1991. 85. L. Nicole, A. Lesage and P. Lalonde. Lower incidence and increased male:female ratio in schizophrenia. British Journal of Psychiatry 161, 556–557, 1992. 86. A. McNaught, S.E. Jeffreys, C.A. Harvey, A.S. Quayle, M.B. King, and A.S. Baird. The Hampstead Schizophrenia Survey 1991. II. Incidence and migration in inner London. British Journal of Psychiatry 170, 307–311, 1997. 87. J. Brewin, R. Cantwell, T. Dalkin, R. Fox, I. Medley, C. Glazebrook, et al. Incidence of schizophrenia in Nottingham. British Journal of Psychiatry 171, 140–144, 1997. 88. A.C. Raman and H.B.M. Murphy. Failure of traditional prognostic indicators in Afro-Asian psychotics: results from a long-term follow-up study. Journal of Nervous and Mental Disease 154:238–247, 1972. 89. D. Bhugra, J. Leff, R. Mallett, G. Der, B. Corridan, and S. Rudge. Incidence and outcome of schizophrenia in Whites, African-Caribbeans and Asians in London. Psychological Medicine 27:791–798, 1997. 90. G. Hutchinson, N. Takei, T.A. Fahy, D. Bhugra, C. Gilvarry, P. Morgan et al. Morbid risk of schizophrenia in first-degree relatives in White and African-Caribbean patients with psychosis. British Journal of Psychiatry 169:776–780, 1996. 91. M. Marcelis, F. Navarro-Mateu, R. Murray, J.P. Selten, and J. Van Os. Urbanization and psychosis: A study of 1942–1978 birth cohorts in the Netherlands. Psychological Medicine Jul;28(4):871–879, 1998. 92. W.W. Eaton, P.B. Mortensen, and M. Frydenberg. Obstetric factors, urbanization, and psychosis. Schizophrenia Research Jun 16;43(2–3):117–123, 2000. 93. P.J. Harrison. The neuropathology of schizophrenia. A critical review of the data and their interpretation. Brain 122: 593–624, 1999.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 94. F. Owen and M.D.C. Simpson. The neurochemistry of schizophrenia. In Schizophrenia, Hirsch, S.R and Weinberger, D.R., eds. Blackwell Science : Oxford, pp. 358–378, 1995. 95. S.S. Kindermann, A. Karimi, L. Symonds, G.G. Brown, and D.V. Jeste. Review of functional magnetic resonance imaging in schizophrenia. Schizophrenia Research 27: 143–156, 1997. 96. C.D. Frith. The Cognitive Neuropsychology of Schizophrenia. Lawrence Erlbaum: Hove, United Kingdom, 1992. 97. K.H. Nuechterlein, M.E. Dawson, and M.F. Green. Information-processing abnormalities as neuropsychological vulnerability indicators for schizophrenia. Acta Psychatrica Scandinavica 90(384):71–79, 1994. 98. J.R.J. Finkelstein, T.D. Cannon, R.E. Gur, R.C. Gur, and P. Moberg. Attentional dysfunctions in neuroleptic-naïve and neuroleptic-withdrawn schizophrenic patients and their siblings Journal of Abnormal Psychology 106: 203–212, 1997. 99. R. Toomey, S.V. Faraone, L.J. Seidman, W.S. Kremen, J.R. Pepple, and M.T. Tsuang. Association of neuropsychological vulnerability markers in relatives of schizophrenic patients. Schizophrenia Research 31: 89–98, 1998. 100. D.R. Weinberger. Schizophrenia as a neurodevelopmental disorder. In: Schizophrenia, Hirsch, S.R. and Weinberger, D.R., eds. Blackwell Scientific: Oxford, pp. 293–323, 1995. 101. R.M. Murray. Neurodevelopmental schizophrenia: The rediscovery of dementia praecox British Journal of Psychiatry 165(25):6–12, 1994. 102. D.R. Weinberger and B.K. Lipska. Cortical maldevelopment, anti-psychotic drugs, and schizophrenia: A search for common ground. Schizophrenia Research 16:87–110, 1995. 103. H. Häfner, K. Maurer, W. Löffler, and A. Riecher-Rössler. The influence of age and sex on the onset and early course of schizophrenia British Journal of Psychiatry 162, 80–86, 1993. 104. J.M. Sutter, M. Porot, and Y. Pelicier. Algerian aspects of mental pathology. Algerie Medicale 63, 891–896, 1959. 105. T. Weaver, A. Renton, G. Stimson, and P. Tyrer. Severe mental illness and substance misuse. British Medical Journal 318: 137–138, 1999. 106. J. Smith and S. Hucker. Schizophrenia and substance abuse. British Journal of Psychiatry 165: 13–21, 1995. 107. D.H. Linszen, P.M. Dingemans, and M.E. Lenior. Cannabis abuse and the course of recent-onset schizophrenic disorders Archives of General Psychiatry 51: 273–279, 1994. 108. D.C. Mathers and A.H. Ghodse. Cannabis and psychotic illness. British Journal of Psychiatry 161: 648–653, 1992. 109. N.E. Waxler. Is outcome for schizophrenia better in nonindustrial societies? The case of Sri Lanka. Journal of Nervous and Mental Disease 167, 144–158, 1979. 110. R. Thara, M. Henrietta, A. Joseph, S. Rajkumar, and W.W. Eaton. Ten-year course of schizophrenia—The Madras longitudinal study. Acta Psychiatrica Scandinavica 90, 329–336, 1994. 111. P. Kulhara and K. Chandiramani. Outcome of schizophrenia in India using various diagnostic systems Schizophrenia Research 1, 339–349, 1998.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 112. A.Verghese, J.K. John, S. Rajkumar, J. Richard, B.B. Sethi, and J.K. Trivedi. Factors associated with the course and outcome of schizophrenia in India. British Journal of Psychiatry 154, 499–503, 1989. 113. J.U. Ohaeri. Long-term outcome of treated schizophrenia in a Nigerian cohort. Retrospective analysis of 7-year follow-ups. Journal Nervous Mental Disorders 181, 514–516, 1993. 114. A. Kleinman. Rethinking Psychiatry. From Cultural Category to Personal Experience The Free Press: New York, 1988. 115. R. Warner. Recovery from schizophrenia in the Third World. Psychiatry 46, 197–212, 1983. 116. C.J.L. Murray and A.D. Lopez. Global Health Statistics. Harvard University Press: Cambridge, 1996. 117. J. van Os, N. Takei, H. Verdoux, and P. Delespaul. Early detection of schizophrenia (Letter to Editor), British Journal of Psychiatry 170, 579, 1997. 118. M. Birchwood, P. McGorry, and H. Jackson. Early intervention in schizophrenia. British Journal of Psychiatry 170: 2–5, 1997. 119. H. Häfner. Disability, stigma and discrimination: A view from outside the USA In: Schizophrenia, Maj, M. and Sartorius, N., eds. Vol. 2, WPA Series Evidence and Experience in Psychiatry. Wiley: Chichester, pp. 288–291, 1999. 120. R.J. Wyatt. Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin 17, 325–351, 1991. 121. American Psychiatric Association. Practice guidelines for the treatment of patients with schizophrenia American Journal of Psychiatry 154, April 1997 Supplement, 1–49, 1997. 122. K. Wahlbeck, M. Cheine, and M.A. Essali. Clozapine versus typical neuroleptic medication for schizophrenia (Cochrane Review) In: The Cochrane Library, Issue 3. Oxford, Update Software, 2000. 123. A. Davies, P.C. Langley, N.A. Keks, S.V. Catts, T. Lambert, and I. Schweitzer. Risperdone versus haloperidol: II. Cost-effectiveness. Clinical Therapy 20,196–213, 1998. 124. K.C. Coley, C.S.Carter, S.V. DaPos, R. Maxwell, J.W. Wilson and R.A. Branch. Effectiveness of antipsychotic therapy in a naturalistic setting: A comparison between risperidone, perphenazine, and haloperidol. Journal of Clinical Psychiatry 60,850–856, 1999. 125. R. Rosenheck, J. Cramer, E. Allan, J. Erdos, L.K. Fisman, W. Xu et al. Cost-effectiveness of clozapine in patients with high and low levels of hospital use. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia. Archives of General Psychiatry 56,565–572, 1999. 126. K.M Lin and M.W. Smith. Psychopharmacology in the context of culture and ethnicity. In: Ethnicity and Psychopharmacology. Ruiz, P., ed. Review of Psychiatry 19;1–36, American Psychiatric Press: Washington, D.C., 2000. 127. E.H. Pi and G.E. Gray. Ethnopsychopharmacology for Asians. In: Ethnicity and Psychopharmacology, Ruiz, P., ed. Review of Psychiatry, 19,91–113, American Psychiatric Press: Washington, D.C., 2000. 128. N.N. Wig, S. Murthy, and T.W. Harding. A model for rural psychiatric services—Raipur Rani experience. Indian Journal of Psychiatry 23, 275–290, 1981.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 129. S. Murthy. Integration of mental health with primary health care—Indian experience. In Community Mental Health. Proceedings of the Indo-U.S. Symposium, Murty, S. and Burns, B.J., eds., National Institute of Mental Health and NeuroSciences : Bangalore, 1992. 130. N.E. Sokhela and L.R.Uys. The integration of comprehensive psychiatric/mental health care into the primary health system: Diagnosis and treatment. Journal of Advanced Nursing 30, 229–237, 1999. 131. F. Schulsinger and A. Jablensky. The national mental health programme in the United Republic of Tanzania: A report from WHO and DANIDA. Acta Psychiatrica Scandinavica 83, Suppl 364, 1–132, 1991. 132. W. Xiong, M.R. Phillips, X. Hu, R.Wang, Q. Dai, J. Kleinman, and A. Kleinman. Family-based intervention for schizophrenic patients in China. A randomised controlled trial. British Journal of Psychiatry 165, 239–247, 1994. 133. T. Caldera, G. Kullgren, U. Penayo, and L. Jacobsson. Is treatment in groups a useful alternative for psychiatry in low-income countries? An evaluation of a psychiatric outpatient unit in Nicaragua Acta Psychiatrica Scandinavica 92, 386–391, 1995. 134. C. Vaughn, K. Snyder, S. Jones, W.B. Freeman, and I.R. Falloon. Family factors in schizophrenic relapse. Archives of General Psychiatry 41, 1169–1177, 1984. 135. S. King and M.J. Dixon. Expressed emotion and relapse in young schizophrenia outpatients. Schizophrenia Bulletin 25(2),377–386, 1999. 136. J. Leff, N.N.Wig, H. Bedi, D.K. Menon, L. Kuipers, A. Korten et al. Relatives' expressed emotion and the course of schizophrenia in Chandigarh: A two-year follow-up of a first-contact sample. British Journal of Psychiatry 156, 351–356, 1990. 137. M.R. Chaudhry. Prevention of disability and stigma: Experience from a developing country. In Schizophrenia, Maj, M. and Sartorius, N., eds., vol. 2, WPA Series Evidence and Experience in Psychiatry, Wiley: Chichester, pp. 308–310, 1999. 138. R.P. Liberman. Social skills training. In: Psychiatric Rehabilitation for Chronic Patients, Liberman, R.P., ed., American Psychiatric Press: Washington, D.C., pp. 147–198, 1988 139. G. Hogarty, C. Anderson, D. Reiss, S.J. Kornblith, D.P. Greenwald, R.E. Ulrich, et al. Family psychoeducation, social skills training, and maintenance chemotherapy in aftercare of schizophrenia. II. Two year effects of a controlled study of relapse and adjustment. Archives of General Psychiatry 48, 340–347, 1991. 140. T.A. Lambo. The importance of cultural factors in psychiatric treatment. In: Cross-Cultural Studies of Behaviour, Al-Issa, I. and Dennis,W., eds. Holt, Rinehart & Winston: Austin, TX, 1970. 141. M.R. Phillips. Are Western models of psychiatric rehabilitation feasible and appropriate for developing countries? In: Schizophrenia, Maj M. and Sartorius, N., eds. WPA Series Evidence and Experience in Psychiatry, Wiley: Chichester, (2),304–306, 1999. 142. R.M. Chen Rong-Min. An investigation of family environmental alteration affecting short-term recovery from schizophrenia in China. British Journal of Psychiatry Feb;166(2),258–261, 1995. 143. K. Lou and D. Yu. Enterprise-based sheltered workshops in Nanjing. A new model for the community rehabilitation of mentally ill workers British Journal of Psychiatry Supplement Aug;(24),89–95, 1994.

OCR for page 217
Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 144. X. Wang. An integrated system of community services for the rehabilitation of chronic psychiatric patients in Shenyang, China. British Journal of Psychiatry Supplement Aug;(24),80–88, 1994. 145. M. Zhang, H. Yan, and M.R. Phillips. Community-based psychiatric rehabilitation in Shanghai. Facilities, services, outcome, and culture specific characteristics British Journal of Psychiatry Supplement Aug;(24),70–79, 1994. 146. M.R. Phillips and V. Pearson. Rehabilitation interventions in urban communities. British Journal of Psychiatry Supplement Aug;(24),66–69, 1994. 147. F. Li and M. Wang. A behavioral training programme for chronic schizophrenic patients A three-month randomized controlled trial in Beijing. British Journal of Psychiatry Supplement Aug;(24),32–37, 1994. 148. F. Qiu and S. Lu. Guardianship networks for rural psychiatric patients. A non-professional support system in Jinshan County, Shanghai. British Journal of Psychiatry Supplement Aug;(24),114–120, 1994. 149. M.R. Phillips and V. Pearson. Rehabilitation interventions in rural communities. British Journal of Psychiatry Supplement Aug;(24),103–106, 1994. 150. Q. Wang, Y. Gong, and K. Niu. The Yantai model of community care for rural psychiatric patients British Journal of Psychiatry Supplement Aug;(24),107–113, 1994. 151. M.R. Phillips and V. Pearson. Future opportunities and challenges for the development of psychiatric rehabilitation in China. British Journal of Psychiatry Supplement Aug;(24),128–142, 1994. 152. M.R. Phillips, S.H. Lu, and R.W. Wang. Economic reforms and the acute inpatient care of patients with schizophrenia: the Chinese experience. American Journal of Psychiatry Sep;154(9),1228–1234, 1997.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Summary of Findings: Bipolar Disorder in Developing Countries Bipolar disorders account for about 11 percent of the neuropsychiatric disease burden and about 1 percent of the total disease burden in developing countries. Between 25 and 50 percent of patients in developed countries with bipolar disorder are estimated to attempt suicide, and as many as 15 percent complete the act. Predisposition to bipolar disorder may be inherited; other apparent risk or precipitating factors include substance abuse, living in an urban setting, and lack of education. The significant impact of social and environmental factors on the presentation, course, and incidence of bipolar disorder argues for increased research in developing countries. There is no known course of primary prevention for bipolar disorder. Risk factors and the physical and psychological symptoms of the disorder can be reduced and controlled but not eliminated following diagnosis. Treatment for bipolar disorder often requires a combination of medications, few of which have been tested in developing countries. Acute episodes of mania are best treated with antipsychotic medications or high doses of mood stabilizers; acute episodes of depression can be treated with antidepressant medication and electroconvulsive treatment. Once acute symptoms are under control, active treatment with mood stabilizers, possibly including psychosocial interventions, must be undertaken to prevent the illness from becoming increasingly severe.