Neurological, Psychiatric, and Developmental Disorders Meeting the Challenge in the Developing World (2001) / Chapter Skim
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7 Schizophrenia
7 Schizophrenia
Pages 217-256
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From page 217... ...
Since the 1970s, the World Health Organization (WHO) and the American Psychiatric Association (APA)
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catatonic signs (h) negative symptoms (i)
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From page 219... ...
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.
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From page 220... ...
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.
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From page 221... ...
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]
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From page 222... ...
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.
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From page 223... ...
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.
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From page 224... ...
Additional direct costs may be incurred by the necessity to Gavel, 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.
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From page 225... ...
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 ]
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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.
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From page 227... ...
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 neuroinfection, 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.
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across 5 ECA sites 15.0 (lifetime) United King- London health dis- Census; interviews of 5.1 dom [69]
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UK [86] London health dis- 2 censuses, 5 years 0.21 (DSM-IIIR)
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Such evidence coupled with the growing urbanization of developing countries would suggest a projected increase in schizophrenia prevalence. Additional research is needed to determine how such environmental risk factors interact with genetic risk factors.
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Such findings have given rise to the hypothesis that schizophrenia is a neurodevelopmental disorder that begins in utero or early in life and becomes clinically manifest when a certain level of central nervous system maturation is reached in late adolescence or early adulthood.~100] Indirect support for this view is provided by prospective studies that have documented a number of behavioral peculiarities, such as poor social skills, 'schizoid' traits, and low 1Q in children who later develop schizophrenia.
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7.~1 0.0 37.0 45.~50.0 14.0 9.~12.0 ] .1 3.0 4.0 1.5 1 .7-10.7 1.4 2.0~.4 6.2 3.4 6.9 4.8 2.3 8.6 30.7 developed countries indicates a higher morbidity in males, is attenuated or inverted in some developing countries (higher rates in women than in men have been reported from prevalence studies in India, Sri Lanka, and China)
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From page 233... ...
there is at present almost no evidence that substance abuse by patients with schizophrenia in developing countries is a comorbidity problem on a scale comparable to that in many developed countries. Factors Affecting Course and Outcome Perhaps the most important difference between schizophrenia in the developed and developing worlds concerns the course and outcome of the condition.
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From page 234... ...
A diagnostic bias resulting from inclusion as "schizophrenia" of a substantial proportion of benign, acute psychotic illnesses of good prognosis, or of psychoses due to transient acute physical illness, can be practically ruled out in the WHO studies, where such cases were carefully screened out. All factors considered, it is entirely plausible that the psychosocial environment plays a central role in the course and outcome of schizophrenia, given the contrasts between developing and developed countries with regard to social support systems, kinship networks, beliefs and expectations about mental disease, and the attributes ofthe "sick role".[ll4,115]
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From page 235... ...
Good practice in the management and treatment of schizophrenia requires addressing both sides of this interaction, as well as the significant individual variation in the course of the disorder. In about 10-15 percent of cases in developed countries and more than 30 percent of cases in developing countries, the disorder is limited to a single psychotic episode that often resolves in a stable remission with little residual impairment.
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From page 236... ...
None of the known risk factors or putative disease markers, and no combination of such risk factors or markers, is sufficiently sensitive and specific to ensure the minimum of positive predictive value required of a screening test for preclinical disease.~117] Nor is there any intervention available that is known to result in a guaranteed high rate of prevention success should preclinical disease be identifiable.
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From page 237... ...
have a different pharmacological profile in that they have a lower affinity for dopaminergic receptors, but target a wider range of brain neurotransmitter systems. Clozapine has been demonstrated to be highly effective in controlling symptoms in patients who have proven resistant to other antipsychotics, and there is also some evidence that the atypicals ameliorate negative symptoms and cognitive disturbances that are uninfluenced by conventional antipsychotics.
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From page 238... ...
and treatment adherence clearly favor the newer atypical drugs.~122] A caveat, however, is that the atypical antipsychotics are increasingly being seen as not entirely free of adverse effects, and longer observation time is needed for a final verdict on their side-effects profile.
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From page 239... ...
The Tanzanian model, in which five generic mental health and neurological problems (acute psychosis, chronic psychosis, depression, epilepsy, and severe anxiety) were targeted for identification and treatment at the primary health care level, was shown to be highly effective in dramatically reducing referrals to mental hospitals, increasing the number of people receiving treatment for mental disorders, and decreasing overall direct costs.
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From page 240... ...
Psychoeda~cation can be delivered in group sessions with families and is cost-effective in low-income settings. A family-based intervention for schizophrenic patients in China, evaluated in a randomized controlled trial, was found to be significantly more effective than standard posthospital management in reducing rehospitalization and the family burden.tl32]
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the Pittsburgh social skills program,~l39] case management, or assertive community treatment—are problematic with regard to their feasibility in most developing-country settings, except in a small number of well-staffed university or research centers.
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Even if the needs of the majority of people with severe mental illness can be met within the community, brief admission to a sheltered environment may be of benefit to a small proportion of patients. The experience of some developing countries shows that such limited inpatient care is best provided in small units within regional or district general hospitals.[130,131]
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This observation applies also to mental health care. For example, some countries with scarce economic resources, such as Cuba and Tanzania, have In place systems of health care delivery that continue to provide basic treatment and social assistance to the majority of people with severe mental disorders.
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In all societies, including developing countries, the stigma surrounding mental illness is likely to mean that people with severe mental disorders are Me first and most seriously disadvantaged by shrinking government health expenditures. Thus it is imperative to initiate on art international scale proactive measures designed to forestall such developments.
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WHO collaborative study of impairments and disabilities associated with schizophrenic disorders. Acta Psychiatrica Scandinavica Supplement 285, 152-163, 1980.
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Mental health economic studies from developing countries reviewed in the context of those from developed countries. Acta Psychiatrica Scandinavica 100: 1-18, 1999.
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The antecedents of psychoses: A case-control study of selected risk factors. Schizophrenia Research Nov 30,46~1~:17-23, 2000.
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Acta Psychiatrica Scandinavica 79, Supplement 348, 157-166, 1989.
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Epidemiology of mental disorders in Iceland. Acta Psychiatrica Scandavica Supplement 173, 1964.
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Ten-year course of schizophrenia The Madras longitudinal study. Acta Psychiatrica Scandinavica 90, 329-336, 1994.
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Journal Nervous Mental Disorders 181, 5]
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An evaluation of a psychiatric outpatient unit in Nicaragua. Acta Psychiatrica Scandinavica 92, 38~391, 1995.
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Wang. A behavioral training programme for chronic schizophrenic patients.
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From page 256... ...
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