Is the developing world better for schizophrenia?

One of the most commonly repeated facts about schizophrenia is that people diagnosed with the condition tend to do better in developing countries, rather than in rich Western countries. A new study has reviewed outcome studies from low and middle-income countries across the world and found the picture just isn’t that clear.

The original finding that people with the diagnosis do better in developing countries was from three World Health Organisation studies.

The recent review has criticised the previous studies for not adequately dealing with some important factors – like mortality.

It’s important to account for deaths in outcome studies, because they could skew the results, if not counted properly, to make outcome look better.

For example, three people with schizophrenia are assessed at the beginning of the study, a year later they are re-assessed, but sadly, one has died. Of the other two, one has improved and one got worse.

Death is, perhaps, the worst possible outcome, and since schizophrenia involves a high risk of suicide and is associated with a lower life expectancy, it is more likely in those affected.

If this isn’t noted, however, the follow-up results might suggest that out of the two remaining, half improved, and half got worse.

In fact, the outcome was worse in two thirds, as one got worse and one died, and only one third improved.

So not being able to account for deaths may make the picture look rosier than it is.

The study looked at these these factors, as well as other more socially relevant effects, such as on marriage, social relationships and employment – rather than purely examining clinical symptoms. It also investigated whether outcomes were different for males and females.

The conclusions of the study suggest that the picture is complex and dependent on many different influences, as it varies greatly between countries:

First, there appears to be great variation in clinical outcomes and patterns of course. Whereas, some studies in India strongly support the “better prognosis” hypothesis outcomes do not appear to be nearly as positive in Brazil and China. Additionally, limited evidence suggests that gender effects vary cross-nationally.

Second, similar patterns are found in the domains of disability and social functioning: good in most studies in India and Indonesia, but poorer in Nigeria, and much poorer in a cohort of untreated persons in Chennai, India. Social functioning by gender also varied: in the MLS [Madras Longitudinal Study], women had high levels, while in Nigeria women fared poorly. Outcomes in occupational and marital status also varied. A more important point, however, is that status in these 2 domains must be interpreted in the context of sociocultural norms and assessed, at least to some degree, qualitatively. Viewed from this perspective, the data in table 7 suggest that rates of marriage for people with schizophrenia are relatively low and rates of divorce/separation are high.

The study was conducted by a team of four researchers, from America, the UK, India and Nigeria and is published in November’s Schizophrenia Bulletin as an open-access paper, so the full text is freely available online.

Link to full text of study.