Better schizophrenia outcomes in developing countries
Schizophrenia outcome, as measured with a number of assessment instruments, has consistently been found to be better in so called third world communities [1-5]. Apparently, the course of change of a developing country into the industrial model seems to worsen the prognosis of schizophrenic patients overall [6]. The use of psychotropic medication has been ruled out as a factor [7-9].
Many explanations purported for these findings range from internal flaws of the methodology used for all the studies to a hypothetical diagnostic and treatment bias in the industrial world towards more severe cases. Actually, some articles question the initial results [10, 11]. Denial is usually an initial response when research results do not match commonly accepted opinions. It is a normal reaction.
A few workers dare to mention the cultural fabric of the patients’ community as a crucial factor [12]. In this vein, it is worth mentioning the encouraging results on a group of patients who availed themselves of a traditional resource in India [13, 14]. All this reminds me of Fritz Schumacher‘s ideas . In a highly technological society like ours, we tend to overlook the subtle cultural nuances that may work for or against us during the healing process. Maybe, in the long run, ethical and spiritual values may weigh more than the drug in fashion at the time.
References:
1. Mathews, M., B. Basil, and M. Mathews, Better outcomes for schizophrenia in non-Western countries. Psychiatr Serv, 2006. 57(1): p. 143-4.
2. Kulhara, P. and S. Chakrabarti, Culture and schizophrenia and other psychotic disorders. Psychiatr Clin North Am, 2001. 24(3): p. 449-64.
3. Jablensky, A., Epidemiology of schizophrenia: the global burden of disease and disability. Eur Arch Psychiatry Clin Neurosci, 2000. 250(6): p. 274-85.
4. Davidson, L. and T.H. McGlashan, The varied outcomes of schizophrenia. Can J Psychiatry, 1997. 42(1): p. 34-43.
5. Kendell, R.E., Long-term followup studies: a commentary. Schizophr Bull, 1988. 14(4): p. 663-7.
6. Douki, S., et al., [Schizophrenia and culture: reality and perspectives based on the Tunisian experience]. Encephale, 2007. 33(1): p. 21-9.
7. Kurihara, T., et al., Clinical outcome of patients with schizophrenia without maintenance treatment in a nonindustrialized society. Schizophr Bull, 2002. 28(3): p. 515-24.
8. Srinivasan, T.N., S. Rajkumar, and R. Padmavathi, Initiating care for untreated schizophrenia patients and results of one year follow-up. Int J Soc Psychiatry, 2001. 47(2): p. 73-80.
9. Srinivasa Murthy, R., et al., Community outreach for untreated schizophrenia in rural India: a follow-up study of symptoms, disability, family burden and costs. Psychol Med, 2005. 35(3): p. 341-51.
10. Cohen, A., et al., Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull, 2008. 34(2): p. 229-44.
11. Patel, V., et al., Is the outcome of schizophrenia really better in developing countries? Rev Bras Psiquiatr, 2006. 28(2): p. 149-52.
12. Luhrmann, T.M., Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here. Cult Med Psychiatry, 2007. 31(2): p. 135-72.
13. Halliburton, M., The importance of a pleasant process of treatment: lessons on healing from South India. Cult Med Psychiatry, 2003. 27(2): p. 161-86.
14. Raguram, R., et al., Traditional community resources for mental health: a report of temple healing from India. Bmj, 2002. 325(7354): p. 38-40.
The Brain Shop 
July 19, 2010 at 20:03
Explanation of the results of treatment at the Muthuswamy temple cannot rise above the level of conjecture without more information; however conjecture can nonetheless be valuable. Raguram, et al report that treatment at the Muthuswamy temple involves “… no specific ceremonies … to promote the recovery of these subjects. Residents merely attended the simple morning prayers (puja) at the shrine for about 15 minutes, and they spent the rest of the day in light maintenance routines of the temple.” Local belief is that results are due to “… the experience of residing in the temple for a period of time, rather than therapy provided by a healer …”
I suspect that absent from the “treatment” at the temple are several factors nearly always present in western treatment of schizophrenia, including explicit discussion of the patients experiences in clinical terms (hallucinations), a focus on symptom reduction as a fundamental goal of treatment, and reinforcement (psychoeduction) of the need to take medication in order to achieve remission of symptoms. I believe that an unintended consequence of the western medicine focus on experiences as symptoms, and the goal of treatment as symptom reduction or control, is often a perpetuation of the experiences which treatment seeks to control. This is a position which is supported by Acceptance and Commitment Therapy (ACT), an evidence based behavioral therapy with many similarities to Cognitive Behavioral Therapy (CBT).
One ACT study tested the treatments efficacy for persons experiencing auditory hallucinations (Bach, P., & Hayes, S. C. (2002). http://contextualpsychology.org/node/2344 and reported that “…a three-hour ACT intervention reduces rehospitalization by 50% over a 4 month follow-up as compared to treatment as usual in the seriously mentally ill.” ACT does not seek symptom reduction or control as a goal of treatment (although symptom reduction may in fact be a long term result), rather ACT treatment “… teaches patients to accept unavoidable private events; to identify and focus on actions directed toward valued goals; and to defuse from odd cognition, just noticing thoughts rather than treating them as either true or false.”
So to conclude my conjecture: Perhaps the salient variable is the explicit or implicit instructions patients are given about how to relate to their distressing experiences, with western medicine generally emphasizing the need to react to and in turn control the distressing experiences, while treatment at the Muthuswamy temple (as well as ACT) seek to reduce the patients interaction with the distressing experience through a focus on ordinary activity (value based behavior) in the presence of the “symptom”.
July 23, 2010 at 02:54
Thanks for reviving this 2-year-old post. This is precisely the venue for conjectures (the first step to formulate hypothesis).
Your comment is quite insightful.
Rephrasing: we westerners need to bring patients back to “reality” and hence we need to infuse (by IV, if possible) “objectivity”. What would the world become without “objectivity”? Let’s not even imagine!