Better schizophrenia outcomes in developing countries

Posted in Clinical topics with tags , , , on April 10, 2008 by nvm.m

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.

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Can psychologists prescribe psychotropics?

Posted in Clinical topics with tags , on April 3, 2008 by nvm.m

The pressure from psychologists to prescribe psychotropics seems to keep increasing, according to the APA. The psychiatrists’ resistance is fierce.

I don’t recall observing this sort of struggle in other specialties, e.g. between neurologists and clinical psychologists. I wonder if we are asking the wrong question above. Perhaps we should ask if psychiatrists are sophisticated enough to distance themselves from other groups who aspire to prescribe drugs.

Do we know enough about the mechanisms of action of psychotropic drugs? Do we have any solid knowledge of psychiatric pathophysiology? Sadly, the answer to these questions is no.

It’s not only a matter of increasing research funding. The average psychiatrist has already shifted his/her focus from the medical aspects of psychiatry to the more social and behavioral aspects, where he/she is guaranteed to find serious competition from other professionals who come with solid and extensive training in areas like psychotherapy, where the purely medical background has only minor relevance. On the other hand, while discussing medications in psychiatric circles, neurophysiological, molecular or computational/cognitive aspects are only casually addressed, if ever. There is already a significant rift between neuroscience and the practice of psychiatry. This fact may be a contributing factor for other health workers’ eagerness to replace psychiatrists in the prescription area.

Partially relinquishing their medical status through their cognitive choices puts psychiatrists at a feeble position to hold their ground in these matters.

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Rest in peace, Bobby

Posted in Miscelaneous with tags , , on March 20, 2008 by nvm.m

The phenomenon at work

For all chess players and aficionados in the world, he was a hero. For a chess generation, he was also a role model. More than a few nerdy young characters wanted to be like him, play like him, act like him. It was not just his portentous talent. It was also his arrogance, his continuous demands (financial and otherwise) and his theatrical bravadoes (a classic one was, “I’m not afraid of Spassky; he’s afraid of me”).

When he won the World Championship in 1972, it was difficult for the general public to imagine him as a protagonist of even more astounding, bizarre or outrageous events than the ones before and during his last match in Reykjavik. They certainly expected even greater chess. When he refused to defend his title first and then he voluntary alienated himself from the chess world, that fueled again a superficial and frivolous journalism. His detractors kept brandishing their pseudo-psychiatric labels against him. Anyway, he had already gained his rightful place in chess history, together with his two favorite champions of the past, Morphy and Capablanca (Bobby considered the latter to be the greatest player of all time).

Nonetheless, everyone was far from figuring what was next. The years to follow were even more surprising. Fearless, he started a one-man political war. For this, he was cheered by many and booed by many more. While his controversial statements can only be fairly evaluated through the microscope of time (future generations will have that advantage), the courage he showed while making them was simply staggering. But this fight was hopeless. He was grossly outnumbered and overpowered; it would have been impossible to win this game. This time, it was check mate for Fischer.

He passed away, at age 64, on January 10 this year. I found out about his death a couple of weeks later. Paradoxically, in the years to come, he will probably be remembered more for his political and personal fights than for his chess.

A lot of superficial speculations have been expressed over the years about his “mental illness”, by journalists, the public and his fellow chess players. The glib labels included “crazy” and “delusional”; another one that I remember reading is “manic-depressive”. Other funny digressions pretended to be Freudian in nature, like “denying himself of chess was denying himself of Jewishness”. Obviously no mental health professional would venture an assessment based only on press notes or radio/TV interviews. However, some points seem to be clear:

  • There is no hard evidence suggesting that he was ever psychotic or delusional.
  • The general behavioral pattern emerging throughout the press reports, his own writings and interviews suggests a narcissistic personality, along with some paranoid traits. However, the narcissistic core could explain most of his extreme attitudes and decisions. He was excessively afraid to lose, more so after he became the World Champion. He was exceedingly sensitive to criticism and took the most minimal dissension of his friends as a betrayal. At some point, he acquired a sense of omnipotence, based on his enormous talent, that led him to defy any individual or organization opposing his demands. Outside the board, he often was seen awkward, with an undeniable sense of inadequacy, which he tried to compensate with an expensive wardrobe.
  • Above all these considerations, his towering genius, makes us willing to forgive his eccentricities. I, for one, have already forgiven him.

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