A major international study threatens to overturn what we thought we knew about schizophrenia.
People with schizophrenia are more likely to get better if they live in poor countries: that's been known for about 25 years. In the 1980s, a series ofpioneering World Health Organization (WHO) studies looked at the prognosis for people diagnosed with schizophrenia around the world.
All of the data showed that people in developed countries were less likely to recover than those from poorer areas.
This paradoxical finding sparked no end of debate. What is it about these countries that makes them a better place to get schizophrenia? Patients in richer countries tend to have access to more and "better" psychiatric care, the latest drugs, and so on. Does this mean that those treatments are useless - worse, harmful? That's been the interpretation of some people.
But is it true? Not always, says a new study, W-SOHO. It's out in the British Journal of Psychiatry.
The authors compared schizophrenia outcomes in 37 countries. They recruited outpatients who were starting, or changing, antipsychotic medication. They found that in terms of "clinical" remission - i.e. improvement in the delusions, hallucinations, and other symptoms of schizophrenia - people in the developing world did indeed fare better than those from rich countries.
Over a 3 year period, 80-85% of patients from East Asia, the Middle East, and Latin America who started off ill, showed clinical remission, compared to 60-65% in Europe. That's not new: it confirms what the old WHO data showed.
But the new study also looked at "functional" remission - essentially, being able to participate in society:
having good social functioning for a period of 6 months. Good social functioning included those participants who had: (a) a positive occupational/vocational status, i.e. paid or unpaid full- or part-time employment, being an active student in university or housewife; (b) independent living; and (c) active social interactions, i.e. having more than one social contact during the past 4 weeks or having a spouse or partner.
For functional remission, Northern Europe (e.g. the UK, France, Germany) was the best place to get sick, with 35% achieving it. Not a very high figure, but better than elsewhere: it was just 18% in the Middle East and 25% in East Asia, despite these areas having the highest chances of clinical remission. Latin America did pretty well, however, at 29%.
This is a very important finding if it's true. Is it solid?
First off, were Northern European patients just less ill to start with? Not really. They had the highest rates of suicide attempts. They tended to be older, and to have been diagnosed at a later age, which was correlated with worse functional remission. Regression analyses confirmed that region was a predictor of remission controlling for all the other variables.
However, Northern European patients did tend to have better function at baseline. They were more likely to be employed, living independently, and socially active when they entered the study. 63% were living independently which is much higher than anywhere else: it was 24% in Middle East and Latin America. 23% had a paid job compared to 17-19% in developing countries.
That's not a flaw in the study as such but it does suggest that the differences, whatever they are, are already in place before people get treated.
One concern I have is that the definition of "functional remission" may be North Europe-centric. "Living independently" is something we aspire to but in other places, with a strong tradition of the extended family household, the idea that it would be a bad thing for someone with schizophrenia to be living with their family might seem silly. If that means they'll be cared for and supported, what's wrong with it?
And in terms of paid employment, Northern Europe just has a stronger economy than most other places (erm... well, it did back in 2000 when these data were collected), so maybe it's no surprise that people with schizophrenia were more likely to have paid jobs.
In terms of the study itself, it was extremely large with over 17,000 patients enrolled. But here's the thing: this study was run by Lilly, the drug company who make olanzapine, an antipsychotic used in schizophrenia. Three of the authors on the paper are Lilly employees, and the lead author was a consultant for them. The study deliberately sampled lots of people taking olanzapine, presumably in order to find out whether they did better.
None of this necessarily means that the data aren't valid, but I'm just not sure I trust Lilly over the WHO.
Haro JM, Novick D, Bertsch J, Karagianis J, Dossenbach M, & Jones PB (2011). Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. The British journal of psychiatry : the journal of mental science, 199, 194-201 PMID: 21881098