Outcomes paradox

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The outcomes paradox (otherwise known as the "better prognosis hypothesis") is the observation that patients with schizophrenia in developing countries benefit much more from therapy than those in developed countries. This is surprising because the reverse holds for most diseases: "the richer and more developed the country, the better the patient outcome." [1] The outcomes paradox came to light in the 1960s due to cross-cultural studies conducted by the World Health Organization on the outcome of severe mental disorders like schizophrenia. [2] [3] This paradox has become an axiom in international psychiatry since.

Contents

Background

Schizophrenia is a severe, chronic disorder characterised by disturbances in thought, perception and behaviour. One way a psychiatrist can diagnose it is if an individual has experienced positive symptoms (e.g., hallucinations) and/or negative symptoms (e.g., apathy) consistently for a month. [4] [5] Its treatment usually involves a combination of cognitive behavioural therapy and antipsychotic medication. [6] Although the treatment for the disorder is the same cross-culturally, treatment success rates differ cross-culturally, and this phenomenon is known as the outcomes paradox.

Cross-cultural studies

Bottom-up research approach

Research into the outcomes paradox followed a bottom-up research approach whereby theories are drawn from the data collected instead of conducting research after theory construction as a means of hypothesis testing. [7]

World Health Organization research

To produce data that could later be subject to theory construction, the World Health Organization launched two supporting international studies: the International Pilot Study of Schizophrenia (IPSS) and the Determinants of Outcomes of Severe Mental Disorders (DOSMeD). [1]

The IPSS included 1202 patients across nine countries: three developing countries (Colombia, India and Nigeria) and six developed countries (Denmark, Taiwan, the UK, the US, the Soviet Union and Czechoslovakia). The schizophrenic patients' therapy outcomes were measured using three indicators – the percentage of time with psychosis symptoms, the degree of social impairment and the type of remission after each episode. These were quantified on a scale from one (best outcome) to seven (worst outcome). By the end of this study, India had the most success as 42% of patients reported 'best outcomes', followed by Nigeria with 33% of patients. However, the developed countries did not demonstrate such positive results as the 'best outcomes' were observed in only 17% of US patients and fewer than 10% in the other developed countries researched.

The DOSMeD study researched the outcome of therapy for schizophrenia, in 1379 patients, across ten countries (Ireland and the IPSS countries). These patients were allocated to one of nine categories depending on the severity of their disorder pre-therapy. These categories ranged from a single episode of psychotic illness followed by complete remission to persistent illness. Post-therapy findings demonstrated that developing countries had higher rates of complete recovery: 37% in developing countries compared to 15.5% in developed countries. Patients from developing countries also experienced longer periods of unimpaired social functioning than those from developed countries. Researchers at the WHO concluded that "a strong case can be made for a real, pervasive influence of a powerful factor, [that] can be referred to as 'culture', [which] influences disease." [1]

Theories and explanations

The role of family

The family milieu theory of developing countries suggests that the better outcome among these patients is attributable to sociocultural factors such as higher levels of family tolerance and a greater dependence on family members for care and support. [1] [8] [9] [10] Expressed emotion is a significant characteristic of the family milieu, and it refers to a caregiver's attitude towards the schizophrenic patient. [11] High levels of negative emotion (e.g., hostility) expressed towards a schizophrenic individual has been found to be a significant psychosocial stressor, and it has a direct association with high relapse rates. [11] [12] Research has shown that the likelihood of creating such a stress-inducing environment is reduced when there are a larger number of people caring for and meeting the needs of the schizophrenic individual as there is a collective sharing of the emotional demand to ensure it is not placed onto the patient. [13] This collectivist attitude of care is found more commonly in developing countries since there is a greater importance placed on kinship relations as well as the fact that, on average, families are larger in these countries. [9] [14] Hence, a key cultural difference is the level of positive family involvement, which in developing countries, is associated with improved therapy outcomes due to the reduced likelihood of relapse.

The role of lifestyle

A psychiatrist named Vikram Patel theorised that the improved therapy outcome in developing countries is due to the less rigid nature of rural life than that of developed countries. [1] It is assumed that the disorganised rural labour markets in developing countries provide more opportunities, such as fieldwork for people with disorders or disabilities. This aids these individuals in integrating into society, reducing perceived stigmas and enabling better social inclusion, which are all thought to facilitate better therapy outcomes. [15] Additionally, research has found that meditation practices such as yoga, which are commonplace in developing countries, reduce both positive and negative symptoms of schizophrenia. [16] Hence, it is thought that schizophrenic patients from developing countries fare better than their developed country counterparts due to the combination of clinical therapy and their own meditational customs.

Criticisms

Limitations in supporting research and the presence of contradictory findings limit the validity of the outcomes paradox. For instance, the IPSS and DOSMeD studies experienced high attrition rates from the participants in developing countries due to issues including premature death. [1] These high dropout rates biased the results, as it was generally the 'worst' patients who dropped out. Hence, the conclusion that those in developing countries have a better therapy outcome than those in developed countries lacks validity.

Additionally, the WHO conducted a follow-up study, the International Study of Schizophrenia (ISoS), 15 and 25 years after their two original studies. [1] The ISoS returned to the IPSS and DOSMeD patients after this period of time to test whether the better outcomes observed in developing countries continued long-term. However, it was found that only half of the patients from developing countries that had the 'best outcomes' in the two previous studies, showed these same positive results longitudinally. Further research supported this longitudinal change, as in 2009, Kulhara reviewed 58 schizophrenia studies to compare long-term outcomes from developed and developing nations. [17] His research found that after 15 years, there was still a larger proportion of patients with better outcomes in developing countries but to a lesser extent than when the study was first conducted. Hence, there is a temporal dimension to the outcomes paradox that is unaccounted for, which reduces its validity.

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<span class="mw-page-title-main">Antipsychotic</span> Class of medications

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Schizophrenia is a mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misperception of reality. Other common signs include hallucinations, delusions, disorganized thinking and behavior, social withdrawal, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially substance use disorders, depressive disorders, anxiety disorders, and obsessive–compulsive disorder.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

<span class="mw-page-title-main">Anhedonia</span> Inability to feel pleasure

Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. While earlier definitions emphasized the inability to experience pleasure, anhedonia is currently used by researchers to refer to reduced motivation, reduced anticipatory pleasure (wanting), reduced consummatory pleasure (liking), and deficits in reinforcement learning. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anhedonia is a component of depressive disorders, substance-related disorders, psychotic disorders, and personality disorders, where it is defined by either a reduced ability to experience pleasure, or a diminished interest in engaging in previously pleasurable activities. While the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) does not explicitly mention anhedonia, the depressive symptom analogous to anhedonia as described in the DSM-5 is a loss of interest or pleasure.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

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In psychology, schizotypy is a theoretical concept that posits a continuum of personality characteristics and experiences, ranging from normal dissociative, imaginative states to extreme states of mind related to psychosis, especially schizophrenia. The continuum of personality proposed in schizotypy is in contrast to a categorical view of psychosis, wherein psychosis is considered a particular state of mind, which the person either has or does not have.

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In medicine, a prodrome is an early sign or symptom that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. More specifically, it refers to the period between the first recognition of a disease's symptom until it reaches its more severe form. It is derived from the Greek word prodromos, meaning "running before". Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura.

Paradoxical laughter is an exaggerated expression of humour which is unwarranted by external events. It may be uncontrollable laughter which may be recognised as inappropriate by the person involved. It is associated with mental illness, such as mania, hypomania or schizophrenia, schizotypal personality disorder and can have other causes. Paradoxical laughter is indicative of an unstable mood, often caused by the pseudobulbar affect, which can quickly change to anger and back again, on minor external cues.

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<span class="mw-page-title-main">Prognosis of schizophrenia</span>

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The epigenetics of schizophrenia is the study of how inherited epigenetic changes are regulated and modified by the environment and external factors and how these changes influence the onset and development of, and vulnerability to, schizophrenia. Epigenetics concerns the heritability of those changes, too. Schizophrenia is a debilitating and often misunderstood disorder that affects up to 1% of the world's population. Although schizophrenia is a heavily studied disorder, it has remained largely impervious to scientific understanding; epigenetics offers a new avenue for research, understanding, and treatment.

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<span class="mw-page-title-main">Basic symptoms of schizophrenia</span> Subjective symptoms of schizophrenia

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References

  1. 1 2 3 4 5 6 7 Padma, T. V. (2014). "Developing countries: The outcomes paradox". Nature. 508 (7494): S14–S15. Bibcode:2014Natur.508S..14P. doi: 10.1038/508S14a . PMID   24695329. S2CID   4463164.
  2. ↑ Cohen, A.; Patel, V.; Thara, R.; Gureje, O. (9 April 2007). "Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World?". Schizophrenia Bulletin. 34 (2): 229–244. doi:10.1093/schbul/sbm105. PMC   2632419 . PMID   17905787.
  3. ↑ Sartorius, N.; Gulbinat, W.; Harrison, G.; Laska, E.; Siegel, C. (September 1996). "Long-term follow-up of schizophrenia in 16 countries: A description of the international study of schizophrenia conducted by the World Health Organization". Social Psychiatry and Psychiatric Epidemiology. 31 (5): 249–258. doi:10.1007/BF00787917. PMID   8909114. S2CID   22846998.
  4. ↑ Patel, KR; Cherian, J; Gohil, K; Atkinson, D (September 2014). "Schizophrenia: overview and treatment options". P & T: A Peer-Reviewed Journal for Formulary Management. 39 (9): 638–45. PMC   4159061 . PMID   25210417.
  5. ↑ "Diagnosis - Schizophrenia". nhs.uk. 12 February 2021.
  6. ↑ "Schizophrenia". www.nhsinform.scot.
  7. ↑ Naheed, Mahmuda; Akter, Khondoker Ayesha; Tabassum, Fatema; Mawla, Rumana; Rahman, Mahmudur (1970-01-01). "Factors contributing the outcome of Schizophrenia in developing and developed countries: A brief review". International Current Pharmaceutical Journal. 1 (4): 81–85. doi: 10.3329/icpj.v1i4.10063 . ISSN   2224-9486.
  8. ↑ Chabukswar. "Notes in Tune: Arts-based Therapy (ABT) at Schizophrenia Awareness Association in Pune, India". www.psychosocial.com. Retrieved 2019-07-09.
  9. 1 2 Cain, M. (1982). "Perspectives on Family and Fertility in Developing Countries". Population Studies. 36 (2): 159–175. doi:10.2307/2174195. ISSN   0032-4728. JSTOR   2174195. PMID   22077270.
  10. ↑ Leh, Keh-Ming; Kleinman, Arthur (1988). "Psychopathology and Clinical Course of Schizophrenia: A Cross-Cultural Perspective". Schizophrenia Bulletin. 14 (4): 555–567. doi: 10.1093/schbul/14.4.555 . PMID   3064282.
  11. 1 2 Amaresha, Anekal C.; Venkatasubramanian, Ganesan (January 2012). "Expressed Emotion in Schizophrenia: An Overview". Indian Journal of Psychological Medicine. 34 (1): 12–20. doi: 10.4103/0253-7176.96149 . PMC   3361836 . PMID   22661801.
  12. ↑ Ng, Siu-Man; Fung, Melody Hiu-Ying; Gao, Siyu (November 2020). "High level of expressed emotions in the family of people with schizophrenia: has a covert abrasive behaviours component been overlooked?". Heliyon. 6 (11): e05441. Bibcode:2020Heliy...605441N. doi: 10.1016/j.heliyon.2020.e05441 . PMC   7658711 . PMID   33210009. S2CID   226976334.
  13. ↑ Pitschel-Walz, G.; Leucht, S.; Bauml, J.; Kissling, W.; Engel, R. R. (1 January 2001). "The Effect of Family Interventions on Relapse and Rehospitalization in Schizophrenia--A Meta-analysis". Schizophrenia Bulletin. 27 (1): 73–92. doi: 10.1093/oxfordjournals.schbul.a006861 . PMID   11215551.
  14. ↑ "Why Do the Poor Have Large Families?". Compassion Australia.
  15. ↑ Koschorke, Mirja; Padmavati, R.; Kumar, Shuba; Cohen, Alex; Weiss, Helen A.; Chatterjee, Sudipto; Pereira, Jesina; Naik, Smita; John, Sujit; Dabholkar, Hamid; Balaji, Madhumitha; Chavan, Animish; Varghese, Mathew; Thara, R.; Thornicroft, Graham; Patel, Vikram (1 December 2014). "Experiences of stigma and discrimination of people with schizophrenia in India". Social Science & Medicine. 123: 149–159. doi:10.1016/j.socscimed.2014.10.035. ISSN   0277-9536. PMC   4259492 . PMID   25462616.
  16. ↑ Bangalore, NG; Varambally, S (July 2012). "Yoga therapy for Schizophrenia". International Journal of Yoga. 5 (2): 85–91. doi: 10.4103/0973-6131.98212 . PMC   3410202 . PMID   22869990.
  17. ↑ Kulhara, Parmanand; Shah, Ruchita; Grover, Sandeep (2009-06-01). "Is the course and outcome of schizophrenia better in the 'developing' world?". Asian Journal of Psychiatry. 2 (2): 55–62. doi:10.1016/j.ajp.2009.04.003. ISSN   1876-2018. PMID   23051029.
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