I’ve been trying to make a renewed and dedicated effort to both read and write more. I’ve realized that waiting for the inspiration to strike doesn’t happen. If I want to read and write more, then I need to set aside time to cultivate the skill. It has been more difficult that I thought.

Still, this is part of that effort. And so today, I decided to review and write about my thoughts on a very important psychiatric article – The International Pilot Study of Schizophrenia: five-year follow-up findings.

Published in 1992, this article is an “oldie but goodie.” It is best known for its provocative finding that people with schizophrenia have better clinical and social outcomes in developing countries when compared with developed countries. In other words, a person with schizophrenia in Agra (India) or Ibadan (Nigeria) was significantly less ill and suffered less occupational and social impairment than someone with the same diagnosis in London (United Kingdom) or Washington, DC (United States).

As discussed in the article, one suggested explanation for this finding is incompleteness of follow-up at the sites in developing countries. However, when they further examined the data, they found that this was an unsatisfactory explanation for the results. A second suggested explanation was if a greater proportion of patients in developing countries had an acute, rapidly resolving psychosis with an inherently better prognosis. This explanation, too, was not supported upon further data modeling.

A third proposed explanation involved greater tolerance and acceptance of the behaviors displayed by people with schizophrenia by their families. This hypothesis had partial support, as a sub-study related to this project showed that patients in Chandigarh (India) who had families with low levels of Expressed Emotion had better clinical outcomes.

Low levels of Expressed Emotions are favorable; alternatively, families with high Expressed Emotion interact more frequently with negative and intense verbal exchanges. Relationships are oppositional or conflictual in nature, and interaction patterns are rigid. Conversations are marked by increased criticism, hostility, and emotional overinvolvement. As described by Amaresha & Venkatasubramanian in a 2012 article, “Researchers have positioned Expressed Emotion within the diathesis-stress model of psychopathology, characterizing it as an environmental stressor that can potentially precipitate/cause relapse of psychosis among people with a genetic vulnerability.”

However, the study concluded with a statement that an exact definition of the elements of culture and society that improve outcomes remains unclear.

There have been additional follow-up studies to this impactful article. In 2000, Hopper and Wanderling revisited this question and hypothesized that cultural factors promoting recovery may include: 1) supportive kin, 2) auspicious or alternative beliefs, 3) flexibly configured work, 4) forgiving domestic space, and 5) more socially integrated subjectivities. They also point out that, subtracting Hong Kong, the remaining sites in the “developing” group are all located within India, which simplifies the question of culture.

“The extraordinary engagement of Indian families in the course of treatment – from the initial decision to seek help, to attending to basic needs and medication adherence during hospitalization, to support afterward, including monitoring medications and functioning – is surely one of the signature features of psychiatry in that country.”

Hopper & Wanderling 2000, “Revisiting the Developed Versus Developing Country Distinction in Course and Outcome in Schizophrenia.”

I can further appreciate this finding while I was reading The Quiet Room by Lori Schiller. The Quiet Room is a biography describing one woman’s experience with schizophrenia. About midway into the book, Lori’s mother realizes that she had seen her own mother, Lori’s grandmother, display the eccentric and psychotic behaviors that Lori appeared to be experiencing. Lori underwent multiple psychiatric hospitalizations and trials of medications. Meanwhile, Lori’s grandmother, who was the daughter of a wealthy man and a housewife, did not. As a quote from the book describes, “My mother [Lori’s grandmother] was rich, and so she was allowed to be eccentric.” (Schiller & Bennett 1994, pg 82)

Lori, who faced the pressures of being a high-achieving, upper-middle class young adult, newly graduated from college, suffered greatly not just from the symptoms of psychosis but also from the loss of her place in society.

“I have lost many things: the career I might have pursued, the husband I might have married, the children I might have had.  During the years when my friends were marrying, having their babies and moving into the houses I once dreamed of living in, I have been behind locked doors.”

Schiller & Bennet 1994, The Quiet Room, pg 5

It brings to mind the pressures that society may place on its members to conform. Of course, conforming is not necessarily bad. Conforming to social norms regulates our social interactions, reduces anxiety, brings us closer to one another, and helps us feel safe. But perhaps there is a price for conformity – a price that is paid by the marginalized among us.

References

Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992 Feb;22(1):131-45.

Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophr Bull. 2000;26(4):835-46.

Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: an overview. Indian J Psychol Med. 2012;34(1):12-20.

Schiller, L., & Bennett, A. The Quiet Room: A Journey Out of the Torment of Madness. New York: Warner Books. 1994.