A Brief Discussion on the International Pilot Study of Schizophrenia

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.


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.

Golden Gate Survivors

This article contains discussion of a topic which some readers may find disturbing. The discussion is not graphic, but may still be upsetting. Please err on the side of protecting yourself if this is a sensitive topic for you.

Trigger warning: self-harm, suicide.

I have only ever been to San Francisco once. At the time, I was a first-year medical student exploring different medical specialties, and I traveled there to attend a conference for obstetrics and gynecology.

It was an incredibly motivating experience. Those of you who have gone to conferences probably know what I’m talking about. The excitement! The hubbub! What could be better than a bunch of people who all love to talk about something that you’re interested in, too? There were workshops for medical students on suturing, delivering babies, robotic laproscopy, a Q&A by current residents and practicing ob/gyns, and more. I was busy morning till night. There was no lack of things to see, people to meet, and places to explore.

Strangely, my most vivid memory is of the protestors who stood outside the convention center with picket signs. I might have expected some anti-abortion groups to show up, but no, not at all! Instead, these were anti-circumcision groups for male newborns. I viewed the protestors with curious amusement, because ob/gyns did not perform circumcisions at the hospital that I rotated through and, well, I have never known an ob/gyn to treat very many patients with male genitalia. Perhaps other places have different practices, but anyways, this topic is not my expertise and I digress.

I was in the city for two days. However, to my regret (and I don’t remember the reason anymore), I didn’t visit the Golden Gate Bridge, one of the “Wonders of the Modern World.”

Golden Gate Bridge as seen from Marshall’s Beach
Golden Gate Bridge as seen from Marshall’s Beach © Frank Schulenburg via Wikipedia.Org

The bridge is renowned for its visual beauty and suspension design. It is famous for one more thing: it is the second-most common suicide site in the world.

In 1975, David H. Rosen, MD published a study of persons who survived jumping from either the Golden Gate or the San Francisco-Oakland Bay bridge. He interviewed seven of ten known survivors. In his publication, he states that, “Each person was made aware that he or she could refuse to answer any of the questions during the interview, and assured that anonymity would be preserved. . . . [T]heir participation was entirely voluntary.” (Rosen, 1975)

In his interviews, Dr. Rosen asked several questions. Why the choice of the bridge? What did they experience during the fall and upon impact? Did they lose consciousness? What has been the long-term impact of this event on their lives?

Dr. Rosen also discusses several psychological aspects of near-death experiences, including the three phases of resistance, life review, and transcendence as described by Russell Noyes, MD, and the phenomenon of ego-death/rebirth. As a survivor said, after his jump, he was “refilled with a new hope and purpose in being alive. . . . I appreciate the miracle of life – like watching a bird fly – everything is more meaningful when you come close to losing it.”

It has been over forty years since this publication. Since then, suicide rates have continued to increase. In this context, there are three points from Dr. Rosen’s article that I would like to discuss. First, the survivors report that they got the idea of jumping from press coverage. Second, the survivors chose the bridge because it symbolized something to them, and if it had not been available, they would not have used any other method of suicide. Third, all survivors interviewed recommended a barrier to prevent others from attempting suicide.

1. Press Coverage

The effect of press coverage on suicide rates has been well documented. Named the “Werther effect” after a character of the novel The Sorrows of Young Werther, who dies by suicide, it is thought that exposure to the idea of solving problems through suicide can send troubled people over the edge. This observation is echoed in Dr. Rosen’s interviews. One survivor said, “Newspaper editors should voluntarily stop all press coverage of the Golden Gate Bridge suicides – extensive press coverage put the idea into my mind.”

In response to this effect, the World Health Organization released a booklet in 1999, titled “Preventing suicide: a resource for media professionals.” The booklet has since been updated twice (most recently in 2017) to accommodate for changes in technology such as social media. It provides evidence of media impacts on suicidal behavior and guidelines for the responsible reporting of suicide. I think that it is a valuable read for anyone working in the media and giving information about suicide.

2. A Symbolic Choice

Second, the bridge was an important, symbolic choice for all of the interviewed survivors. Dr. Rosen reports that “four of the six [survivors] said they would not have used any other method if the Golden Gate Bridge had not been available… Often this was related in a symbolic way to the association of the Golden Gate Bridge with death, grace, and beauty.”

Symbolism plays a large role in our understanding of the world, and this holds true for the concept of suicide. People use symbols to communicate with others, guide our behavior, and inspire our actions. Symbolism is also apparent in suicide prevention, for example Project Semicolon, a non-profit organization dedicated to suicide prevention. A quote from their website: “Instead of ending a sentence, a writer can use a semicolon to continue on, and so too can an individual choose not to end his or her life, but continue on living.”

When discussing methods of suicide completion with people who present to the psychiatric emergency room, my level of concern increases when the plan clearly has symbolic meaning to the person. I become further alarmed when the person appears to view death as romantic or desirable. These statements are important to my evaluation, as they give valuable insight into the person’s psychological state.

Although an individual suicidal action is unpredictable, there can be certainty that an event may or may not occur in some places. If a place holds meaning to a community, then further events will likely occur. Places of symbolic significance, like the Golden Gate Bridge, should be monitored.

3. The Aftermath

Third, all the survivors recommend a suicide barrier. This is related to an area of suicide prevention called means reduction, in which lethal means are made less available or deadly. Although there may be some displacement to other methods, the overall suicide rate decreases.

In 2013, a barrier was installed at a bridge in Canada. The study showed that suicide rates at this site decreased, which persisted even when attempts at other bridges or jumping sites were studied. Little to no displacement to other jumping sites occurred. (Perron, 2013)

This holds true for other methods of suicide, including the famous coal gas story. Prior to the 1950s, most households in the United Kingdom used coal-derived gas, which contained about 10-20% carbon monoxide. As time progressed, more people began to use natural gas, which releases much less carbon monoxide. This resulted in a sustained decrease in overall suicide. (Kreitman, 1976)

Currently, the installation of netting at the Golden Gate bridge is scheduled to be completed in 2021 at an estimated project cost of $221 million. (San Francisco Chronicle)

Suicide prevention is a complicated topic that encompasses much more than the aspects presented in this brief discussion. As a young physician, this article is especially memorable, as the idea of approaching survivors of suicide and broaching a sensitive topic takes a certain type of courage. I am thankful that Dr. Rosen wrote this article, as there are important lessons to be learned from his discussions with these survivors. I hope these lessons can save future lives.

You can find the publication on PubMed Central here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1129714/

More Information

Rosen, D.H. Suicide survivors: A follow-up study of persons who survived jumping from the Golden Gate and San Francisco-Oakland Bay bridges. Western Journal of Medicine 122: 289-294, Apr 1975.

World Health Organization. Preventing suicide: A resource for media professionals. Geneva, Switzerland: Author. 2017. http://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/

Perron S, Burrows S, Fournier M, Perron PA, Ouellet F. Installation of a bridge barrier as a suicide prevention strategy in Montréal, Québec, Canada. American Journal of Public Health. 2013 Jul;103(7):1235-9.

Kreitman N. The coal gas story. United Kingdom suicide rates, 1960-71. Br J Prev Soc Med. 1976;30(2):86-93.

If you or someone you know is suicidal, please seek help.

International Resources

United States

Please let me know if any of these links are out of date.