Functional outcomes in schizophrenia

A recent expert panel has proposed consensus criteria for remission in schizophrenia. They distinguished remission from recovery, noting that the latter outcome was likely to require not only remission of symptoms, but also improvement in cognitive and psychosocial functioning. The panel deferred the task of establishing operational criteria for recovery since there was insufficient research on the topic. This article provides a summary of this still "uncharted" aspect of treatment.     

Research on schizophrenia in Southern European countries

The research on schizophrenia during the last 50 years in the Latin language countries of Southern Europe is briefly surveyed. Particular emphasis is given to the contributions of French authors to the diagnostic concept of schizophrenia, as well as to the phenomenological studies concerning the "essence" of schizoidia/schizophrenia, and some initial schizophrenic "Erlebnisse." The development of biological, psychological, and sociological theories concerning the etiology of schizophrenia is outlined, and contributions such as the "aminotoxic theory" of V. M. Buscaino and the theoretical principles of "alternative psychiatry" are examined in detail. Lastly, the role of French, Italian, Spanish, and Portuguese psychiatrists in the introduction and improvement of somatic treatments is described.     

Long-term follow-up of schizophrenia in 16 countries

An unexpected finding of the International Pilot Study of Schizophrenia, launched by the World Health Organization (WHO) in 1967, was that patients in countries outside Europe and the United States have a more favourable short- and medium-term course of the disease than those seen in developed countries. Since then, WHO has intensified its schizophrenia research programme and has initiated a set of international studies that have confirmed these initial findings and explored possible reasons for such differences in the course and outcome of schizophrenia. While such work has provided important findings and has generated additional pertinent hypotheses, it did not explain the differences in outcome. The present paper describes a new initiative in which approximately 2500 subjects involved in previous WHO multicentre schizophrenia studies are being followed up for between 15 and 25 years after initial examination. Nineteen research centres in 16 countries are taking part in this work. The research methodology is described.On behalf of the collaborating investigatorsThis paper is based on the data and experience obtained during the participation of the authors in the International Study on Schizophrenia (ISoS), a project sponsored by the World Health Organization, and funded by the World Health Organization, the Laureate Foundation (Untied States of America) and the participating centres.The chief collaborating investigators in the 19 field research centres and one methodological support centre of this study are: Aarhus: A. Bertelsen; Agra: K.C. Dube; Beijing: Shen Yucun; Cali: C. Leon; Chandigarh: V. Varma; Dublin: D. Walsh; Groningen: R. Giel; Hong Kong: P. Lee; Honolulu: A.J. Marsella; Ibadan: M. Olatawura; Khartoum: T. Baasher; Madras: R. Thara; Mannheim: H. Häfner; Moscow: S.J. Tsirkin; Nagasaki: Y. Nakane; Nottingham: G. Harrison; Orangeburg: E. Laska; Prague: S. Skoda; Rochester: L. Wynne; Sofia: K. Ganev. At WHO Headquarters, Geneva, the study has been coordinated by N. Sartorius (until August 1993), by W. Gulbinat (September 1993–April 1996) and Dr. Janca (since May 1996).     

Psychiatric stigma in non-Western societies

Factors bearing on social stigma in persons with a psychiatric illness are the subject of this review of the literature. The review concentrates on material pertaining to non-Western societies. This is a topic that has not received much systematic attention. The cultural meanings associated with psychiatric illness are examined. Emphasis is given to societies ordinarily studied by anthropologists and social historians of non-Western medicine. Stigma is variable in the more elementary societies. It is present in India and especially China, and studies suggest the social stigma is less prevalent in Islamic societies. It is important to distinguish between how psychiatric illness is handled in community settings as versus in the system and tradition of medicine.     

Family interventions in schizophrenia: Issues of relevance for Asian countries

A growing body of research evidence has confirmed the efficacy of family-interventions as adjuncts to antipsychotics for the treatment of schizophrenia. Much of the recent evidence for such interventions derives from Asian, principally Chinese, studies. These trials have shown that relatively simple forms of family-interventions have wide ranging benefits, and can be implemented successfully in routine clinical settings. With the accumulation of this evidence in their favour, family-interventions for schizophrenia in Asia are poised to take the next critical step, that of wider implementation and improved accessibility for potential users. However, several issues merit consideration. Family-interventions need to be based on a culturally-informed theory, which incorporates cultural variables of relevance in these countries. While the ideal format for conducting family-interventions is still to be determined, it is quite evident that for such interventions to be useful they need to be simple, inexpensive, needs-based, and tailored to suit the socio-cultural realities of mental health systems in Asian countries. The evidence also suggests that delivery by non-specialist personnel is the best way to ensure that such services reach those who stand to benefit most from these treatments. However, there are several existing challenges to the process of dissemination of family-interventions. The major challenges include the achievement of a critical mass of trained professionals capable of delivering these interventions, and finding innovative solutions to make family-interventions more acceptable to families. If these hurdles are overcome, we could look forward to a genuine collaboration with families, who have always been the mainstay of care for the mentally ill in Asia.     

Amotivation and functional outcomes in early schizophrenia

Negative symptoms, particularly amotivation/apathy, are intimately tied to functional outcomes. In the present study, apathy strongly predicted psychosocial functioning in a sample of early course schizophrenia patients. This relationship remained robust even after controlling for other clinical variables. These data suggest amotivation is core to functioning across the disease course.     

Quality of life assessment in non-Western cultures

The introduction of quality of life (QOL) assessment has shifted clinical focus away from symptom measurement towards assessment of functional areas important to the patient. Most QOL instruments were conceptualized and developed primarily in Western society, and have not been validated against non-Western indigenous beliefs of what it means to have quality of life. As a result QOL assessment has cultural limitations. Only by awareness of these limitations can one validly interpret QOL findings from non-Western cultural groups. This article highlights the main areas for attention: concept and construct of QOL, peoples' baseline and expectations of QOL, coping mechanisms and communication of QOL. A literature review from 1966 to present of QOL in non-Western cultures revealed that many studies comparing cross-cultural QOL scores do not consider such cultural limitations. In addition the most popular QOL cross-cultural assessment tool, the WHOQOL, does not consider all factors. We conclude that only through true appreciation and understanding of the cultural limitations of QOL can one validly interpret results from non-Western QOL assessments.     

First rank symptoms and diagnosis of schizophrenia in developing countries

Schneider's first rank symptoms (FRS) among schizophrenics in Karachi are compared with samples from Saudi Arabia and the UK. Although the incidence of one or more FRS were very close to Saudi Arabia, the individual FRS were different, and somatic passivity was similar to the UK. It is concluded that cultural factors are more important than religious affinity in determining symptomatology. The results could be due to selection of schizophrenic patients on Western parameters. The place of FRS in developing countries and the changing concept of schizophrenia is discussed.     

Does DSM-III-R diagnose depression in non-Western patients?

The author reports the cases of three non-Western patients with impaired functioning due to symptoms of major depression. Their characteristic style of symptom expression was different from the usual manifestations, emphasizing vegetative rather than cognitive and affective aspects of depression. Non-Western patients may be either misdiagnosed or overdiagnosed, which may complicate their assessment and treatment, because the diagnostic criteria used reflect Western values of behaviour. To improve the treatment of non-Western patients who seek therapy for depressive symptomatology in Western countries, therapists should seek broader understanding and deeper appreciation of non-Western belief systems and cultural differences.     

Functional outcomes in schizophrenia: understanding the competence-performance discrepancy

A problem in the study and treatment of functional disability in schizophrenia is that factors other than competence (what one can do) can limit real-world performance (what one does). We examined predictors of the competence-performance discrepancy in both adaptive and interpersonal domains. Patients with schizophrenia (N = 96) were evaluated at baseline of a clinical treatment study. Discrepancy scores were created by considering each subject’s competence relative to their real-world performance in interpersonal and adaptive behaviour domains. Logistic regression analyses revealed that for the interpersonal competence-performance discrepancy, living in a group home, better neurocognition, more time spent in the hospital since a first episode of psychosis, and a longer first hospitalization predicted a greater discrepancy between interpersonal competence and performance measures. For adaptive behaviour, shorter time since most recent hospitalization, more depressive symptoms, greater number of months of first hospitalization, older age at baseline, younger age at first hospitalization, and more time spent in the hospital since a first episode of psychosis predicted a greater adaptive competence-performance discrepancy. A different pattern of demographic and clinical features may limit the extent to which patients are deploying interpersonal versus adaptive skills in everyday life.     

Medication treatments for schizophrenia: translating research findings into better outcomes

The atypical or novel antipsychotics have advanced the treatment of schizophrenia, especially given their reduced extrapyramidal side effect liability. In this article, the authors examine a number of recently published or presented studies of the atypical antipsychotics, many of them post approval studies, that shed additional light on this class of medications. Clozapine stands alone as a medication for treatment-resistant schizophrenia, but the other first-line atypical agents appear to reduce relapse rates during maintenance treatment and to have less of a long-term risk for tardive dyskinesia. However, additional research is needed to distinguish the atypical antipsychotics from each other and to better understand their non-neurological side effects.     

Achieving better outcomes for schizophrenia patients in Hong Kong: Strategies for improving treatment adherence

Recent research on second-generation long-acting injectable antipsychotics (LAI SGAs) has proven its effectiveness in minimizing medication nonadherence problem and reducing relapses. Administered by medical professionals, making quick detection of nonadherence possible, long-acting injectable antipsychotics (LAIs) facilitate immediate intervention and recovery process, and thus are favored by psychiatrists. Despite a higher initial cost with LAIs, the subsequent schizophrenia-related health costs for hospitalizations and outpatients are greatly reduced. With reference to guidelines published by psychiatric associations around the globe, this article looks at scenarios in Hong Kong on the management of severe mentally ill patients with regard to the use of a host of psychosocial interventions as well as LAI SGAs as a preferable treatment. In particular, it examines the benefits of using LAI SGAs for Hong Kong patients who demonstrated high nonadherence treatment rates due to their social environment. It assesses the rationale behind the early usages of LAI SGAs, which help to provide better recovery outcomes for patients.