Commentary on Alex Cohen et al: “Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World”

In the 1950s, 60s, and 70s, the field of cross-cultural (or transcultural) psychiatry provided what was largely Euro American psychiatry with several useful alternatives. Based on limited research, it balanced the near hegemonic American and British research materials and conclusions with data from the non-Western world, and with new findings about established psychiatric disorders that challenged diagnoses, programs, and treatments. Cultural psychiatry still provides those contributions, but psychiatry itself has changed. We are now in an era of global psychiatry, where psychiatrists from Asia, Latin America, and Africa are contributing numerous studies on mental illness and mental health care, and these are now becoming part of psychiatric science. Not surprisingly, over the past few decades, studies of depression, suicide, psychosis, and substance abuse in a wide range of societies have greatly increased. One outcome of this increase is that we now have a much more detailed and complex view of these conditions in different socioeconomic, cultural, and political settings. The review by Cohen et al needs to be understood in this context of globalization. They show that the data about the course and outcome of schizophrenia are much more complicated for all societies, but especially for poor and middle income societies. They conclude that one of the conclusions of the past—namely that schizophrenia has a better outcome in those societies compared with rich nations—needs to be reconsidered. And they bring a substantial body of data to bear on that process of reassessment, along the way pointing to the deep processes of family responses, work conditions, stigma, and adult mortality, about which much more needs to be understood. I am persuaded by their comments and find their conclusion well reasoned and reasonable. Cohen has made a career of criticizing World Health Organization (WHO) studies of schizophrenia. And many of his concerns are important. Readers need to balance the questions he and his distinguished colleagues raise with the conclusions of the WHO studies' authors. Given that we do not know the cause of schizophrenia, that many suspect it contains multiple distinctive conditions, that research on treatment has been controversial, and that the course of psychosis has been shown to be influenced by many factors, it is impressive to begin with that there is a strong cross-cultural hypothesis in the field. This hypothesis and this article's criticism have contributed, in my view, to move the field ahead conceptually and empirically. That there is still uncertainty, confusion, and controversy is a sign of how very much more we need to learn. But let us also celebrate how far we have come. What we now know about the course of schizophrenia appears to argue against any simple conclusion. The still dominant view in psychiatry that schizophrenia is a disorder of progressive, unrelenting deterioration is not supported by long-term outcome studies, even in North America. The view that schizophrenia has a more favorable outcome in poorer societies now also appears less certain. And this should lead to a more complex and sophisticated appreciation both of the biosocial course of the group of psychotic conditions that constitutes schizophrenia and of the diverse research perspectives in psychiatry that wrestle with how to make context as important as condition in the understanding of outcome. This sense of progress in our cross-cultural understanding of mental illness can also be illustrated by other early formulations that have been proved inaccurate or inadequate. For example, when the first set of WHO studies concluded that outcome was better in low-resource societies, it was proposed that those societies were more sociocentric than psychocentric industrialized societies and therefore outcome might reflect greater family and community support systems wrong. We have learned over the years that virtually all societies contain both strong interpersonal ties and individualistic orientations. While family connections may seem stronger in certain poor societies with powerful cultural supports for patriarchy, they have been shown to be as much a source of stress as support. The same holds for stigma. Stigma about serious mental illness seems to exist almost everywhere. Its sources and patterns may differ but its consequences for the mentally ill are terrible in rich and poor societies alike. Societies cannot be categorized as high support or low stigma. The social processes involved in the course of chronic illness are no more easily stereotyped than ethnicity is. No one can believe today that all Chinese act one way, all Americans another. Intraethnic and intrasocietal diversity is large. And this means, we need a more nuanced and complex modeling of social processes just as we require a more subtle and precise understanding of symptoms and syndromes. That recognition represents the kind of progress in cross-cultural psychiatric understanding that our improving understanding of course and outcome of schizophrenia also represents.