Revisiting the Developed Versus Developing Country Distinction in Course and Outcome in Schizophrenia: Results From ISoS, the WHO Collaborative Followup Project

Abstract

This article examines the long-standing and provocative finding of a differential advantage in course and outcome for persons with schizophrenia living in "developing" countries, using results from the newly completed World Health Organization (WHO) collaborative project, the International Study of Schizophrenia (ISoS). The article addresses two questions: Has the differential survived the 13 years since it was last reported? If so, are the results demonstrably not attributable to artifactual confounding? The analysis focuses on the 809 subjects who make up the combined incidence cohort of ISoS. These include members of the original treated incidence cohorts of two earlier WHO studies (the Determinants of Outcome of Severe Mental Disorders and the Reduction of Disability Studies) as well as subjects drawn from two additional samples (Hong Kong and Madras/Chennai). We first review the consistency of the finding of a "developed versus developing" differential in course and outcome and then examine a variety of course and outcome measures for the ISoS incidence cohorts. Evidence of differences in illness trajectory in favor of the developing centers was consistently found. Six potential sources of bias are then examined: differences in followup, arbitrary grouping of centers, diagnostic ambiguities, selective outcome measures, gender, and age. None of these potential confounds explains away the differential in course and outcome. We conclude with suggestions for further research, with particular attention to the need for close documentation of everyday practices in the local moral worlds that "culture" refers to.

Rethinking theoretical approaches to stigma: A Framework Integrating Normative Influences on Stigma (FINIS)

“…Often mentioned or implicated, but rarely conceptualized or directly operationalized, is the role of media in establishing predominantly negative societal templates for responses to persons with mental illness (Wahl, 1997). Similarly, at a higher level, the World Health Organization International Study of Schizophrenia (ISoS) concluded that a society's level of development may shape an accepting or rejecting climate for recovery from mental illness (Hopper & Wanderling, 2000).…”

“…Researchers concluded that differences in stigma across "developing" and "developed" societies may be a critical mechanism explaining this finding (Hopper & Wanderling, 2000).…”

Dispelling a myth: developing world poverty, inequality, violence and social fragmentation are not good for outcome in schizophrenia

“…2 Finally, the International Study of Schizophrenia (ISoS) included 1633 patients comprising 14 treated incidence cohorts and 4 prevalence cohorts from culturally diverse sites in 12 countries. 15,16 At 15 years, Hopper and Wanderling showed that the finding of a consistent outcome differential favouring the developing countries remained robust and remained significant when strict ICD criteria were applied as well as when 'broad' versus 'narrow' definitions of schizophrenia were used. 16 These authors argue that the ISoS analyses dealt adequately with various possible sources of bias in the previous studies and that such bias could not account for the differences in outcome.…”

Recovery From Schizophrenia: What It Means?

“…Prognosis of schizophrenia depends on various factors and cross-national studies conducted by the World Health Organization includes the International Pilot Study of Schizophrenia (IPSS), the Determinants of Outcome of Severe Mental Disorder (DOSMeD) [3] and their successor, the International Study of Schizophrenia (ISoS) [2] found that course and outcome is better in developing countries and possible reasons include Insidious onset with good premorbid adjustment & younger age of onset, which is not so in developed countries. Other good predictors of prognosis include short duration of illness, regular drug compliance, no schizoid premorbid traits, absence of economic difficulties, increase in socio-economic levels, and lack of dangerous behavior.…”