Prognosis for schizophrenia in the third world: A reevaluation of cross-cultural research

ALEX COHEN

P R O G N O S I S F O R S C H I Z O P H R E N I A IN T H E T H I R D W O R L D :

A R E E V A L U A T I O N OF C R O S S - C U L T U R A L R E S E A R C H

INTRODUCTION

There is a widely held belief in cross-cultural psychiatry that schizophrenia has a better prognosis in the Third World than in the industrialized nations of the West. The purpose of this paper is to demonstrate that the case for this majority opinion has not yet been made definitively. First, it will briefly discuss several important research projects and theoretical works in the field. Second, it will critique Waxler's research on the course and outcome of schizophrenia in Sri Lanka. Third, it will attempt to generalize the implications of this analysis to other cross-cultural research on schizophrenia. Fourth, it will offer suggestions on the information we need in order to understand schizophrenia cross-culturally and the methodology that is required to obtain it.

The most oft-cited evidence of the cross-cultural variation in the prognosis of schizophrenia is the World Health Organization's International Pilot Study of Schizophrenia (IPSS) (WHO 1979 and Sartorius, Jablensky, and Shapiro 1978). This research found some of the variation could be accounted for by specific sociodemographic (e.g., social isolation) and clinical (e.g., type of onset) factors. However, the larger part of the variation remained unexplained. IPSS suggested, but did not test, three factors that might explain the contrasts in prognosis for schizophrenia: (1) differences in structural elements of cultures (e.g., family structure or socioeconomic features); (2) distinct treatment modalities in different cultures; and (3) patients with the same symptomatology may be suffering from disorders with different biological bases (WHO 1979: 371).

The WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders addressed some of the methodological issues raised by IPSS. Most importantly, rather than using a hospital-based sample, this study attempted, within each catchment area, to identify all individuals exhibiting schizophrenic behavior who were making a first lifetime contact with any one of a number of "helping agencies" in the community. Follow-up examinations of these patients were conducted one and two years after their inclusion in the study. The preliminary results (Sartorius et al. 1986) indicated that the incidence of schizophrenia was similar across different populations, and supported the IPSS finding that the prognosis for this mental disorder was better in the

developing countries of the world. However, this research did not attempt to provide explanations for the apparent cross-cultural variation.

Culture, Medicine and Psychiatry 16: 53-75, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

54 ALEX COHEN

Murphy and Raman (1971), in another frequently cited study, conducted a 12- year follow-up of schizophrenic patients in Mauritius which demonstrated that

they had a better prognosis than a comparable group of patients in Britain. This

evaluation was based on the fact that, at follow-up, not only were a greater proportion of patients in Mauritius functioning normally, but they had suffered

relatively fewer relapses between discharge from the hospital and follow-up than the patients in the British sample. Murphy and Raman did not provide a precise explanation for these results, but did suggest that cultural differences in beliefs about mental illness might influence the course and outcome of schizophrenia. Interestingly enough, however, they found the better prognosis was true only for relatively "mild" cases. In both countries, about one-third of all cases of schizophrenia were found to be severe and chronic. Furthermore, these patients did not differ as to the course and outcome of their illness. Murphy and Raman concluded, therefore, "not all varieties of the disease are milder in, or are benefitted by the Mauritian setting" (1971: 48).

Murphy and Taumoepeau (1980) later explored the theory that populations from traditional societies exhibit relatively better mental health than those from

complex societies by investigating the prevalence of psychotic and non- psychotic mental disorders in Tonga. In fact, they found Tonga had relatively

low rates of schizophrenia, affective psychosis, and chronic organic psychosis and pointed to "traditionalism ''1 as the explanation. They offered the following

scenario for how the structure of a traditional culture might influence the manifestation of mental disorders:

In schizophrenia, psychological experiments have shown that symptoms are exacerbated when patients are confronted with complex tasks, but not exacerbated by tasks which are simple, clearly explained and attainable ... If one extrapolates from these findings to hypothesize regarding the still healthy but schizophrenia-prone individual, it seems likely that the disease might sometimes be avoided if the demands to which he must respond were light and the models for action which were provided him were clear and achievable (1980: 481).

Cooper and Sartorius (1977) were also interested in this notion and claimed that social and family structures in nonindustrial societies exerted a comparatively benign effect upon people with schizophrenia. They suggested that rapid increases in the size of urban areas, changes in perinatal and infant mortality and morbidity, and changes in family structure might be the mechanisms by which industrialization could affect an individual's response to mental disorders. This explanation, however, is based on an idealization of nonindustrial societies in which the environment for a person with schizophrenia is assumed to be "supportive and tolerant, and [with] little risk of prolonged rejection, isolation, segregation and institutionalization" (1977: 53). The ethnographic record, as discussed below in the section on labeling theory, does not support this view.

Another problem is that we have little cross-cultural knowledge about the

SCHIZOPHRENIA IN THE THIRD WORLD 55

day-to-day lives of psychotics; nor do we have any comparative scale of cultural demands, as experienced by individuals, with which to test the hypothesis offered by Murphy and Taumoepeau. Furthermore, individuals in all cultures are faced with the conflict between individual and societal needs. How well those conflicts are resolved may or may not have anything to do with the "traditional"/modern, nonindustrial/industrial, or "simple"/complex dicho- tomies. Without evidence about the lives of psychotics in specific cultural settings, and the means to evaluate it, the supposition that "traditional society" exerts an influence on the occurrence of schizophrenia must remain an intrigu- ing hypothesis deserving further study.

In extensive literature reviews, H.B.M. Murphy (1982) and Warner (1983, 1985) attempt to demonstrate that the prognosis for schizophrenia is better in Third World nations than among the industrialized nations of the West.

H.B.M. Murphy (1982: 79) suggests this phenomenon is due to differences in social organization and cohesion, and hypothesizes that the crucial factors might include the nature of social expectations, the attainability of the rewards associated with those expectations, and the nature of social rules and guidelines for action (1982: 89).

For Warner, the apparently better prognosis for schizophrenia in the Third World is a result of better social integration of the psychotic who "is more likely to return to a useful working role and to retain his or her self-esteem, a feeling of value to the community, and a sense of belonging" (1983: 210). In a later work, Warner (1985) looks specifically to political economy to account for cross- cultural and historical variations in the course and outcome of schizophrenia. He

offers unemployment rates as a predictive measure of the prognosis for schizophrenics in a given society. Low unemployment/high demand for labor is presumably associated with better prognosis since those persons suffering from severe mental disabilities are more likely to be given the opportunity to work, i.e., an appropriate role which leads to integration into their culture, while their

counterparts in societies in which there is high unemployment/low demand for

labor have few opportunities to be assimilated. Warner cites Sri Lanka, and Waxler's research, as an example of a predominantly agricultural society with little unemployment in which schizophrenia has a relatively benign course and

outcome. The problem is that theory is confounded by fact. At the time of Waxler's research (1970-1975), the International Labour Office (1976) conducted an economic study of Sri Lanka which found not only a shortage of cultivable land in relation to the population, but also an unemployment rate of 15%. Unemployment among those 15 to 24 years old (a group which is highly susceptible to first onset of schizophrenia) was especially high - 40%.

A recent issue of the British Journal of Psychiatry devoted to cross-cultural

psychiatry attests to the continued acceptance of the notion of better prognosis for schizophrenia in the developing nations (Left 1990 and Littlewood 1990; see

56 ALEX COHEN

Makanjuola and Adepo (1987) for a dissenting opinion as to Nigeria). In the same issue, we can see that the results from IPSS and the Determinants of Outcome Study have become axiomatic for subsequent research even though neither project could account for the apparent cross-cultural variations in the prognosis for schizophrenia. For example, Left et al. (1990: 355), working with a sample of patients from the Determinants of Outcome Study, suggest the important influence of "the tolerance and accepting attitudes of family members," but state this did not fully explain "the relatively good two-year outcome ... of schizophrenic patients in Chandigarh." This inability to theoretically account for the demonstrated variation does not necessarily invalidate the research, but it should force us to question the results and not accept the WHO studies so readily.

Waxier (1979) submits her research in Sri Lanka as confirming the findings of IPSS and Murphy and Raman. This paper will examine Waxler's research and theoretical orientation in view of methodological considerations and ethnographic evidence in an attempt to identify widespread problems in cross- cultural research into the course and outcome of schizophrenia. The discussion will focus on four areas: labeling theory and specific cultural variables as protection against chronic mental illness, the ethnographic depiction of Sri Lanka, the problems of hospital-based studies, and follow-up studies and informant accuracy. 2

SUMMARY OF WAXLER'S STUDY IN SRI LANKA

Waxler (1979) conducted a 5-year follow-up study of 44 schizophrenic patients discharged from Kandy Hospital's psychiatric ward in 1970. All patients were Sinhalese Buddhists, most of whom (83%) lived in rural areas. Less than half were from affluent land-owning families; the rest were from tenant fanning or laboring families. On the average, these patients were 29 years old and had received 7 years of education. More than half (57%) were not married. The initial information for each patient was collected from family interviews and hospital records. At follow-up, patients' clinical statuses were determined by an interview and evaluation of the patient by a psychiatrist, and supplemented by the administration of a standardized psychiatric interview. Patients' treatment histories and the nature of their social performance in the previous 5 years was obtained through a search of hospital records and interviews with family members.

At the 5-year follow-up, results from the standardized psychiatric interview revealed 45% of the patients exhibited no symptoms of psychosis. A Sinhalese psychiatrist's evaluation of patients' overall clinical status at follow-up determined, despite the presence of symptoms, 50% of the sample displayed normal


adjustment and 27% had only mild maladjustment. Reports of the patients' activities on the day previous to the interview demonstrated 58% of the sample were able to lead a normal social role at home as viewed by family members. In order to achieve a fuller portrait of patients' social performance, family members were asked to report on the patients' activities during the 6 months prior to follow-up. A checklist of common instrumental and expressive activities showed 42% of the patients displayed no social impairment; another 12% were only mildly impaired. Family members were also asked to report on the patients' work experience over the entire 5-year period. Only 17% of the patients never worked, while 45% worked continuously and 38% worked occasionally. 3 Finally, hospital records and family reports were used to determine how many psychotic episodes each patient had suffered since the episode of inclusion. According to these sources, 40% of the patients had no additional episodes, 24% had episodes with full remission between them, 7% experienced mild, but continuous symptoms, and 29% suffered from severe and continuous symptoms.

Waxier (1979: 156) interpreted these data as demonstrating "the social and clinical outcome for schizophrenia in Sri Lanka [to be] remarkably good," especially when it was compared to the results obtained by IPSS about the illness in industrialized countries. Moreover, the prognosis for the illness in Sri Lanka looked similar to what IPSS and murphy and Raman (1971) found to be the case in other nonindustrial countries, e.g., Nigeria, India, and Mauritius. IPSS was circumspect in its conclusions as to why this might be the case and only indicated "the course and outcome of schizophrenia is affected by sociocultural conditions and lead[s] to hypotheses that can be tested in subsequent studies" (WHO 1979: 371). Waxier (1979: 157) went further and identified three factors in Sinhalese culture that, she claimed, contribute to the better prognosis for schizophrenia in Sri Lanka: (1) large, tolerant, and strong families; (2) a treatment system based on short-term care that does not give messages to patients which may prolong illness; and (3) a system of belief that explains disease in terms of extemal causation, does not stigmatize the patient, and believes mental illness can be cured. Likewise, Murphy and Raman (1971: 48) considered cultural beliefs about mental disorders and the establishment of "sick-roles" to be important determinants of cross-cultural variance in the course and outcome for schizophrenia, but noted the data suggested that severe cases of schizophrenia were unaffected by cultural forces.

IMPACT OF THE SRI LANKA STUDY

Ever since the publication of Waxler's article about schizophrenia in Sri Lanka, it has been cited widely as an example of a pre-industrial society in which the course and outcome of schizophrenia is relatively benign. Murphy (1982),

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Warner (1985), and Torrey (1980) all employ Waxler's study as evidence supporting their various arguments as to why the prognosis for schizophrenia is apparently better in the Third World. Kleinman (1981: 259) cites Waxier, along with IPSS, as cross-cultural research which demonstrates "outcome from schizophrenia varies inversely with social development of the country." Eron and Peterson (1982: 244) mention Waxler's study as evidence that the prognosis for schizophrenia is better in nonindustrial societies. Estroff (1982: 385) writes,

I am convinced that psychosis occurs universally, but do not think that chronicity develops with such frequency, regularity, and great cost as it does within the confines of our sociocultural system, 4

and cites Waxier and IPSS as evidence for this belief. Lin (1983: 76) points to Waxler's study, among others, and states the major task of mental health researchers in the Third World should be to identify the elements influencing the favorable prognosis for psychoses in the undeveloped countries. Bland (1982: 58) invokes Waxier in a discussion of the effects of culture on the outcome of mental illness. Beiser (1985: 134) cites her work in an attempt to

apply the lessons of transcultural psychiatry to clinical practice. Beels (1981) and Beels and McFarlane (1982) look at the influence of social support on the course of schizophrenia; the Sri Lanka data are cited in both articles. Karno et al.

(1987: 143) note the evidence from Sri Lanka as being among those studies that look to "familial and community responses to schizophrenic disorder [as] the

link between culture and prognosis." A perusal of the literature reveals dozens of citations of Waxler's research in

Sri Lanka. For the most part, the results are accepted without question. I hope to demonstrate this acceptance has been, at best, premature. If we are ever to gain a precise understanding of schizophrenia such studies must be analyzed carefully so that erroneous assumptions do not become assumed truth.

SOCIAL LABELING THEORY

In its most extreme form social labeling theory asserts social deviance to be a structural device that functions in an effort to achieve social integration in traditional societies (Seibel 1972: 253). This theory, as it relates specifically to mental disorders, leads Waxier (1977: 249) to the conclusion that such societies will exhibit little chronic, long-term mental illness because "there is less need

for, less belief in and less provision for secondary deviation." This is in sharp contrast to industrialized societies in which "sanctions given to the labeled mentally ill are uniformly rejecting, stigmatizing ... or serve to alienate or

isolate the sick person from normals" (238). Hahn (1978) and Eaton (1985) criticize, on methodological grounds, the use

of labeling theory to explain better prognosis for schizophrenia in non-industrial


societies. It is difficult to specify what constitutes "modernization" or "traditional." Moreover, the ethnographic record belies the notion that all traditional societies necessarily have the beliefs and expectations about mental illness posited by labeling theory. Edgerton (1966, 1969, 1980) presents us with instances of cultures in East Africa that badly mistreat psychotics. One Pokot healer used the following "cure":

I am able to cure roads. I order the patient tied and placed on the ground. I then take a large rock and pound the patient on the head for a long time. This calms them and they are better (1966: 417).

Prince (1964: 117-118) reports mentally ill Yoruba patients are sometimes shackled for long periods of time, beaten, and "poisoned" to make their madness look worse than it really is so that healers can charge higher fees. Gelfand (1964: 170) writes of the Shona that while well-behaved patients are cared for by their families, those who are difficult to manage are confined to a cave to die of starvation, or driven into the woods to fend for themselves. Finally, J.M. Murphy (1981: 820) states that the use of confinement, restraint, and exclusion are universal.

Evidence from cross-cultural psychiatry itself seems to contradict labeling theory's hypothesis that there is less chronic mental illness in "traditional" societies. Hahn (1978: 159) points out that labeling theory does not account for the chronicity of about 30% of the schizophrenic patients in Mauritius and Britain. Waxler's (1979: 150) study provides additional data to support this observation: at follow-up, 29% of the patients in her study were found to have suffered from serious and continuous symptoms throughout the previous 5 years. Labeling theory may offer an explanation for better prognosis for

schizophrenia in "traditional" societies, but it cannot explain why, cross- culturally, a certain proportion of people become chronically ill and remain so.

Furthermore, Waxier (1977: 235) argues that no deviance exists until a person is labeled as such by others in the same society: "the labeling process itself, the act of defining and sanctioning behavior, is the etiological agent." This may not be true, either. Evidence from Edgerton (1966) suggests the idea of the social construction of mental illness (Eisenberg 1988) may not be satisfactory. Even though four East African tribes had different beliefs about the etiology and prognosis of mental illness, all of them recognized the same constellation of behaviors as constituting "madness." J.M. Murphy (1981) also found this to be true among the cultures in which she worked. It must be concluded, therefore, that mental illness is not the social construct it is assumed to be by labeling theory.

Waxler's (1979: 156) version of labeling theory looks to specific social and cultural variables that influence the outcome for schizophrenia. In considering the evidence from Sri Lanka, Waxier rejected the suggestion that the results from her 5-year follow-up study of schizophrenia could be explained by

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sampling bias, problems in diagnosis, differential access to treatment, or family tolerance of deviance. She claimed the better outcome for schizophrenia in Sri Lanka could only be accounted for at the cultural level:

... each society, through the interaction of family, treatment people, and patients, molds the mentally ill person into the kind of role, whether "chronic", "briefly psychotic", [or] "eccentric" most acceptable in that culture (1979: 157).

Waxier identified three domains in Sinhalese culture that lead to the social construction or "molding" of mental illness. The first factor was the Sinhalese family that was described as being "large, tolerant, 5 and relatively strong" (157): mentally ill members were neither alienated nor rejected, but rather cared for and given positive social support. The second factor was the treatment system in which there were many choices and all care was short-term. Waxier believed this meant, "The family retains control not only over treatments themselves but also over the messages about illness given by treatment people" (157). Finally, cultural beliefs about mental illness affect the outcome of schizophrenia. The Sinhalese explain mental illness in terms of external causation: gods, demons or sorcery are responsible for the aberrant behavior in the mentally ill (Waxler 1977: 240). For these reasons, the mentally ill person's self and social past are not under suspicion, stigmatization can be avoided, and treatment follows a "standard and ritualistic" course (Waxier 1979: 157).

Although Waxier may offer Sinhalese culture as the reason schizophrenia seems to follow a relatively benign course in Sri Lanka, she never provides us with ethnographic evidence to support these claims. Without basic information about behavior within the Sinhalese family and the manner in which

schizophrenics are treated, statements concerning how beliefs pertaining to mental illness are translated into better prognosis must remain conjectures rather than fact. For example, Waxier (1979: 157) asserts that short term treatment consistently results in short term illness, but does not provide any confirming evidence. Nor does she demonstrate the mechanisms by which beliefs about mental illness influence prognosis. Finally, although Waxier argues chronicity is not a factor in Kandy, that view may not be accurate. She contends Sinhalese

culture discourages the development of chronic forms of schizophrenia, yet, as

can be seen in her own data, 29% of the patients in the sample presented serious and chronic psychotic symptoms over the course of five years. Moreover, Wijesinghe et al. (1978: 427) found most psychiatric disorders were chronic and, more specifically, "all schizophrenic illnesses had lasted 2 years or more." We also know (Nikapota 1981) that schizophrenic patients make up the large

majority of all long-stay patients in the two psychiatric hospitals in Sri Lanka. Seventy-three percent of patients who had been in these facilities for 1 to 5 years, and 79% of patients hospitalized for more than five years, had a principal

diagnosis of schizophrenia.


THE FAMILY AND EXPRESSED EMOTION

The family is one of the domains of Sinhalese culture invoked by Waxler to account for why schizophrenics do better in Sri Lanka.

In contrast to Western cultures, Sinhalese families are large, tolerant, and relatively strong; they do not give messages that alienate or reject mentally ill members. Large families make care of a sick person easier and prevent crisis and rejection by ensuring that a temporary role substitute for the sick person is available. Further, the traditional norm of peasant society, that family must care for each other, has not broken down and thus no psychiatric patient is socially isolated or rejected from his family, particularly his family of origin. Positive social support for the sick person is almost universally available within the S inhalese family (Waxier 1979:157).

However, Waxler does not provide detailed information about what is taking place within the family setting in regard to the mentally ill. We must know how schizophrenics are being treated by their parents, siblings, and other relatives before we can state with certainty that they are not, in fact, being rejected or alienated. For example, although Waxier claims Sinhalese families contribute to the relatively good prognosis for schizophrenia in Sri Lanka, there is contrary evidence. Nikapota (1981: 43), in his study of two psychiatric hospitals in Sri

Lanka, cites abandonment as a major factor in determining who will become a long-stay patient in those facilities. That this should be so does not correspond to

the impression Waxier (1979: 157) gives of almost universal family support for

the mentally ill among the Sinhalese. Expressed emotion is an empirical measure o f the quality o f social interac-

tions in families, and consists o f ratings of critical comments, hostility, and

emotional over-involvement. A number of studies have demonstrated a significant correlation between ratings of high expressed emotion in families to relapse rates for a schizophrenic member of the family. This finding has been

replicated cross-culturally (Vaughn and Left 1976, Vaughn et al. 1984, Lef t et al. 1987, Karno et al. 1987, Left et al. 1990, and Barrelet et al. 1990) and is often cited as evidence to explain the apparent cross-cultural variation in the course and outcome of schizophrenia (Kuipers and Bebbington 1988: 901). Expressed emotion is not without its critics, however. Edgerton (1980: 183) is skeptical of the cross-cultural measurement of expressed emotion until that time when

the sociocultural context has been holistically studied and sufficiently understood to permit the specification of variables without violating ... the world of meaning within which life takes place.

That is, assumptions about the meaning of behavior in one culture may not be

relevant to another cultural setting. DiNicola (1988: 213) notes Lef t et al. (1987) found a positive correlation between critical comments and warmth in a sample of families from Chandigarh, although these variables were negatively corre-

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lated in the European studies. Similarly, in articles on social support for children in Africa, Weisner (1989) and Wegner (1989) suggest support is often accom- panied by aggression and conflict. This would seem to indicate that contextual information is important because speculations about family support or abstrac- tions of hostility may not reflect the complexity of the relationships.

In a critical review, Koenisberg and Handley (1986) agree that a number of studies have demonstrated the relationship between family expressed emotion and risk for relapse, but go on to say that its clinical meaning has yet to be defined, and point to several problems which are relevant to this discussion. Briefly, their questions are concemed with: the relevance of the interview to actual patterns of family interactions; how this interaction is experienced by the schizophrenic; the problem of measurement during times of crisis; the need to determine what is happening during the intervening periods; and cultural influences on expressed emotion. The nature of these questions precludes the use of a structured interview conducted at two or more points in time; only ethnography and detailed descriptions of the daily lives of schizophrenics and their families will be of use in this regard. 6

THE ETHNOGRAPHIC PORTRAYAL OF CENTRAL PROVINCE, SRI LANKA

Sinhalese Buddhists are the majority ethnic-religious group in Sri Lanka, and the Kandyan up-country area is the more traditional part of the country that has been, comparatively, less affected by colonialism (Waxier 1976: 225). Wood (1961) also describes this area as being more isolated and traditional than the maritime provinces, noting English rule did not come to Central Province until 1815, 300 years after the Portuguese first arrived in Sri Lanka. Both Wood and Waxler depict the country as being a predominantly agricultural society.

However, this portrayal of Central Province as being "traditional ''7 and therefore a good test case for social labeling theory may be open to question. Bandarage (1980: 3) presents a somewhat different view of the area. Beginning in approximately 1833, the British began to develop large plantations in Sri Lanka, and the impact of this "was most direct and dramatic in the central highlands of the pre-colonial Kandyan Kingdom." Moreover, plantation development was made possible only by the importation of unskilled Tamil laborers. The Sinhalese were unwilling to work as farm laborers and were used, for the most part, only as managers (Wood 1961: 16).

The presence of many foreign-owned plantations, a large, unskilled proletariat, ethnic tensions, a shortage of land, and widespread unemployment are not usually associated with traditional agricultural societies. Even if we accept Central Province as being "more traditional" than the maritime provinces, Waxler's conclusions about the effect of certain aspects of traditional Sinhalese


culture on the course and prognosis of schizophrenia must be questioned. She (1979: 157) hypothesizes that the combined effect of the family, the treatment system, and the system of beliefs about mental illness in Sinhalese culture impels schizophrenic patients to a "quick return to normality." Although this may seem reasonable, the lack of comparative data from Sri Lanka itself makes Waxler's explanation speculative.

First, if we had information about the cultural contrasts between Kandy and the non-traditional, capital city of Colombo, and these were shown to correspond to variations in the course and outcome of schizophrenia for the two areas, a case could be made for the role of "traditionalism." Mendis (1986), however, obtained results very similar to Waxler's from a sample of patients in a Colombo hospital. If this is true, the effect of "traditional" culture on the course and outcome of schizophrenia is decreased substantially. Second, by limiting the study to Sinhalese Buddhists, Waxier disregards the fact that approximately 15% of the population in Central Province is Tamil (Tambiah 1986: 10). Without evidence concerning the prognosis for schizophrenic Tamils, it is difficult to evaluate Waxler's statement that specific aspects of Sinhalese culture

account for the apparently "benign" course of schizophrenia in Central Province. The absence of ethnographic information impels us to ask whether the sample

of patients under investigation was representative. Eighty-three percent of the

sample patients had rural origins and almost half 8 of them came from "the more affluent land-owning village families" (Waxier 1979: 146). There is little reason to believe the proportion of rural patients is unusual, but there may be reason to

wonder if the same is true of their socioeconomic status. It seems unlikely that a random selection of schizophrenics in the study's catchment area would have produced a sample in which almost half came from an affluent family. This is crucial because there is a putative relationship between social class and the prevalence of mental illness (e.g., Hollingshead 1986). Although this relationship has not been established definitively (Eron and Peterson 1982, Bland 1982), it is enough of a question that a preponderance of affluent patients in the sample should have been avoided because of possible bias. 9

Finally, Waxler's sanguine view of Sinhalese culture in Sri Lanka at the time of the study is not universally accepted. Obeyesekere (1977: 178), in an article about Ayurvedic medicine, writes,

[H]ysteria and the somatization of intra-psychic conflicts are common in the culture. These tendencies have increased within the last twenty years owing to economic pressures and mass unemployment. Two consequences of these economic conditions are relevant: the existence of a large number of unmarried persons, and also an increase in the age of marriage. Given the puritan-type sexual ethic, particularly in the urban "middle-class", the existence of sexual segregation, and lack of opportunity for heterosexual expression, there would be an increase in sexual frustration leading to widespread hysterical tendencies in the population...

This assessment implies that Sri Lankan society is not as "traditional" as some

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might believe. It also raises the question of diagnostic validity in that hysterical disorders are often difficult to differentiate from certain forms of schizophrenia (Kiev 1972: 72). Finally, if Sinhalese culture is not as protective as Waxier claims, then we are forced to look elsewhere to account for the apparently

"benign" prognosis for schizophrenia in Sri Lanka.

PROBLEMS OF HOSPITAL-BASED STUDIES

IPSS (WHO 1979: 370-371) recognized their hospital-based study might have been biased because the shortage of hospital beds in developing countries could have resulted in a preponderance of acute cases being treated at those centers. A high proportion of acute cases could profoundly affect the results of a study because "previous studies have indicated that acutely disturbed patients are more likely to have good course and outcome than patients who are not so acutely disturbed at the time of admission..." Despite this caution, and without any investigation, IPSS dismissed the possibility that samples of schizophrenic patients from hospitals in the Third W o r d were systematically nonrandom and might prejudice their findings.

Nonetheless, the apparent dichotomy found in prognosis for schizophrenia in Nigeria (good) and Denmark (bad) may be explained by hospital use patterns in the two countries. Denmark is a small country in which everyone has ready access to medical care. It is also an excellent site for research because of the availability of "registers of virtually all psychiatric patients ... and information concerning the whereabouts of individuals over the years" (Lidz, Blatt, and Cook 1981: 1063). Nigeria, however, is a large country which is plagued by a shortage of psychiatric personnel (Yin 1983: 73) and hospital beds (Onyeama 1987: 580). This could mean the difference between these two countries in the prognosis for schizophrenia (as demonstrated by IPSS) was a consequence of differing rates of hospital contact rather than any significant differences in the

course of the mental illness. There is also evidence that the psychiatric hospital populations in Denmark

and Nigeria are clinically distinct. The absence of universal access to psychiatric care in Africa means schizophrenic patients are often selected for hospitalization on the basis of whether they are violent (German 1987: 437). Onyeama

(1987: 48) writes of Nigeria:

Those patients who needed admission to hospital usually had an acute clinical presenta- tion and a history of associated violence. Not surprisingly, the most usual reason given for admission was the need for restraint. In this setting, hospital admission therefore seems to be an emergency response aimed at containing socially disruptive behavior and is seldom a purely elective procedure.

Although violence is certainly a criterion for hospitalization in Denmark, we


might expect, because of the greater access to hospitals, that acute patients would account for a lower proportion of hospitalized schizophrenics than in Nigeria. If this is the case, IPSS may be presenting an overly optimistic view of prognosis for schizophrenia in the Third World, since acute schizophrenics seem to have a better prognosis than those with the chronic form of the disease.

Similar to IPSS, Waxier (1979: 152) considered the possibility that a hospital sample might exclude some mentally ill people in the community who did not receive treatment in a Western hospital or clinic, and dismissed it as unlikely: "Knowledge of Sinhalese Buddhist culture leads us to believe that no one who is defined as ill remains untreated, particularly at the onset of the illness." Waxier supported this view by conducting a survey which showed that in four randomly selected villages "all people ever defined by family members as mentally ill" (152, italics in the original), received care at government hospitals, clinics, and/or got a variety of native treatments as well. In addition, the low cost and general availability of care in the Kandy Hospital catchment area is presented as evidence of the universal availability of care. Finally, Waxier (1979: 152) cited a mental health survey (Wijesinghe, Dissanayake, and Dassanayake 19781°)

which demonstrated that only 4 of 29 schizophrenics in a suburb of Colombo had never received care in a Westem hospital or clinic. However, Waxler's hospital-based sample may have been biased. Mental health surveys and studies

of illness behavior in Sri Lanka reveal a different picture than the one presented by Waxier in which nearly all schizophrenics, particularly at onset, receive care at Western facilities. Although Wijesinghe et al. (1978: 438--439) found that

only 4 of 29 schizophrenics (13.8% 11) never received care at a Western facility,

Waxier failed to note that at the time of this survey "58.6% of schizophrenic subjects were not receiving any [ongoing] psychiatric care, although they were

in close proximity to at least four psychiatric facilities" (438). These data are supported by Jayasundera (1969: 60) who conducted a similar survey in Sri Lanka and determined:

Only a comparatively small proportion of the mentally ill seek Western psychiatric treatment, and, probably of even more significance, around 50 per cent of the mentally ill were under no treatment at all...

Finally, Satkunanayagam (1980), noting that relatively few of the mentally ill receive care in Western psychiatric facilities, suggests the mental health system

in Sri Lanka should turn to indigenous healers to alleviate the crisis. Further evidence of problems with this hospital-based sample comes from

Wolffers' (1988) study of illness behavior in Sri Lanka which demonstrates that

psychiatric treatment in Western facilities is limited, and illness behavior in Sri Lanka follows a hierarchy of choices. The first response of nearly three-quarters

of the villagers with a family member displaying mental illness is to go to the

"adura," or native healer; the others go to a Western medical facility (550). 12

Wolffers goes on to note, "multiple treatment strategies may be undertaken at

66 ALEX COHEN

the same time" (550), but people usually follow the stated pattern. Most importantly, the people of Sri Lanka turn to Western medicine for acute conditions and use traditional medicine for the treatment of many chronic and psychosomatic diseases (551). Therefore, we may infer that acute schizophrenics in Sri Lanka are more likely to be treated in hospitals, whereas chronic patients are brought more often to the "adura." Furthermore, Nikapota (1981) states that the two psychiatric hospitals near Colombo provide services for all of Sri Lanka. This could mean chronic patients from Kandy were under- represented in Waxler's study because many of them had been transferred to the two psychiatric facilities near Colombo. As stated above, the relative absence of these chronic patients would have seriously biased the results of the study. All of this would challenge Waxler's (1979: 152) contention that if the sample was biased, the mentally ill persons who were excluded were probably "the less

severe diagnostic types."

THE DETERMINANTS OF OUTCOME STUDY

While it is true that the WHO Collaborative Study on the Determinants of Outcome of Severe Mental Disorders (Sartorius et al. 1986) attempted to address some of these problems through the use of case finding methods, their patient samples may not have been significantly more representative than Waxler's. First, "the vast majority were urban residents" (916), and most were identified

through Westem medical practitioners or facilities (917). Second, identifying "first contact" patients can prove to be difficult and may lead to inaccuracies (NiNuallain, O'Hare, and Walsh 1987). Third, in developing countries, violence was a factor in initiating a first contact in about 25% of the cases, whereas it played a role in only about 10% of the cases in the developed countries (Sartorius et al., 1986: 917). This may reflect variations in pathways to treatment

and the availability of psychiatric care more than actual differences in presenta- tion of symptoms. Finally, the proportion of cases with acute onset in the developing countries was twice as great as that in the developed countries (917).

As with the previous point, this variation in the proportion of acute onset cases may be indicative of real differences in the cross-cultural manifestation of schizophrenia, but with the problems of hospital-based samples and the poor

state of mental health services in the Third World (Yin 1983) it seems more likely that these differences are a reflection of processes having little to do with

schizophrenia.


PROBLEMS OF FOLLOW-UP STUDIES AND INFORMANT ACCURACY

Follow-up studies assume that information obtained from informants will be accurate. However, Bernard et al. (1984), in a literature review, state that informants, to a great extent, are not reliable in reporting about events in their lives. Accounts of recent medical events are no exception. Reports about chronic conditions are especially inaccurate. Overall, informant accuracy in the recall of events and behaviors decreases sharply as time elapses. IPSS was fully aware of these problems, but chose to ignore them despite their own caution:

The difficulties of assessing the reliability of informants in reporting intervening history remain largely unresolved. The problems of controlling for differences in intervening events in the lives of schizophrenic patients followed up over a long period of years and of understanding the effects of such differences on course and outcome are only now being approached (WHO 1979: 42).

From the above, we might infer that follow-up studies which depend on interviews with schizophrenic patients and their families for the relevant information about an extended period of investigation are open to gross errors. Waxier (1979: 148), nevertheless, argues that a 5-year follow-up study, as compared to the 2-year period investigated by IPSS, would negatively bias the prognosis for schizophrenia because the longer time span would make for a greater likelihood of hospitalizations subsequent to inclusion in the study. In fact, the opposite may be true: longer term follow-up periods might mean that a relatively greater number of episodes and hospitalizations are forgotten by informants. This in itself could produce what looks like low rates of hospitalization for psychotic episodes in those studies with relatively long follow-up

periods. The same point could be made about the Murphy and Raman (1971) research which compared the results of a 12-year follow-up to one of 5 years.

The Sinhalese belief that each episode of schizophrenia is the result of a different illness rather than "the same underlying disease process appearing again after a period of remission" (Waxier 1979: 157) may also lower informant accuracy. If informants are asked to report on the progress of a specific mental illness, but their beliefs lead to a perception of several diseases being responsible for a constellation of symptoms over time, it seems inevitable that informants would not identify some episodes as being pertinent to the survey questions. Although hospital records were used to supplement informant accounts in order to guarantee reasonably complete information about the course of each patient's illness during the research period, in light of plural medical systems, the predominant patterns of illness behavior, a majority of schizophrenic patients who do not receive on-going care at western psychiatric facilities, and long-term patients with mental disorders who are often transferred

to two psychiatric hospitals outside of Colombo, it would seem that records at

one hospital in Kandy would be inadequate to amend the information obtained

68 ALEX COHEN

through interviews with schizophrenic patients and their families. A further complication is that not all psychotic episodes result in hospitalization. This is an extremely important point. I f informants and hospital records together almost certainly provided a substantial underestimation of schizophrenic episodes during the 5-year period of study, then Waxler's claim for a "better" course and outcome of schizophrenia in Sri Lanka may be far more optimistic than can be justified by the data.

The problems of follow-up methodology would have influenced several of Waxler's other outcome measures. Patients' social performance over five years was obtained through interviews with family members. Part of the interview concentrated on the patients' activities in the previous six months and the day before the interview. The primary question here is the ability of family members to recall and assess events over such a long time. Of course, reports on patients' activities on the day prior to the interview might not be subject to the same degree of distortion due to memory loss, but misrepresentation must be considered. Ethnographic observation of both patients and their families would have

been far more valuable. IPSS and the Determinants of Outcome Study also employed follow-up

methods to collect data. Even though the follow-up periods were reduced to one and two years, it is unlikely that this change would have reduced substantially the problems discussed above. Besides profiles of symptomatic outcome (which could have been shaped by sample bias), IPSS relied on follow-up interviews and hospital records to determine patients' course and outcome in the nine study sites. The following variables were considered: percentage of follow-up period in a psychotic episode; pattern of course based on number and length of psychotic episodes; types of subsequent episodes; degree of social impairment; and percentage of follow-up period not in the hospital. Even the length of episode of inclusion was determined at follow-up. The problems inherent with each of these measures could be discussed at length, but, to be brief, reliance on hospital records, assessment of clinical matters after the fact, informant reliability, beliefs about the nature of mental illness, and the use of plural medical systems are methodological dilemmas which must be faced by all follow-up studies.13

CONCLUSIONS

The two most critical areas of this reevaluation of cross-cultural research in schizophrenia, with particular emphasis on Waxler's study, are as follows:

First, the problem of sampling bias cannot be ignored. Short of conducting a census in each catchment area, a practice that is usually precluded for reasons of money and time, the possibility of sample bias will always be a question in the


research on schizophrenia, especially when it is concerned with cross-cultural variations in course and outcome. In view of this, hospital-based studies of schizophrenia are certainly flawed. There are too many powerful socioeconomic and sociocultural forces influencing patterns of illness behavior and determining

access to medical care to justify making hospital admissions the primary source for a research sample. We need to answer a number of questions before we can

interpret the evidence from such studies: Who is using the Western psychiatric facilities? Are these patients different from the schizophrenics who only seek the help of an indigenous healer? Is it possible certain symptoms and not others prompt a visit to a hospital? How are these decisions reflected in the clinical profiles of the hospitalized patients? Such evidence will help determine whether the prognosis for schizophrenia varies cross-culturally or if the available evidence is based on biased samples of patients.

The case-finding methods of the Determinants of Outcome Study are better, but still uncertain. Cases may be systematically missed for a number of reasons. First, the definition and identification of a "helping agency" (Sartorius et al. 1986: 912) might exclude sections of the treatment system. It also assumes that all schizophrenics receive care at onset. Second, reliance on key-informants and/or agencies to identify subjects could result in systematic differences among sites. Sartorius et al. (911-912) remark, "complete uniformity in the composi- tion of the case-finding networks and in the procedures leading to screening was impossible to achieve." Without more complete information about the case- finding networks and their cultural contexts it is difficult to evaluate the

samples. The second major conclusion of this critique is that follow-up studies are

inherently unreliable in the study of the course and outcome of schizophrenia.

We should not depend on informants for data which they cannot provide

accurately. Individuals fail to report even recent medical events, and, as time elapses, their memories become more and more uncertain. Supporting and supplementary evidence from clinic and/or hospital records may not be helpful, either. In an area such as Central Province, Sri Lanka, the existence of plural medical systems and complex patterns of illness behaviors means that psychotic episodes which result in a contact with a Western facility (and a resultant record) will represent only a partial history of the course of schizophrenia for an individual. Furthermore, if informants cannot be relied on for information about

concrete events, it would seem their evaluations of another person's behavior and social adjustment during a study's follow-up period would be poorer still.

Anthropology has important contributions to make to psychiatry (Kleinman 1987), but, I would contend, it has not yet supplied compelling evidence of cross-cultural variation in the prognosis for schizophrenia. Edgerton (1980: 184) writes that to meet this challenge anthropological research in this area must

employ

70 ALEX COHEN

a longitudinal perspective that permits relatively continuous monitoring of persons and settings; it cannot rely solely on data collected at one or two points in time. While future longitudinal research should continue to include careful clinical diagnosis and evaluation as well as interviews with patients, family members and others, systematic observation of patients, families and others should also be conducted.

In other words, we need to conduct ethnographic research into the lives of

individuals with schizophrenia. W e cannot merely employ follow-up strategies,

we need to follow patients. This may be a daunting task, but it is necessary,

because, I suspect, careful analysis of any o f the cross-cultural research would

probably reveal many of the same problems that are obvious in Waxle r ' s work

in Sri Lanka. Long-term, ethnographic information about persons with

schizophrenia is required to assess the current debates in cross-cultural

psychiatry. In order to do this we must follow the research model suggested by

Edgerton (1967, 1976, 1984, 1988) and Koegel (1989). Until more research is

moved out of the clinics and hospitals and into the day-to-day lives of

schizophrenics, our impressions of this mental disorder will remain incomplete

and inaccurate.

Department of Anthropology University of California, Los Angeles Los Angeles, CA 90024, U.S.A.

ACKNOWLEDGEMENTS

I would like to thank the Program in Psychocultural Studies and Medical

Anthropology for financial support during this research. The following persons

offered suggestions on an earlier draft of the paper: Carole Browner, Michael S.

Goldstein, Douglas Hollan, Marvin Kamo, John Kennedy, Keith Keman, Jim

Turner, and Thomas Weisner. Byron Good ' s editorial comments were crucial in

the final preparations for publication. Most of all, I am grateful to Robert

Edgerton for suggesting the topic, then encouraging me at every stage o f the

process.

NOTES

1 Murphy and Taumoepeau define a traditional society as one which displays the following characteristics: "a) respectful of law and tradition; b) relatively free from social and technological complexity; c) relatively undisturbed by outside influences; d) with many generations of stable settlement; e) predominantly agricultural" (1980: 472). This is the best operationalization of "traditional society" that I have found in the cross-cultural psychiatry literature. As it is most often used, the term "traditional society" refers to an idealization that may have little in common with the reality of the ethnographic record. z It is not within the scope of this paper to address the problem of the definition and diagnosis of schizophrenia in cross-cultural research. For those interested, Littlewood's (1990) review article on "the new cross-cultural psychiatry" and Left's (1990) reply is a


Food introduction to this question. Since the area in which the research was conducted was mainly rural, "work" included

jobs both in the household and on the farm. It is difficult to know whether this work experience is comparable to industrialized societies. The reports may reflect concepts of work and actual work requirements more than anything else. 4 In fact, evidence from Waxier, IPSS, and Murphy and Raman demonstrates otherwise: about one-third of all patients with schizophrenia suffer from severe and chronic symptoms. 5 The argument Waxier presents about the Sinhalese family's tolerance seems contradic- tory. At first (p. 154), she argues that tolerance for those suffering from schizophrenia cannot account for the better prognosis. Later (p. 157) she cites tolerance as one of the essential features of the Sinhalese family which impels the mentally ill person toward recovery. 6 An extensive discussion of EE is not within the scope of this paper, either. For those interested, the references cited above will serve as an introduction. In addition, current anthropological thinking on this subject is represented by Jenkins (in press) and Jenkins and Karno (in press). 7 My use of the term "traditional" in the discussion which follows might be criticized as unfair. An argument could be made that Waxler 's version of labeling theory hypothesizes specific aspects of culture which make for a better prognosis for schizophrenia. Despite this, I stand by my use of the term in this context because it is one of the glosses (among the others are "nondeveloped" and "preindustrial") that is used by many researchers in cross-cultural psychiatry. 8 Since Waxier does not provide the actual data concerning socioeconomic status, I cannot be any more precise than this. I am assuming that what she refers to as "less than half" is closer to 50% than 33.3%. 9 The fact that there was an apparent over-representation of affluent patients in Waxler 's sample seems to indicate differential use, if not access, to hospitals in Central Province, Sri Lanka. 10 Waxier cites Wijesinghe et al. (1975). I refer to Wijesinghe et al. (1978) which presents the same data, but was subsequently published in Acta Psychiatrica Scan- dinavica. 11 Waxier (1979: 152) seems to think 13.8% is an insignificant proportion. However, if this group of schizophrenics was experiencing exclusion from care because of a specific aspect of their illness we would be forced to regard as biased the conclusions based on the hospital sample. In addition, 13.8% does not seem insignificant to me. A similar rate in the treatment of measles or tuberculosis would probably be considered alarming. 12 Only one respondent of 86 went to an Ayurvedic practitioner (Wolffers 1988: 550). 13 It is more difficult to evaluate the follow-up methodology of the Determinants of Outcome Study because only a brief summary has been issued as of this date. Sartorius et al. (1986: 925) indicate that in addition to two evaluations of symptomatology and one assessment of social disability, "longitudinal, month-by-month ratings and narrative notes on symptoms and behavior provided the basis for an evaluation of the 2-year ... pattern of course of the disorder." This would appear to be a great improvement over previous studies, but judgment must be withheld until a complete report is published.

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Prognosis for schizophrenia in the third world: A reevaluation of cross-cultural research