Who Schizophrenia

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    Division of Mental Healthand Prevention of Substance Abuse

    World Health OrganizationGeneva

    Schizophreniaandpublic health


  • Nations for Mental Health:An Action Programme on Mental Health for Underserved Populations

    Objectives of Nations for Mental Health

    To enhance the attention of people and governments of the world to the effects ofmental health problems and substance abuse on the social well-being and physicalhealth of the worlds underserved populations. A first step is to increase awareness andconcern of the importance of mental health through a series of key high profile regionaland international events. Secondly, efforts will be devoted to building up the will of thekey political authorities to participate. Thirdly, and finally, efforts are to be directed atsecuring political commitments by decision-makers.

    To establish a number of demonstration projects in each of the six WHO regions of theworld. They are meant to illustrate the potential of collaborative efforts at country level,with the view of leading on to projects of a larger scale.

    To encourage technical support between countries for service development, researchand training.

    The implementation of the programme depends on voluntary contributions from governments,foundations, individuals and others. It receives financial and technical support from the EliLilly and Company Foundation, Johnson and Johnson European Philanthropy Committee,the Government of the United Kingdom of Great Britain and Northern Ireland, the Instituteof Psychiatry at the Maudsley Hospital of London (United Kingdom), the Free and HanseaticCity of Hamburg (Germany), the Villa Pini Foundation (Chieti, Italy), Columbia University(New York, USA), the Laboratoires Servier (Paris, France) and the International Foundationfor Mental Health and Neurosciences (Geneva, Switzerland).

    Further information on Nations for Mental Health can be obtained by contacting:

    Dr J.A. Costa e Silva, DirectorDivision of Mental Health and Prevention of Substance AbuseorDr B. Saraceno, Programme ManagerNations for Mental HealthDivision of Mental Health and Prevention of Substance AbuseWorld Health OrganizationCH 1211 Geneva 27, SwitzerlandE-mail: saracenob@who.chTelephone: (41) 22 791.36.03Fax: (41) 22 791.41.60



    WHO/MSA/NAM/97.6English onlyDistr.: General

    Schizophreniaandpublic healthAngelo Barbato

    Division of Mental Health andPrevention of Substance Abuse

    World Health OrganizationGeneva

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    World Health Organization, 1998

    This document is not a formal publication of theWorld Health Organization (WHO), and all rights are

    reserved by the Organization. The document may, however,be freely reviewed, abstracted, reproduced and translated,

    in part or in whole, but not for sale nor for usein conjunction with commercial purposes.

    The views expressed in documents by namedauthors are solely the responsibility of those authors.

    Designed by WHO Graphics

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    Preface v

    Chapter 1Introduction 1

    Chapter 2Clinical issues 2

    Diagnosis 2Clinical picture 4

    Chapter 3Epidemiology 6

    Incidence and prevalence 6Course and outcome 7

    Risk factors 9Comorbidity 10

    Chapter 4Consequences of schizophrenia 12

    Mortality 12Social disability 12

    Social stigma 13Impact on caregivers 14

    Social costs 14

    Chapter 5Prevention, treatment and care 16

    Preventive interventions 16Drugs 17

    Family interventions 21Other psychosocial interventions 22

    Chapter 6Service delivery 25

    Chapter 7Conclusion 27

    References 28

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  • vPreface

    The World Health Organization has established a new Action Programme onMental Health for Underserved Populations. This programme, called Nationsfor Mental Health, has been created to deal with the increasing burdens ofmental health and substance abuse worldwide. The main goal of the programmeis to improve the mental health and psychosocial well being of the worldsunderserved populations.

    Solutions to mental health and substance abuse problems entail a joint mobiliza-tion of social, economic and political forces as well as substantial changes ingovernmental policies related to education, health, and economic developmentin each country. This demands an intense and sustained effort from the nationsof the world through joint cooperation between governments, nongovern-mental organizations and the organizations within the United Nations system.The programme is of utmost importance to the work of WHO and WHO iswilling to lead and coordinate this ambitious task. Several international meetingsand launchings have been organized, in collaboration with other internationalorganizations and academic institutions. A number of demonstration projectsrelated to the programme have already been initiated in several countries. Theseprojects are meant to illustrate and/or demonstrate the potential of collabora-tive efforts at country level, with the view of leading on to projects of a larger scale.

    This document addresses important public health issues related to schizophrenia.It was written by Angelo Barbato, Centre Antonini, Milano, Italy.

    I am very pleased to present this document as part of the global process of raisingawareness and concern about the effects of mental health problems. It is hopedthat this important document will help support health ministers, ministry officials,and regional health planners whose task is to deliver and improve mental healthpolicy and services within a strategic context.

    Dr. J. A. Costa e SilvaDirectorDivision of Mental Health and Prevention of Substance Abuse (MSA)World Health Organization

  • 1Schizophrenia and public health

    Chapter 1Introduction

    The term schizophrenia was introduced into the medical language at thebeginning of this century by the Swiss psychiatrist Bleuler. It refers to a majormental disorder, or group of disorders, whose causes are still largely unknownand which involves a complex set of disturbances of thinking, perception,affect and social behaviour. So far, no society or culture anywhere in the worldhas been found free from schizophrenia and there is evidence that this puz-zling illness represents a serious public health problem.

  • Nations for Mental Health2

    Chapter 2Clinical issues

    2.1 Diagnosis

    In the absence of a biological marker, diagnosis of schizophrenia relies onexamination of mental state, usually through a clinical interview, and observa-tion of the patients behaviour. Table 1 shows the diagnostic guidelines ac-cording to the two major current classification systems.

    As can easily be seen, the two systems overlap to a considerable extent, whileretaining some differences. The ICD-10 represents a compromise betweenresearch findings and various diagnostic practices in different countries and isprobably better suited for worldwide utilization.

    Any approach to the diagnosis of schizophrenia should, however, take intoaccount the following:

    Current operationalized diagnostic systems, while undoubtedly very reliable,leave the question of validity unanswered in the absence of external validatingcriteria. Diagnosis of schizophrenia should therefore be considered a provisionaltool that organizes currently available scientific knowledge for practical pur-poses, but leaves the door open to future developments.

    Since the boundaries between schizophrenia and other psychotic disordersare ill-defined, differential diagnosis, particularly during the early stages, canbe difficult. No single sign or symptom is specific of schizophrenia so thediagnosis always requires clusters of symptoms to be recognized over aperiod of time. Careful standardized diagnostic assessment, while useful forresearch, may not be necessary in clinical practice.

    The diagnosis of schizophrenia does not carry enough information fortreatment planning. Symptoms suggestive of schizophrenia can be found ina number of neurological and psychiatric disorders. Therefore, differentialdiagnosis should consider the following conditions:

    epilepsy (particularly temporal lobe epilepsy); central nervous system neoplasms (particularly frontal or limbic); central nervous system traumas; central nervous system infections (particularly malaria and other parasitic

    diseases, neurosyphilis, herpes encephalitis); cerebrovascular accidents; other central nervous system diseases (leukodystrophy, Huntingtons

    disease, Wilsons disease, systemic lupus erythematosus etc.); drug-induced psychosis (especially related to use of amphetamines, LSD

    and phencyclidine); acute transient psychosis; affective disorder; delusional disorder.

  • 3Schizophrenia and public health

    Table 1. Diagnostic criteria for schizophrenia

    ICD-10 DSM-IV

    A. Characteristic symptoms: Two or more of thefollowing, each present for a significant portion of timeduring a 1-month period, or less if successfully treated:1) Delusions, 2) Hallucinations, 3) Disorganized speech,e.g. frequent derailment or incoherence, 4) Grosslydisorganized or catatonic behavior, 5) Negativesymptoms, i.e. affective flattening, alogia or avolition.

    Note: Only one criterion A symptom is required ifdelusions are bizarre or hallucinations consist of avoice keeping up a running commentary on thepersons behaviour or thoughts, or two or more voicesconversing with each other.

    B. Social/Occupational dysfunction. For a significantportion of the time since the onset of the disturbance,one or more major areas of functioning such as work,interpersonal relations, or self-care are markedly belowthe level achieved prior to the onset (or when the

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