Institute of Mental Health, West China University of Medical Sciences, Chengdu, China
Correspondence: Dr Maosheng Ran, Institute of Mental Health, First University Hospital, West China University of Medical Sciences, Xiaoxue Lu, No 7, Chengdu Sichuan 610041, China
Declaration of interest Funding from the China Medical Board of New York.
See invited commentary, p.
159, this issue.
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ABSTRACT |
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Aims This prospective study tests the hypothesis that the natural outcome of schizophrenia would be favourable in a Chinese rural area.
Method We investigated all patients with schizophrenia, including patients who had not received any treatment, among 149 231 rural community population in Xinjin County, Sichuan in 1994. Those patients who had never received treatment were followed up for two years.
Results Three-quarters of patients with schizophrenia who had not been treated remained symptomatic. As the duration of illness increased, the illness became more serious. The clinical outcome of the drug-treatment group was significantly better than for patients who had not received any treatment.
Conclusions The natural clinical outcome of schizophrenia in the Chinese rural community was poor, and occupational functioning of patients with schizophrenia was comparatively better. Schizophrenia itself has a specific natural course antipsychotic drug treatment and psychosocial treatment will produce an improvement in prognosis.
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INTRODUCTION |
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In contrast, other investigators reported that the evidence for a more favourable course in developing societies was not conclusive. Indeed, a favourable course has also been reported in various industrialised societies (Edgerton & Cohen, 1994). In order to identify the natural course of the illness and factors affecting it, we identified a prevalence sample of patients with schizophrenia from Xinjin County, Sichuan province and followed up those who had never received any treatment from March 1994 to April 1996.
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METHOD |
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Measurement
Widely used national epidemiological schedules and rating scales were used
to assess symptoms and social abilities. Standard instruments including the
Screening Schedule for Psychoses, Present State Examination (PSE-9, Chinese
translation), the General Psychiatric Interview Schedule and Summary Form
(including the project diagnosis), and the Social Disability Screening
Schedule (SDSS) were used (Shen &
Wang, 1985; Shen et
al, 1986; Cooper &
Sartorius, 1996). When positive answers were obtained for a
subject on the screening procedures for psychosis, a comprehensive general
psychiatric interview was then completed with that subject by an investigator
who was a member of the survey team. All the investigators were lecturers,
associate professors and professors of psychiatry. The senior professor
trained investigators, reviewed all ratings and completed ratings for many of
the patients. The mean percentage agreement on the Screening Schedule for
Psychoses, PSE-9 and SDSS on the ratings for 10 patients ranged from 80.5 to
99.0%. Kappa values between pairs of investigators ranged from 0.74 to 1.0.
Two main assessments were conducted, the first at the beginning of the study,
and the second at the end of the follow-up period.
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RESULTS |
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Treatment and management
Thirty of the 510 patients (5.9%) maintained regular antipsychotic
treatment (regular treatment group) for more than one year, and 156 (30.6%)
received no treatment at all (never-treated group). The others were treated by
a variety of agencies, including: trained practitioners of traditional Chinese
medicine (such as acupuncture and herbal remedies - traditional treatment
group), psychiatric hospitals, psychiatric out-patient clinics, and local
healers, but received irregular treatment or discontinued treatment (brief
and/or irregular treatment group), as shown in
Table 1.
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All the 510 patients were in the age range 15-95 years; the mean age, age of onset and duration of illness for the four groups of patients are shown in Table 2.
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The results indicated that the duration of illness in the regular treatment group was significantly shorter than that in the brief and/or irregular treatment, traditional treatment and never-treated groups.
Characteristics of patients who had never received treatment
Of the total 156 patients who had never been treated at all, 39.7% were
single, 41.7% were married, 8.3% were divorced, and 10.3% were widows or
widowers. This divorce rate is very much higher than that of the overall
Chinese sample in the Nationwide Epidemiological Survey, 1982 (<1%)
(Cooper & Sartorius, 1996). The gender ratio (male:female) was 1:0.93, and no significant difference was
found between the proportion of males (n=81, 51.9%) and females
(n=75, 48.1%; P>0.05). The marital status indicated that
the sample included more unmarried male patients (42.0%) than female patients
(4.0%; P<0.01); the mean (s.d.) number of people per household was
3.45 (1.50), and 34 patients (21.8%) lived alone. The rate of illiteracy or
those who had never attended school was 25.0%, 57.1% had attended primary
school and 17.9% had attended middle school. The socio-economic level of each
household was assessed: 5.8% were high, 32.0% were middle and 62.2% were low.
This indicated that most patients who had never received treatment were from a
poorer family background.
The reasons for not receiving treatment included: lack of money (n=55, 35.3%); relatives' uncertainty about the patients' illness (or not thinking the patient was suffering from mental illness) (n=46, 29.5%); patients' refusing to accept drug treatment (n=29, 18.6%); no relatives to care for patient (n=23, 14.7%); and local unavailability of medical facilities (n=3, 1.9%).
The 10 most frequent symptoms of schizophrenia in 156 patients (PSE-9 definitions) were: delusions of persecution (39.7%), apathy (34.0%), incongruency of affect (28.2%), splitting of thought (26.3%), withdrawal (24.4%), affectively neutral auditory hallucinations (21.2%), delusion of observation (21.2%), auditory hallucinations (commentary) (19.2%), poverty of thought (17.9%), and other delusions (15.4%).
Patients' ability to work
Among the patients who had never received treatment, the percentages of
patients who could do full- or part-time farm- or housework, or could do no
work were 32.1% (n=50), 45.5% (n=71) and 22.4%
(n=35), respectively.
Social disability
Among the patients with schizophrenia who had never received treatment,
there were 129 (82.7%) whose social ability was rated as being more than a
mild disability. Of the 129 patients, 69 (53.5%) were rated as having the most
seriously impaired social functioning, 19 (14.7%) were rated as serious, 14
cases (10.9%) were rated moderately impaired, and 27 cases (20.9%) were rated
as mildly impaired.
Suicidal thoughts and behaviour
Of the 156 patients who had not received treatment, seven had experienced
suicidal thoughts or behaviour during their illness history. The rate of
suicidal thought and behaviour was 4.5%. The prevalence of suicidal thoughts
and behaviour found in this study was not consistent with some previously
published reports in Western countries
(Black et al, 1985;
Landmark et al, 1987). Between 20% and 42% of patients with schizophrenia attempt suicide, and 10-15%
are successful in these studies. The results of our study were the same as
that found in a study in India (Verghese
et al, 1989). This might be caused by cultural
differences and differences in the groups of patients studied. In a rural area
of China, the patients with schizophrenia might endure less social pressure
and discrimination than in other places.
Baseline clinical status
The baseline clinical status of the 510 patients with schizophrenia is
shown in Table 3. The clinical
status in the regular treatment group was significantly better than that in
the brief and/or irregular treatment, traditional treatment, and never-treated
groups (P<0.05). No significant difference was found between the
brief and/or irregular treatment and traditional treatment groups in clinical
status. This result might be caused by the fact that none of the patients
maintained regular drug treatment in the brief and/or irregular treatment
group. Meanwhile, this result also supports the theory that the Chinese
traditional treatment group will have a slightly improved outcome. The
clinical status of the nevertreated group was the worst of the four groups
(P<0.001).
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Factors affecting outcome
For the 156 patients with schizophrenia who had never received treatment,
the study showed that patients' mean age, age of first onset, family history
of mental illness, marital status, psychosocial factors and their family care
state were not significantly related to the clinical outcome
(P>0.05) (see Table
4). There were 58.3% patients who had no partner or had not
married, and 37.8% of patients whose family care status was poor. All these
results showed that their social support state was not good.
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There was a significant difference in the natural clinical outcome between male and female patients (P<0.05). The female patients' clinical prognosis and rate of complete remission were better and higher than those of male patients. More male patients had marked symptoms and deteriorated.
Among those patients whose duration of illness was less than 1 year, there were five cases (35.7%) who recovered fully, and none deteriorated. For those patients whose duration of illness was more than 1 year, the percentage of complete remission was less than 7.6%, and deterioration more than 6.7%. The results strongly indicate that the longer the duration of the illness, the worse the patient's prognosis (P<0.05).
Outcome at follow-up
We followed up all the patients who had never received treatment for 2
years. We provided community mental health services in the pilot area, during
the follow-up period, and 55 people (35.3%) accepted treatment. Six patients
(3.8%) had died: one in an accident, two from physical diseases and three
because of poor care. Ninety-five (60.9%) still remained without
treatment.
Of 95 cases, 12 had recovered, while two patients relapsed during the 2-year follow-up. The relapse rate was 8.3% per year.
At the end of follow-up period, the clinical outcome of 95 patients with schizophrenia who had not received treatment showed that there were 10 patients (10.5%) whose illness was in complete remission, 11 patients (11.6%) whose illness was in partial remission, 68 patients (71.6%) whose illness still maintained marked symptoms, and six patients (6.3%) whose illness had deteriorated. There was no significant difference in clinical status between baseline (Time 1) and follow-up (Time 2) (P>0.05).
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DISCUSSION |
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Davis & Andriukaitis (1986) reported that the natural course of schizophrenia is poor in the absence of consistently effective and broadly applied treatment, about two-thirds of patients with schizophrenia remain symptomatic. The results of this study showed that 30.6% of patients with schizophrenia received no treatment at all among the population of people with schizophrenia in a rural area of China. The main reasons for not receiving treatment were lack of money and relatives not perceiving the patients to be suffering from a mental illness. For these patients, their mean age was older and duration of illness was longer than those receiving regular treatment. Most untreated patients (75.6%) continued to experience marked symptoms, and some (6.4%) experienced a further deterioration in their illness. Social functioning was damaged severely and social disability was quite strongly correlated with clinical outcome. Our original expectancy was that the natural course of schizophrenia would be favourable in a rural area of China. In every instance, however, the results also supported the conclusion that the natural course of schizophrenia, especially clinical outcome, was poor - even in a Chinese rural area. Compared with patients who received treatment for schizophrenia, the results of this study still suggested that the natural outcome of schizophrenia was heterogeneous and poor in the rural area studied. Antipsychotic drug treatment, particularly when received regularly, may be very important in improving the prognosis of these patients.
Belitsky & McGlashan (1993) once reported that there was strong evidence that deterioration in schizophrenia generally occurs earlier rather than later in the disorder's natural history and is typically not relentlessly progressive. Schizophrenia with many negative symptoms has been thought to be associated with poor premorbid functioning, insidious onset and partial or no remissions during the first several years of illness, and in most cases a progressive course leading to permanent disability. Patients with the poorest long-term out-come tend to show an increase in negative symptoms during the early years of their illness (Fenton & McGlashan, 1991). Wyatt (1991) showed that early intervention with neuroleptics in patients with first-episode schizophrenia increased the likelihood of an improved long-term course. In our study, we found that no patients deteriorated in the first year. Deterioration developed gradually after 1 year. The deterioration rate was maintained at a specific level, and did not increase significantly after 2 years. This result indicates that not all patients with schizophrenia will experience deterioration in their mental health by the end of the illness. Schizophrenia remains a severe disorder that can be chronic and, in a proportion of patients, unremitting throughout life. Therefore, intervention for schizophrenia, including psychosocial intervention and medication, should occur during the early stages of the illness.
A gender effect on the course of illness has been suggested in this study. Females had a significantly better clinical outcome than males (P<0.05). That women had a better outcome than men, was also reported in India (Verghese et al, 1989). Oestrogen has been thought to play a protective, that is, neuroleptic-like, role in the disease process of schizophrenia, resulting from a hypothesised antidopaminergic effect that could delay the development of the illness (Seeman, 1982; Seeman & Lang, 1990). Bilder et al (1992) used the hold test of the Wechsler Adult Intelligence Test-Revised to determine the degree of intellectual deterioration in schizophrenia and found significantly greater deterioration among men than women. Apart from biological factors, we consider that culture might have an effect on this result. Females in Chinese rural areas take on most of the housework, taking care of their children, and some farm work, despite suffering from schizophrenia. We suggest that working and exercising social functioning in patients with schizophrenia has a strong effect on preventing deterioration and improving the prognosis of the illness.
Even though 82.1% of patients still retained marked symptoms, 77.6% of the patients in the never-treated group could still do full- or part-time work. The occupational functioning of these patients was comparatively good. This result shows that any decrease in work ability caused by the illness did not correspond with the severity of symptoms of the illness. The patients who had marked psychotic symptoms could still do general housework or farm work in the rural area. Therefore, even patients who have psychotic symptoms should not be restricted in work. The importance of work as a prognostic variable was also reported in another Indian study (Kulhara et al, 1989).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication April 12, 1999. Revision received April 12, 1999. Accepted for publication June 22, 1999.