The WHO IPSS paradox study

This is the study which shows people in developing world countries with
schizophrenia can do better than those in developed world countries.

Sartorius, J. et al. 1992, The International Pilot Study of
Schizophrenia: five year follow-up findings, Psychological Medicine

http://www.madinamerica.com/madinamerica.com/Schizophrenia_files/who1.pdf

This study, for people who consider social psychiatry, is both
significant and important. It is another example of how society and
culture interacts with the 'illness'. This is the second study on the
IPSS data.

The result seems unequivocal but, as with any research, there's areas
where the quality of the findings can be questioned. In this study it is
very difficult since a significant amount of effort has gone into the
design. Inter-rated reliability is 0.75 which means 25% of the time the
different people rating a person's level of impairment (in a very
simplistic way necessitated by the problem of low agreement on
prognosis) didn't agree. This may have worsened over time and the
authors assume this drift may not cause a systemic error but it's an
assumption. The study alsouses a very broad diagnosis of schizophrenia.
First admissions and readmissions were also used. These do take away
from the study except for the power of the effect of the variable of
where the person was. There were other factors too.

The paper references and mentions a few other World Health Organisation
studies which show the same result: in some developing world countries
people with schizophrenia are doing significantly better than in
developed world countries.

There's a startling and grim figure. At least 4.9% of all people in the
study killed themselves within 5 years of their diagnosis. Though not
noted in the study I think a lot of these deaths would have been in the
first six months.

There is one bit that leapt out at me. Of all the predictors it was
developing world/developed world which was most significant but the
study also found negative life experiences prior to illness were
associated with better clinical and social outcomes.

Sadly the authors haven't sought to explore how cultural and social
factors affect outcomes. I think later studies such as the WHO
determinants one will elucidate further. They caveat with "it is
possible" rather than a stronger term in their last line and cite little
evidence to support it in their conclusion.