Antho330: Textbook Notes: Chapter 2

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in 1967, WHO initiated set of studies investigating the manifestation, consequences and course of

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schizophrenia and related disorders

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Two main studies

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International Pilot Study of Schizophrenia (IPSS)

Determinants of Outcome of Severe Mental Disorder (DOSMel)

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people in West ___________ outcomes than counterparts in developing countries

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less favourable

found over time

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analytical adequacy of developed vs. developing questioned

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with so many researchers + over time - diagnostic ambiguities invariability intrude

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What accounts for the apparent benefits of underdeveloped remained

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mysterious - though speculation has ranged greatly

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ISoS study:

address at least the question of

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outcome over time

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Follow up interviews of both the original

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IPSS and DOSMed cohort and other groups of groups of subjects

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this chapter examines the durability of that findings of a distinct advantage in

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course and outcome for developing countries

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Both is this finding real and how good is this evidence?

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,

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focus is on course and outcome for the combined ________ chart of ISoS - subjects followed since first treated episode

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incidence

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Asks two questions

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do results of WHO studies of schizophrenia support the case for taking culture seriously in assessing the course and outcome of it

what guidance do they offer to investigators seeking to take the measure of cultural influence and identify likely vehicles of its effects

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Uses of Culture in the WHO Collaborative Studies of Schizophrenia:

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.

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task of mounting an international cross cultural psychiatric research project is primarily for a

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clinical audience

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argues that the historical curiosities in the West

large extended families, in relatively self-sufficient communities, flexible and accommodating work roles unchecked by educational or skill requirements, undifferentiated notions of mental illness that overlap with religious and magical beliefs are still

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ital parts of 3rd world cultures and may help explain the favourable picture of schizophrenia seen there

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For the most part “culture” in WHOstudies : seen as

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synonym for specific place

can lead to troubling language/phrasing

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how culture should be measured is still

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a vexing question

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culture in WHO literature used to refer to

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“there” as opposed to “here”

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lead to convention of

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developing vs. developed

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some anthropological critiques may be owing in part to what is misperceived as the substitution of

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geographical space (location) for cultural space (toolkit of beliefs, practices, notions, and things held dear)

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how culture makes its appearance in WHO studies

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uneven and disappointingly thin

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Descriptions of Agra + Ibadan: two centres with highly favourable outcomes

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condescending pointing out that things like local medicines/traditions are not as good

filled with internal tensions:

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DOSMeD deisgned to further inquire into the

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effect of culture on Schizo

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Findings

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developing did better than developed centers

culture recedes into -> geographic area but bring it back

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note that neither IPSS nor DOSMeD was designed to penetrate in

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sufficient depth below surface on which the impact of this unknown factor was established

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for most part, culture is everywhere in the WHO studies - but how its presence is registered ranges

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from mysterious to the subtly substantial

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Bias that creeps into prevalence study of schizophrenia owing simply to local treatment centres

Irregularities in sampling in IPSS: resulted in the inclusion of more patients with _________ in developed centres

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long histories of schizoprenia

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Converse bais

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extent that ease of access affects the threshold at which families etc. report to psychiatric facilities there should be profound differences in the mix of cases brought to clinical attention

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When threatholds of accessibility are high and local alternatives exist may decide it makes

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practical sense to triage informally all but the most recalcitrant cases

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Bias to both

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entry and course of illness

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When Attention was Paid: Explicit Attempts to take culture into account: Section

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.

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three subsidies of DOSMed tried take culture seriously in specific domains of “risk”

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the role of expressed emotion among relatives of those diagnosed

the role of stressful life events in precipitating psychoses

the cultural shaping of the expression of psychoses

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expressed emotion: some cross cultural differences in distribution and covariance of the elements of EE within

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Western cohorts and between rural Indian families

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documented lower EE in

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Indian relatives (may help explain favourable short term outcome)

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documenting of these variables is

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labor intensive and extreme

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ISoS - Promise and Limits: meaning

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international study of schizophrenia

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Limitations

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.

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as a follow up study ISOS is heir to the faults and hostage to the blindspots of its

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germinal studies - methodological problems

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micro sociology of knowledge production on an

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international collaborative research project + inherited methodological deficiencies

not a lot of social scientists in the group overall

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fallback effort to collect information on social factors -

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family participation in treatment - stigma, and attitudes was the final instrument added and the one least consistently use

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dangerous in relying on

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self appointed experts on custom and belief (reliable informants or that local cultures are relatively coherent and uniform)

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without extensive documentation don’t know if people fall into range of

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acceptable variation by local cultural standards

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diagnostic terminology: used

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common psychopathology assessment tool

Present sState Exam - supplemented by others

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conceptually how “objective” can the term schizo really be?

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"disciplinary objectivity" - not universal criteria of validity but particular, yet still authoritative disciplinary criteria

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Three Findings

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the developed vs. developing differential in course and outcome is constant:

the differential holds for a variety of course and outcome indicators in the ISOS

potential sources of bias and confounding can’t explain the ISOS findings:

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the developed vs. developing differential in course and outcome is constant:

consistent outcome differential favouring developing enters for

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all three WHO projects

holds for brief and long term

for various diagnostic groups for different country groups etc.

relatively constant

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the differential holds for a variety of course and outcome indicators in the ISOS

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holds for general clinical state

symptomatgology

disability

social functioning

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the differential holds for a variety of course and outcome indicators in the ISOS

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.

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attrition: loss to follow up rates were comparable for the two groups and differences in morality were small -

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chances of being retained in the study better for subjects in the developed world than their counterparts

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questionable groupings:

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ex: moving of Hong Kong to developed - only changes difference a little

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diagnostic ambiguities: NARP a misdiagnosis of schizophrenia with a markedly better prognosis could explain the developing advantage - failed to pan out

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NARP was more common among cases labeled schizophrenia in developing world

the difference NARP made in improving chances of recovery was greater in developed world

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inappropriate outcome measures: certain measures of outcomes like hospitalization not an elastic indicator of need met could conceivably skew findings

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gender and age

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women enjor small advantage over men - larger effect in developed world

rates favor subjects over 40 at the time of follow up ranks of developing centres are disproportionately young

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in summary none of these potential sources or bias can explain

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long term course findings

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Time plays a role

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those characterized by a remitting course are much better in the developing world

but delayed advantage is apparent among those subjects whose early illness course was unfavourable (more in developing world would recover)

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Reclaiming Culture: Section

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.

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logistical difficulties and local turmoil prevented two of the original cast of

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developing countries from participating in ISOS follow up

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its intent is to urge researchers to seek the vital signs of living culture locally - at the level

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documented practice rather than ecologically at the level of reputed habitat

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Ex: different roles of the same variable _____ may play in mediating course and outcome in ISOS

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family -

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In Chandigarh: favourable outcomes - some have attributed to

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lack of emotional over involvement and paucity of critical comments in family environments

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in Sofia: poor results some attribute to high-level of family

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involvement in ongoing care - reflects cultural factors

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in Moscow: investigator suspects that follow up cohort may be biased in direction of

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better outcome

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variant expressions of family - if able to document this it would

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thicken the epidemiological story

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how psychosis it affects marriage: in India

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odds of marriage of ISOS Indian cohort at follow up 3:1 ( much higher)

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For developed centres

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for developed countries 3:5

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high martial success in India (for people w/schizo) due to

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dharma, children, continuity of lineage

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Throughout india martial rates of _____ among middle aged adults are the norm

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90-95%

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martial inclusion to disabled members is a gesture of

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support + cultural dissonance (as they have big stigma against mental illness)

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Good outcomes especially with measures of

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social recovery

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DOSMed offer evidence for the protective effect of marriage in

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delaying the onset of psychosis - resiliency of relationship may bear upon prospects of recovery

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But for marriage to endure it is an

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adaptive capacity of relationship practical and emotional support and resiliency

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China parent negotiate matrimony on

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behalf of schizo kids

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Disability India Journal:

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mother finds match for daughter - another affected family

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how cultural lessons could be applied elsewhere

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is anything but clear

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can’t prescribe marriage as

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adjunctive therapy

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maybe re-examining circumstances under which people with psychiatric histories are

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encouraged to seek life partners

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practice of partical knowledge

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improvisation upon received ways of thinking and doing may also be a vital aspect of the work of recovery as practiced by troubles selves and supported by well placed others