CLINICAL HANDBOOK OF SCHIZOPHRENIA

53. Schizophrenia in Developing Countries 551mental illness being a curse or punishment for wrongdoings in a past life, past deeds, badparenting, or a form of divine punishment. Issues related to the stigma of mental illnesshave far-reaching social consequences and necessitate persuasive skills of psychiatrists tosoothe the suffering families, whose children may not find spouses or business partners.RESEARCHThe Importance of Studying Schizophrenia across the GlobeHistorically, science initially needed to substantiate the notion that schizophrenia was indeeda biological entity, and that this could be accomplished by establishing the prevalenceof schizophrenia across cultures and nations. Additionally, for the purpose ofstrengthening the reliability and validity of psychiatric diagnosis, it was important to testprevailing taxonomic systems globally. In addition, schizophrenia was, and remains, asource of significant burden on individuals with the ailment, and their families and communities.It was a large enough problem to merit investigation to facilitate a better understandingof the illness.There remains a need for localized research studies within communities, especiallywithin the developing world, by researchers from the same culture/geographical region,who can more reliably seek to explain the interplay between illness, socioeconomics, andculture. The application of this information into a broader global perspective will be thenext major step in enhancing our knowledge of this enigmatic universal condition.International Collaborative StudiesOver the years, the WHO organized two trend-setting studies—the International PilotStudy of Schizophrenia (IPSS) and the Determinants of Outcome of Severe Mental Disorder(DOSMD). The IPSS, a groundbreaking study initiated jointly by the WHO and theNational Institute of Mental Health (NIMH) in 1967, brought together researchers fromnine countries across the “developed” and the “developing” world. The research teamsstudied progress of schizophrenia across multiple cultures, and compared outcomes in thenine centers for the study. This pioneering study was considered a model for successful internationalcross-cultural collaboration.The IPSS revealed multiple highly consequential and even controversial findings. Itshowed almost universally better outcomes in all outcome measures in the developingworld. IPSS findings have led to much investigation worldwide to establish this pattern,and several scholars have proposed hypotheses in an attempt to explain this pattern. Initially,this finding was considered by many to be counterintuitive given the more sophisticatedhealth care available in the developed world. The WHO has reviewed the IPSS dataat intervals to study whether this “developed” versus “developing” divide persists. It alsolaunched the DOSMD, a 10-center international study that confirmed IPSS findings andoffered culture-based explanations. The WHO has also launched the more recent InternationalStudy of Schizophrenia (IsoS), which used many of the patients studied in theDOSMD.Proposed Explanations for Better Outcomesin the Developing WorldThis remains a controversial topic, with no universally accepted explanation. Early deathof the more seriously ill, genetic heterogeneity, social tolerance, better family support, less