CLINICAL HANDBOOK OF SCHIZOPHRENIA

552 VII. POLICY, LEGAL, AND SOCIAL ISSUEScompetitive society, and several such psychosocial factors are considered to contributethis apparently superior outcome. Culture-based explanations have not been extensivelystudied, but it is accepted that cultural norms often provide explanations and promotemore optimistic stances. Supernatural causes (possession, “evil eye”), alternative explanationfor behavioral changes (isolation as a way to avoid being cursed), and more sociallytolerant stances based on these explanations often play critical roles in destigmatizingmental illness, which may be a key factor in these outcomes.A body of literature contests the existence of the “developing” versus “developed”world divide in schizophrenia outcomes, citing methodological flaws in the IPSS study designas potential sources of bias, but there is not enough evidence either to revalidate thisfinding soundly or, indeed, to disprove it.The Need for More Local StudiesIt is important to note that no evidence currently links the etiology of schizophrenia tocultural or social factors. In light of this, the fact that culture affects outcome suggeststhat there is much to learn about the role of specific cultures in schizophrenia. These culturalfactors have intricate links to schizophrenia, and it may not be possible to examinethis in a broad, global study. It has often been pointed out that the aforementioned IPSS,DOSMD, and IsoS all aimed at studying schizophrenia from a “Western” perspective,and this may not be the ideal perspective to identify the interplay of culture and schizophrenia.Several small studies in Africa, India, and South America have looked at this, butmore literature is necessary. Indeed, there may be valuable lessons in this form of activityfor the entire global community.TREATING SCHIZOPHRENIA IN THE DEVELOPING WORLDIn addition to sociocultural attitudes influencing perception of both psychiatry andschizophrenia, there are unique challenges to overcome in addressing the issue of mentalhealth in the developing world. Two major factors tend to be shortage of adequatelytrained staff (especially in rural areas) and poor access to available services. The treatmentgap for schizophrenia tends to be exaggerated in rural areas in developing nations.Given the socioeconomic diversity in different parts of the world, it has been difficult tocreate a care model that can be meaningfully generalized.A strategy that has been employed in multiple areas is a decentralized system of mentalhealth care that involves setting up community-based outreach programs. This remainsthe most extensively implemented and studied model worldwide, with historicalorigins in the “barefoot doctor” system of care practiced in China from 1967 to 1981,where specialized training is provided to volunteer outreach workers who are not medicalprofessionals. Identification of illness and referral to appropriate care is done by theseworkers. They also perform the critical task of educating patients and families about thenature of the illness. This has proven to be an effective tool for identifying untreatedschizophrenia and ensuring compliance to medication once care is received. An adaptationof this model has been well studied in India, where “multipurpose health workers”are trained to identify mental illness and to refer patients to primary health centers(PHCs), where they have access to medical professionals and, if necessary, specializedpsychiatric care via referral to district health care centers. This model was found to significantlyreduce symptoms of psychosis, family burden, and disability. Increased costs of