Recovery From Schizophrenia: Psychiatry And Political Economy

THE POLITICAL ECONOMY OF SCHIZOPHRENIA 199We have to be cautious, however. Historical information faces the sameproblem as present-day Third World data—the low incidence rates, in eachinstance, may be a result of restricted access to treatment, and the low prevalencerates may be due to the same problem and to higher death rates and more rapidrecovery of people with the illness. They may bear relatively little relationship tothe actual occurrence of new cases during the period in question. On balance, itseems quite probable that schizophrenia did become more prevalent during thenineteenth century, presumably in response to socioenvironmental changesassociated with the Industrial Revolution; possible biological mediatingmechanisms include nutritional, immunological and infectious causes.IS THE INCIDENCE OF SCHIZOPHRENIA ON THEDECLINE?A number of researchers have pointed out that the incidence of schizophrenianow appears to be on the decline. The studies that examine changes in theincidence of schizophrenia since 1960 are listed in Table 9.1. 16 About threequartersof these studies indicate a decrease in the incidence of the illness since1960, and about a quarter reveal no change or an increase. All of the studies relyupon data gathered from treatment services, counting patients diagnosed assuffering from schizophrenia who are admitted or making treatment contact forthe first time; the figures are age-standardized in only a few instances. Theobserved changes could be artifacts, therefore, rather than true changes in theoccurrence of schizophrenia.It is possible, for example, that a diagnostic shift from schizophrenia toanother diagnostic category could account for a decrease in the observedoccurrence of schizophrenia. 17 Australian psychiatrist Gordon Parker and his coworkers,found that the decrease in the treated incidence of schizophrenia in NewSouth Wales was accompanied by an increase in the diagnosis of manic-depressiveillness following the introduction of lithium carbonate. 18 Some other studies showa similar increase in the prevalence of affective psychoses, 19 but many do not.One study provides quite strong evidence that the changing incidence ofschizophrenia is an artifact resulting from a diagnostic shift. Researchers inEdinburgh, Scotland, have found that the proportion of patients who werediagnosed as suffering from schizophrenia by hospital psychiatrists at the time offirst admission decreased by 22 per cent between 1971 and 1989. When diagnosesfor these patients were made according to a computer algorithm, however, therewas no such decline; in fact there was a small increase in the proportion diagnosedwith schizophrenia. 20Another source of error may arise from an increase in the number of casesmissed by traditional treatment-based statistics. 21 It is likely that the increased useof antipsychotic drugs treatment has led to a greater number of people withpsychotic disorders in Europe and elsewhere being treated successfully by generalpractitioners. These people, consequently, may never be referred to any type of