Recovery From Schizophrenia: Psychiatry And Political Economy

THE POLITICAL ECONOMY OF SCHIZOPHRENIA 201psychiatric treatment agency or included in service-based incidence statistics. 22Similarly, more people with psychotic illness these days may escape any kind oftreatment and, instead, lead eccentric, reclusive lives, live as vagrants, stay inshelters for the homeless or get arrested and jailed. An incidence study ofschizophrenia in Nottingham, England, 23 for instance, found that ten per cent ofthe sample of cases that were ultimately detected were missed by the originalscreening procedure as they were only fleetingly in contact with the treatmentfacilities; further cases with no contact at all with the formal psychiatric treatmentsystem would have escaped detection altogether.If there is, in fact, any true decrease in the incidence of schizophrenia, thefinding could give us important clues as to the causes of the illness. Possiblebiological mechanisms would include a decrease in the fertility of people withschizophrenia, a change in the population’s immunity to an infectious agent, anda decrease in brain damage resulting from improvements in obstetric care.It is not likely that there has been a recent decrease in the fertility of peoplewith schizophrenia. For the incidence of schizophrenia to decrease throughoutthe 1970s, it would have been necessary for a change in fertility in schizophreniato have been in effect through the 1950s. The decrease in the use of hospitalconfinement for people with mental illness, which began in many countries in themid-1950s, makes it more likely that fertility has been increasing rather thandecreasing among people with schizophrenia. The fertility of patients withschizophrenia, moreover, is unlikely to have a major impact on the incidence ofthe illness because only 11 per cent of people with schizophrenia have a parentwith the illness. 24Changes in hygiene have produced changes in the general populationimmunity to various infectious agents. Poliomyelitis is an example of an illnesswhose prevalence increased with industrialization as a result of changes in hygiene;improvements in sanitation delayed exposure to the poliovirus until later in life,when the virus is more dangerous. 25 Similar changes in immunity or exposure toviral infection might account for the reported changes in the prevalence ofschizophrenia.Developments in obstetric practice may similarly account for the observedchanges in the incidence of schizophrenia. The postwar decline in early neonatalmortality rates in England and Wales is paralleled by the subsequent fall—20 yearslater—in the first-admission rate for schizophrenia in the 1960s and 1970s. 26 Thispossibility is discussed at greater length below.In summary, schizophrenia may or may not be on the decline in Westernindustrial countries. If it is, possible underlying biological mechanisms wouldinclude changes in immunity to an infectious agent or improvements in obstetriccare. Next we should look at the remaining element of the complex pattern ofchanging occurrence of the illness over time—changes in the rate of occurrence ofthe illness in different social classes.