What Did the WHO Studies Really Find?

The article by Cohen et al. raises important issues and provides a useful synopsis of published studies on schizophrenia outcomes in 11 lowand middle-income countries. The authors use this material to challenge what they claim to be an ‘‘axiom’’ (ie, a self-evident proposition requiring no proof) of better course and outcome in developing countries which has been ‘‘embraced’’ by international psychiatry. They impute the origin of this belief primarily to World Health Organization (WHO)–led international collaborative research conducted over the past 30 years and caution that the publication of the final report from the International Study of Schizophrenia (ISoS) might even further bolster convictions in the ‘‘better prognosis’’ hypothesis. Based on evidence from research conducted outside the WHO studies, they conduct a reexamination of the axiom. Having been directly involved with the WHO schizophrenia research program over decades, we wish to point out that Cohen et al have misunderstood key aspects of the design and conclusions of the WHO studies. They claim that ‘‘the sampling methods utilized in the WHO studies may have resulted in overly optimistic perceptions of course and outcome’’ because ‘‘case-finding methods which focus exclusively on help-seeking agencies will miss large proportions of seriously ill, poor prognosis individuals.’’ They state, mistakenly, that the WHO studies provide no evidence allowing an evaluation of ‘‘the quality of family and social interactions,’’ and impute to them by implicating a view that ‘‘scarcity’’ of care resources is responsible for better outcomes. Because these claims repeat an earlier critique of the WHO 10-country study (Determinants of Outcome of Severe Mental Disorders [DOSMeD]) by Edgerton and Cohen in 1994, which was answered by us in a publication not quoted in the present article, we summarize briefly the relevant features, findings, and conclusions of that study. An unexpected finding of the follow-up stage of the WHO International Pilot Study of Schizophrenia (IPSS) was a markedly better overall outcome of schizophrenia patients in India and Nigeria at 2-year and 5-year follow-up. Because the IPSS cohort was not necessarily representative and the finding could be an artifact of selection, a second, epidemiologically designed study was launched in the early 1980s. DOSMeD was the first large-scale study in which a unified design, stringent methods, and standardized instruments were concurrently applied to first-episode incident cohorts (total study population = 1379) at 12 research sites in diverse sociocultural settings (Colombia, Czechoslovakia, Denmark, India, Ireland, Japan, Nigeria, Russia, United Kingdom, and United States). The cohorts were recruited by 2-year active case finding within defined geographical areas, aiming to intercept all new onsets at all kind of facilities—not just mental health services, but including primary care, police/prisons, traditional healers, and religious shrines (notably, 28% of the cases in India and Nigeria were recruited through such ‘‘alternative’’ care sources). For 86% of the cases, the duration of untreated psychosis was less than 1 year, and only 10% had been prescribed antipsychotic drugs prior to entry into the study. Repeated ‘‘leakage’’ checks on the completeness of case finding found that only a handful of incident cases had been missed by this technique, thus categorically ruling out an ascertainment bias favoring inclusion of milder or good prognosis cases. Patients and key informants were interviewed at baseline and at 1-year and 2-year follow-up (78.2% of the cohort), and a large proportion of the original cohort was traced and assessed again at 15 years (as part of the ISoS) in 8 of the 12 field research centers. Throughout the study, high intraand intercenter reliability of assessment using the Present State Examination (PSE) was maintained by joint rating of live and prerecorded interviews. Diagnostic stringency was ensured by processing of the PSE data using a computerized diagnostic algorithm. During the first 2 years, nested studies were conducted on the impact of potential precipitants of psychotic relapse: stressful life events (in 10 of the centers) and expressed emotion (in Chandigarh, India). These studies did provide important information on family and social interactions. Operationally defined measures of course and outcome included 1 categorical To whom correspondence should be addressed; tel: 618-92240290; fax: 618-9224-0285; e-mail: [email protected] Schizophrenia Bulletin vol. 34 no. 2 pp. 253–255, 2008 doi:10.1093/schbul/sbm151 Advance Access publication on January 18, 2008