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The Social Determinants of Schizophrenia: An African Journey in Social Epidemiology
Public Health Reviewsvolume 34, Article number: 8 (2012)
The epidemiology of schizophrenia in developing countries, and especially in Africa, is controversial. One of the major findings of the World Health Organization multisite studies of schizophrenia conducted during the 1970s–1990s was that outcome of schizophrenia was better in developing countries. More recent research suggests this may not be the case in contemporary Africa. Rapid urbanization, industrialization, migration, conflict and ongoing poverty and deprivation characterize most of sub-Saharan Africa in recent decades; and it is likely that these potent risk factors for psychosis have contributed to shifts in the social epidemiology of psychosis and schizophrenia in that continent. In studying the epidemiology of schizophrenia, it is also necessary to examine evidence on first-episode psychosis (FEP) since it is often difficult to confirm a diagnosis of schizophrenia at onset. The author reviews nearly 50 years of epidemiological research on psychosis and schizophrenia in Africa; and argues that novel and flexible methods are required in contemporary efforts to study schizophrenia in the region. Specific contexts require specific approaches that are relevant and sensitive to local political, socio-economic and cultural conditions and dynamics. The future role of social epidemiology in helping clarify the burden, risk factors and natural history of schizophrenia within Africa depends largely on its success in integrating classic approaches with novel methods that are relevant to the specific socio-economic, political and cultural transformations taking place on that continent.
Dubos R. Man Adapting. New Haven, CT: Yale University Press; 1965. p. 236–7.
Lambo TA. Further neuropsychiatric observations in Nigeria, with comments on the need for epidemiological study in Africa. Br Med J. 1960;2:1696–704.
Guinness EA. Patterns of mental illness in the early stages of urbanization. Introduction. Br J Psychiatry Suppl. 1992;16:4–11.
World Health Organization. International Pilot Study of Schizophrenia. Geneva: WHO; 1973.
Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992;22: 131–45.
León CA. Clinical course and outcome of schizophrenia in Cali, Columbia: a 10-year follow-up study. J Nerv Ment Dis. 1989;177:593–606.
Dube KC, Kumar N, Dube S. Long term course and outcome of the Agra cases in the International Pilot Study of Schizophrenia. Acta Psychiatr Scand. 1984;70:170–9.
Carpenter WT, Strauss JS. The prediction of outcome in schizophrenia IV: eleven-year follow-up of the Washington IPSS cohort. J Nerv Ment Dis. 1991;179:517–25.
Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1–97.
Harrison G, Hopper K, Craig T, Laska E, Siegel C, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br J Psychiatry. 2001;178:506–17.
Hopper K, Harrison G, Janca A, Sartorius N (editors). Recovery from Schizophrenia: An International Perspective. Oxford: Oxford University Press; 2007.
Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative follow-up project. Schizophr Bull. 2000;26:835–46.
Cohen A. Prognosis for schizophrenia in the Third World: a reevaluation of cross-cultural research. Cult Med Psychiatry. 1992;16:53–75.
Edgerton RB, Cohen A. Culture and schizophrenia: the DOSMeD challenge. Br J Psychiatry. 1994;164:222–31.
Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008;34:229–44.
Warner R. Commentary on Cohen, “Prognosis for schizophrenia in the Third World.” Cult Med Psychiatry. 1992;16:85–8.
Jablensky A, Sartorius N, Cooper JE, Anker M, Korten A, Bertelsen A. Culture and schizophrenia: criticisms of WHO studies are answered. Br J Psychiatry. 1994;165:434–6.
Bresnahan M, Menezes P, Varma V, Susser E. Geographical variation in incidence, course and outcome of schizophrenia: a comparison of developing and developed countries. In: Murray RM, Jones PB, Susser E, van Os J, Cannon M (editors). The Epidemiology of Schizophrenia. Cambridge: Cambridge University Press; 2003.
Susser E, Collins P, Schanzer B, Varma VK, Gittelman M. Topics for our times: can we learn from the care of persons with mental illness in developing countries? Am J Public Health. 1996;86:926–8.
Leff J, Wig NN, Ghosh A, Bedi H, Menon DK, et al. Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. Br J Psychiatry. 1987;151:166–173.
Warner R. Recovery from Schizophrenia: Psychiatry and Political Economy. London: Routledge & Kegan Paul; 1985.
Gureje O. Psychiatry in Africa: the myths, the exotic, and the realities. S African Psychiatry Rev. 2007;10:11–4.
Lauber C, Rössler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry. 2007;19:157–78.
Kebede D, Alem A, Shibre T, Negash A, Fekadu A, et al. Onset and clinical course of schizophrenia in Butajira-Ethiopia — a community-based study. Soc Psychiatry Psychiatr Epidemiol. 2003;38:625–31.
Shibre T, Kebede D, Alem A, Negash A, Kibreab S, et al. An evaluation of two screening methods to identify cases with schizophrenia and affective disorders in a community survey in rural Ethiopia. Int J Soc Psychiatry. 2002; 48:200–8.
Kebede D, Alem A, Shibre T, Negash A, Deyassa N, Beyero T. The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia. Schizophr Res. 2004;69:133–41.
Teferra S, Shibre T, Fekadu A, Medhin G, Wakwoya A, et al. Five-year mortality in a cohort of people with schizophrenia in Ethiopia. BMC Psychiatry. 2011; 11:165.
Teferra S, Shibre T, Fekadu A, Medhin G, Wakwoya A, et al. Five-year clinical course and outcome of schizophrenia in Ethiopia. Schizophr Res 2012;136: 137–42.
Kebede D, Alem A, Shibre T, Negash A, Deyassa N, et al. Short-term symptomatic and functional outcomes of schizophrenia in Butajira, Ethiopia. Schizophr Res 2005;78:171–85.
Alem A, Kebede D, Fekadu A, Shibre T, Fekadu D, et al. Clinical course and outcome of schizophrenia in a predominantly treatment-naïve cohort in rural Ethiopia. Schizophr Res 2009;35:646–54.
Novick D, Haro JM, Hong, J, Brugnoli R, Lepine JP, et al. Regional differences in treatment response and three year course of schizophrenia across the world. J Psychiatr Res. 2012;46:856–64.
Burns JK. The mental health gap in South Africa: a human rights issue. Equal Rights Rev. 2011;6:99–114.
United Nations. World Urbanization Prospects: The 2001 Revision. New York NY: Department of Economic and Social Affairs, Population Division; 2002.
Burns JK, Esterhuizen T. Poverty, inequality and the treated incidence of first-episode psychosis–an ecological study from South Africa. Soc Psychiatry Psychiatr Epidemiol. 2008;43:331–5.
Kirkbride JB, Errazuriz A, Croudace TJ, Morgan C, Jackson D, et al. Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and meta-analyses. PLoS One. 2012;7:e31660.
Burns JK, Jhazbhay K, Emsley RA. Causal attributions, pathway to care and first-episode psychosis: a South African perspective. Int J Soc Psychiatry. 2011;57:538–45.
Burns JK, Kirkbride JB. Social capital, pathway to care and duration of untreated psychosis: findings from a low and middle income country context. S Afr J Psychiatry. (under review).
Burns JK. Unpublished data.
Anderson BA, Phillips HE. Adult mortality (age 15–64) based on death notification data in South Africa: 1997–2004. Report No. 03-09-05. Pretoria: Statistics South Africa; 2006.
UN-HABITAT. State of the World’s Cities: Trends in Sub-Saharan Africa, Urbanization & Metropolitanization. Available from URL: http://ww2.unhabitat.org/mediacentre/documents/sowc/RegionalAfrica.pdf (accessed 4 August 2012).
Peen J, Dekker J, Schoevers RA, Have MT, de Graaf R, Beekman AT. Is the prevalence of psychiatric disorders associated with urbanization? Soc Psychiatry Psychiatr Epidemiol. 2007;42:984–9.
Peen J, Scheovers RA, Beekman AT, Dekker J. The current status of urban-rural differences in psychiatric disorders. Acta Psychiatr Scand. 2010;121:84–93.
Van Os J, Hanssen M, Bijl RV, Vollebergh W. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry. 2001;58:663–8.
Pedersen CB, Mortensen PB. Evidence of a dose-response relationship between urbanicity during upbringing and schizophrenia risk. Arch Gen Psychiatry. 2001;58:1039–46.
Van Son GE, van Hoeken D, Bartelds AI, van Furth EF, Hoek HW. Urbanization and the incidence of eating disorders. Br J Psychiatry. 2006;189:562–3.
Lauritsen MB, Pedersen CB, Mortensen PB. Effects of familial risk factors and place of birth on the risk of autism: a nationwide register-based study. J Child Psychol Psychiatry. 2005;46:963–71.
Flisher AJ, Chalton DO. Urbanisation and adolescent risk behavior. S Afr Med J. 2001;91:243–9.
Cantor-Graae E, Selten J-P. Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry. 2005;162:12–24.
Girma E, Tesfaye M. Patterns of treatment seeking behavior for mental illnesses in Southwest Ethiopia: a hospital based study. BMC Psychiatry. 2011;11:138.
Alem A, Jacobsson L, Araya M, Kebede D, Kullgren G. How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia. Acta Psychiatr Scand Suppl. 1999; 397:40–7.
Colvin M, Gumede L, Grimwade K, Maher D, Wilkinson D. Contribution of traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa. Int J Tuberc Lung Dis. 2003;7:S86–91.
Makanjuola V, Doku V, Jenkins R, Gureje O. Impact of a one-week intensive ‘training of trainers’ workshop for community health workers in south-west Nigeria. Ment Health Fam Med. 2012;9:33–8.
Petersen I, Bhana A, Baillie K, Mha PP. Research Programme Consortium. The feasibility of adapted group-based interpersonal therapy (IPT) for the treatment of depression by community health workers within the context of task shifting in South Africa. Community Ment Health J. 2012;48:336–41.