A Global Enigma
While our understanding of the human brain is constantly advancing, one of the least understood psychological disorders with the most ubiquitous global impact, is schizophrenia. Schizophrenia is a chronic mental illness characterized by symptoms generally falling into three categories:[1,2]
Psychotic Symptoms: Hallucinations, delusions, disorganized speech and behaviors
Negative Symptoms: Withdrawal from aspects of life, difficulty functioning normally, affective flattening, lack of motivations
Cognitive Impairment: Problems in attention, concentration and memory.
The prevalence of the disease is approximately 1% worldwide and accounts for a large healthcare burden. It is highly heritable (e.g., the likelihood of the disorder to aggregate among family members), estimated at around 80%.[3] Further, Degnan et al. (2018) note that the incidence rate of schizophrenia in ethnic minority populations are triple that of major White populations.[4]
In itself, the definition and categorization throughout the history of schizophrenia has differentiated across countries. Schizophrenia was first described by Emil Kraepelin (1899), a German psychiatrist, as “attentional impairments”.[5] Eugen Bleuler (1911) later famously coined it as a disorder which originates from the splitting of different psychic functions leading to loss of unity within the personality (hence the name “schizophrenia”) from the Greek roots “split-mind.”[6] Our foundational understanding of the disease is still limited, and this article aims to review some current cross-cultural perspectives on the research and management of the disease.
The diverse faces of psychosis in schizophrenia
Recent research has consolidated the literature on the effects of cultural and social perspectives on the framing of schizophrenic/psychotic symptoms. While psychosis is present globally as a symptom for schizophrenia, the actual content of the psychotic symptom is culturally determined.[7] For example, research conducted in India, Nigeria and Trinidad in 2016 concluded that “disruptive behaviors, wandering and decline in functioning” are more commonly thought of as psychosis rather than the “distorted perceptions and beliefs” emphasized in Western understanding of the condition.[8]
Additionally, the interpretations of psychiatrists determine what behaviors constitute psychosis; this, too, will vary based on one’s training, education, upbringing and life experiences, which differ across cultures.[9] In a case study in 2008, a NHS psychiatric nurse in a London hospital recounted his conflict for a Nigerian patient diagnosed with schizophrenia under his care. While in Nigeria, the patient’s “psychotic symptom” of religious delusions would have been considered gifted, the patient was coerced into taking medication in the UK.[10] Therefore, it is important to consider cultural backgrounds as a crucial factor in determining the symptoms of the disease.
Cross-national context and culturally-adapted interventions of schizophrenia
Schizophrenia has been identified as a globally-prioritized mental health problem with the magnitude of its impact on individuals’ health, economic and social hardships, increased mortality rates and human rights violation (e.g., involuntary hospitalization or imprisonment with inadequate mental health care).[11,12] Recommendations from the World Health Organization (WHO) guidelines and the Disease Control Priorities (DCP3) have shown that there are two kinds of intervention for schizophrenia that have strong enough evidence to deem them significant: antipsychotic drugs and psychosocial treatments.[13] However, one important limitation is that there is little evidence supporting these interventions in low and middle income countries (LMIC), and few of them have been actually implemented in high income countries.[14]
Psychosocial Interventions:
The psychosocial treatments of schizophrenia with strongest empirical support are: social skills training; family psychoeducation; cognitive behavioral therapy (CBT) and cognitive rehabilitation.[15,16]
In 2012, Lora et al. noted that among 50 LMICs, around 69% of those diagnosed with schizophrenic disorders do not have access to specialized care despite evidence that psychosocial interventions alone can alleviate symptoms of the disorder, and not all patients may require treatment with antipsychotics.[17,18] In 2018, Degnan et al. published a review on adaptations of Western psychosocial interventions to specific ethnic groups or subculture studying these adaptations in 13 different countries.[19] It was found that all cultural adaptations included language, a majority adapted to concepts and illness models, cultural norms and practices, and family. Noticeably, there were modifications to include spiritual/religious activities, adjustments to communication styles and family dynamics. The analysis demonstrated significant outcomes in support of adapted interventions, however only two studies out of 43 compared the effectiveness of adapted and non-adapted interventions, and neither found significant differences in outcomes.[20] Overall, while the study indicates positive results for culturally-adapted psychosocial interventions, the limited studies providing support for adapted over non-adapted treatments is not enough evidence of a significant increase in effectiveness.
Antipsychotic Interventions:
While psychosocial interventions have been increasingly researched and recognized as effective care for schizophrenia, antipsychotics have long been the popular measure of intervention for medical professionals.[21] Common antipsychotic agents are classified as first-generation (chlorpromazine, haloperidol) or second-generation (clozapine), which work by blocking dopamine receptors.[22] According to Wood et al. (2003), first-generation drugs are more-likely to induce parkinsonian side effects and second-generation drugs are thought to have enhanced therapeutic efficacy.[23] However, research by Agid et al. (2006) questions if the side effects of first-generation schizophrenia drugs may actually be from unintentionally overdosing patients while searching for optimal drug efficacy (hence, inadvertently causing more-pronounced side effects).[24]
Recent research on culturally-adapted antipsychotics and alternative drug treatments for schizophrenia has been scarce. However, a study done by Chong et al. (2004) on differences in antipsychotics usage in East Asian countries revealed that prescription patterns of antipsychotic drugs vary greatly between countries.[25] This can be explained by the differences in respective healthcare policies, preferred treatment modality, availability and cost of the drugs.[26]
For example, Japan has a long history of national health insurance and a preference for treating patients with mental health issues in psychiatric hospitals over community care. Therefore, a higher prevalence of antipsychotics is prescribed due to the longer hospitalization period for schizophrenia in the country.[27] Meanwhile, Xiang et al. (2017) also found that while community-based services are increasingly encouraged, a large number of patients in China end up receiving hospital-based services.[28] Additionally, as clozapine is the most effective and affordable antipsychotic medication in China, over one-third of schizophrenia patients have been prescribed the drug.[29] This is not the case for all countries in the surrounding regions, as the cost of second-generation antipsychotic is considerably higher, thus is often restricted and difficult to prescribe.[30] However, as first-generation antipsychotics for schizophrenia are known as “major tranquilizers” with more serious side effects, this may create a disparity in treatment of the disorder in different countries.[31]
Alternative treatments may also prove valuable. In 2017, a study conducted by Deng et al. on Wendan decoction (WDD), a traditional Chinese medicine for schizophrenia, discovered that WDD demonstrated some short-term positive effects on its own. Further, when WDD was used alongside an antipsychotic, positive outcomes were observed with fewer adverse effects.[32]
Future directions: beyond the “one-size-fits-all” treatment framework
While there is still more research to be done, this brings the question to whether popular antipsychotics are the ultimate pharmacological treatment for schizophrenia, or if there are alternative options we need to take into consideration. Specialists have long called for the facilitation of mental health care by traditional practitioners due to lack of resources in LMICs; research has echoed the sentiment that traditional healers are generally more accessible and affordable, and patients benefit from sharing cultural beliefs and world views with them.[33]
Traditional healers have often been more open to collaborating with primary health care than vice versa.[34] Watt et al. (2017) studied this issue qualitatively with populations in Ghana, Kenya and Nigeria. They found that many patients and caregivers still distrust non-medical treatments; despite some medical practitioners advocating for their validity, traditional care is often met with ridicule and doubt. The study further found that there appear to be suggestions to “convert” non-medical healers to a medical paradigm, and that rivalry and perceived superiority seem to be the underlying cause of this attitude.[35]
However, it is also important to note that patients who implore both methods of care seem to reap more benefits, overall.[36,37] Watt et al. note that non-medical healers also desire to be recognized in their validity and not be exoticized simply due to their non-Western practices and beliefs.[38] Many studies have supported that labeling these practices as “witchcraft” or “inferior” is failing to understand indigenous knowledge and meaningful perspectives, and thus a missed opportunity to improve population health.[39,40]
Social and cultural perspectives continue to inform the characteristics and future directions of both the research and treatment of schizophrenia. Yet, as we have seen, the current landscape of what we know about the disorder in a cross-cultural context is lacking. As we expand on this field of research in a broader context, it is important to note the potentials of alternative medicine, culturally-adapted measures and how they can benefit the accessibility of health care for ethnic minorities, non-Western or low/middle-income patients. Acknowledgement and deeper insight into culturally-appropriate diagnosis and care for patients with schizophrenia is crucial to shift the evolution of global mental health into a truly global discipline.
If you or someone you know are experiencing any signs of schizophrenia, it’s best to speak with a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss your concerns and determine the underlying cause of symptoms.
Contributed by: Mai Tran
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 Rahman, T., & Lauriello, J. (2016). Schizophrenia: An Overview. Focus (American Psychiatric Publishing), 14(3), 300–307. https://doi.org/10.1176/appi.focus.20160006
2 NHS. (2023, April 13). Symptoms - Schizophrenia. NHS. https://www.nhs.uk/mental-health/conditions/schizophrenia/symptoms/
3 McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360
4 Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., Husain, N., Rathod, S., & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714–727. https://doi.org/10.1017/S0033291717002264
5 Kraeplin, E. (1950). Dementia praecox and paraphrenia (J. Zinkin, Trans.).
6 Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press.
7 Shalhoub, H. (2012). Decoding schizophrenia across cultures: Clinical, epidemiological and aetiological issues (Doctoral dissertation, School of Social Sciences Theses).
8 Cohen, Alex; Padmavati, Ramachandran; Hibben, Maia; Oyewusi, Samuel; John, Sujit; Esan, Oluyomi; Patel, Vikram; Weiss, Helen; Murray, Robin; Hutchinson, Gerard; Gureje, Oye; Thara, Rangaswamy; Morgan, Craig (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project. BMC Psychiatry, 16(1), 388–. doi:10.1186/s12888-016-1090-4
9 Shalhoub (2012)
10 Ibid.
11 Wigand, M. E., Orzechowski, M., Nowak, M., Becker, T., & Steger, F. (2021). Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights. The International Journal of Social Psychiatry, 67(2), 168–174. https://doi.org/10.1177/0020764020942797
12 Patel V. (2016). Universal Health Coverage for Schizophrenia: A Global Mental Health Priority. Schizophrenia Bulletin, 42(4), 885–890. https://doi.org/10.1093/schbul/sbv107
13 Ibid.
14 Ibid.
15 Alan. S. Bellack (2001) Psychosocial treatment in schizophrenia, Dialogues in Clinical Neuroscience, 3:2, 136-137, DOI: 10.31887/DCNS.2001.3.2/asbellack
16 Cooper, R. E., Laxhman, N., Crellin, N., Moncrieff, J., & Priebe, S. (2020). Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review. Schizophrenia Research, 225, 15–30. https://doi.org/10.1016/j.schres.2019.05.020
17 Ibid.
18 Lora, Antonio; Kohn, Robert; Levav, Itzhak; McBain, Ryan; Morris, Jodi; Saxena, Shekhar (2012). Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. doi:10.2471/BLT.11.089284
19 Degnan et al. (2018)
20 Ibid.
21 Guo, Xiaofeng; Zhai, Jinguo; Liu, Zhening; Fang, Maosheng; Wang, Bo; Wang, Chuanyue; Hu, Bin; Sun, Xueli; Lv, Luxian; Lu, Zheng; Ma, Cui; He, Xiaolin; Guo, Tiansheng; Xie, Shiping; Wu, Renrong; Xue, Zhimin; Chen, Jindong; Twamley, Elizabeth W.; Jin, Hua; Zhao, Jingping (2010). Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Archives of General Psychiatry, 67(9), 895–. doi:10.1001/archgenpsychiatry.2010.105
22 Wood, Alastair J.J.; Freedman, Robert (2003). Schizophrenia. New England Journal of Medicine, 349(18), 1738–1749. doi:10.1056/NEJMra035458
23 Ibid.
24 Agid, O., Seeman, P., & Kapur, S. (2006). The “delayed onset” of antipsychotic action—An idea whose time has come and gone. Journal of Psychiatry & Neuroscience, 31(2), 93–100.
25 Chong, M. Y., Tan, C. H., Fujii, S., Yang, S. Y., Ungvari, G. S., Si, T., Chung, E. K., Sim, K., Tsang, H. Y., & Shinfuku, N. (2004). Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences, 58(1), 61–67. https://doi.org/10.1111/j.1440-1819.2004.01194.x
26 Ibid.
27 Ibid.
28 Xiang, Y. T., Kato, T. A., Kishimoto, T., Ungvari, G. S., Chiu, H. F. K., Si, T. M., Yang, S. Y., Fujii, S., Ng, C. H., & Shinfuku, N. (2017). Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009). Asia-Pacific Psychiatry: official journal of the Pacific Rim College of Psychiatrists, 9(4), 10.1111/appy.12277. https://doi.org/10.1111/appy.12277
29 Ibid.
30 Chong et al. (2004)
31 Ibid.
32 Deng H, Xu J. Wendan decoction (Traditional Chinese medicine) for schizophrenia. Cochrane Database Syst Rev. 2017 Jun 28;6(6):CD012217. doi: 10.1002/14651858.CD012217.pub2. PMID: 28657646; PMCID: PMC6481906.
33 van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342
34 Ibid.
35 Ibid.
36 Abbo C. (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global health action, 4, 10.3402/gha.v4i0.7117. https://doi.org/10.3402/gha.v4i0.7117
37 Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154–170. https://doi.org/10.1016/S2215-0366(15)00515-5
38 Watt et al. (2017)
39 Konadu, K. (2008) Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology. African Studies Quarterly, Vol. 10 (2&3).
40 Shaw, I., & Middleton, H. (2013). Approaches to “mental health” in low-income countries: A case study of Uganda. Mental Health Review Journal, 18, 204–213. doi:10.1108/MHRJ-07-2013-0025