Schizophrenia And Public Health - WHO
aandpublic healthDivision of Mental Healthand Prevention of Substance AbuseWorld Health OrganizationGeneva
Nations for Mental Health:An Action Programme on Mental Health for Underserved PopulationsObjectives of Nations for Mental Health To enhance the attention of people and governments of the world to the effects ofmental health problems and substance abuse on the social well-being and physicalhealth of the world’s underserved populations. A first step is to increase awareness andconcern of the importance of mental health through a series of key high profile regionaland international events. Secondly, efforts will be devoted to building up the will of thekey political authorities to participate. Thirdly, and finally, efforts are to be directed atsecuring political commitments by decision-makers. To establish a number of demonstration projects in each of the six WHO regions of theworld. They are meant to illustrate the potential of collaborative efforts at country level,with the view of leading on to projects of a larger scale. To encourage technical support between countries for service development, researchand training.The implementation of the programme depends on voluntary contributions from governments,foundations, individuals and others. It receives financial and technical support from the EliLilly and Company Foundation, Johnson and Johnson European Philanthropy Committee,the Government of the United Kingdom of Great Britain and Northern Ireland, the Instituteof Psychiatry at the Maudsley Hospital of London (United Kingdom), the Free and HanseaticCity of Hamburg (Germany), the Villa Pini Foundation (Chieti, Italy), Columbia University(New York, USA), the Laboratoires Servier (Paris, France) and the International Foundationfor Mental Health and Neurosciences (Geneva, Switzerland).Further information on Nations for Mental Health can be obtained by contacting:Dr J.A. Costa e Silva, DirectorDivision of Mental Health and Prevention of Substance AbuseorDr B. Saraceno, Programme ManagerNations for Mental HealthDivision of Mental Health and Prevention of Substance AbuseWorld Health OrganizationCH – 1211 Geneva 27, SwitzerlandE-mail: saracenob@who.chTelephone: (41) 22 791.36.03Fax: (41) 22 791.41.60
iNATIONSFORMENTALHEALTHWHO/MSA/NAM/97.6English onlyDistr.: GeneralSchizophreniaandpublic healthAngelo BarbatoDivision of Mental Health andPrevention of Substance AbuseWorld Health OrganizationGeneva
ii World Health Organization, 1998This document is not a formal publication of theWorld Health Organization (WHO), and all rights arereserved by the Organization. The document may, however,be freely reviewed, abstracted, reproduced and translated,in part or in whole, but not for sale nor for usein conjunction with commercial purposes.The views expressed in documents by namedauthors are solely the responsibility of those authors.Designed by WHO Graphics
iiiContentsPrefacevChapter 1Introduction1Chapter 2Clinical issues2Diagnosis2Clinical picture4Chapter 3Epidemiology6Incidence and prevalence6Course and outcome7Risk factors9Comorbidity10Chapter 4Consequences of schizophrenia12Mortality12Social disability12Social stigma13Impact on caregivers14Social costs14Chapter 5Prevention, treatment and care16Preventive interventions16Drugs17Family interventions21Other psychosocial interventions22Chapter 6Service delivery25Chapter 7Conclusion27References28
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vPrefaceThe World Health Organization has established a new Action Programme onMental Health for Underserved Populations. This programme, called ‘Nationsfor Mental Health’, has been created to deal with the increasing burdens ofmental health and substance abuse worldwide. The main goal of the programmeis to improve the mental health and psychosocial well being of the world’sunderserved populations.Solutions to mental health and substance abuse problems entail a joint mobilization of social, economic and political forces as well as substantial changes ingovernmental policies related to education, health, and economic developmentin each country. This demands an intense and sustained effort from the nationsof the world through joint cooperation between governments, nongovernmental organizations and the organizations within the United Nations system.The programme is of utmost importance to the work of WHO and WHO iswilling to lead and coordinate this ambitious task. Several international meetingsand launchings have been organized, in collaboration with other internationalorganizations and academic institutions. A number of demonstration projectsrelated to the programme have already been initiated in several countries. Theseprojects are meant to illustrate and/or demonstrate the potential of collaborative efforts at country level, with the view of leading on to projects of a larger scale.This document addresses important public health issues related to schizophrenia.It was written by Angelo Barbato, Centre ‘Antonini’, Milano, Italy.I am very pleased to present this document as part of the global process of raisingawareness and concern about the effects of mental health problems. It is hopedthat this important document will help support health ministers, ministry officials,and regional health planners whose task is to deliver and improve mental healthpolicy and services within a strategic context.Dr. J. A. Costa e SilvaDirectorDivision of Mental Health and Prevention of Substance Abuse (MSA)World Health Organization
Schizophrenia and public healthChapter 1IntroductionThe term schizophrenia was introduced into the medical language at thebeginning of this century by the Swiss psychiatrist Bleuler. It refers to a majormental disorder, or group of disorders, whose causes are still largely unknownand which involves a complex set of disturbances of thinking, perception,affect and social behaviour. So far, no society or culture anywhere in the worldhas been found free from schizophrenia and there is evidence that this puzzling illness represents a serious public health problem.1
2Nations for Mental HealthChapter 2Clinical issues2.1 DiagnosisIn the absence of a biological marker, diagnosis of schizophrenia relies onexamination of mental state, usually through a clinical interview, and observation of the patient’s behaviour. Table 1 shows the diagnostic guidelines according to the two major current classification systems.As can easily be seen, the two systems overlap to a considerable extent, whileretaining some differences. The ICD-10 represents a compromise betweenresearch findings and various diagnostic practices in different countries and isprobably better suited for worldwide utilization.Any approach to the diagnosis of schizophrenia should, however, take intoaccount the following: Current operationalized diagnostic systems, while undoubtedly very reliable,leave the question of validity unanswered in the absence of external validatingcriteria. Diagnosis of schizophrenia should therefore be considered a provisionaltool that organizes currently available scientific knowledge for practical purposes, but leaves the door open to future developments. Since the boundaries between schizophrenia and other psychotic disordersare ill-defined, differential diagnosis, particularly during the early stages, canbe difficult. No single sign or symptom is specific of schizophrenia so thediagnosis always requires clusters of symptoms to be recognized over aperiod of time. Careful standardized diagnostic assessment, while useful forresearch, may not be necessary in clinical practice. The diagnosis of schizophrenia does not carry enough information fortreatment planning. Symptoms suggestive of schizophrenia can be found ina number of neurological and psychiatric disorders. Therefore, differentialdiagnosis should consider the following conditions: epilepsy (particularly temporal lobe epilepsy);central nervous system neoplasms (particularly frontal or limbic);central nervous system traumas;central nervous system infections (particularly malaria and other parasiticdiseases, neurosyphilis, herpes encephalitis);cerebrovascular accidents;other central nervous system diseases (leukodystrophy, Huntington’sdisease, Wilson’s disease, systemic lupus erythematosus etc.);drug-induced psychosis (especially related to use of amphetamines, LSDand phencyclidine);acute transient psychosis;affective disorder;delusional disorder.
3Schizophrenia and public healthTable 1. Diagnostic criteria for schizophreniaICD-10DSM-IVA minimum of one very clear symptombelonging to any one of the groupslisted below as (a) to (d) or symptomsfrom at least two of the groupsreferred to as (e) to (i) should havebeen clearly present for most of thetime during a period of 1 month ormore.A. Characteristic symptoms: Two or more of thefollowing, each present for a significant portion of timeduring a 1-month period, or less if successfully treated:1) Delusions, 2) Hallucinations, 3) Disorganized speech,e.g. frequent derailment or incoherence, 4) Grosslydisorganized or catatonic behavior, 5) Negativesymptoms, i.e. affective flattening, alogia or avolition.a) Thought echo, thought insertion orwithdrawal and thought broadcastingb) delusions of control, influence or passivity,clearly referred to body or limb movementsor specific thoughts, actions or sensations;delusional perceptionc) hallucinatory voices giving a runningcommentary on the patient’s behaviour ordiscussing the patient among themselves, orother types of hallucinatory voices comingfrom some part of the bodyd) persistent delusions of other kinds that areculturally inappropriate and completelyimpossible, such as religious or politicalidentity, or superhuman powers and abilities(e.g. being able to control the weather orbeing in communication with aliens fromanother world)e) persistent hallucinations in any modality,when accompanied either by fleeting or halfformed delusions without clear affectivecontent or by persistent over-valued ideas, orwhen occurring every day for weeks ormonths on endf) breaks or interpolations in the train ofthought, resulting in incoherence orirrelevant speech, or neologismsg) catatonic behaviour, such as excitement,posturing. or waxy flexibility, negativism,mutism and stuporh) ‘negative’ symptoms such as marked apathy,paucity of speech and blunting or incongruity of emotional responses, usually resultingin social withdrawal and lowering of socialperformance; it must be clear that these arenot due to depression or neurolepticmedicationi) a significant and consistent change in theoverall quality of some aspects of personalbehaviour, manifest as loss of interest,aimlessness, idleness, a self-absorbedattitude and social withdrawal.Note: Only one criterion A symptom is required ifdelusions are bizarre or hallucinations consist of avoice keeping up a running commentary on theperson’s behaviour or thoughts, or two or more voicesconversing with each other.B. Social/Occupational dysfunction. For a significantportion of the time since the onset of the disturbance,one or more major areas of functioning such as work,interpersonal relations, or self-care are markedly belowthe level achieved prior to the onset (or when theonset is in childhood or adolescence, failure to achieveexpected level of interpersonal, academic oroccupational achievement).C. Duration. Continuous signs of the disturbance persistfor at least 6 months. This 6-month period must includeat least 1 month of symptoms (or less if successfullytreated) that meet criterion A, i.e. active-phasesymptoms, and may include periods of prodromal orresidual symptoms. During these prodromal or residualperiods, the signs of the disturbance may bemanifested by only negative symptoms or two or moresymptoms listed in criterion A present in an attenuatedform (e.g. odd beliefs, unusual perceptual experiences).D. Schizoaffective and mood disorder exclusion.Schizoaffective and mood disorders have been ruledout because either (1) no major depressive, manic ormixed episodes have occurred concurrently with theactive-phase symptoms or (2) if mood episodes haveoccurred during active-phase symptoms, their totalduration has been brief relative to the duration of theactive and residual periods.E. Substance/general medical conditionexclusion. The disturbance is not related to the directphysiological effect of a substance (e.g. a drug ofabuse, a medication) or a general medical condition.F. Relationship to a pervasive developmentaldisorder. If there is a history of autistic disorder oranother pervasive developmental disorder, theadditional diagnosis of schizophrenia is made only ifprominent delusions or hallucinations are also presentfor at least a month (or less if successfully treated).
4Nations for Mental HealthMost neurological disorders can usually be ruled out by the presence of typicalphysical signs or by the findings of laboratory tests. However, the possibility ofa neurological or medical disease should be suspected and carefully investigated at the first onset of psychosis, especially if this occurs in childhood or oldage, in the presence of unusual features or when there is a marked change inquality of symptoms during the course of the disorder.Differentiation between schizophrenia and other mental disorders requiresconsideration of the patient’s history and clustering of symptoms, sometimessupplemented by longitudinal observation of the course of the illness.2.2 Clinical pictureAlthough the clinical presentation of schizophrenia varies widely amongaffected individuals and even within the same individual at different phases ofthe illness, some of the following symptoms can always be observed: Thought disorder: usually inferred from abnormalities in spoken or writtenlanguage, such as loosening of associations, continuing digression in speech,poverty of speech content and use of idiosyncratic expressions. Delusions: false beliefs based on incorrect inferences about reality, at oddswith the patient’s social and cultural background. Ideas of reference, controlor persecution can often be observed. Hallucinations: sensory perceptions in the absence of external stimuli.Auditory hallucinations (especially voices) and bizarre physical sensationsare the most common. Abnormal affect: reduction in emotional intensity or variation as well asaffective responses inappropriate or incongruous with respect to the contextof communication. Disturbances in motor behaviour: adoption for a long time of bizarre positions; repeated, aimless movement patterns; intense and disorganizedactivity or reduction of spontaneous movements with an apparent lack ofawareness of surroundings.In the seminal International Pilot Study of Schizophrenia, carried out byWHO, auditory hallucinations and ideas of reference were the most frequentlyobserved symptoms, found in about 70% of patients (WHO, 1973). This,cannot hold true, however, in all social or cultural groups.Furthermore, considerable empirical evidence points to a continuity between mostpsychotic symptoms and ordinary experience. The tendency to bizarre thinkingand peculiar sensory experiences is spread across the population more widely thanis usually acknowledged by clinicians (Claridge, 1990). Therefore, symptomassessment may be a threshold issue and should always be seen within the contextof the person’s overall emotional state and social functioning.
Schizophrenia and public healthVarious attempts have been made to classify symptoms of schizophrenia inorder to define meaningful subtypes of the disorder. In the past 20 years thedistinction between the two broad categories of positive and negative symptoms gained widespread popularity (Crow, 1980). However, more recentmultivariate analysis has suggested not two but three symptom clusters: realitydistortion, disorganization and psychomotor poverty (Liddle, 1987).5
6Nations for Mental HealthChapter 3Epidemiology3.1 Incidence and prevalenceThe distribution of a disorder in a given population is measured in terms ofincidence and prevalence. Incidence refers to the proportion of new cases perunit of time (usually one year), while prevalence refers to the proportion ofexisting cases (both old and new). Three types of prevalence rate can be used:point prevalence, which is a measure of the number of cases at a specific pointin time; period prevalence, showing the number of cases over a defined periodof time (usually six months or one year); and lifetime prevalence, reflecting theproportion of individuals who have been affected by a disorder at any timeduring their lives.Incidence studies of relatively rare disorders, such as schizophrenia, are difficult to carry out. Surveys have been carried out in various countries, however,and almost all show incidence rates per year of schizophrenia in adults within aquite narrow range between 0.1 and 0.4 per 1000 population. This has beenthe main finding from the WHO 10-country study (Jablensky et al., 1992).Taking into account differences in diagnostic assessment, case-finding methodsand definition of adulthood, we can say that the incidence of schizophrenia isremarkably similar in different geographical areas (Warner and de Girolamo,1995). Exceptionally high rates that emerged from the Epidemiologic Catchment Area Study in the United States (Tien and Eaton, 1992) may be due tobiased assessment. Although few data are available on incidence in developingcountries, early assumptions on consistently lower rates outside the westernindustrialized countries have not been confirmed by recent thorough investigations in Asian countries (Lin et al., 1989; Jablensky et al., 1992; Rajkumar etal., 1991).High incidence figures have recently been reported in some disadvantagedsocial groups – especially ethnic minorities in western Europe, such as AfroCaribbean communities in the United Kingdom and immigrants from Surinamin the Netherlands (King et al., 1994; Selten and Sijben, 1994). Such findings,plagued by uncertainties about the actual size and age distribution of thepopulations at risk, still await convincing explanations.In the last 15 years a variety of reports from several countries have suggested adeclining trend in the number of people presenting for treatment of schizophrenia (Der et al., 1990). However, changes in diagnostic practices andpatterns of care or more rigorous definitions of new cases as a result of improved recording systems, have not been ruled out as an explanation. So far,the case for a true decrease in incidence is suggestive but not proven(Jablensky, 1995).
Schizophrenia and public healthMuch wider variation has been observed for prevalence, which has been moreextensively studied. Point prevalence on adults ranges between 1 and 17 per 1000population, one-year prevalence between 1 and 7.5 per 1000, and lifetime prevalence between 1 and 18 per 1000 (Warner and de Girolamo, 1995). Variations inprevalence can be related to several factors, including differences in recovery, deathand migration rates among the affected individuals.Consistently lower point and period prevalence rates in almost all developingcountries have usually been explained by most investigators as due to morefavourable course and outcome of the disorder (Leff et al., 1992). However,other factors, such as increased mortality in patients with poor prognosis maycontribute as well.Pockets of high prevalence have been found in small areas of central andnorthern Europe, in some segregated groups in North America and in somepopulations living on the margin of the industrialized world, such as indigenous peoples in Canada or Australia (Warner and de Girolamo, 1995).Genetic isolation or selective outmigration of healthier individuals can explainsuch findings. However, it has been suggested that social disruption caused bythe exposure of culturally isolated communities to western lifestyles, may haveincreased the risk of schizophrenia in vulnerable
The term schizophrenia was introduced into the medical language at the beginning of this century by the Swiss psychiatrist Bleuler. It refers to a major mental disorder, or group of disorders, whose causes are still largely unknown and which involves a complex set of disturbances of thinking, perception,
Langfeldt stressed several factors: insidious onset, feelings of derealization and depersonalization, autism, and emotional blunting. Researchers after Langfeldt gave true schizophrenia other names: nuclear schizophrenia, process schizophrenia, and nonremitting schizophrenia. Schneider de
Describe the disabling psychiatric disorders associated with schizophrenia. 2. Identify the incidence and prevalence of schizophrenia. 3. List the various causes linked to schizophrenia. 4. Discuss the signs and symptoms of schizophrenia. 5. Differentiate between the positive and negative symptoms of schizophrenia. 6. Illustrate the phases of .
Schizophrenia is one of the top leading causes of disability in the United States and roughly 3.5 million people in America are diagnosed with schizophrenia (Schizophrenia and Related Disorders Alliance of America, n. d.). Approximately 25% of patients with schizophrenia reached full remission, roughly 50% of schizophrenic patients show improvement
Schizophrenia in Children and Adolescents Background: Pediatric schizophrenia is divided into two basic categories according to age of onset. When onset occurs before the age of 13, it is referred to as very-early-onset schizophrenia (VEOS). Depending on the source, VEOS may also be referred to as Childhood-Onset Schizophrenia, or COS;
Schizophrenia: Nursing, Pharmacy, & Social Work Perspectives. Brooke Kempf, PMHNP. Psychiatric Mental Health Nurse Practitioner. Hamilton Center, Inc. . Relapse prevention is a major challenge in the care of patients with schizophrenia. 2 Patients with schizophrenia are typically prescribed several different
Schizophrenia and Other Psychoses? 133 P. McGorry 2.9 Long-term Treatment in Schizophrenia: For Whom and How Long? 135 W. Gaebel 2.10 Novel Antipsychotics in Schizophrenia and Related Disorders: Preliminary Findings from a First-episode Study 137 S. Opjordsmoen 2.11 The Pharmacotherapy of Sc
the candidate's relationship with schizophrenia. In contrast, sPGS estimated the risks to the candidate trait alone. Variant Selection, Model Testing and Validation With the sPGSs, we evaluated the relationship between these candidate traits and schizophrenia diagnosis using logistic re-gression where schizophrenia diagnosis was the outcome and
significantly more often than a matched control group, which points to the existence of a figurative language comprehension deficit in schizophrenia. Keywords: schizophrenia, irony comprehension, figurative language 1. Introduction Schizophrenia is a common and debilitating mental illness (Frith and Ca-hill 2001).
