The Many Mysteries Of Schizophrenia And Culture

Over the last few days, I have bumped into several interesting items concerning schizophrenia and culture. An article this week in the Washington Post which examined, post-Cho, problems faced by many immigrants in the DC-area with mental illness, especially schizophrenia. One of the big takeaways is that cultural barriers prevent immigrants from getting properly medicated American style. Nice simplistic thesis, especially in light of an article in the same paper two years ago by Shankar Vedantam, examining why schizophrenics in India do so much better than schizophrenics in the US and other developed countries, but which the present reporter fails to mention or account for in her piece. Nice 'dissing of your colleague! Wouldn't it be kind of interesting to ask about that little socio-cultural dynamic?

Whatever the case in the US, the fact remains that schizophrenics do much, much better in lesser-developed countries than in glossy high-tech ones. Which brings me to a fascinating book review in the current American Journal of Psychiatry. Thus:

"Outcome from schizophrenia is routinely better in developing world settings, and this difference becomes apparent during the initial 2 years of illness. But even for developing world patients with a poor early course, outcome is superior to that of developed world patients with an equivalent early course. Employment rates are substantially greater for developing world subjects, and some authors have attributed this to the freedom from the economic disincentives to employment that can accompany the provision of disability benefits in the industrial world. The editors, who include a well regarded medical anthropologist, are cautious about attributing the improved developing world outcomes to specific cultural factors. Shantytowns may not be ideal "communities of recovery," they point out, and extended families can be tyrannical as well as supportive. They conclude, however, that family involvement may be a key positive factor. They point to "the extraordinary engagement of Indian families in the course of treatment," coupled with low criticism and reduced demands. They also point to a startling difference in one component of social inclusion. Nearly three-quarters of Indian subjects with schizophrenia were married at follow-up, compared with about one-third of people with the illness in the developed world centers."

Well, lift the scales from my eyes. Looks like this op-ed Robert Whitaker penned in USA Today five years ago was dead on. And, it sure makes the Hearing Voices Network people look like geniuses. I don't really have any good answers for why folks do better in other countries than in the US, aside from families and support systems, but we are clearly doing something wrong in this country when most schizophrenics continue to see a lifetime of repeated psychosis, unemployment, rejection by families and friends, and the hard fist of the streets. And, here, I am thinking of the ones who take their meds and play by the rules--and get fucked up by their meds--and don't smoke crack and the like. Why?

I'm not sure that evolutionary theory holds too many clues for us. But there is this fascinating piece from Nature going into a study asserting that schizophrenia genes--whichever ones those are exactly!--must have an evolutionary purpose, because they made it through eons of natural selection processes just as robustly as did other human attributes. The study authors cannot account for why. But perhaps it's just possible that a given set of schizophrenia genes in a Homo sapien in one environment and culture lead to one set of results and the same genes in a similar Homo sapien in an environment and culture such as America's lead to completely different, and much worse, outcomes. In which case, one could argue that this has a whole lot to do with environment and evolution--or God, if you prefer--must be mighty pissed off at Western cultures.

Whoever sorts this business out to the good of these poor folks will get a free ticket courtesy of me to pick up their Nobel Prize. Until then, we are going to be stuck in a mystery unless someone in a position of influence starts pushing the game a bit differently. Something tells me that person will not be Fuller Torrey. He stopped asking questions decades ago.