Leff points to a ' High Expressed Emotion' [ EE ] found in urban living compared to rural living, as accounting for the better outcomes in rural living.
He marks this difference as explaining significantly, the difference between the case finding outcomes discovered between 'third world countries' and 'developed countries' - that the third world countries can have better outcomes for schizophrenia than those being cared for in the developed world.
He does not explain why the High EE should be there in urban living; less so in rural living. That is for further study as to how the difference comes about.
There may be care situation differences which have an influence, at the same time as diminishing the disagreements that can arise between people, living together, provoking high EE Thee may be more 'empty space' similar to the asylum grounds with walkabout in safety from worldly hullabaloo
Greater access to simple outdoor living, where the cues for behaviour are natural and historically unchanging, which can be more leisurely, where work can be taken with less intensity and at a slower pace, so that those with continuing illness can take part in it , are given time and space better, or be there observing but receiving less requests to have to react to in conversation, and maybe with adverse criticism and reproach.
Distancing from high domestic EE may be easier.
Other relatives may accept a family obligation, to be more accepting for refuge and break periods.
It needs more study
The external framework in rural areas, may give those with continuing illness, more reminders, more unthreatining time to recall what is held in memory, of what to be doing, in a less hurried way.
The relatively unchanging ways of rural living may mean that the emancipation in adolescence and early adulthood is not such a challenge to live in new and unfamiliar expectations, in settings new to the person, who has to do growing away, and taking charge of their own lives, hampered by an illness in which remembering, finding and holding appropriate contingencies and skills is difficult and often withheld. ; in rural settings, life goes on as it usually has done.
The sufferer has accumulated much experience and acceptable habits in behaviour appropriate to a relatively unchanging domeatic and work routine
The experimental work on 'holding to memories' may help in a more fruitful general explanation of the difficulty within schizophrenia: that is gaining access to those expereinces in memory which are currently useful, and holding these in the background when other matterrs intrude, as more pressing in demanding attention.
Extracted ...
Discussion A limitation of this study was that despite a comprehensive search, we were able to obtain DUP [ Duration of Untreated Psychosis ] data for only 18 of 152 LAMI [ Low And Middle Income countries ] countries. Lack of data is likely to be a limitation in any study of mental healthcare in LAMI countries and probably reflects the poor state of mental health services. Health administrators in many countries may not even be aware of the extent of the unmet need for treatment of psychosis.
Long DUP in LAMI countries may be associated with low income
The hypothesis that DUP is longer in LAMI countries was confirmed. We also found a linear relationship between GDP [ Gross Domestic Product ] purchasing power parity and DUP in LAMI countries and this raises the possibility of a causal relationship between low income and treatment delay. However, this finding is qualified as the DUP in the small number of studies from upper-middle-income countries was shorter than the average mean DUP of high-income countries.
Long DUP in high-income countries is usually attributed to lack of insight on the part of the patient, the gradual onset of psychosis in some patients and the families' lack of understanding of the need for treatment. The reasons for longer DUP in LAMI countries warrants further investigation, but is likely to include the lack of services in many areas as well as the cost of treatment.
The cost of treatment is frequently reported as a barrier to care in low-incomeand lower-middle-income countries. For example, in a region of Nigeria the only available antipsychotic was a low dose of chlorpromazine for a few weeks per year provided by a charityIn India, the direct cost of treating schizophrenia is a quarter of the average family income in dollars.Even if the patient's family were able to purchase some antipsychotic medication it could be at the expense of other forms of essential medical care or even food. Hence, it is not surprising that mean DUP declined with even modest increases in income.
Better prognosis in LAMI countries with long DUP?
The relationship of DUP to outcome in LAMI countries has not been extensively investigated.
Although it is widely believed that the prognosis of schizophrenia is better in LAMI countries,[ Cohen et al Schizophrenia Bulletin ] we found a number of studies reporting a worse outcome in these regions. For example, both treated and untreated patients from Morocco were less likely to be employed than a similar sample from the USA,and in rural China where very few patients received adequate treatment, untreated patients were found to have marked social and occupational disability and a fourfold increase in mortality.
Another study from the Indonesian Island of Bali reported an association between long DUP and increased mortality in the decade after contact with services. In Bali and in rural China the excess mortality was not from suicide, but from a lack of physical care.
Our finding of a very long DUP in low-income and lower-middle-income countries, and other studies that found large numbers of patients who had never received treatment, raises the possibility that a subset of patients with long DUP in some outcome studies either died or were lost to follow-up for other reasons.
Subsidised psychiatric treatment may shorten DUP
This study has highlighted the initial delay in receiving treatment in LAMI countries. The overall treatment gap may be greater, as there are studies from LAMI countries that describe large numbers of patients who never receive any treatment.
Worldwide, schizophrenia is the eighth largest cause of disability and the illness may shorten life expectancy by 10 years.
The direct effects of schizophrenia are comparable to those of many infectious and chronic physical illnesses that receive more funding for both treatment and research.
Cost-effective treatment is now available for schizophrenia. A public health initiative to subsidise antipsychotic medication for the
critical first 2 years of psychotic illness could greatly improve outcome for psychotic illness worldwide.
Combining subsidised mental health services with other forms of primary healthcare, as reported from Zambia, a low-income country where the DUP was comparatively short, could also significantly reduce the delay in treatment and improve the prognosis of mental illness in poorer countries.
Patients with psychosis in low-income and lower-middle-income countries may be among the most disadvantaged
people on earth and providing them with access to basic treatment would be a cost-effective public health measure.
Matthew Large, FRANZCP B J Psych October 2008