Geographical and cultural variation

To date, no population or culture has been identified in which schizophrenic illnesses do not occur. Also, there is no strong evidence that the incidence of schizophrenia varies widely across populations, provided that the populations being compared are large enough to allow a low-incidence disorder such as schizophrenia to 'breed'. The evidence that psychosocial factors or culture play an aetiological role in schizophrenia is also weak. However, there are well-replicated findings of some significant variation in the course and outcome of schizophrenia across populations and cultures which involves, above all, a higher rate of symptomatic recovery and a lower rate of social deterioration in traditional rural communities. Data supporting this conclusion were provided by the WHO studies (1. ,11) which found a higher proportion of recovering or improving patients in developing countries such as India and Nigeria than in the developed countries. Sampling bias (e.g. a higher percentage of acute-onset schizophreniform illnesses of good prognosis among Third World patients) was not a likely explanation. A better outcome in the developing countries was found in patients with various modes of onset, and the initial symptoms of the disorder did not distinguish good-outcome from poor-outcome cases. What causes such differences in the prognosis of schizophrenia remains largely unknown. The follow-up in the WHO studies demonstrated that outcome of paranoid psychoses and affective disorders was also better in the developing countries. Such a general effect on the outcome of psychiatric disorders may result from psychosocial factors, such as availability of social support networks, non-stigmatizing beliefs about mental illness, and positive expectations during the early stages of psychotic illness, from unknown genetic or ecological (including nutritional) factors influencing brain development, or from an interaction between cultural and biological factors.

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