independently, had close relationships, were employed or otherwise productive citizens, were able to care for themselves, and led full lives in general.” 42 This was a startling good long-term outcome for patients who had been seen as hopeless in the 1950s, and those who had recovered, Harding told the
APA Monitor
, had one thing in common: They all “had long since stopped taking medications.” 43 She concluded that it was a“myth” that schizophrenia patients “must be on medication all their lives,” and that, in fact, “it may be a small percentage who need medication indefinitely.” 44
The World Health Organization cross-cultural studies
In 1969, the World Health Organization launched an effort to track schizophrenia outcomes in nine countries. At the end of five years, the patients in the three “developing” countries—India, Nigeria, and Colombia—had a “considerably better course and outcome” than patients in the United States and five other “developed countries.” They were much more likely to be asymptomatic during the follow-up period, and even more important, they enjoyed “an exceptionally good social outcome.”
These findings stung the psychiatric community in the United States and Europe, which protested that there must have been a design flaw in the study. Perhaps the patients in India, Nigeria, and Colombia had not really been schizophrenic. In response, WHO launched a ten-country study in 1978, and this time they primarily enrolled patients suffering from a first episode of schizophrenia, all of whom were diagnosed by Western criteria. Once again, the results were much the same. At the end of two years, nearly two-thirds of the patients in the “developing countries” had had good outcomes, and slightly more than one-third had become chronically ill. In the rich countries, only 37 percent of the patients had good outcomes, and 59 percent became chronically ill. “The findings of a better outcome of patients in developing countries was confirmed,” the WHO scientists wrote. “Being in a developed country was a strong predictor of not attaining a complete remission.” 45
Although the WHO investigators didn’t identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in the poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries. Moreover, in Agra, India, where patients arguablyfared the best, only 3 percent of the patients were kept on an antipsychotic. Medication usage was highest in Moscow, and that city had the highest percentage of patients who were constantly ill. 46
In this cross-cultural study, the best outcomes were clearly associated with low medication use. Later, in 1997, WHO researchers interviewed the patients from the first two studies once again (fifteen to twenty-five years after the initial studies), and they found that those in the poor countries continued to do much better. The “outcome differential” held up for “general clinical state, symptomatology, disability, and social functioning.” In the developing countries, 53 percent of the schizophrenia patients were simply “never psychotic” anymore, and 73 percent were employed. 47 Although the WHO investigators didn’t report on medication usage in their follow-up study, the bottom line is clear: In countries where patients hadn’t been regularly maintained on antipsychotics earlier in their illness, the majority had recovered and were doing well fifteen years later.
Tardive dyskinesia and global decline
Tardive dyskinesia and tardive psychosis occur because the dopaminergic pathways to the basal ganglia and limbic system become dysfunctional. But there are
three
dopaminergic
APA Monitor
, had one thing in common: They all “had long since stopped taking medications.” 43 She concluded that it was a“myth” that schizophrenia patients “must be on medication all their lives,” and that, in fact, “it may be a small percentage who need medication indefinitely.” 44
The World Health Organization cross-cultural studies
In 1969, the World Health Organization launched an effort to track schizophrenia outcomes in nine countries. At the end of five years, the patients in the three “developing” countries—India, Nigeria, and Colombia—had a “considerably better course and outcome” than patients in the United States and five other “developed countries.” They were much more likely to be asymptomatic during the follow-up period, and even more important, they enjoyed “an exceptionally good social outcome.”
These findings stung the psychiatric community in the United States and Europe, which protested that there must have been a design flaw in the study. Perhaps the patients in India, Nigeria, and Colombia had not really been schizophrenic. In response, WHO launched a ten-country study in 1978, and this time they primarily enrolled patients suffering from a first episode of schizophrenia, all of whom were diagnosed by Western criteria. Once again, the results were much the same. At the end of two years, nearly two-thirds of the patients in the “developing countries” had had good outcomes, and slightly more than one-third had become chronically ill. In the rich countries, only 37 percent of the patients had good outcomes, and 59 percent became chronically ill. “The findings of a better outcome of patients in developing countries was confirmed,” the WHO scientists wrote. “Being in a developed country was a strong predictor of not attaining a complete remission.” 45
Although the WHO investigators didn’t identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in the poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries. Moreover, in Agra, India, where patients arguablyfared the best, only 3 percent of the patients were kept on an antipsychotic. Medication usage was highest in Moscow, and that city had the highest percentage of patients who were constantly ill. 46
In this cross-cultural study, the best outcomes were clearly associated with low medication use. Later, in 1997, WHO researchers interviewed the patients from the first two studies once again (fifteen to twenty-five years after the initial studies), and they found that those in the poor countries continued to do much better. The “outcome differential” held up for “general clinical state, symptomatology, disability, and social functioning.” In the developing countries, 53 percent of the schizophrenia patients were simply “never psychotic” anymore, and 73 percent were employed. 47 Although the WHO investigators didn’t report on medication usage in their follow-up study, the bottom line is clear: In countries where patients hadn’t been regularly maintained on antipsychotics earlier in their illness, the majority had recovered and were doing well fifteen years later.
Tardive dyskinesia and global decline
Tardive dyskinesia and tardive psychosis occur because the dopaminergic pathways to the basal ganglia and limbic system become dysfunctional. But there are
three
dopaminergic
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