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The International Pilot Study of Schizophrenia: Five-Year Follow-Up Findings

Article in Psychological Medicine· March 1992

DOl: 10.1017/50033291700032797' Source: PubMed

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 psrc/ioiogicaiMedicine, 1992, 22, 131-145
Primed in Great Britain

The International Pilot, Study of Schizophrenia:

five-year follow-up findings 1
1. LEPP," N. SARTORIUS, A. JABLENSKY, A. KORTEN AND G. ERN BERG
I
From the World Health Organization, Geneva, Switzerland

SYNOPSIS A five-year follow-up of the patients initially included in the International Pilot Study
of Schizophrenia was conducted in eight of the nine centres. Adequate information was obtained
for 807 patients, representing 76 % of the i .ial c hort. Clinical and social outcomes were
significantly better for patients in Agra an VIbada!Y'ihan for those in the centres in developed
countries. In Cali, only social outcome wa ~ntl etter.

INTRODUCTION to apply standardized interviews in eight dif-

ferent languages. Despite this linguistic diversity,
The International Pilot Study of Schizophrenia satisfactory inter-rater reliability was achieved
rrpSS) is a transcultural psychiatric investigation

I
for the schedules used. It was discovered that
of 1202 patients in nine countries - Colombia, patients with characteristic patterns of signs and
' ,
Czechoslovakia, Denmark, India, Nigeria, symptoms, closely corresponding to descriptions
~
it China, Union of Soviet Socialist Republics,
'E. of schizophrenia in the most widely used
li'
.~. United Kingdom and the United States of textbooks, were found in each of the settings. In
1- America.
~ seven of the nine centres, the diagnostic term
.~ The IPSS sample was recruited from suc- schizophrenia was applied by the research

iI
cessive admissions or referrals to psychiatric psychiatrists to a group of patients whose clinical
facilitiesin the different centres and thus was not characteristics were very similar across these
necessarily representative of the wider popu- centres, In the two remaining centres, Washing-
lation of schizophrenic and other psychiatric ton and Moscow, the psychiatrists included
'~. patients in the community.
~'
broader clinical groupings under the rubric of
~,
The first publication related to this study schizophrenia, This was confirmed by the use of

I ~
(WHO, 1973) presented a detailed account of a computer program, CAT EGO (Wing ef af.
the origins of the study as well as description of 1974), which functioned as a reference classifi-

I
the place of the IPSS in the World Health cation with which to compare the diagnostic
Organization's long-term programme in epi- practices in each of the centres. Agreement
~. t demiological and social psychiatry. The results between the centres on a core group of patients
f:r.~' of a two-year follow-up of the original cohort of diagnosed as schizophrenia was sufficient to
patients were published in a second volume

,
,
+ (WHO, 1979). The initial phase of the study,
justify comparison of the outcome of patients in
the various centres.
which occupied the period between April 1968
l and September 1969, demonstrated the feasi-
A two-year follow-up study of the original
~ cohort was successfully completed although the
bility of a large-scale international collaborative proportion of patients with complete assess-
~ ~
study, which required the field workers involved
,~ ments was rather low in some of the centres,
~. notably London and Ibadan. In London there
*
f ;}
I This paper on the 5-year follow-up of patients included in the
International Pilot Study of Schizophrenia of the WHO was prepared
on behalf of the collaborating investigators (see Appendix).
were difficulties due to insufficient staff, while in
Ibadan problems arose in tracing rural patients.
Of the 1202 patients given an initial examination,

i•
e Address for correspondence: Dr Norman Sartorius, Division of
Menial Health World Health Organization, 1211 Geneva 27. it was possible to obtain sufficient information
SWitzerland .
about 77 % to include them in the basic follow-
11. 131 5-2
t
-.

132 1. Leff and others

up analyses. In presenting the material, the

METHOD
Agra, Cali and Ibadan centres will be referred to
as centres in developing countries because of the Instruments
prevailing socio-economic conditions in India, Four main types of schedule were used during
Colombia and Nigeria. Taipei has not been the follow-up phase of the IPSS: the Present
Not foil'
included as a centre in a developing country State Examination (PSE), the Follow-up Psy- Follow~'
because the characteristics of medical care chiatric History schedule (FUPH), the Follow- but nO:
PSE wi!!
facilities and the principal causes of death in the up Social Descriptions schedule (FUSD) and the o mont
city resemble those of a centre in a developed Follow-up Diagnostic Assessment schedule 5 vr [til
(FUDA). The PSE was originally devised by PSf. me?
country. Aarhus, London, Moscow, Washing- I>morii
ton and Prague are referred to as centres in Wing et al. (1974) and was translated from 5 yr r§'
developed countries. English into the seven other languages of the Toti!,
Using this convention, the two-year follow-up IPSS with the usual precautions (WHO, 1973). ,.-: 1
data revealed that patients with an initial The development of the other three schedules is ,~

diagnosis of schizophrenia had a considerably described in the second IPSS publication (WHO, ~
better course and outcome in centres in devel- 1979). The main purposes of the five-year FUPH ~
were to collect information on the course of the Tal:~
oping countries than in centres in developed
patient's illness in the interval between initial
countries (WHO, 1979). This remained true
whether clinical outcome, social outcome, or a examination and the five-year follow-up, and to l~-;;
combination of the two was considered. A provide an account of any socioeconomic 44',
01:
strikingly good outcome characterized 'schizo- changes affecting the patient during the same
phrenic patients in Agra, where over 90 % were period. The FUDA schedule requires the psy- ".
03 'di!
followed-up, as well as in Ibadan, where the chiatrist assessing the patient at follow-up to 04 J
OS J
follow-up rate was 50%. The poorest outcome state his diagnosis of the patient using follow- 1J64
was evident in Aarhus, where a similar definition up information only, and to reformulate the 071

of schizophrenia was applied as in Agra and diagnosis using all the information available. In 08,1
addition to interviews with the patient, in-
09i
Ibadan. Hence neither the relative success of the l0't
formation was obtained from family members, 11#
follow-up. nor the diagnostic practices of the 12i]i
psychiatrists can account for the markedly better health records and health professionals. 13: 1
outcome for schizophrenia in the developing 14',
Reliability of instruments lSi
countries. 16
Another artefactual explanation for this find- This was established for the instruments used 11-
ing cannot be excluded, namely that patients for initial assessment and for the follow-up IS
I'
who chose to attend the sparse facilities in the schedules by interviews being regularly rated by 2
centres in developing countries were selected, by a number of research workers, both within
themselves or relatives, on the basis of a good centres and between centres. Various measures
~
prognosis. The follow-up data, as yet unpub- of reliability of rating were presented for the
lished, from the WHO Determinants of Outcome two-year follow-up data (WHO, 1979). With
¢.
study (Sartorius et al. 1986) provide evidence respect to the PSE, the intracentre reliability was
against this possibility. since they relate to a extremely high for all 129 units of analysis t
strict epidemiological sample making a first derived from the PSE items (intraclass cor- ~
'relation coefficient, agreement ratio 0,87). The com,
contact with psychiatric facilities, yet still dem-
intercentre reliability was about 5 % lower ~ of O·
onstrate a better outcome for schizophrenic
than in the intracentre exercises, but still very Tl
patients in developing countries.
satisfactory. sche
We present here the findings from the five- > five-
year follow-up of the IPSS, which not only For the various measures of course and
outcome, with the exception of social outcome, not;
confirm the two-year results, but amplify them, > OCCl
since a more complete follow-up was achieved in the inter-rater agreement ranged from 0-58 to
0·75. When social outcome was analysed as a stud
some of the centres. The centre in Taipei ceased (l.
trichotomous variable, low levels of reliability prot
participating in the IPSS before the five-year
resulted. Therefore the categories were collapsed sessi
follow-up study was completed so that data
into 'severe impairment' and 'all other out- ~ fron
from that centre are not included in this paper.

1>

~
 133
The tnsemaiiona! Pi/or Study (~f' Schi:opilrenia

Table 1. Number iJ!'patients in each centre with a PSE at ..five-year

-_.-----_ ..-.... -.
fo//olt'-up _
- ---"'-- .. '" -- .. -.--." - _. ,"

/\.\1 centres
Aarhus Agra Cali Ibad"n London
----_ .. _-----
Moscow
-- _.-.------_ .... -.
Praque \VJshinglon
_ •... _---_ .._--- .. _ ..-_.--_.-.-_.
.._---_ .._._---
---'----'-'-- ._-_.-_._---- ------ ..--.-.-
:V (~'~l) N tl ) N (%) N ( ~/o) N (~"(j )
N (%) tV (%) ( f~ -

sed durin; N ("o) tv (n/~)

--------_
_._-_._-_._----_.-_._.-----_. __ ._._ _- --_ ..
... _ ...
...

20 (14) 17 (14) 62 (471 258 (241

45 (35)
he Prcscll', ~ (6) 37 (26) 10 (~I 59 (41)
010) .' (21 o (iJ) 26 (2)
. ,::",,"'d up 10 (ii) 2 (I) I (I)
w-up p~\. 4 (3) 6 (41
..'......
,~Jup 624 (:\9)
4X (34) 98 (78) 67 (51)
ae Follo\~· n,' Vs[
113 (87) S8 (63) 102 (80) 53 (37) 55 143)
-",l1ll1\
D) and the ··,.,nlh ...of
schedule- ,'\l\ll'\~ up 26 (20) 72 (511 7 (6) ~ (~) t57(15}
9 (6) 5 (4) 31 (21 )
5 (4)
~evised h\ ;-:\i,rc than
after
"'Jed fro 1;1 '·".nti"
iI,i\(H' up 115 131 1065
145 127 140
s of tlk 130 140 127
; "Ui-.
,19n)
redules I'
(WHO.
r FUPII Iable 2. Distribution of all patients assessed at five-year fol101V-UP bv FCl).._--diagnosis and centre
... --_.__ ..---------
___ . ____________ •__ •___ ._. ___ •______ •__ ~ __ •.___ '_______ •___________ ~ _______ . ___ .•_____ •_______ _____---
- ••._-
------ .._._. .._-- ._"-
-0. _____ __
• __ - ,-'-.'- .-
.se of till' ----_._-_ ..---_.- -_.-----_._---_._. __ ._-------- ._ .._.-_._---_. --
.,-,_._------------_ .._-- praque Washington All centres
. n initial
l! Il diagnosis
Aarhus Agra Cali
..- •._._----
l badan
-_.-_._--_._-_._-
London
-----<._ .._--
Moscow
.---_ .._----_. __
._-----_._---------_ ..
3
.P, and tl)
'c
conomic
. the saIllC
- .- pucrperal psychosis
~i ! - Simple schizophrenia
2
Ii 2 I
19
I
S 7
20
4~
3~
,:.- Hebephrenic schizophrenia II
15 12 (, :1 201
the psv- ,'I -,,;Catatonic schizoph rcnia 2
17 2~ 44 1~ 30 33
,,; Paranoid schizophrenia 26 II 4 (, 60
ow-up II' g 27 4 11
~I
.,' ACUle schizophrenia
Ig follow- ..
''" _~l.utern schizophrenia
3 II
69
3

'l:J.ulate the p Residual schizophrenia

14 15 4 15
4'
~ilablc. In ," .<: Schizo- aiffccuve
3 (, 2 28 3
26
: ~; .. Other ,chizophrenia 1
,ktient. ill- ii' Lnspecified schizophrenia 20 5
I 58
Agilall.!O depression 18
t,mb'" ..
\1atlic-depressive depression
\-tanic-deprcssive manic
17
19
3
16
4
7 5:!
11
IS
., Other affective disorder 4

In" 9 15
Paranoid stales
I 24
Other psychoses
u,,,1 Reactive depression 13
S 45
~:foIlow-ul' lnsnecificd psychosis S 6
5 43
I' rated h
Depressive neurosis
'." .. Other neurosis 2 12 23 4

807
'1ih within pcrsonulitv disorders 86 82 120 108 69
122 103 117 53 76
Imeasure, All 65 86 86
94 74 92 59
Percentage of

I
for·d the Initial cohort
"9). With
,bility was
ff analysis
iclass cor-
10,87), The d~mes', which resulted in inter-rater agreement Completeness of follow-up
$% lower "I 0·75. The absence of the Taipei centre from the five-
iri-
still very The checks on inter-rater reliability of the
schedules continued between the two-year and
year follow-up removed 137 patients from the
i. initial cohort of 1202, leaving 1065 to be
urse and hIe-year follow-Ups, but analyses of the data are followed-up in the remaining eight centres.
.1,outcomc. not available. While it is possible that rater drift
From Table I it can be seen that 59 % of
0·58 [(1 occurred over the long follow-up period of this, patients were examined with the PSE within six
ysed as a -iudy, there is no reason why this should have months either side of the five-year follow-up
:reliabiJit) produced a systematic bias affecting the as- point. No patient was seen earlier than the limit,
.,collapsed -essment of outcome in one centre differently
but 15 % were interviewed more than five and a
'lher out- Irorn the others.
134 J. Lef] ami others

PeJ
Table 3(a). Distribution of Centre diagnoses ill
original cohort am/five-year follow-up sample
Table 3(e). Marital status of original cohort
and five-year follow-up sample inl
-2
------------_._-----------_._------_._---
.... ---------~--.------
Follow-up sample fiv~
Original cohort Follow-up sample Original cohort
----_._--,-_ .. .--_._------
tV
__ ceiJ
N
o.
-u
tV % (15
--_._-_ ... _---_._-- _._------ -_._--_. _.--"----_._---.----
-.~,-----~- ..-- ..---. ----.-----~----.---,--------.-- ..-- .. ------'.-_ .._--- ._------- An
727 68·3 531 65·8 Centre schizophrenia
Schizophrenia
64 (',0 52 6-4 Married or 298 41·1 210 39·6 exc
Mania
Other 274 25·7 224 278 cohabiting
60·4
dia
58·9 320
:c==.=-=--c:"_-.-
__ .=_--._-__-._-__ -'--_--- Single/widowed/ 427
(6~
divorced
(l~
All diagnoses
Table 3 (h). Distribution of CA TEGD classes in 508 47·8 383 47·5 fqJ
patients given diagnosis ojschizophrenia
Married or
cohabiting
555 52-2 423 52·5
~.
Single/widowed!
divorced
p~
Follow-up sample
Original cohort -_._. __ .-----_._.----' ----_."._-_ .. _----
_--_._
-,----_. __ .-.. ..._- ._----- -, ..-- -----"-_.-
._--_.--,---_ .. -_._------_._-------- sti
_--_
------ ... ... -----._- ... _--_._ ..
------_ ... .._.- ----_. ----- ..•.. --- ---",

is1
:V
CA TEGO class
._------------------_ .._--------.------------,._---
443 60·9 32:1
-------
60·8 Table 3 (f)· Type ofonset of original cohort and
f4
S+
79·9 421 79·3 five-year follow-up sample
s. P. 0 581
20·7
Other 146 20·1 110 ..-----.-,- .. ..-- ... -.- ..-_._--_.----------_.--
---~-.--~-.- .--.- .. -~-- ..--..--.---.-- ..-.--

Follow-up sample ~.'

Original cohort
--.---.-.-------.-------.-~-----
% N '"
al
Table 3 (c). Sex distribution oj' original cohort . _. ----.-~--_.-
tV "
- .---_.-._ .._ ..... - _._----_. -----.- ..---~--.-------.-.---- s~
and five-year follow-up sample Centre schizophrenia
cc
13·6 72 13·6 2I
Sudden 99
Original cohort
_ ... __
Follow-up sample Slow,li nsidious 623 85·7 457 86·1
fi,
-----_._---------
"',
._---_.-_._---_
II,'
.._'---
All diagnoses
14·8 119 14·8
\i:'1
" Sudden 158
--_.- ..--- --_.,---_._---- .._--' _._--,_._-_. . _.".- .-. _. ---_.- _._._"--_._------
Slow/insidiuLLs 897 R4·2 683 84·6 r~
Centre ,chizophrenia
4\),1 261 49·\
.~-.----- ----_ ..- ..- ._-_._-------------- dl
Female
1'v1a1e
J57
)70 50·\) 270 509 d1
/\11 diagnoses In addition to the patients assessed with all 1
5-16 '1-1] SH
Fcmulc 5X2
45·4 364 45·1
the instruments including the PSE, for another
Male 4~.\
26 individuals information was obtained by
using only the FU PH and FUSD schedules.
Thus, sufficient information to characterize
Table 3 (d). Age distribution of original cohort
outcome over five years was obtained for a total
and jive-year follow-up sample
--
._ ...
- ._._._-,.' - -_ .. ... _._--_.-
_ ._-" .... __ .. _. __ .----_ .... -
.._ .. .__ . ---,_ .. _--- --- --_. ---_._-----,-- --" --_ ..-_ ..-- .------_._---_. --- ,-- ---_._. -, ._---
of 807 patients, representing 76 % of the initial
,

Original cohort Follow-up sample cohort.

--_._----------,---_._-_ .. -_.,_.- ._-_. __ .__ ...---_ .... _---------_ ..._ ... -
.tv A frequent reason for not tracing or not
tV %
assessing patients at the five-year folow-up was
Centre schizophrenia death. A total of 52 patients, or 4·9 % of the
Age ( 3D 4}O 592 312 5R'~ i<
219
original cohort, died during the follow-up
Age) 30 196 40·8 41·2
period. There may have been additional deaths
All diagnoses
among patients who were not traced. Suicide t
Age < 30 573 53·9 425 52·7
Age )JlI 491 46·1 )82 47·3 (ascertained and suspected) was the commonest s
-_. __ ..---_." ----_._,--_ ..--_._-- .__ .__ ._-,-----_ ... _-----_. ------
cause of death among the study patients, r
accounting for 38 % of all known deaths. It is r
half years after the initial examination. The
well-established that the suicide risk in schizo-
longest duration of follow-up, recorded for a
phrenia is as high as in affective illnesses (e.g.
single patient. was seven years and three months.
Tsuang et al. 1979) and this is borne out in the
In all, 74 % of the original cohort were given a
IPSS. In two of the centres (Ibadan and Agra)
PSE at the five-year folow-up, a creditable
the percentage of patients who died was 9·0 and
success rate and very similar to the 76 %
7.1 respectively. The centre with the lowest
reinterviewed at the two-year follow-up.
 135
The Interncuional Pilot Study of Schizophrenia

In none of these comparisons did the sample

''''rccntage of deaths (0·8) was surprisingly not
iginal culu n! followed-up differ significantly from the original
:~ a dcv;loped country but in Cali.
cohort. In fact for most of the variables, the
ample or the 807 patients satisfactorily assessed at distributions are virtually identical. These results
,,,c-vear follow-up 531 (65·8 %) had an initial
:;"ollow-up :-.ampL' eliminate one interpretation of the findings.
.::nt~C diagnosis of schizophrenia and 126
N " .. :;6 lIO) a diagnosis of an affective psychosis .
\:!1l'ng the 1065 patients originally assessed, RESULTS
110 3l}.(: .\(!tlding the patients from the Taipei centre, a Clinical course and outcome of patients with an
.!:d"nosis of schizophrenia was given to 727 initial diagnosis of schizophrenia
'320 AII·J
""~3"0) and of affective psychosis to 154
The IPSSwas deliberately focused on schizo-
\.\,1I;,). These figures suggest that successful
phrenia. and we will present outcome data
38} ~o , .':\Jl\\-UP is not influenced by initial diagnosis.
mainly for this group. Hov"ever. comparisons
The initial diagnostic distribution of these 807
~23 )~ ..-: will also be made with other diagnostic groups.
ii :",:lcnt5is shown for each centre in Table 2. The
-:dIlH! variation in distribution between centres P SE at five-year [ollow-up
-,ilkd) to be due to a combination of selection
The PSE covers one month preceding the
J,tors and, in the case of the subtypes of
interview. When given at a follow-up of a cohort
.,hilllphrenia, differences in diagnostic prac-
of schizophrenic patients. it will only record
:,~, However, the high proportion of catatonic
active symptoms over that period. Usually a
-,hl/ophrenia in Agra, Cali and Ibadan reflects
high proportion of patien ts are in a q uiescen t
, ~cJluine difference in the prevalence of this
phase. However, those with chronic symptoms
-ubiype between developing and developed
and those who happen to be in an acute episode
.ountries (Leff, 1988). It can be seen from Table
at the time will be identified by a PSE assessment.
2 l.~·fl
: that sufficient outcome data were obtained
7 XI,· 1 Some patients suffer from neurotic symptoms
.rom ,1 low of 53 % of the initial cohort in
when not in a psychotic phase, and these have
9 14·.'
\\a~hlngton to a high of 94 % in Aarhus. It is
been included in Fig. 1. Patients have been
3 X41. ':,,<,suring that in one of the centres in a
divided into those who at five-year follow-up
.icvcloping country, Cali, the success rate in
J' "bIJ!ning follow-up data was over 90%.
had at least one clearly psychotic or three
~' possibly psychotic symptoms; those who were
~ssed with dl! symptomatic but did not fulfil these criteria and
~, for another Potential bias introduced by incomplete
those with no symptoms recorded by the PSE .

r
follow-up
'.~·'·"".Obtail.lCd
h\ Chi-square analysis indicates that the differences
.' schedule- ""'CC patients lost to follow-up may bias the
among the centres are statistical1y significant
, characteri.« ~':01111nder of the sample either towards a better
(P < 0'001). The highest proportion of asyrnpto-
: [ed for a Inti!! , ;: \\()J"seoutcome, it is necessary to compare
matic patients was found in both Agra and
';of the iniu.« 11: patients successfully followed up with the
Ibadan, amounting to two-thirds of the sample
i .CIngor 'i~II];j1cohort. In particular
::lIst include factors commonly
such a comparison
associated with
seenvat follow-up. The highest proportion of

i
,wi
k prognosis Of the major psychiatric illnesses .
actively psychotic patients (nearly 60 %) was
.,-olow-up \"1'
shown by the samples from Aarhus and
. ;4·9 % or ih, \!:'~.51:\ and marital status are almost invariably
Moscow,which also had the lowest proportion of
e follow-up «icnuficd as influencing the outcome of the
·:tionai death- whulc range of psychiatric conditions,
'\ pc of onset is particularly important
while
in
asymptomatic patients (under 5 %).
taced. Suicide Time spent in a psychotic episode
he commonc-: ,,,hllUphrcnia. Tables 3 (a-j) show the com-
['\lfhOn of the five-year follow-up sample with The cross-sectional data from the PSE at the
:hdy paucni-.
five-year follow-up need to be supplemented by
a deaths. It 1\ members of the original cohort on all those
information of a more longitudinal nature. The
~sk in schizo- -.mables. as well as on the distributions of
(entre diagnoses (made by the research psychi- follow-up psychiatric histories provide this type
:~illnesses (c.u
'!ine out in ll;c .tlflsts in each centre) and CAT EGO diagnoses of data, and were used to estimate the percentage
i made by the computer program). In each of the follow-up period that each patient spent
.n and Agru I
the value of the variable was that in a psychotic episode. A psychotic episode was
was 9·0 and lll>tJncc
one which the psychiatrists completing the
the lowest determined at initial interview.

,~
·'

136 1. Lei}' and others

"I
,0

100
90
~O
70
60
50
40 1
,]l
~
30
~~
~
20
10 _1
-----,.~
0 Puucrn 011;
on
c: p:-...,chotic ell
::l '"
50 ~ 3: <> c:
'" ::l

:::'~:~
s: 0 0 0 !1l~-lus·lon.iii:
~ ~ u "0
ee "0
c:
U
on
OJ)
M
< :::: 0 0
0::'" c:
-I
::f ~
~'"
FtG. I Percentage of followed up initial evaluation schizophrenic patients. psychotic. non-psychotic and asymptomatic at five-
year follow-up, 81. Psychotic: g. non-psychotic: 0, asymptomatic. X' = 168,2: df 14: P < (H10I.
c·t
The pere
Table 4. Distribution ofschizophrenic patients assessed at five-year follow-up by percentage of' a psychcl
time spent in a psychotic episode betweeri~
between!
----.---~------

0- 5 (y·15 1(,45 46-75 Known

Not ~~:~
treatin .-
---"-- --- .-- _.' -- ..------

IV (tli;,) s (O'u) ,\, 1%) .v ("'0) ,\' (u/n) .v (~,'il)

psychia
._-"-"--,._---"-- .... - .... . _-------- ..- .. _-"-"--------- .. -.---------~----~---------.--~--------------- pattern'
Aarhus II 0,
5 III 7 14 ~ 16 19 38 () detaile .
Agru 30 41 I~ 2j <) 12 4 5 II 15 I
Cali 38 41 20 00
8 <) 5 19 21 2 2
111 sam
lbadan 36 52 16 23 4 6 3 4 9 13 j'ollow~.
London 16 25 13 20 16 25 4 6 14 22 2 distribt
Moscow 24 36 15 23 8 12 J 5 15 23
Prague 14 22 16 25 12 19 5 8 17 26 2 differed
Washington 23 44 9 17 4 8 I 13 25 :> 4 df 14,
All centres 192 VerY;
. - ... -.. --------~-. _
-. -,-------
.. ,
36
- .... - -- .. - ..-".---
--_
112
_ 21
..-._----_-."---_
__... .,"-"--",
6H
... ,._-------"
.•-. --. -_....__
13 33
---_'
117
_-..__ ._--_." --- ..,--_._------_.,_
22
_
9
_ .. .._-_., •..-----------
_-- .\ and
Kruskal-Wallis test mot known excluded), X' = 31·7, df7, P < 0,0001.
episodes
episodes,
follow-up schedules considered to be definitely A Kruskal-Wallis test indicates that the shows t
schizophrenic, probably schizophrenic. an centres differ significantly with regard to the centres, ;
affective psychosis. or 'another psychosis', distribution of patients into the five groups (P < from the
Usually episodes classified as psychotic were 0,000 1). Inspection of the Table reveals that the percenta
characterized by hallucinations and/or delu- greatest variation occurs in the first and fifth ersely, t
sions. The results are presented in Table 4, col LImns.The centres with the highest proportion proporti
which shows that, for all centres together, over of patients spending 5 % or less of time in a represerr
one third of patients initially diagnosed as having psychotic episode are Agra, Cali, Ibadan and centre h
schizophrenia spent less than 5 % of the five year Washington, Agra and Ibadan also have the ~howing
follow-up period in a psychotic episode" while smallest proportion of patients spending more small pr
about a fifth were in a psychotic episode for than three-quarters of the period in a psychotic vered frc
more than 75 % of the time. episode. hies Agr

-
 137
The [nternational Pilot Study 0/ Schizophrenia

i ~,bk 5_ Distribution of schizophrenic patients assessed at five-year follow-up by pattern of course

Pattern of course
-----------_ .. __ .._-------_.,--_._-----_.---------_.- - _._--_. __ ---.--------_._" ..

2
.---- ---_.- --~-.-- -'---'.--'-" ._-----_.--- _ .. _----_.-
0/
N ';" N N 0'
/0 v
N ,0

-- ---_ .._----_ .._----_.- .._----- --_ ... _-_.----_. ".---- ---_ ..

() I 17 34 20 40
Aarhus 3 6 9 is ()
10
7
Agra 31 42 3 4 o 19 26 II 15
21
I I II 12 33 36 19
10 II 16 17 I
Cali 00 32 9 13 7 10
lbadan 23 33 5 7 o 3
9 14
9 14 31 40
London 3 5 8 13 () 6
14 21
4 6 17 26 o 3 o 29 44
Moscow 27 40 15 23
Prague 6 9 6 9 o o II 17
:> 4 6 12 18 35 12 23
Washington 9 17 J 6 I
79 15 175 33 103 19
89 17 67 13 4 II
All centres ."- .. -- --
----.--.------------'---'---------.-.-~
... -- ..... ... ---.-----.----.-~..
.. -"-- _.-_ ..-_.--_. __ .._----
!"T.;',ltmlli"course: 1, full remission of episode of inclusion. no further episodes; 2. partial remission. no further episodes: 3. at IC:.:Ist one non-
..d:,'"C epi,ode alter episode of inclusion. full remission bel ween all episodes: 4. OIl least one non-psvchouc episode after episode of
.;'~I}I1, Incomplete remission bet ween episodes; 5, at least one subscq uent psychotic episode. full remission bel ween episodes: 6. at least
".,bcquenl psychotic episode. incomplete remission between episodes: 7. episode of inclusion continues throughout follow-up period

"',:" ,l[ remission.

Cali has been grouped with the centres in

of" course
i'LlI/C/"Il
developing countries, the pattern of course
shown by its sample of schizophrenic patients
Iht percentage of the follow-up period spent in
closely resembles that of samples from centres in
.;psychotic episode showed significant variation
developed countries. Among the latter. Aarhus
~<lweencentres. However, it does not distinguish
is conspicuous for a particularly poor outcome,
oetwcenpatients who experience one prolonged
rrlSode and those who suffer several short-lived nearly 40 % of its patients being continuously
psychotic for the whole 5-year follow-up.
I q'l,odrs. This distinction can be made by
.rcating the information from the follow-up
These various approaches to categorizing the

I f1<\chiatric histories in a different way. Seven

f'~lltcrns of course (PaC) were delineated as
clinical outcome over 5 years of the schizo-
phrenic patients in the IPSS consistently indicate
,.k:ai\cdin Table 5. In view of the small numbers that the patients from Agra and Ibadan fared

.f ~
..--.'
....
':'
....
t
r ---- ;1 -orne cells the columns were combinaed as best while those from Aarhus had the worst
, ,
\,;Ji(1WS for analysis: 1+2+3.4+5,6+7. The outcome.
dl\\ribution of patients according to the POCs Social outcome of patients with an initial
dilfcrcd significantly between centres (X2 = 83,
diagnosis of schizophrenia
j! 14. P<O·OOOI).
The d;ta in the follow-up schedules were used to

'Is= s ----

that the
Very few patients from any centre show pac
; and 4. indicating the rarity of non-psychotic
:;p!sodes occurring in isolation from psychotic
,pbodes_ POC I, representing the best outcome,
,hows the most striking variation between
make a global assessment of the degree of social
impairment suffered by each patient during the
follow-up period. The assessment was based on
the patients' occupational adjustment, relation-
~ard to the .rntres. with Agra and Ibadan standing out ship with friends, and degree of social inter-
~groups (P < trorn the rest as having an exceptionally high action. Experience with analysis of the two-year
teals that the percentage of patients in this category. Conv- follow-up data indicated that acceptable inter-
1st and fifth ersely. these two centres have strikingly low rater reliability was achieved when patients were
11 proportion
,~~

proportions of patients with pac 6 and 7, divided into two groups, those with severe social
<:[ time in Ll representing the worst outcomes. No other impairment and those without severe impair-
.~
(~l1lrChas less than one-third of its patients ment. The five-year follow-up data analysed in
.-~ :0
...'.~....
badanhave and
the ,110wlI1gPOC 6. but London has a surprisingly this manner are displayed in Table 6. The
'hding more small proportion of patients who never reco- differences between the Centres are highly
,
·a psychotic vcrcd from the episode of inclusion, and resem- significant (P < 0,001).
~:; ble, Agra and lbadan in this respect. Although The smallest proportions of patients with
138 J. Left" and others

The pattern of distribution for developed and

Table 6. Social impairment of schizophrenic
developing countries is very similar, although
patients assessed at five-year follow-up
definite schizophrenic episodes preponderate in
Severe social Moderate. mild or the former, and possible schizophrenic episodes
impairment no social impairment in the latter. In the sample as a whole 59 % of
N N %
schizophrenic patients with subsequent episodes
------------_
Aarhus
Agra
.. -.--~--.-----.------.---------------- ..----.
25
9
50
13
25
62
50
87
received definite and/or probable schizophrenic
diagnoses for those episodes. The comparable
figure for the two-year follow-up was 76 % This
~~;~~u
Ibadan'
Cali 15 17 73 83
Londort;
Ibadan 13 19 55 HI difference is not due to an increase in the
London 17 n 47 73 Moscow
Moscow 15 23
percentage of patients with only subsequent Washi.If
51 77
Prague 19 30 45 70 affective psychotic episodes in the longer follow- Pragu~1
Washington 13 25 39 75 up, since the figures are 16 % in the two-year Tot,)

follow-up and 15 % in the five-year follow-up.

9
All centres 126 24 398 76

Rather it is attributable to patients who suffered

x' = 28·12. df7.
severe social impairment are found in the three
centres in developing countries, Agra, Cali and
Ibadan, while the largest proportion is shown by
Aarhus. These findings closely parallel the
clinical outcome data. Indeed Spearman's rank
order correlation between severe social impair-
ment and the worst clinical outcome (column 7,
Table 5) is 0·76. However, it is worth noting that
although Cali has twice the proportion of the
worst clinical outcome patients as Agra and
Ibadan. the percentage with severe social im-
pairment is of the same order as in the other two
developing centres. This same pattern charac-
terized the Cali patients at the two-year follow-
lip.
In all centres the majority of patient with
schizophrenia did not suffer severe impairment
of their social functioning.
Types of subsequent episodes in patients with an
initial diagnosis of schizophrenia
A long follow-up makes it possible to determine
the consistency of the initial diagnosis over time.
The key question is whether subsequent episodes
of psychiatric illness conform to the episode of
inclusion in terms of diagnosis. On the basis of
the follow-up history data. episodes during the
follow-up period were classified as definitely
schizophrenic. probably schizophrenic, affective
psychosis, other psychoses. and non-psychotic.
These judgements were based on the WHO /
ICD-8 glossary criteria. Table 7 shows the
percentage distribution by clinical type of sub-
sequent episodes of patients with an initial
diagnosis of schizophrenia.
P < 0·001.
episodes of mixed schizophrenic and affective,
and mixed schizophrenic and unknown diag-
noses, who constituted 17 % of the patients in
Table 8. The category of unknown diagnosis
does not appear in the two-year follow-up
analysis, presumably reflecting the difficulty in
obtaining clinical information in the longer
follow-up.
The distribution for individual centres appears
generally similar, except for Aarhus, which
shows a strikingly high proportion of only
definite schizophrenic episodes, and no
patients with only subsequent affective psychotic
episodes.
Comparison between findings at two-year and at
five-year follow-up
It is instructive to compare the findings for
outcome at the two-year and five-year follow-
ups, to determine whether the pattern of course
changed substantially over the additional three
years. The results of this comparison for the
seven patterns of clinical course are shown in
Table 8. >
whi,
There was an overall gain of 40 patients in the
as vJi
second follow-up. This introduces an ambiguity >
into the interpretation of any changes observed, patiJ
since gains in any column may be due to an inter
alteration in the pattern of course of patients findh
seen at the two-year follow-up or to the of T
acquisition of patients followed up for the first ditTel
O·OO(
time at five years. Nevertheless, the differences
in pattern between the two follow-ups are Al
rever
sufficiently uniform across centres to merit
comment. Indeed. identical changes are apparent who
in the developing centres as in the developed of sc
whic
centres, and in centres like Agra and Moscow,
 The International PilOT Studv ot' Schizophrenia 139

Table 7. Percentage distribution of" schizophrenic patients bv clinical tvpe ot subsequent episodes
Jr developed and - - .-"'.~.... _--, .. --_ .. _ .._--_.
--_.- .-----.-- .. _-_._.- ---_. . _. ---'-'" --- -_._ ..-------._._--_
_.-.
.. .- _--------------_ .. -
imilar, although Unknown
preponderate in Affective mixed
Definite and (definite Schi zoph ren ic Unknown unknown
phrenic episodes
No of Only definite Only possible possible and/or and Other and and
a whole 59 % of patients schizophrenic schizophrenic schizophrenic possible) uffert: ve episodes schizophrenic affective
sequent episodes
-\arhus 18 61 17 II 0 6 6 I) 0
ole schizophrenic ., (, 12 0 0
-\gr" .'. 22 34 22
The comparable CJli 4~ 21 :> I K 10 S 17 12
.I 9
ip was 76 % This load"n 34 26 32 9 12
i.ondon 44 30 16 211 1(> II
increase in the vloscow 31 " 29 {J 19 13 6 (J 0
-'.
only subseq uent \\'ashington 2X :> I IK 4 I I II 14 IK
he longer follow- I',agllc 3X 29 J:: 0 IS II I)

,in the two- yea r Towl 273 29 25 15

Developed 159 34 23 16
~year follow-up. Developing 114 23 2X 14 9
ts who suffered ----~---.-----,----. --
---------------_._._--_._------_ ... ---_.- . . -.~----..----- .-.-,---- ... --_ . ... --_.------.-------
and affective,
•nknown diag- Table 8. A Comparison ofpat terns of" course at two-year andfive-yeur follow-up
:the patients in
,:own diagnosis
Number or
ear follow-up F,U patients (,

e difficultv in
·iin the longer Aarhus 2 48 II o o
50 ') o o
Agra 90 46 I> I) () i1

scentres appears ,.'

7' 31 3 (I 19
Cali 77 15 12 II !J 10
.~. arhus, which I II
92 10 16 I
16.·.·' rtl.'on of only Ibadan 59 34 (j I i.1
~.I :-:
¥des, and no 69 II
London 57 13 4 o
!ective psychotic 64 8 o 4
F- Moscow :> 69 21 ()

}, 66 4 17 o
o

...
,t.·.'..
~;two-year and at Prague 53 9 13 II

65 6 (, o () II

~ Washington 38 8 (, o iJ n
lJ ) (,
52 I
All centres+ 491 I 33 7~ iJ 57
v:_~~a~i~~~l:~~ 531 89 67 II 79
. ttern of course Overall changes +40 -44 -II
," dditional three
fparison for the * For key see Table S.
4e are shown in + X'.~ 4~·8. df 5. P < 0·000 I (columns 3 and 4 combined).

f~'. which lost patients between the two follow-ups, noteworthy, it indicates the possibility of some
~ patients in the
¥s an ambiguity as well as in all the other centres. which gained clinical improvement over time in patients whose
fanges observed. patients, In view of this uniformity, and in the illness has pursued an unremitting course for
ay be due to an interests of clarity, we will concentrate on the two years. The overall loss of 27 patients from
Surse of patients findings for all centres combined (bottom 3 rows column 7 might be attributable to failure to
v-up or to the of Table 8), which demonstrate a significant follow them up, except that centres like London
4 up for the first difference between the two follow-ups (P < and Washington contacted more patients at five
j; the differences 0'000 I), years than at two years but still showed a
i'follow-ups are Analysis of the differences between columns reduction in the number of patients with the

....'.··.·
i:ntres to merit reveals the unsurprising fact that some patients worst outcome. In addition, a trend emerges
who remain well for two years after an episode that is important for epidemiological studies: as
es are apparent.

E ' the developed

:'a and Moscow,
>jc

~
of schizophrenia, have subsequent attacks from
which they make a good recovery. More
schizophrenic patients are followed up over
longer periods of time, those who recover

,
.~!

•j..
 140 J. Leff and others

completely tend to be lost to the study, while variables, the probability of better outcomes Tabll
others with a relatively poor outcome are being significantly greater in developing coun-
retained. tries. Other variables were also included in the
model, one at a time, together with the first
Predictors of outcome
factor. None explains anywhere near the same
It is evident from the foregoing analyses that variance as does the developed/developing Predictor Val
both clinical and social outcome for this cohort dichotomy. There are significant associations
of schizophrenic patients were better for the Developing/d.
however. Male patients are more likely than DEV+Sex
developing than the developed countries. Pre- female patients to have a poor outcome on all DEV+Age(-
vious research has consistently identified other three measures. Current age is not associated DEV I- Marita
other)
predictors of outcome, such as sex, marital with outcome. Being married at initial exam- DEV + Acute!
status, pre-morbid personality and type of onset, ination means a higher probability of good DEV + Durati
as being important in schizophrenia. It is possible social functioning, but is not associated with (0 c1asses):l
[)EV+CATEj
that differences between patients from devel- clinical outcome. Subjects who had sudden onset DEY e Social)
oping and developed countries with respect to (overnight or a few hours) or those whose DEV + Sexual
these factors could account for the superior I)EV + Pre.~
symptoms were comparatively recent were less IlO) _
outcome of the former. likely to have poor outcomes. Having a symptom [) l, V .i, Life e~
To test these possibilities, a series of analyses profile corresponding to CA TEGO S + was [)FV,. Loss 9
were conducted where outcome variables were not associated with either social functioning or
or 110) . 1!
.... _-,. ~
modelled to be dependent on the values of the the length of time in psychotic episodes. but was • (j th9t
IS

developed/developing dichotomy as well as a associated with a significantly lower probability The first liji
The subsecj
number of other predictor variables. Log-linear of a good pattern of course. Social isolation at C)
models were used, where the logarithm of the initial examination was associated with poor Table 1'(
odds of a particular outcome is expressed as a social and clinical outcomes, while poor pre-
linear combination of the predictors. This model morbid sexual adjustment affected social func-
is sometimes referred to as the log-odds model tioning only. A history of pre-morbid personality
or. especially where the predictors are con- disorder was associated with poor outcomes on
tinuous. the logistic regression model. Analyses all three variables. unlike the experiences of
were made using the procedure CA TMOD from negative life events prior to illness, which were
SAS version 5'18. which provides a general- associated with better clinical and social out-
ization to handle more than two classes of comes.
outcome variables. Maximum likelihood esti- Thus. while clinical predictors affect clinical
mation was used. The size of the log-likelihood outcome and social predictors influence social
statistic. - 2 log L. indicates the goodness-of-fit outcome, there is also some cross-over; for
of the model. Itis distributed as a ,\'2 statistic example, a slow onset predicts social impairment
with degrees of freedom dependent on the at follow-up, and initial social isolation predicts signific .~
number of categories of the independent vari- a poor pattern of course. lishing .
ables included. The contribution of each in- In addition to the predictors listed in Table 9, much,
dependent variable to the model may be repre- the relationship between subgroups of schizo- patients."
sented by its corresponding contribution to the phrenia. derived from the fCD categories, and lirsl corr
value of -2 log L. outcome was examined. It was found that acute develope
The outcome variables against which the schizophrenia (295.4) and schizoaffective schizo- clling W~
models were tested were the time spent in phrenia (295.7) were both associated with signifi- effect of
psychotic episode (4 classes: < 5 %; 5-14 ~.'O; cantly better clinical and social outcomes than taken in
15-94 %; 95-100°;;,). pattern of course (4 classes: the other sub-groups. This is probably attribu- <ignificai
I; 2--5; 6; 7) and social impairment (3 classes: table to the influence of acuteness of onset and dichoton
none; mild or moderate: severe). Results are life events before onset on the outcome variables. A nur
summarized in Table 9. (see Table 9). llSll1g m
The first factor to be entered into the model . Another predictor of outcome that was urder te
was whether a patient came from a centre in a studied was first contact with psychiatric prcdicto
developed or developing country. This is highly services. Many studies have shown that patients outcome
significant as a predictor of each of the outcome with schizophrenia making a first contact have a develops

S@
 Thl' International Pilot Stud)' ofSchizophrenia ]41

tcaml"
; COUIl-
Table 9, Log-linear modelling oftlie relationship of predictor variables to Three indices or
outcome
in t hl· -_--_.-------
..'---"--'------- ~- .. --. __ ... -._._--,"-"- - ---_ .._--. __ ._-."-_._--
..__ .- ------_.- ------- .._--_ .. _._-------
. ---""
--- ~----'-------.-,-.--------,-
---_._-_._-_._---------- _------_._
_--_._ ..... __ ........_
,
,-_._--_ - -
---- ..---- ..------- .. _--
-

re fJr~>! Time spent in a Pattern of Social

psychotic episode course impairment
e saml'
!Iopin[? l~dlCl"r variables df p G* df p Got p
iation~ -.------.----~..---'-----~--------.--.---.------,--~--.----'-.-.-----.-~.------
<":'eloping/developed (DEV) 21·2 0·001 50,8 0·001 34·7 (1,001
'I thall DEV· •..Sex 11·6 [)'O()9 10·9 0·012 7·1) OIl}O
On all Df'\ ,Ago i < 25, 25·-34. > 34) 12·0 4 1}062 0-469 1· 7 4 On}

I
5'6
)ciatcd i,[\' '-\'l~lfil~.11status at onset (single. married. )-l) 6 0,434 S-4 0'490 15·0 4 (1·(105
"lher!
exa 111- :In' " Acuteness of onset (Sudden or slow) 11·4 ()-(1I0 14,3 0·002 0·002
good Dr\·· .• Duration or symptoms prior to assessment 4,}7 18 (1-1)01 50·4 IX (I'O(lI 12 (i'011
(, (ia,,~~~J
I with OF\ CAT EGO S+ (yes or no) 2·2 0·522 7· J 0·067 }·2 11,202
liOnsct un Social isolation initially (5 classes) 20,0 12 0·066 25·5 I~ 0'03} 41·6 IHIOI
Dl Y- Sexual adjustement initially (3 classes) 6·~ 19-6
~hosl' 6 0·340 11·2 6 O'OX2 0·1101
DE\" ~ Pre-morbid personality disorder (yes or 10-2 36-4
. less 0·017 44·3 0·001 O'IJUI

:tom DF.\' -- Life event preceding onset (yes or no) 21·6 (I'OOt 16·1 (j'OOI 31·2 (HIOI
.wa-, il[\' -- Loss of either parent before 15 years (yes 4·5 0·212 20 O'5~1 1-4 0·502
"; nl))
or
~ li j~ the resultant change in - 2 log L where extra variables are added to the model. distributed as ,\'~ with degrees of freedom shown.
fhe Iirst line shows the changes in -2 log L due to DEV alone.
The subsequent lines show the change in -2 log L due to the addition of each predictor with DEV.
c! 1
'001'
Table 10, Patterns of course in patients with schizophrenia from all centres combined compared
re-
with those in patients with mania and psychotic depression
'. nc-
li t \
.'. --. __ .._--_._._ ..__ . __
. -.~.. ----- .. --~-----.---.--
.. ---------..-- --------------
._---_._._._------_._._-------_...
.. .. - ._- .. _-------_._ .....
- - __
._-_._---_._-_ .. _--- .._---_ .. _-_-. .__ ... _--_.
Pal tern or course"
10;1
rs 01 -----_._-._- -------_
4
..-
~erc
fout-
N
-.-_ .. _ .._._._---- ._- _._---,,-
IV <n
." N "/0 X o·
'0
,\ '\. N o
" S ':'<' N

Schizophrenia 531 89 17 67 13 4 II 2 79 15 175 33 103 19

&' Mania + psychotic 130 29 22 22 19 6 6 26 20 36 28 4
depression

• For key see Table 5,

.•.;for
iu.~
c•·~~:
...... X' = 34'13, Ji'(" P < (J·OOI.
enl
icts

~.·
..
'i......
I.'
significantly better outcome than patients estab- were significant no matter which other variables

.
lishing subsequent contacts. In this cohort a were added into the analysis, implying that each
much higher proportion of schizophrenic of these two predictors exerts an independent
9.
, 0-
patients in developing centres were making their influence on outcome.
nd first contact with the services (83 %) than in The most important conclusion from this
" te
..
ll
developed centres (38 %). Linear logistic mod- series of analyses is that when the effects of all
0-
elling was applied and showed that when the other significant predictors are taken into ac-
I. ifi-
an
effect of first contact on pattern of course was
taken into account, there was still a highly
count. the powerful influence of the developing/
developed dichotomy on all three outcome
ibu- significant effect of the developing/developed variables remains, This indicates that the
&nd dichotomy (X2 = 18'86, df 2, P < 0'005). superior five-year outcome of schizophrenic
des, A number of other analyses was conducted
E,
-,. patients in developing countries is not explained
" llsing more than two predictors at a time, in by the set of predictor variables tested in the
ras order to get an idea of the extent to which modelling procedures. These were chosen be-
Ie predictors have an independent influence on cause their predictive value for the outcome of
its Outcome. It emerged that the developing/ schizophrenia had been established by many
. r:a developed dichotomy and acuteness of onset previous studies. It is evident that the expla-
 I

i'-
r
..
i
I
I.
r

142
1. Leff and others

Table II. Social impairment oj' patients with eluded as well as those with affective psychosis
schi:::ophreniil from all centres combined in order to boost the numbers. It was found that pre-morbi.
compared with that of patients with mania and patients with non-schizophrenic diagnoses from life event
psychotic depression developing and developed countries had signifi- from prev
.. ._---------_._-
-- ----------------~---------.-.------.------.-~--
----------.-~-------..---- .. --.---- ..-----.- --.----. --'---'-
-_._---- --._" ---....
------_ cantly different patterns of course (P < 0'01) plained tlu
Moderate. mild and social outcomes (P < 0·00 I). but that oping coui
Severe social or no social that from t
impairment impairment percentage of time spent in a psychotic episode
-------------- __
------_. ._------ was not significantly different. and could
N N 0.,
." :v ·U
lJ!
selection a
--------.-----------.-.-.----.--- ..--..--.-~-----------._--._--_.
Schizophrenia 53 I I c6
fuci Ii ties ill:
398 76 DISCUSSION
Mania + psychotic 130 8 Ic I the situatij
94
depression
A five-year follow-up was successfully carried planation]
out on 76 % of the original cohort of patients.
congruentj
x' with Yales correction ~. 19'1 J. df I. P < (HJO I.
There was a selective loss of patients with Out~ome ~
schizophrenia from the follow-up. but within the sampl~
nation for the better outcome in developing base d $,I
this diagnostic group those who were lost did
countries needs to be sought elsewhere.
not introduce a significant bias with respect to 'Th~ fi~Sj
need to bC~
Comparison of course and outcome between any of the variables that are known to influence
schizophrenic patients and other diagnostic outcome. r n terms of clinical outcome, measured r01Jow-uP'~ ....
groups by symptomatic status at time of follow-up, time dcvelopec :·...
spent in a psychotic episode and pattern of
tollowed b
Kraepelins original distinction between schizo- has beenai
course. schizophrenic patients from Agra and ;:0
phrenia and manic-depressive psychosis was developeds
fbadan did conspicuously better than those '~
partly based on the worse outcome of the
former, which was one of the reasons that
from the other six centres. An exceptionally X. advantagti
sclection ji
prompted him to employ the term den/entia
good social outcome also characterized these / 1i' ization of~'
patients. and additionally the patients from
praecox. Many subsequent studies have con- reviewed
Cali. This resulted despite the fact that Cali had
firmed this difference in outcome, and it was up of schi
double the proportion of patients with the worst
considered worth exploring with the five-year rnOSI im ,
pattern of course as those in Agra and Ibadan.
follow-up data. In addition to the 53 I patients the 1'0110
This may be explained by a much greater
with a diagnosis of schizophrenia. 130 with less than;
tolerance and acceptance of symptomatic schizo-
diagnoses of mania and psychotic depression
phrenic patients in Cali than there is in developed
were successfully followed up. The patterns of
countries. Supportive evidence for this is pro-
course of these two diagnostic groups are
vided by a survey of public attitudes to the
compared in Table 10.
mentally ill in Cali (Leon & Micklin, 1971) and
As expected. patients with affective psychosis
by a study of relatives' attitudes to schizophrenic
have a significantly better outcome in terms of
patients in Mexican-American families (Jenkins
pattern of course than patients with schizo- eta!' 1986). -rnce
phrenia. There is a shift across all columns recoveree
towards lesser morbidity for manic-depressive
Comparison
follow-up data
of the two-year
suggested
and five-year
that some schizo-
Course I r
patients, but the greatest difference appears for -irnilar t6"
phrenic patients who remained continuously
POC 7. unremitting symptoms throughout the combined.
psychotic for two years underwent some im-
follow-up period .' Stephens, '1
provement in subsequent years. It also indicated
Social impairment is displayed in Table 11 "<tried froi
that over time there was a differential loss from
and also demonstrates a significantly better certainly r
the cohort of those who recovered completely
outcome for patients with affective psychosis. The avera
from the initial episode.
The influence of the developing/developed mean of S
A number of factors was found to predict
country dichotomy on the outcome variables Pattern ol
either clinical or social outcome or both.
was examined for non-schizophrenic patients in However
including sex, marital status, acuteness of onset.
order to determine whether it was diagnostically com bined,
first contact with services. duration of symptoms
specific. In this analysis. patients with diagnoses rises to 23:
before con tact. a CA TEGO class of S +. initial
of neurosis and personality disorder were in- (hat deriv
social isoiation and sexual adjustment. a poor
ratit;nts w
 .. :.; - .. ,"-

143
il
The InternatiOnal Pilot Study (d" Schi:ophrelli
of the episode of inclusion, with no further
episodes. Stephens' figures for 'unimproved'
.pre-morbid personality and the occurrence of a
patients range from 4 to 84 % with a inean of
.life event before onset. These are all familiar
52 %. The corresponding figures for developed
from previous studies, but none of them ex-
countries in our study are 58 to 74 % with a
plained the good outcome of patients in devel-
mean of 65 %. The much narrower range is
oping countries. This finding is identical with
almost certainly due to standardization of
that from the two-year folloW-UP (WHO, 1979),
methOdology in the IPSS. Since Stephens'
and could be ascribed to a differential self-
review, a five-year fonow-up study has been
selection of patients attending scarce medical
published (Watt el al. 1983) which is of particular
facilities in developing countries compared with
relevance since the patients were examined with
the situation in developed countries. This ex-
the PSE. A feature of the study which added to
planation has been rendered implausible by the
its rigor, but renders it less comparable with the
congruent findings of the Determinants of
IPSS, is that the sample of patients was
Outcome Study (Sartorius et al. 1986) in which
epidemiologicany based. The proportion of
the samples of patients were epidemiologically
patients with a single episode and no impairment
based. was 16 %, while the proportion with repeated
The five-year follow-UP data from the IPSS
episodes and no return to normality was 52 %.
need to be put in the context of other long-term
These figures indicate a rather better outcome
follow-UP studies of schizophrenia. Studies in
than the corresponding data for the London
developed countries will be considered first.
centre (POC 1, 5 % ~POC 6 + 7. 62 %) and may
followed by those in developing countries. There
be attributable to the nature of the catchment
has been a large number of relevant studies in
area, which was semi-rural with little socio-
developed countries, incurring the usual dis-
advantage of a great variety of methods of economic deprivation.
In a more extensive presentation of their
selection of patients, assessment and categor-
findings, Shepherd et al. (1989) analysed the
ization of course and outcome. Stephens (1978)
relationship between clinical outcome and social
reviewed 38 studies involving a long-term follow-
outcome. This was found to be approximately
up of schizophrenic patients. Of these 13 are of
linear, with 25 % of the variation in overall
most immediate relevance to our design, since
social adjustment being attributable to clinical
the foHow-uP was at least five years but averaged
status at fonow-up. In no case with severe global
less than ten. Stephens classified outcome as
social impairment was clinical status unim-
'recovered' _ complete recovery without evi-
ved paired, but in a small number of patients social
dence of residual pathology; 'unimpro '-
ved function was unimpaired in the presence of
active chronic psychosis; and 'impro '-
severe clinical morbidity. Shepherd et at, Suggest
either the subject has residual symptoms at time
that the good social outcome of these patients
of foHow-uP or appears recovered, but has had
may be a consequence of family support and the
repeated exacerbations and hospitalizations
fact that they were able to stay in employment .
since entering the study. The category
This speculation may be relevant to the findings
. recovered' corresponds to our Pattern of
Course 1, while that of 'unimproved' is very for the Cali patients.
Extensive comparisons of the IPSS data with
similar to our Patterns of Course 6 and 7
very long-term follow-UP studies (Bleuler, 1972 ~
combined. In the 13 studies reviewed by
Huber et al. 1975; Tsuang et a/. 1979~ Ciompi,
Stephens, the proportion of' recovered' patients
1980; Harding et al. 1987) are not productive
varied from 6 to 39 %, this wide range almost
because of differences in method and the
certainly reflecting methodological differences.
suggestion from these studies that a progressive
The average was 21 %, more than double the
improvement occurs in schizophrenia over
mean of 9 % for developed countries showing
Pattern of Course 1 in our study (Table 5). several decades.
"ct To turn to studies in developing countries,
However if Patterns of coursel and 2 are
one of the earliest was conducted in Mauritius
combined, the mean for developed countries
" 'et, by Murphy & Raman (1971). They identified all
rises to 23 %. This figure, which is very similar to
Ins that derived from Stephens' review, includes first admissions to the only hospital on the
ial patients who have had a full or partial remission
or
• ~ I

144
1. Leff and others

Table 12. Five-year outcome of IPSS ~!

Chandigarh could be explained by the relative )j
schizophrenic patients by centre compared with incompleteness of follow-up. This explanation Tbag}
other studies in developing countries Cali:I'
has some cogency since the current study has
---.~-----.-~- shown that in an extended follow-up it is the city~"
Length of
~/o with
patients with the best outcome who are most direc]
follow- up % with full % with best
Location worst thanf
in years int'ormUlion outcome likely to be lost from the cohort. Furthermore,
.._-_.-
-----.--.~---.-- ._-_. __ ._---_._------_._------_._-_ outcome
TPSS centres in the Determinants of Outcome Project grap4
Aarhus
94 (Sartorius et al. 1986) follow-up of an epidemi- threei
Agra 6 40
5 74 42 ologically based sample of schizophrenic patients order
Cali 10
5
Ibada n
92 II 21 in the Chandigarh centre revealed a significantly of schi
London
Moscow
5
5
59
65
33
5
10
14 better outcome than comparable patients in up. Ii
86
Prague 6 21 developed countries. Evidence against this in- sampl·:···'·
Washington
86 9 :23 terpretation is provided by data from the Cali also ,'.
53 17 23 develd
Other studies centre (Table 12) in which the follow-up was
Mauritius
Hong Kong
12 98 59 24 virtually complete, while the proportion of fore ti

;~;
10 62 t~tctotl
Chandigarh 21' 32 patients with the best pattern of Course was low.
5 58
Sri Lanka 29 32
5 98 40 On the other hand, Ibadan had the least complete
----------
----._-----_.- 29
follow-up of the rpss centres, but a high
proportion of patients with the best outcome.
island during the year 1956 who were given a It is evident that completeness of the follow-

"'N',
diagnosis of schizophrenia. They succeeded in up is not a satisfactory explanation for the
tracing 98 % of the sample 12 years after the first divergent findings from developing countries. former-(iJ
admission, and defined the best outcome as But taken as a whole the data do indicate a F Eng~
complete recovery from the initial episode and better outcome for schizophrenia in some devel- Dr A. J~
no further episodes during the follow-up period. oping countries compared with developed coun- R Sha~
This is identical with Pattern of Course I in this tries. One possible explanation is that the land' .. E)~
samples from the developing centres contain a Iiga tor,~1a
study, allowing comparison between the two .I llcl-Ni'
sets of data. Tn the Mauritian follow-up 59 % of disproportionate number of patients with acute,
cnllabo·
the sample exhibited this outcome, a higher rapidly resolving psychoses which have an
iicld re~
proportion than in any of the rpss centres. This inherently better prognosis. This explanation is L'ollabo'
may be explained by the fact that the Mauritian not supported by the results of the log-linear F Zam
sample comprised first admitted patients only. modelling, which demonstrated that acuteness ('olem
whereas the TPSS samples were mixtures of first of onset as a predictive factor did not detract \csligai'
admissions and readmissions. from the effect of the developing/developed the fiel
dichotomy. Another explanation involves the Wing.-
Two studies of first admitted schizophrenic
!'rudo'
patients with findings that conflict with those of greater tolerance for and acceptance of schizo-
phrenic patients by family members in devel- London'(
Murphy & Raman were conducted in Hong chief c'
Kong by Lo & Lo (1977) and in Chandigarh by oping countries We have referred to this above
Ih<lriko'
Kulhara & Wig (1978). In these two studies the in relation to the data from Cali, and evidence L'SSR; ~
proportion of patients with a complete recovery for this is provided by the Chandigarh sub-study llgator, ar
from the initial episode and no subsequent on relatives' Expressed Emotion in the Deter- In Prague,
relapse was 21 and 29 % respectively. Another minants of Outcome project (Leff et al. 1987. L Wynne
comparable study was carried out by Waxler 1990). In Chandigarh, the low levels of relatives' Invcstigate
(1979) in Sri Lanka with results that Supported Expressed Emotion were associated with a better Lenlrc in \
those of Murphy & Raman, since 40 % of her clinical outcome at one-year and at two-year
follow-up. However, this was not the situation Funding fe
sample conformed to the best outcome category. Health ~ OJ
The findings of these four follow-up studies in in Cali where patients had a similar clinical v!ental He
developing countries are displayed alongside the COurse to those in developed countries, but had
five-year follow-up data from the IPSS centres a superior social outcome. Therefore, although
the tolerance of relatives might be invoked as a REFEREr
for comparison. At first, it might appear that the
contradictory results from Hong Kong and partial explanation for the better clinical out- hk"/"r. M.
come of schizophrenic patients in Agra and /.(( h!(~ I-ling
\tullgilrc
 The international Pilot Study of Schizophrenia
145
Ibadan, different factors must be operating in Ciompi. L. I I 980). Catamnestic long·term study on the course of life
Cali. These may be linked with the nature of the and aging of SChizophrenics. Schi:ophrellia Bulletin 6. 606.-6IR.
city of Cali, which has moved further in the Harding. C. M .. Brooks. G. W .. Ashikaga. T., Strauss. S. S. &
Breier. A. (1987). The Vermont longitudinal study of persons with
direction of urbanization and industrialization severe mental illness. I: Methodology. study sample and overall
than either Agra or Jbadan. The socioderno- status 32 years later. American journal ofPsvchiatrv ]44. 718--726.
graphic and cultural differences between these Huber. G .. Gross. G. & Schuule», R. (1975). A long-term follow-up
study of schizophrenia: psychiatric Course of illness and prognosis.
three IPSS centres need further exploration in Aua Psvrhiatricn Scandi!/ClI'ica 52. 49-57.
order to understand the variation in the outcome Jenkins. 1. H .. Karno. M .. De La Selva. A. & Santana, F. (19H6).
Expressed Emotion in cross-cultural context : familial responses 10
of schizophrenia revealed by the five-year follow- schizophrenic illness among Mexican Americans. In Treatment oj"
up. It is noteworthy that patients in the IPSS Schizophrenia (ed. M. J. Goldstein. 1. Hand and K. Hahlweg), pp
35-49. Springer. Verlag: Berlin.
sample with diagnoses other than schizophrenia
Kulhara, P. & Wig. N. N. (1978). The chronicity of schizophrenia in
also had better clinical and social outcomes in North West India: results of a follow-up study. British Journal of
developing than in developed countries. There- Psvchiatrv 132. 186-190.
Leff, J. (1988). Psvchiatrv Around the Globe 2nd edn. Gaskell:
fore it is possible that the social and cultural London.
factors responsible for a good outcome operate LeR·. J. P.. Wig. N .. Ghosh. A.. Bedi. H .. Menon. D. K .. Kuipers. L..
across diagnostic boundaries. Karlen. A .. Ern berg. G .. Day. R .. Sartorius. N. & Jablensky, A.
(1987). Ill. Inf uencc of rela rives' Expressed Emotion 011 the course
of schizophrenia in Chandigarh. British Journal O/' Psyrhiatr v 151.
APPENDIX 166-173.
Leff, .1., Wig, N. N .. Bedi, H .. Menon, D. K .. Kuipers. L.. Karlen.
Collaborating investigators A .. Emberg. G .. Day, R .. Surtor-iuc, N. & Jablensky. A. (1990).
Dr N. Sartorius, Principal Investigator, Dr T. Y. Lin, Relatives' Expressed Emotion and the Course or
schizophrenia in
Chandigarh. A two-year follow·up of a first-contact sample.
former principal investigator, Ms E. M. Brooke, Dr British Journai n] Psvchiatrv 156.351-356.
F. Engelsmann, Dr G. Ginsburg, Mr W. Gulbinat, Leon. C. A. & Micklin. M. (1'971). Opiniones communitarias sabre
Dr A. Jablensky, Mr M. Kimura, Dr A. Richman, Dr enfermedad mental y su lratamiemo en Cali. Colombia. Act a
Psiouiatrica y Ps,rculogia de America Latina ]7, JgS-J94.
R. Shapiro, at WHO Headquarters, Geneva, Switzer- Lo, W. H. & La, T. (1977). A ten-year follow-up of Chinese
land; Dr E. Stromgren, chief collaborating inves- schizophrenics
63-66.
in Hong Kong. British Journal or
Psvrhtairv 131.
tigator, Drs A. Bertelsen, M. Fisher, C. Flack and N.
Juel-Nielsen, Aarhus, Denmark; Dr K. C. Dube, chief Murphy, H. B. M. & Raman. A. C (1971). The chronicity of
schizophrenia in indigenous tropical peoples. British Journal (~I
collaborating investigator, and Dr B. S. Yadav at the Psychiatrv 118. 489·-497.
field research centre in Agra, India; Dr C. Leon, chief Sanorius. N., Jablensky, A .. Karlen. A .. Ernberg. G .. Anker. M ..
collaborating investigator, and Drs G. Calderon and Cooper. J. E. & Day. R. (19H6). Early manifestations and first.
E. Zambrano at the field research centre in Cali. contact incidence of schizophrenia in different cultures. Psvcho-
logical M"dil'ine 16. 909-928.
Colombia; Dr T. A. Lambo, chief collaborating in-
Shepherd. M .. Watt. D .. Falloon. 1. & Smeeton. N. (19~9). The
vestigator, Dr T. Asuni and Dr M. O. Olatawura at nat ural history of schizophrenia: a five-year follow-up study of
the field research centre in Ibadan, Nigeria; Dr J. K. outcome and prediction in a representative sample of schizo-
Wing, chief collaborating investigator, and Drs R. phrenics. Psvctiotogicat Meditine. Monograph Supplement 15.
Stephens. J. H. (1978). Long-term prognosis and follow-up in
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London, United Kingdom; Dr R. A. Nadzharov, Tsuang, M. T .. Woolson. R. F. & Fleming, J. A. (1979). Long-term
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Bleuler, M. (1972). Die Schi~ophrenen Geistes.\'l()rungen im
Lichte Langjiihriger Kranken-unn Familien-Geschichtell. Thieme:
Stuttgart.

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