Abstract
The characteristics of patients with schizophrenia in rural China do need be explored as there about 63.8% of the Chinese population lives in rural areas [1]. According to a previous study [2], there are about 5.49 million persons with schizophrenia in China. Among these patients, 3.5 million patients live in rural areas. Moreover, the current condition of patients with schizophrenia in rural China is unsatisfactory [3]. Thus, the study on these patients will be helpful for planning mental health services, which are insufficient at present, to accommodate them [3, 4].
Clinical course in schizophrenia has been the subject of extensive investigation throughout the last century. A number of reports have indicated that gender, age at onset, and treatment condition (e.g. maintenance treatment) may influence the course of schizophrenia [5–7]. Moreover, culture can affect various aspects of the illness process, including illness definition, help-seeking behaviour, response to treatment, and post-treatment adjustment [8]. The course of schizophrenia appears to be better in developing, than developed countries; reasons for this are far from clear, nevertheless, it can be safely assumed that culturally determined processes, whether social or environmental, are partly responsible [9, 10]. However, although many studies of factors affecting schizophrenia (e.g. gender, age at onset, housing) have been conducted in other countries [11–16], this issue has been seldom touched in China.
The aims of this study were to assess the characteristics of schizophrenia and related factors affecting it.
Methods
Methods are as previously described by Ran et al. [4]. Total population in the rural area of Xinjin county identified (framework populations) was 235 546. The six townships (including 149 231 people in the rural community, of whom 123 572 were aged over 15 years) were randomly selected from all 14 townships of Xinjin County in the south of Chengdu. There was not much in or out migration when the investigation was conducted. An epidemiological investigation of all the people was conducted in the six townships in October 1994. First, the face-to-face interview was conducted with each head of household (together with key informant method) for identifying potential cases of mental disorder. The Psychoses Screening Schedule (PSS) was filled in by means of interviewing the heads of all the households, and discussion with village doctors and neighbourhoods comprising the survey sample [17, 18]. Second, when positive answers were obtained for a subject on the screening procedures for psychosis, a comprehensive general psychiatric interview was then completed with that subject by a survey psychiatrist. All the patients who met the criteria of schizophrenia of the Chinese Classification and Diagnostic Criteria of Mental Disorder (CCMD-2-R) and the International Classification of Disease (ICD-10) were included in the study.
Measurement
Widely used national epidemiological schedules and rating scales were used to assess symptoms and social abilities. Standard instruments including PSS, Present State Examination (PSE-9, Chinese translation), the Psychotic Diagnosis and Record Schedule, and the Social Disability Screening Schedule (SDSS) [17, 18] were used. Family history was obtained in a structured way. Age at onset refers to the age of the first sign of psychotic behaviour. All the raters (15 psychiatrists) were trained prior to investigation. The mean percentage agreement of all the above instruments on the ratings for 10 patients ranged from 80.5% to 99.0%. Kappa values between pairs of investigators ranged from 0.7 to 1.0 [4].
Results
All persons with positive results of PSS were assessed by the raters. There were 510 patients with schizophrenia among the population whose age was above 15 years. The number of males was 239 (46.9%), and females was 271 (53.1%). The number of current-episode patients (with psychotic symptoms at the time of the survey) was 367 cases, of which the number of males was 173 (47.1%), and females was 194 (52.9%). For the 510 patients with schizophrenia, the patients' age ranged from 15 to 95 years (mean = 44.6, SD = 15.5), and the mean duration of illness was 12.5 years (SD = 11.3). Among these patients, there were 45 cases (8.8%) whose duration of illness was less than 1 year; and 357 cases (70.0%) whose duration of illness was more than 5 years.
Overall, 143 of 510 patients (28.0%) had a family history of mental illness (including psychosis, mental retardation, epilepsy, alcohol dependence) in first- or second-degree relatives, and this prevalence did not differ by gender (70 of 238 men (29.4%); 73 of 272 women (26.8%) (p < 0.05)). Of all the patients, 108 (21.2%) were single, 327 (64.1%) were married, 40 (7.8%) were widowed and 35 (6.9%) were divorced.
Mean age at onset (mean = 31.0, SD = 12.9). For 397 of 510 patients (77.8%) onset was before the age of 40. The peak period of onset was 15–29 years for males and 20–39 years for females. Mean age at onset among males (mean = 29.6, SD = 13.5) was significantly younger than that among females (mean = 32.3, SD = 12.5) (ANOVA, F = 5.50, p < 0.05). Moreover, mean age at onset among all the patients who had a positive family history of mental illness (mean = 29.0, SD = 12.3) was significantly younger than that among all the patients who had a negative family history of mental illness (mean = 31.8, SD = 13.2) (ANOVA, F = 5.02, p < 0.05).
Prevalence
The total prevalence of schizophrenia among 123 572 people (over 15 years) was 4.13 per 1000. The current prevalence of patients with schizophrenia (not recovery patients) was 2.97 per 1000. Meanwhile, there were no significant differences in the total and current prevalence between females (4.38 per 1000, and 3.12 per 1000) and males (3.88 per 1000, and 2.82 per 1000) (p < 0.05).
Treatment condition
In Xinjin county, there was one mental hospital and many general hospitals. Of the 510 patients with schizophrenia, 156 (30.6%) never accepted any treatment, 30 (5.9%) were accepting antipsychotic drug treatment, 8 (1.6%) were in the mental hospital, 118 (23.1%) had been hospitalized at one time, 92 (18.0%) maintained irregular treatment for less than 2 months, and 106 patients (20.8%) had only used Chinese herbal medicine. Of all the patients with schizophrenia, 278 cases (54.5%) had once consulted a traditional healer and accepted spiritual treatment. There were more females (163 cases, 58.6%) accepting spiritual treatment than males (115 cases, 41.4%) (χ2 = 7.4, p < 0.05).
For 354 patients (69.4%) who once accepted treatments including antipsychotic drugs, Chinese herbal medicine and spiritual healing, the mean duration of psychosis before treatment was 3.6 months (SD = 10.7 months). The first three agencies consulted by these patients are shown in Table 1.
The first three agencies consulted (first three contacts)
For the first consultations by patients, about two-fifths went to see doctors at the mental hospital. The proportion of patients who went to see the primary health workers including doctors of traditional Chinese medicine in the village and general hospital was 32.8%. Of 510 patients, 38 (7.5%) had experienced suicidal thoughts or behaviour during their illness history.
Compared with the patients who accepted treatment in the first contact, the proportion seeking treatment in the second and third contacts significantly decreased to 67.0% and 27.4%, respectively (χ2 < 55, p < 0.001). Although the proportion of patients who accepted treatment was decreased in the second and third contacts, the proportion of patients who went to see a spiritual healer still maintained a relatively high level (more than 37.1%).
Families' recognition of illness
Among 354 patients who once accepted the treatment, the first symptom of the patients that caused their relatives to take them to seek help were as follows: the change of the behavioural manner including bizarre behaviour in speaking and other behaviours (268 cases, 75.7%), violent, aggressive or suicidal behaviour (40 cases, 11.3%), change of routine life including personal hygiene, sleeping and diet (24 cases, 6.8%), disabilities of social function at school, work unit, and home (14 cases, 3.9%) and complaints of physical discomfort or pain (8 cases, 2.3%). The results indicated that most families would not take the patients to see a doctor unless the patients had severe behavioural symptoms.
For the 354 treated patients, their relatives' recognition of their abnormal symptoms was as follows: 169 relatives (47.7%) did not know what problem the patients had, 105 (29.7%) thought that something was wrong with the patients' brain, 45 (12.7%) believed that the patients thought too much, 28 (7.9%) insisted that the abnormal behaviour was caused by ghosts or gods and 7 (2.0%) believed that the patients suffered from physical illness. The results indicated that most relatives in the rural community had no knowledge of mental illness.
Factors affecting course
To examine the relation between course of the illness and other variables, patients were classified (at the point of assessment) as in complete remission with no residual symptoms (125 cases, 24.5%), partial remission of positive symptoms but with some remaining residual positive or negative symptoms (68 cases, 13.4%), marked symptoms (no remission of severe symptoms, 274 cases, 53.7%), and deteriorated (43 cases, 8.4%).
Duration of the illness before treatment and duration of psychotic symptoms were correlated significantly with the measure of clinical course (p < 0.01). Age at onset and age at the investigation point were not significantly associated with the level of remission (p < 0.05) (Table 2).
Correlation of variables with level of remission of patients with schizophrenia
As shown in Table 3, treatment condition, family economic level, housing situation and status of relatives' care were significantly associated with the clinical course of schizophrenia. There was no significant difference of course between males and females among the patients. The course in the patients who maintained regular medication for more than 1 year was better than the other patients. The course in the patients who once accepted medication and/or traditional treatment was significantly better than that in the patients who accepted no treatment at all. Meanwhile, there was no significant difference in the clinical course between the patients who accepted medication irregularly and the patients who accepted the traditional treatment
Factors influencing clinical course of schizophrenia
Moreover, the better economic condition of the patient, stable housing and better care by the family were significantly related to better remission of the illness. The results also showed that most of the patients (92.4%) had stable living arrangements.
Patients' work ability
Among all the patients with schizophrenia, the percentage who could do full-time farm- or housework, part-time farm- or housework, or could do nothing was 43.1% (220 cases), 38.1% (194 cases) and 18.8% (96 cases), respectively. Among the 274 symptomatic patients, there were 199 cases (72.6%) who could do full-time, or part-time farm- or housework.
Of the total group of 510 patients with schizophrenia, there were 117 (22.9%) who had a negative influence on society by destroying property, injuring people or disturbing social order, and 6 (1.2%) who caused severe disturbance (killing or arson) to society.
Discussion
The prevalence of schizophrenia (4.13 per 1000) in this study is similar to the prevalence of schizophrenia (4.26 per 1000) in the 1982 epidemiological study of 12 districts in China (p < 0.05) [18]. Moreover, there is no significant difference between the prevalence of males and females in this study. The results did not correspond with the results of 12 districts in 1982, which showed the prevalence of females was significantly higher than that of males. This finding needs to be studied further.
The results of the study indicate that the male patients had an earlier mean age of onset (29.6 years) than the female patients (32.3 years) this was similar to that in a number of previous studies [6, 19–21]. Although the gender effect on the course of illness had not been found among all the patients with schizophrenia, the effect was found among the patients who accepted no treatment [4]. Among patients who had never received any treatment, females had a significantly better clinical course of the illness than males (p < 0.05), which is consistent with a few previous studies [15, 22]. Except biological reasons [13], this could be related to the fact that female patients in Chinese rural area have been accepted better at home than male patients, resulting in an apparent delayed age at onset and a better course.
Patients with a positive family history of mental illness had an early mean age of onset of illness than those with a negative family history, which was consistent with the study of Alda et al. [23]. This may reflect the vulnerability of the persons with family history. Moreover, there is evidence indicating that patients with a family history of psychosis improved more in 5 years follow-up as compared with those without a family history [15]. However, the results of this study didn't support this issue.
There was evidence which indicated that there was a potential impact of duration of untreated illness on course, such as the time interval between symptom onset and institution of neuroleptic treatment [14, 24]. Early neuroleptic treatment may enhance treatment response and course in patients with schizophrenia [14, 25, 26]. The duration of psychosis before treatment may also be an important predictor of course in first-episode patients with schizophrenia [27]. The results of the present study also indicate that the duration of illness prior to treatment and the total duration of illness might be important predictors of course in rural patients with schizophrenia. Delay in drug treatment may be associated with a significantly worse course and shorter duration of untreated illness prior to the initial acute episode which may be significantly associated with favourable course. Thus, how to diagnose and treat these patients in an early stage of illness should be emphasized in Chinese rural areas.
The results of this study indicate that 75.5% patients were assessed as having symptoms, this was consistent with previous studies [11, 28]. Moreover, the relationship between treatment condition and clinical course was also found in this study. The overall course in the samples of this study was gloomy, and the course in untreated patients was negative [4]. The course was better in the patients with any kind of treatment (e.g. medication or traditional methods) than those without any treatment. The clinical course of patients in the regular treatment group was the most favourable, which has also been indicated by many other studies [7, 14, 29]. Meanwhile, it is interesting to note that complete remission occurred in a similar proportion (about 30%) among patients with different treatments except the patients without treatment at all (remission < 10%). The results also indicated that there was a substantial subgroup of patients with schizophrenia with a good prognosis [15], and the importance of the treatment should be emphasized [30].
The better courses appeared to be related to the greater availability of housing alternatives [16, 31]. Patients with unstable housing were more likely to be literally homeless, highly symptomatic, and rehospitalized during follow-up. The results of the present study also supported this issue. Poor family economic and housing situations were correlated with the poor clinical course. Housing instability remains an important signifier of risk. The reason might be that patients with schizophrenia in Chinese rural areas who had unstable housing situations usually lived in a poor family, experienced multiple psychosocial problems, had few supports, and exhibited dangerous behaviours and medication noncompliance [32]. So, besides the treatment, especially medication, stable housing is also crucial for successful community service for these patients.
Although remission depended greatly on early treatment and good treatment compliance [33], this study indicated the situation was serious as the fact that only 37.8% patients initially consulted a psychiatrist in a mental hospital, and 30.6% patients never accepted treatment at all. The reason for the delay of help-seeking behaviour might be associated with the following:
1. Family recognition on mental illness was poor: the family usually thought that it was undesirable to talk with psychotic patients, and they saw psychotic illness as a stigma; family members might tolerate psychopathology to a greater extent and seek medical service for their ill relatives only after severe behaviour symptoms; for the treatment, 90.0% of patients' families who seek spiritual treatment said that they had to turn to seek the Gods' help when the patients did not get recovery after the first-treatment; and they didn't know the necessity of long-term treatment.
2. The attitudes of family members towards the patients was poor: family attitude was to let the patients live as normal if they had no serious disruptive behaviours, or to lock up or even restrain them at home if they had severe disruptive behaviours [32].
The results of this study indicated that poor clinical course was associated with the insufficient family care or maltreatment. Therefore, it is crucial to educate the public and patients' families about the knowledge of mental illness and how to care for the patients. Family intervention may be an effective approach of improving treatment compliance and should be an important part of community mental health care in rural China [34]. Meanwhile, it was very important to train the primary health workers (general doctors and village doctors) to conduct community mental health care in rural China as one-third of patients went to see them first.
The limitation of the present study is the assessment outcome data based on a prevalence sample (with wide variation in duration of illness). However, this study recruited a representative sample including all the patients with schizophrenia in a rural community. As mentioned in our previous study [35], it is unavoidable that true cases may be missed using the screening instrument.
Footnotes
Acknowledgements
This study was supported by grant from the China Medical Board of New York, Inc. (CMB, Grant No: 92-557). We thank Professor Julian Leff for advice on this paper.