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When this tome first came through my letter box, I groaned. It felt weighty in every sense. A look at the contents page was no more reassuring. A list of papers with titles like "Twenty five years of WHO co-ordinated activities concerned with Schizophrenia" and "Long term mortality experience of international cohorts of persons with schizophrenia and related psychoses." These are followed by nearly seventy pages of tables and statistics--never my ideal reading. So I began to review this book with considerable trepidation. I started with the Introduction and was startled by the opening sentence. "Since the early 1980's a body of epidemiological evidence has taken shape... challenging the early Kraepelian view... that the long term prognosis for schizophrenia was uniformly poor." (p.xi) This surprised me and I realized that my own, unconscious assumption was that a diagnosis of schizophrenia was the psychic equivalent of terminal cancer. One had periods of recovery; palliative care was available but the eventual outcome was in no doubt. Psychic death followed schizophrenia as surely as physical death followed from terminal cancer. This optimism is continued in the introduction with this comment "In the judgment of three leading researchers, it may well be time for chronicity to give way to the expectation of 'slow uphill returns to health' with allowances for 'multiple levels of functioning in housing, occupational and social skills.' (Harding, Zubin and Strauss, 1992) I found this heartening. As a lecturer in Mental Health Nursing I have always found it a little difficult to present my students with an optimistic picture of schizophrenia. With this new perspective my optimism could be revived; thus giving more hope to my students who, in their turn, could offer more hope to their patients.
One of the fascinating aspects of this collection is its breadth of data. Individuals with a diagnosis of schizophrenia were studied across continents and in both rural and urban settings. Thus there are studies from the Germany; China; India; Prague; The Netherlands; The U.K.; Japan and Moscow. Definitions of schizophrenia were agreed along with methodology, outcome measures, and a host of other criteria. Another interesting and important aspect of this trial is the length of time over which it was run. Patients were followed up for between 12-26 years which gives added weight to the findings of this study. I am not aware of many comparable studies which combine length and depth of information in quite this way.
Another aspect of this study that surprised me was the fact that people in the developing world with a diagnosis of schizophrenia had better outcomes than individuals in the developed world. (I had assumed that the reverse would be true.) In their paper, Hopper et al comment "Whether using a strict (ICD 10) or a broad (spectrum) diagnostic classification, and whether considering overall clinical status, symptoms, disabilities, or social functioning (as indexed by work), subjects in the developing centers showed a more favorable picture." (p.33) The reasons given for this are to do with family support and attitudes; acceptance by the wider community and the increased possibility of finding meaningful work, which gives any individual a sense of self worth along with social contact. (This contrasts starkly with the developed world where employment for those with a long term mental health problem is very limited. Whenever I ask my students if they would declare a long term mental health problem to a potential employer, their answer is always a resounding "No way!")
There are many more "fascinating facts" that could be taken from these studies e.g. that in India there is still a 73% chance that a patient will be married compared to a 38% chance in the developed world. Or that one's health outcomes are better in a rural setting than in an urban one. As a source book for lecturers wanting interesting facts this book is a must have! But it has more value than this. It offers a breadth and depth of study that I have not previously seen in one place.
My reservations about volumes like this (costly) one are about who will read it or buy it? In my university we do still buy books--but they represent a small slice of our library budget. Most of the money is spent on journals with an on-line presence. I, too, am increasingly accustomed to doing a "Google scholar" search on a topic, highlighting some major papers and then searching for them on line. I do read books--my study is already overcrowded and we have moved house at least once to accommodate our library. My nursing students are increasingly of a one–click generation. This book would not be seen by them, which would be a great shame. I am very pleased to have seen this book. It has already changed some of my perceptions about schizophrenia and I. in my turn, will share these insights with successive generations of student nurses.
© 2009 Terry Burridge
Terry Burridge is a Senior Lecturer in Mental Health Nursing at Buckinghamshire New University. He has spent most of his professional life as a psychiatric nurse and now spends considerable time and energy trying to inspire future psychiatric nurses to be the best kinds of nurses that they can be! He is very much influenced by psychoanalytic thinking and sees analytic theory as offering a valuable critique to many other areas of human activity. He can be contacted at Terry@dancingbears.co.uk
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